Europace Advance Access originally published online on April 17, 2008
Europace 2008 10(7):877-879; doi:10.1093/europace/eun102
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CASE REPORTS
Temporary pacing wire in the coronary sinus: a novel treatment of acute heart failure?
Department of Cardiology, University Hospital of North Staffordshire NHS Trust, City General Hospital, Newcastle Road, Stoke-on-Trent, Staffordshire ST4 6QG, UK
Manuscript submitted 3 March 2008. Accepted after revision 28 March 2008.
* Corresponding author. Tel: +44 1782 552344. E-mail address: faizel.osman{at}btinternet.com
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Abstract |
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Treatment of acute heart failure relies initially on medical therapy. Patients can be considered for cardiac resynchronization therapy once they are able to lie flat for several hours. However, placement of a temporary pacing wire (TPW) into the coronary sinus may allow the patient to receive resynchronization therapy in the acute phase. We report a case of a patient who had a dramatic improvement of symptoms and blood pressure after a TPW was placed in the coronary sinus.
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Introduction |
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Cardiac resynchronization therapy (CRT) is known to reduce morbidity and mortality in patients with left ventricular (LV) systolic dysfunction, prolonged QRS duration, and New York Heart Association (NYHA) class III–IV symptoms, despite optimal medical therapy.1
However, CRT is difficult to perform in acute heart failure as patients may be unable to lie flat for prolonged periods, and medical therapy is often the mainstay of treatment. We report the case of a temporary pacing wire (TPW) placed in the coronary sinus in a patient with acute heart failure, who had a dramatic improvement in symptoms. |
Case report |
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A 77-year-old woman was admitted with a 3-week history of breathlessness. She had a past history of ischaemic heart disease with LV systolic impairment (ejection fraction <30%) and was taking an angiotensin-converting enzyme inhibitor, low dose β-blocker, and oral diuretic. Her blood pressure was 105/62 mmHg and pulse rate was 75 b.p.m. Her resting 12-lead electrocardiogram (ECG) revealed sinus rhythm with left bundle branch block (QRS duration 130 ms), and chest X-ray showed the evidence of pulmonary oedema. She was commenced onto intravenous nitrate and diuretic therapy.
A few hours after admission, she developed pre-syncope associated with a transient drop in heart rate to 40 b.p.m., which was due to intermittent atrio-ventricular (AV) heart block. Given her pre-syncope and bradycardia, she had a TPW inserted and paced at 80 b.p.m. The physician placing the TPW commented that placement of the wire was difficult and was left in a higher position on fluoroscopy than desired, but due to good threshold and stable capture, the TPW was not repositioned. The patient noticed an immediate improvement in her breathlessness and had no further pre-syncope. Her blood pressure was 138/84 mmHg immediately after pacing, and 12-lead ECG revealed a paced rhythm with a right bundle branch block pattern and inferior QRS axis suggesting pacing from the LV base (Figure 1). Her symptoms improved greatly by the following day and fluoroscopy in the left and right anterior oblique views confirmed that the TPW was in the coronary sinus (Figure 2A and B). The TPW was switched off revealing an underlying intrinsic sinus rate of 70 b.p.m. Unfortunately, the patient's breathlessness almost immediately worsened and blood pressure dropped to 100/60 mmHg; the TPW was switched back on with a rapid positive response in terms of breathlessness and blood pressure (which improved to 136/80 mmHg). She subsequently underwent CRT and her β-blocker dose was slowly increased. She remains well at follow-up.
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Discussion |
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The latest published guidelines for CRT recommend that heart failure patients with NYHA class III–IV symptoms on optimal medical therapy, a broad QRS complex (
120 ms), and a dilated LV with an ejection fraction <35% should be considered as potential candidates.2 Unfortunately, patients admitted acutely are often too unwell to undergo CRT and may not respond well enough to medical therapy to ever become candidates for CRT. Implantation of these devices often requires the patient to lie flat for several hours, which may be impossible in acute severe heart failure. The insertion of a TPW in the coronary sinus to pace the LV may help improve the patient's clinical state and allow quicker recovery from heart failure and facilitate implantation of a CRT device. Our patient's symptoms and blood pressure improved almost instantaneously once the TPW was switched on and worsened just as quickly when the TPW was switched off. This rapid response to temporary pacing suggests that LV pacing led to the positive response and is further supported by only a minor difference between the intrinsic sinus rate and paced rate. Biventricular and LV pacing alone improve the short-term systolic function to a similar extent and improve symptoms, quality of life, and exercise capacity in patients with severe heart failure.3 Temporary pacing could lead to loss of AV synchrony and may reduce any potential benefit of resynchronization using a TPW. Before recommending temporary LV pacing in patients with acute severe heart failure without bradycardia, data on procedural success (how frequently appropriate LV pacing can be achieved with a TPW in a timely fashion), efficacy in improving acute heart failure symptoms, and safety of procedure (e.g. risk of coronary sinus damage, infection, etc.) need to be evaluated. Unfortunately, data on these are limited and further study is required.
The use of temporary coronary sinus pacing has been reported previously.4,5 McNulty et al.4 reported successful coronary sinus pacing using an angioplasty guidewire in 8 of 10 patients undergoing percutaneous coronary intervention. The use of temporary resynchronization pacing with impedance cardiography was shown to be feasible and provides evidence of haemodynamic benefit before permanent pacemaker implantation in a heart failure patient who had an angioplasty guidewire placed in a branch of the coronary sinus.5
The use of a TPW in the coronary sinus may represent a novel approach in the treatment of patients with acute severe heart failure and bradycardia; it may allow patients to benefit from resynchronization therapy when acutely unwell and enable patients to be considered for a CRT device once they can lie flat for a longer period.
Conflict of interest: none declared.
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References |
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[1] McAlister F, Ezekowitz J, Hooton N, Vandermeer B, Spooner C, Dryden DM, et al. Cardiac resynchronization therapy for patients with left ventricular systolic dysfunction: a systematic review. JAMA (2007) 297:2502–14.
[2] Vardas PE, Auricchio A, Blanc JJ, Daubert JC, Drexler H, Ector H, et al. Guidelines for cardiac pacing and cardiac resynchronization therapy: the task force for cardiac pacing and cardiac resynchronization therapy of the European Society of Cardiology. Developed in collaboration with the European Heart Rhythm Association. Eur Heart J (2007) 28:2256–95.
[3] Auricchio A. Pacing the left ventricle; does underlying rhythm matter? J Am Coll Cardiol (2004) 43:239–40.
[4] McNulty PH, Rice KS, Saraiya RB, McCann J, Ettinger SM, Gilchrist IC, et al. Usefulness of temporary left ventricular pacing through the coronary sinus as an adjunct to transfemoral percutaneous coronary intervention. Am J Cardiol (2004) 94:1055–7.[CrossRef][Web of Science][Medline]
[5] Gimbel JR. Method and demonstration of direct confirmation of response to cardiac resynchronization therapy via preimplant temporary biventricular pacing and impedance cardiography. Am J Cardiol (2005) 96:874–6.[CrossRef][Web of Science][Medline]
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