Provocative Cases -> Teaching Case Reports D-AB16 - Conundrums for Device Implanters (ID 2) Abstract

D-AB16-02 - Tachy-brady Syndrome Due To An Infiltrating Cardiac Angiosarcoma: Utilizing The Pericardiophrenic Vein For Permanent Pacing (ID 1393)

 G.P. Siroky: Nothing relevant to disclose.


Background: Primary cardiac angiosarcoma (PCA) is a rare cardiac malignancy with median survival of 10-24 months. Symptoms include weight loss, dyspnea, palpitations, and syncope. Given the tumor’s predilection for the RA, mass effect can lead to vena caval obstruction, arrhythmias, and conduction disturbances.
Objective: To discuss unique placement of a pacing device due to anatomical obstruction.
Results: 56 y/o woman with progressive dyspnea and 30-pound weight loss found to have a right-sided intracardiac mass on CT. TTE (1) and cMRI (2) showed an RA mass spanning from the SVC into the RA near the IVC. TEE-guided (3) biopsy revealed PCA. Course was complicated by paroxysmal SVT (4), prolonged sinus pauses, and junctional bradycardia (5). Rhythm control with amiodarone exacerbated her bradycardia. Due to near-complete obstruction of the SVC and RA, neither a transvenous nor a leadless PPM could be implanted. CT venography revealed the left pericardiophrenic vein (PPV) extending from the brachiocephalic vein to the epicardial surface of the left ventricle (6). Implantation of a single-lead PPM using a bipolar LV lead in the left PPV (7/8) enabled treatment of the patient’s bradycardia and SVT, but led to intermittent phrenic nerve capture. Following chemotherapy, the tumor was resected 8 months later. The lead was then replaced with a His-bundle lead.
Conclusion: RA obstruction can complicate treatment of symptomatic bradycardia. Without access to the right-sided cardiac chambers for pacing, non-conventional access may be considered. While not an ideal route for pacing, given its proximity to the phrenic nerve, the PPV facilitated treatment of both bradycardia and SVT.