Abstract
WEBSITE FEATURE
An 85-year-old man with a 4-day history of generalized fatigue presented at our emergency department with worsening symptoms of fatigue and dyspnea. Electrocardiography revealed a junctional escape rhythm at a rate of approximately 50 beats/min and ST-segment elevations in the inferior leads and in V4R. Coronary angiography revealed proximal occlusion of the right coronary artery and nonobstructive disease in the left coronary system (Figs. 1A and 1B). Attempts to pass a guidewire through the right coronary artery occlusion were unsuccessful. Right-sided heart catheterization revealed a severely reduced cardiac index (1.39 L/min/m2), elevated right-sided pressures, and dramatic right ventricular (RV) pulsus alternans (Fig. 1C). Transthoracic echocardiography performed in the catheterization laboratory showed RV dilation and akinesis that spared a small segment of the RV apex (Fig. 2). Despite intra-aortic balloon pump support and high-dose dobutamine administration, the patient remained in refractory cardiogenic shock with persistent pulsus alternans. Right ventricular pacing repeatedly resulted in ventricular tachycardia, and attempts at atrial pacing from several positions failed to capture the atrium, which suggested concomitant right atrial infarction. Consequently, we advanced the pacing wire into the coronary sinus. Fluoroscopy and electrocardiography then confirmed mid-coronary sinus pacing (Fig. 3). Coronary sinus pacing substantially improved hemodynamic activity, to the extent that the pulsus alternans resolved (cardiac index, 2.4 L/min/m2; Table I). Repeat echocardiography suggested improved RV septal function (Fig. 4).
Fig. 1 Coronary angiograms show A) nonobstructive coronary artery disease in the left system and B) proximal occlusion of the right coronary artery (arrow). C) Hemodynamic tracings show right-sided and aortic pressures. The right atrial (RA) tracing reveals large V waves consistent with severe tricuspid valve regurgitation. The right ventricular (RV) tracing exhibits depressed and broadened systolic peaks. The right atrial, right ventricular, and pulmonary artery (PA) pressure tracings show a dramatic alternating pattern within the magnitude of all systolic peaks, whereas only subtle changes are noted on the aortic (Ao) pressure tracing. The findings are consistent with RV infarction with predominantly right-sided pulsus alternans.
Fig. 2 Baseline transthoracic echocardiogram (apical 4-chamber view) shows the right ventricle in systole, before coronary sinus pacing. The right ventricle is severely dysfunctional, with mildly spared contractility in the apex.
Real-time motion image is available at www.texasheart.org/journal.
Fig. 3 Transvenous pacemaker placement in the proximal coronary sinus. A) Posteroanterior and B) left anterior oblique views show a transvenous pacing wire from the right internal jugular vein to the mid coronary sinus. C) Electrocardiogram confirms left ventricular pacing.
CS-PW = coronary sinus pacing wire; RV-PW = right ventricular pacing wire; SG = Swan-Ganz catheter
TABLE I. Patient Hemodynamic Data Before and After Coronary Sinus Pacing
Fig. 4 Echocardiogram (apical 4-chamber view) shows the right ventricle in systole after coronary sinus pacing. The observed improvement in right ventricular function is due mostly to increased septal contractility.
Real-time motion image is available at www.texasheart.org/journal.
Comment
Right ventricular infarction results in significant hemodynamic compromise that is associated with high in-hospital mortality rates.1,2 Traditional methods to support the failing RV include volume-loading, inotropic and mechanical support, and maintenance of atrioventricular synchrony and a high heart rate.
This, to our knowledge, is the first report of the efficacy and safety of coronary sinus pacing as an alternative to atrial and ventricular pacing in patients with RV infarction. In addition, we highlight a classic teaching point (the importance of heart rate in maintaining cardiac output in RV infarction) and publish our finding of isolated RV pulsus alternans in the setting of RV infarction.3
Supplementary Material
Footnotes
Address for reprints: Igor F. Palacios, MD, Cardiology Division, GRB800, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA 02114
E-mail: ipalacios@partners.org
References
- 1.Goldstein JA. Pathophysiology and management of right heart ischemia. J Am Coll Cardiol 2002;40(5):841–53. [DOI] [PubMed]
- 2.Zehender M, Kasper W, Kauder E, Schonthaler M, Geibel A, Olschewski M, Just H. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993;328(14):981–8. [DOI] [PubMed]
- 3.Bansal RC, Johns VJ Jr, Willis WH Jr, Isaeff DM. Isolated right ventricular mechanical alternans in right ventricular infarction. Chest 1980;77(1):115–8. [DOI] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.