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(Circulation. 2007;115:e386-e387.)
© 2007 American Heart Association, Inc.

Images in Cardiovascular Medicine

An Unusual Case of Embolic Stroke After Permanent Pacing

Tim Lockie, BSc, MBChB; Azad Ghuran, MD; David Hildick-Smith, MD

From the Sussex Cardiac Centre, Brighton, United Kingdom.

Correspondence to Tim Lockie, BSc, MBChB, Flat 6, 32 Coin St, London SE1 8YG, UK. E-mail timlockie{at}doctors.org.uk

A 54-year-old Caucasian male transatlantic airline pilot with no cardiovascular risk factors presented to a neurology clinic after a transient episode of dysphasia. He reported no additional neurological symptoms. Eleven years previously, he had developed asymptomatic sinus node disease and had undergone implantation of a dual-chamber permanent pacemaker to retain his commercial pilot’s license. He was in sinus rhythm, was normotensive (120/70 mm Hg), and had no cardiac murmurs or carotid bruits. Neurological examination was normal.

A computerized tomography scan of his head showed a focal left cerebral infarct. Carotid ultrasonography, holter monitoring, and a thrombophilia screen were normal. A diagnosis of a left-hemisphere transient ischemic event was made. The patient was referred for a transoesophageal echo to exclude an intracardiac source of embolus. Structurally, the heart was normal, but on venous bubble contrast injection from the left arm, there was dense simultaneous opacification of both the left and right sides of the heart, without Valsalva maneuvers (Figure 1). Transthoracic images were subsequently repeated with bubble contrast from the right arm; on this occasion, there was no opacification of the left side of the heart, even with Valsalva maneuvers, effectively excluding a significant patent foramen ovale or intrapulmonary arteriovenous malformation (Movie I).

View larger version (99K): [in this window] [in a new window]   Figure 1. Transesophageal echocardiography and bubble study illustrates bubbles entering the left atrium (LA) before the right atrium (RA). Ao indicates aorta.

The patient underwent a venogram from the left basilic vein (Figure 2). This demonstrated a proximal occlusion of the left subclavian vein (in which the 2 pacing leads ran), 2 small collaterals crossing the mediastinum into the superior vena cava (which remained fully patent), and 1 large serpiginous collateral from the subclavian vein at the level of the occlusion draining directly into the left upper pulmonary vein.

View larger version (82K): [in this window] [in a new window]   Figure 2. A, Venogram from the left arm illustrating an occluded left subclavian vein (LSCV) containing the pacing leads, with collaterals and a fistulous connection to the left atrium (LA). SVC indicates superior vena cava. B, Fistula occluded with an Amplatzer vascular plug (AVP).

The patient was anticoagulated. In view of likely paradoxical embolization through the venovenous right-to-left shunt, the patient was readmitted for closure of the collateral vessel. A 6-mm Amplatzer vascular plug (AGA Corporation, Plymouth, Minn) was deployed via a guide catheter from the left basilic vein, with complete closure of the collateral channel. Repeat contrast echocardiography the next day showed no residual shunt. The patient remains well with no further symptoms, but he has not been able to return to his former employment.

Occlusion of the access vein is a recognized complication of permanent pacing, with an incidence of 15% to 30%,¹ unrelated to lead size or number.² This occlusion rarely causes symptoms because venous collaterals quickly develop. Systemic-to-pulmonary venovenous collaterals have been reported in superior venacaval obstruction³ but not with subclavian vein occlusion alone. It represents a rare but important potential complication from transvenous pacemaker lead implantation.

	Disclosures

Top Disclosures References

 
None.

	Footnotes

 
The online-only Data Supplement, consisting of Movies I and II, is available with this article at http://circ.ahajournals.org/cgi/content/full/115/14/e386/DC1.

	References

Top Disclosures References

 

1. Rozmus G, Daubert JP, Huang DT, Rosero S, Hall B, Francis C. Venous thrombosis and stenosis after implantation of pacemakers and defibrillators. J Interv Card Electrophysiol. 2005; 13: 9–19.[CrossRef][Medline] [Order article via Infotrieve]
   
2. Bracke F, Meijer A, Van Gelder B. Venous occlusion of the access vein in patients referred for lead extraction: influence of patient and lead characteristics. Pacing Clin Electrophysiol. 2003; 26: 1649–1652.[CrossRef][Medline] [Order article via Infotrieve]
   
3. Ho HT, Horowitz AL, Ho AC. Systemic to pulmonary venous communication (right-to-left shunt) in superior vena cava obstruction demonstrated by spiral CT. Br J Radiol. 1999; 72: 712–713.[Abstract]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Lockie, T. Articles by Hildick-Smith, D. Search for Related Content PubMed PubMed Citation Articles by Lockie, T. Articles by Hildick-Smith, D. Related Collections Anticoagulants Transient Ischemic Attacks Pacemaker Cardiovascular imaging agents/Techniques Echocardiography Embolic stroke