Shock-induced right ventricular pacing failure caused by a short circuit: Uncommon but life-threatening complication of the Riata lead Itsuro Morishima,

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Presentation transcript:

Shock-induced right ventricular pacing failure caused by a short circuit: Uncommon but life-threatening complication of the Riata lead Itsuro Morishima, MD, PhD, Hiroshi Nakajima, MD, PhD, Hideyuki Tsuboi, MD, PhD, Yumiko Yokoyama, MD, PhD, Kazuhiro Naito, MD, Takahito Sone, MD, PhD HeartRhythm Case Reports Volume 1, Issue 2, Pages 46-50 (March 2015) DOI: 10.1016/j.hrcr.2014.11.005 Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 1 Surface electrocardiogram showing right ventricular pacing failure. The right ventricular pacing (arrows) at the programmed lower rate of 60 beats/min due to appropriate mode switching during atrial fibrillation did not capture the myocardium. HeartRhythm Case Reports 2015 1, 46-50DOI: (10.1016/j.hrcr.2014.11.005) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 2 A: Trend of pacing lead impedance and capture threshold. The right ventricular pacing lead impedance and pacing threshold had been stable since device implantation, but markedly increased after shock delivery. B: Stored intracardiac electrograms before and just after the second shock delivery. The shock was delivered inappropriately owing to the rapid ventricular response during atrial fibrillation. No noise or nonphysiologic signals were apparent before shock delivery. Noise appeared shortly after shock delivery on the right ventricular electrogram. RA EGM = right atrial electrogram; RV EGM = right ventricular electrogram. HeartRhythm Case Reports 2015 1, 46-50DOI: (10.1016/j.hrcr.2014.11.005) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 3 Presumed mechanisms of the electrical short circuit. A: Hypothesis 1: An electrical short circuit between the RV tip conductor and the RV coil conductor. B: Hypothesis 2: An electrical short circuit between the RV tip conductor and the SVC coil conductor. C: Hypothesis 3: An electrical short circuit between the RV tip conductor and the ICD can. Dotted arrows indicate the direction of the short current. The myocardium surrounding the RV tip electrode was ablated by the short current, resulting in an increase in the RV pacing lead impedance and capture threshold. Because the impedance increase occurred in the myocardium surrounding the RV tip electrode owing to the first shock, the shock impedances of the subsequent shocks were increased to the near-normal range. RV = right ventricular; ICD = implantable cardioverter-defibrillator; SVC = superior vena cava. HeartRhythm Case Reports 2015 1, 46-50DOI: (10.1016/j.hrcr.2014.11.005) Copyright © 2015 Heart Rhythm Society Terms and Conditions