Endovascular Treatment of Superior Vena Cava Syndrome via Balloon-in-Balloon Catheter Technique with a Palmaz Stent

Superior vena cava syndrome is a well-known disease entity that carries substantial rates of morbidity and mortality. Although most cases of superior vena cava syndrome are secondary to a malignant process, additional causes (such as mediastinal fibrosis, pacemaker lead implantation, or central venous catheter placement) have been reported. Multiple treatment options include percutaneous transluminal angioplasty, stent implantation, thrombolysis, mechanical thrombectomy, and venous grafting. We present a case of superior vena cava syndrome in a symptomatic 30-year-old woman who obtained complete relief of obstruction and marked symptomatic improvement through venoplasty and stenting, aided by our use of a balloon-in-balloon catheter system.

Plasma Exchange for Urgent Apixaban Reversal in a Case of Hemorrhagic Tamponade after Pacemaker Implantation

We report the case of an 82-year-old man in whom hemorrhagic pericardial effusion occurred one week after pacemaker implantation, while he was taking apixaban. Few therapies exist for reversing the anti-Xa effect of apixaban. To reverse anticoagulation, our patient underwent plasma exchange, which facilitated pericardiocentesis and prevented possible surgical intervention. To our knowledge, this is the first report of the use of plasmapheresis to reverse the anticoagulant effect of apixaban.

Chest pain associated with moderator band pacing

A 65-year-old man was evaluated for chronic chest pain that had been present for 8 years after placement of a dual-chamber implantable cardioverter-defibrillator to treat inducible ventricular tachycardia. Previous coronary angiography had revealed nonobstructive coronary artery disease and a left ventricular ejection fraction of 0.45 to 0.50, consistent with mild idiopathic nonischemic cardiomyopathy. Evaluation with chest radiography and transthoracic echocardiography showed the implantable cardioverter-defibrillator lead to be embedded within the right ventricle at the moderator band, which had mild calcification. Treatment included extraction of the dual-coil lead and placement of a new single-coil right ventricular lead at the mid septum. The patient had complete relief of symptoms after the procedure. This case shows that chest pain can be associated with the placement of a right ventricular implantable cardioverter-defibrillator lead in the moderator band and that symptomatic relief can occur after percutaneous lead extraction and the implantation of a new right ventricular lead to the mid septal region.

Predictors of severe tricuspid regurgitation in patients with permanent pacemaker or automatic implantable cardioverter-defibrillator leads

Patients with permanent pacemaker or automatic implantable cardioverter-defibrillator (AICD) leads have an increased prevalence of tricuspid regurgitation. However, the roles of cardiac rhythm and lead-placement duration in the development of severe tricuspid regurgitation are unclear. We reviewed echocardiographic data on 26 consecutive patients who had severe tricuspid regurgitation after permanent pacemaker or AICD placement; before treatment, they had no organic tricuspid valve disease, pulmonary hypertension, left ventricular dysfunction, or severe tricuspid regurgitation. We compared the results to those of 26 control subjects who had these same devices but no more than mild tricuspid regurgitation. The patients and control subjects were similar in age (mean, 81 ±6 vs 81 ±8 yr; P = 0.83), sex (male, 42% vs 46%; P = 0.78), and left ventricular ejection fraction (0.60 ±0.06 vs 0.58 ± 0.05; P = 0.4). The patients had a higher prevalence of atrial fibrillation (92% vs 65%; P=0.01) and longer median duration of pacemaker or AICD lead placement (49.5 vs 5 mo; P < 0.001). After adjusting for age, sex, and right ventricular systolic pressure by multivariate logistic regression analysis, we found that atrial fibrillation (odds ratio=6.4; P = 0.03) and duration of lead placement (odds ratio=1.5/yr; P = 0.001) were independently associated with severe tricuspid regurgitation. Out study shows that atrial fibrillation and longer durations of lead placement might increase the risk of severe tricuspid regurgitation in patients with permanent pacemakers or AICDs.

Upper-extremity deep vein thrombosis and downhill esophageal varices caused by long-term pacemaker implantation

Upper-extremity deep vein thrombosis is common after pacemaker or cardioverter-defibrillator implantation. Only 1% to 3% of patients with upper-extremity deep vein thrombosis become symptomatic. Downhill esophageal varices develop in the upper third of the esophagus as a result of the obstruction of the superior vena cava. Herein, we report the case of a 54-year-old man--a recipient of multiple implanted cardiac pacemakers--who presented with bilateral upper-extremity deep vein thrombosis. This severely symptomatic condition was complicated by very rare and life-threatening downhill varices of the upper esophagus, but without bleeding. To the best of our knowledge, this is the 1st report of this array of conditions.

Ascites secondary to indolent pacemaker infection in a Fontan patient

This report describes what we believe is the 1st reported case of indolent pacemaker infection's causing abdominal ascites in a patient who has undergone a Fontan operation. Abdominal ascites in a Fontan patient is commonly due to protein-losing enteropathy, systemic venous thrombosis, myocardial dysfunction, chylous ascites, liver cirrhosis, or pancreatitis. Our patient, who had a functional single ventricle, presented with ascites 3 years after undergoing the Fontan operation and pacemaker implantation. After extensive testing and evaluation, we attributed the ascites to indolent infection of the abdominal pacemaker.

Pulmonary embolism after pacemaker implantation

One day after implantation of a permanent pacemaker in an 82-year-old man, transthoracic echocardiography showed a mass in the right ventricle and a small pericardial effusion. Transesophageal echocardiography revealed a mass attached to the pacemaker lead. Subcutaneous administration of enoxaparin was begun, and the patient remained free of symptoms for the duration of his hospital stay Follow-up echocardiography performed before discharge failed to show the right ventricular mass, but a lung perfusion scan revealed multiple bilateral perfusion defects consistent with pulmonary emboli. The patient was discharged on a regimen of enoxaparin for another 30 days. Two years later, he remained asymptomatic.