Intercommissural Lead Placement into a Right Ventricular Coronary Sinus

History

A 61-year-old man with a history of Ebstein’s anomaly, which initially went to had repaired in 1997; he then underwent tricuspid valve replacement with a 35-mm bioprosthesis in 2001. The initial surgery also involved an intraoperative ablation of an accessory pathway and right atrial maze procedure. For recurrent paroxysmal atrial fibrillation, he underwent a successful pulmonary vein isolation procedure in 2004. The electrophysiologic study performed at that time revealed severe sinus node dysfunction, but he remained asymptomatic. It was also noted that the tricuspid valve prosthesis was implanted proximal (atrial) to the coronary sinus.

Current Medications

The patient takes aldactone, furosemide (Lasix), warfarin, losartan (Cozaar), atorvastin (Lipitor), and aspirin.

Current Symptoms

More frequent spells of presyncope continued, but no frank syncope occurred. The patient also described infrequent tingling of the face and arm.

Physical Examination

• BP/HR: 116/66 mm Hg/52 bpm and regular

• Height/weight: 169 cm/93 kg

• Neck veins: No jugular venous pressure elevation

• Lungs/chest: Clear

• Heart: Moderate right ventricular heave, with a regular heart rate; second heart sound (S ₂ ) normal/split. 1/6 systolic murmur at the left sternal border; no diastolic murmur or gallop

• Abdomen: Soft, nontender, with no organomegaly

• Extremities: No cyanosis, no edema

Laboratory Data

• Hemoglobin: 14.4 g/dL

• Mean corpuscular volume: 92.2 fL

• Platelet count: 202 × 10 ⁹ /L

• Sodium: 142 mmol/L

• Potassium: 4.2 mmol/L

• Creatinine: 0.9 mg/dL

• Blood urea nitrogen: 16 mg/dL

Electrocardiogram

Findings

Electrocardiography revealed marked sinus bradycardia with right bundle branch block and a ventricular rate of 45 bpm ( Figure 9-1 ). A sinus arrhythmia is present, in addition to a premature atrial complex.