Author + information
- Received June 5, 2017
- Accepted June 15, 2017
- Published online August 30, 2017.
- James Gabriels, MDa,∗ (, )
- Roger Fan, MDb,
- Stuart Beldner, MDa,
- Ram Jadonath, MDa,
- Mitchell Weinberg, MDc and
- Apoor Patel, MDa
- aDivision of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York
- bDivision of Electrophysiology, Department of Cardiology, Stony Brook University Hospital, Stony Brook, New York
- cDivision of Vascular Medicine and Vascular Intervention, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York
- ↵∗Address for correspondence:
Dr. James Gabriels, Department of Cardiology, North Shore University Hospital, Northwell Health, 300 Community Drive, 4DSU GME Suite, Manhasset, New York 11030.
A 65-year-old woman required a permanent pacemaker due to tachycardia-bradycardia syndrome. Vascular access was complicated by a left arm arteriovenous graft and a prior right upper extremity fistula. Imaging revealed occlusion of a previous right subclavian vein stent, right brachiocephalic vein, and right internal jugular vein. The patient was felt to be at high operative risk for an epicardial lead due to prior coronary artery bypass graft surgery and recent percutaneous coronary intervention necessitating dual antiplatelet therapy. A decision was made to implant a Micra Pacemaker (Medtronic Inc., Minneapolis, Minnesota).
The 27-F Micra delivery system could not be advanced past the patient’s nonretrievable inferior vena cava (IVC) filter, which was implanted 20 years prior. The filter was crossed in a subsequent procedure initially with an angled support catheter. A 10.0- × 40-mm Mustang balloon (Boston Scientific, Marlborough, Massachusetts) on a 75-cm shaft was then inflated within the filter. The deflating balloon was used as a rail for the advancing sheath (Figure 1, Online Video 1), resulting in successful implantation of the Micra pacemaker in the right ventricular apex without complications.
Prior reports have demonstrated that a femoral approach can be used to pass multiple 6- to 7-F catheters and 8-F sheaths across IVC filters (1). Afzal et al. (2) reported a case where a Micra permanent pacemaker was successfully implanted via an IVC filter; however, there are a variety of technical and clinical factors that affect the ability to cross a filter or the decision to instrument them at all. Filter design, duration of the implantation, interaction of the filter with the caval wall, extent of in-filter thrombus, and the patient’s ability to tolerate anticoagulation in the event the filter is rendered less effective post-dilation all may affect the crossing process. To our knowledge, this is the first report of leadless pacemaker placement following balloon-facilitated IVC filter crossing.
For a supplemental video and legend, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 5, 2017.
- Accepted June 15, 2017.
- 2017 American College of Cardiology Foundation