Subklaviyan Ven Darlığı Olan Hastada Kalp Pili İmplantasyonunda Farklı Bir Teknik Dr. Ahmet VURAL, Dr. Gökhan ERTAŞ, Dr. Ayşen AĞAÇDİKEN, Dr. Ender EMRE Kocaeli Üniversitesi Tıp Fakültesi, Kardiyoloji Anabilim Dalı, Kocaeli, Türkiye ÖZET Kalıcı biventriküler pacemaker medikal tedaviye dirençli kalp yetersizlikli hastalarda semptomların kontrolünde önerilmektedir. Fakat bazı hastalarda, venöz tromboz veya stenoz gibi implantasyonu kısıtlayan faktörler vardır. Subklaviyan ven trombozu transvenöz kalp pili elektrotlarının implantasyonundan sonra gözlenebilir. Biz iskemik dilate kardiyomyopati ve klinik ventriküler taşikardi nedeniyle implante edilebilir defibrillatör (ICD) implantasyonu yapılan 71 yaşında erkek bir hastayı sunduk. Bir yıl takip sonrası, hastada kalp yetersizliği semptomlarının kötüleşmesi üzerine biventriküler kalp pili (BVP) implantasyonu planlandı. Sol subklaviyan yaklaşımı ciddi darlık nedeniyle mümkün olmadığından, BVP implantasyonu sağ subklaviyan venden gerçekleştirildi. A NAHTAR K ELİMELER Biventriküler kalp pili, subklaviyan ven darlığı; kalp pili. Different Pacemaker Implantation Technique in Patient With Subclavian Vein Stenosis ABSTRACT Permanent biventricular pacing has been advocated for the symptomatic control of patients with medically refractory cardiac failure. In some patients, there are several limitations for implantation such as anatomic variations, venous thrombosis or stenosis. Thrombosis of the subclavian vein can occur after the implantation of transvenous pacemaker electrodes. It can cause problems when replacing the leads. We describe a 71 years old male patient who underwent implantable cardioverter defibrillator (ICD) implantation due to ischemic dilated cardiomyopathy and clinical ventricular tachycardia. After one year follow-up, the patient’s symptoms of heart failure worsened and biventricular pacemaker (BVP) implantation was planned. BVP implantation was performed via the right subclavian vein where left subclavian vein access was not possible due to severe stenosis. K EYWORDS Biventricular pacing, subclavian vein stenosis; pacemaker. İLETİŞİM ADRESİ Dr. Gökhan ERTAŞ Kocaeli Üniversitesi Tıp Fakültesi, Kardiyoloji Anabilim Dalı, Kocaeli Subklaviyan Ven Darlığı Olan Hastada Kalp Pili İmplantasyonunda Farklı Bir Teknik Case Report Currently available pacemaker lead technology and appropriate experience, left ventricular pacing can be undertaken through the left-sided epicardial tributaries of the coronary sinus with a high success rate (1). In some patients, there are several limitations for implantation such as anatomic variations, venous thrombosis or stenosis. We presented an image of a 71 years old male patient who underwent intracardiac defibrillator (ICD) implantation due to ischemic dilated cardiomyopathy and clinical ventricule tachycardia. The underlying diagnoses were ischemic dilated cardiomyopathy, left bundle branch blocke on ECG, NYHA III class, ventricular conduction delay (QRS>120 msn), reduced left ventricular ejection fraction (%30) (2,3). At that time we planned to implant biventricular pacemaker with ICD implantation. Right atrium and right ventricule leads were positioned bu we couldn’t succeed advance the coronary sinus lead. After one year follow-up, the patient’s symptoms of heart failure worsened (NYHA functional class IV), despite adequate medical therapy, requiring repeated hospital admissions. So we planned to imp- 135 lant another lead to coronary sinus again. But left subclavian venography revealed a severe stenosis (Figure-1-A). Subacute and chronic axillary and subclavian occlusion is a well-described complication of cardiac device implantation, occurring in up to 25% of cases (4). So the right subclavian vein was used in patient for left ventricular lead positioning (Figure-1-B). This lead was advanced to pacemaker subcutaneously. After follow up, patient discharged uneventfully. Clinical and echocardiographic improvement was observed during follow-up. In those patients undergoing biventriculer pacemaker implantation, right subclavian vein approache should be considered. R EFERENCES 1. Walker S, Levy T, Rex S, Brant S, Paul V. Initial United Kingdom experience with the use of permanent, biventricular pacemakers: Implantation procedure and technical considerations. Europace 2000; 2: 233–239. 2. Vural A, Ağaçdiken A, Komsuoğlu Baki.Biventricular pacemaker. Turkiye Klinikleri J Int Med Sci 2005; 1: 6-21. 3. Abraham WT, Hayes DL. Cardiac resynchronization therapy for heart failure. Circulation 2003; 108: 2596–603. 4. Rozmus G, Daubert J.P, Huang D.T, Rosero S, Hall B, Francis C. Venous thrombosis and stenosis after implantation of pacemakers and defibrillators. Journal Interventional Cardiology and Electrophysiology 2005; 13: 9–19. FİGURE 1 (A) Left subclavian venography revealed a severe stenosis. (B) Coronary sinus lead was implanted through right subclavian vein. CİLT 9, SAYI 3, Ekim 2011