Europace Advance Access originally published online on August 1, 2007
Europace 2007 9(9):851; doi:10.1093/europace/eum159
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CONGENITAL HEART DISEASE
Deep vein thrombosis in a patient with congenital heart disease and permanent transfemoral pacing
Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
Manuscript submitted 21 June 2007. Accepted after revision 8 July 2007.
* Corresponding author. Tel: +44 7747632019; fax: +44 2073518629. E-mail address: giannak{at}med.auth.gr
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A 45-year-old woman with previous repair of coarctation of aorta, ventricular septal defect closure, and progressive decline in her exercise capacity was admitted for the treatment of left leg deep venous thrombosis (DVT). She had a history of complete heart block and insertion of a pectoral pacemaker. After numerous problems with pocket infections, multiple box changes and fracture of the atrial lead, the pectoral system was extracted, and a transfemoral permanent pacemaker was implanted. Even though transfemoral pacing is considered a safe alternative to epicardial lead placement, this may not be the case in functionally impaired patients with mobility problems. Physicians caring for such patients should be alert to symptoms of DVT and provide prompt treatment to avoid major complications.
Key Words: Deep vein thrombosis, Congenital heart disease, Transfemoral pacing
Transfemoral pacing is a valid alternative to implantation of a pectoral system in cases in which the latter is not feasible due to abnormal venous circulation (e.g. persistent left superior vena cava), thinness of the anterior chest wall, infection of previous pectoral pacemaker systems and in children. No long-term thromboembolic complications from a femoral pacing system have been reported in small available series.
We report the case of a 45-year-old woman with congenital heart disease (CHD) and severe kyphoscoliosis who was admitted for the treatment of left leg deep venous thrombosis (DVT). She had a history of previous repair of coarctation of aorta at age 1, reoperation for recoarctation at age 7, and ventricular septal defect closure at age 14. One year later she presented with complete heart block and a pectoral permanent pacemaker was implanted. At age 40, after numerous problems with pocket infections, multiple box changes, and fracture of the atrial lead, the pectoral system was extracted, and a DDDR system was implanted via the left femoral vein (Figure 1). She recently presented with signs of left-sided DVT, after a period of decreasing functional capacity and reduced mobility due to deterioration of her left ventricular function and skeletal problems. Thrombosis of the left deep femoral vein was confirmed on ultrasound investigation. The patient was treated with low-molecular weight heparin followed by warfarin and was discharged a few days later.
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Even though transfemoral and transiliac pacing are considered a safe alternative to epicardial lead placement, this may not be the case in functionally impaired patients with mobility problems. This could be especially true in patients with heart failure due to acquired or CHD, in which reduced cardiac output, peripheral oedema, anaemia, or cyanosis and immobilization may predispose to venous stasis and hypercoagulability. Physicians caring for such patients should be alert to symptoms of DVT and provide prompt treatment to avoid major complications, such as pulmonary embolism or chronic complications such as venous insufficiency.
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