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(Circulation. 2008;117:2297-2298.)
© 2008 American Heart Association, Inc.

Images in Cardiovascular Medicine

Pseudonormal Position of an Atrial Pacemaker Lead Associated With a Contralateral Pneumothorax

Where Is the Atrial Lead?

Hirotaka Yada, MD; Toshiaki Sato, MD; Kyoko Soejima, MD; Yusuke Jo, MD; Masahiro Jinzaki, MD; Ikuko Togashi, MD; Hikaru Nakamizo, MD; Kotaro Fukumoto, MD; Kojiro Tanimoto, MD; Shunichiro Miyoshi, MD; Sachio Kuribayashi, MD; Satoshi Ogawa, MD

From the Cardiopulmonary Division (H.Y., T.S., K.S., Y.J., I.T., H.N., K.F., K.T., S.M., S.O.), Department of Diagnostic Radiology (M.J., S.K.), School of Medicine, Keio University, Tokyo, Japan.

Correspondence to Hirotaka Yada, MD, Cardiopulmonary Division, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160–8582, Japan. E-mail hirotaka.yada@cpnet.med.keio.ac.jp

An extract of the first 250 words of the full text is provided, because this article has no abstract.

An 83-year–old man with coronary artery disease was hospitalized for syncope due to sick sinus syndrome and underwent dual-chamber pacemaker implantation. An axillary vein was accessed using venography in the absence of a cephalic vein. A right ventricular screw-in lead (Medtronic 5076, Medtronic, Minneapolis, Minn) was inserted and placed easily in the right ventricular apex with a hydrophilic 0.038-inch guidewire retained. After positioning the right ventricular lead, an attempt to insert the sheath for the atrial lead over that wire proved challenging because of the narrow space beneath the clavicle. The guidewire became dislodged from the inferior vena cava to the superior vena cava and was readvanced into the right atrium using fluoroscopy in the anteroposterior view. A 7-French peel-away sheath was inserted, and the guidewire was removed. Then, a screw-in atrial lead (Guidant 4472, Guidant, Indianapolis, Ind) was advanced but encountered resistance at the junction of the brachiocephalic vein. The atrial lead was gradually advanced into the right atrium and positioned with acceptable sensing (1.0 to 1.4 mV), pacing threshold (2 V/0.4 ms), and resistance (457 ) values.

The next day, a posteroanterior chest x-ray revealed that an asymptomatic pneumothorax had occurred on the contralateral side of the implant (Figure 1A). An echocardiogram showed that no fluid had accumulated in the thorax or pericardial space. However, the lateral chest x-ray view revealed an unusual course of the atrial lead (Figure 1B). The atrial lead ran apart from the ventricular lead at the level of the . . . [Full Text of this Article]