2. CASE PRESENTATION
A 42 years old man from Iraq with frequent episodes of syncope since one
month ago was admitted to the Tehran heart center hospital. He had a
history of tricuspid atresia type 2c without reparative surgery. On his
admission, the patient had fatigue. On physical examination, he had nail
clubbing and cyanosis with an O2 saturation of 75%. His
electrocardiogram revealed a complete heart block with a right bundle
branch block (figure 1). Echocardiography showed tricuspid atresia with
transposition of the great arteries (TGA type), severe pulmonary
hypertension (mean of PAP:85mmHg), and dominant left ventricle with
LVEF:35%. Cardiothoracic CT was done to evaluate better the cardiac
structure, which revealed a large pulmonary trunk, hypoplastic ascending
aorta, aortic arch with large PDA, and interrupted aorta. Detailed
findings of the Cardiothoracic CT scan are shown in figures 2 and 3. In
abdominal CT, an accidental finding was bilateral perirenal fluid
accumulation (figure 4).
The risk of the surgery for the epicardial lead placement was high due
to pulmonary hypertension; on the other hand, the transvenous pacing
would increase the risk of systemic thromboembolism. We discussed the
risk associated with each procedure with the patient and recommended the
endocardial route, which he accepted. Thus, endocardial pacemaker
implantation was scheduled for the patient. After prep and drape, local
anesthesia and light sedation were conducted. The left subclavian vein
access was gained, and a dual-chamber rate-modulated (DDDR) permanent
pacemaker was implanted using a peel-away introducer. Atrial lead was
inserted in the right atrial auricle. Ventricular lead was advanced
through the atrial septal defect and mitral valve and was placed in the
common ventricle. The patient was on heparin during the procedure, and
lifelong warfarin was initiated for the patient 24 hours after the
surgery. On follow-up, the patient was well and had no complaints. The
pacemaker was in the proper position without clot formation. The
post-pacing electrocardiogram is shown in figure 1.