New visualization methods are helpful in the noninvasive diagnosis of heart diseases. However,
sometimes epicardial and endocardial leads can cause problems due to a large number of
artifacts. Based on the presented case, we conclude that it is possible to perform multi-slice
computed tomography of coronary arteries despite the coexistence of transvenous and epicardial
leads

Młynarska, Agnieszka

Młynarski, Rafał

Sosnowski, Maciej

Wilczek, Jacek

English

Via Medica Journals

87www.cardiologyjournal.orgCASE REPORTCardiology Journal2013, Vol. 20, No. 1, pp. 87–8910.5603/CJ.2013.0014Copyright © 2013 Via MedicaISSN 1897–5593Address for correspondence: Agnieszka Młynarska, MS RN, Upper-Silesian Medical Center, Electrocardiology Department,ul. Ziołowa 45/47, 40–635 Katowice, Poland, tel: +48 32 202 40 25, fax: +48 32 2524098, e-mail: agnieszkawlodyka@o2.plReceived: 24.12.2011 Accepted: 03.01.2012Can multi-slice computed tomography of the heartbe useful in patients with epicardial leads?Agnieszka Młynarska1, 2, Rafał Młynarski1, 2, Jacek Wilczek1, Maciej Sosnowski2, 31Department of Electrocardiology, Upper-Silesian Medical Centre, Katowice, Poland2Unit of Noninvasive Cardiovascular Diagnostics, Upper-Silesian Medical Centre, Katowice, Poland33rd Division of Cardiology, Medical University of Silesia, Katowice, PolandAbstractNew visualization methods are helpful in the noninvasive diagnosis of heart diseases. How-ever, sometimes epicardial and endocardial leads can cause problems due to a large number ofartifacts. Based on the presented case, we conclude that it is possible to perform multi-slicecomputed tomography of coronary arteries despite the coexistence of transvenous and epicar-dial leads. (Cardiol J 2013; 20, 1: 87–89)Key words: implantable cardioverter-defibrillator, patch electrodes, lead,multi-slice computed tomographyThe first human implanted cardioverter--defibrillator (ICD) was invented in 1980 in Balti-more by the team of Michel Mirowski, MortonMower, and William Staewen [1]. Approval for cli-nical use was granted by the American Food andDrug Administration in 1985. Early devices consist-ed of a pulse generator implanted in the abdominalcavity and patch electrodes for defibrillation placeddirectly on the heart. Implant procedures requiredthoracotomy and had a mortality rate of about 4%[2]. In most implanted patients, an upgrade of theabove characterized system to a transvenous sys-tem with endocardial leads was performed aftera long period of time.Multi-slice computed tomography (MSCT) isa noninvasive method for the visualization of coro-nary vessels [3]. However, the question as towhether it is possible to perform MSCT in patientswith epicardial patch electrodes remains current.We present a case study of an 81 year-old pa-tient who was implanted in 1987 due to a ventricu-lar fibrillation (secondary prevention of sudden car-diac death) with an automated ICD (Ventak-P, Pace-setters Inc, St. Jude Medical, St. Paul, MN, USA).The device was implanted to the abdominal cavitywith patch defibrillation leads (no data about thetype of leads was available) placed by thoratocomy.After a few years, the system was upgraded — thedevice was re-implanted to the left subclavian areausing transvenous leads. At the same time, the ICDwas extracted from the abdominal cavity while thepatch leads were left in the heart. Presently, thepatient has Epic TM + VR Model V-196 (St. JudeMedical, St. Paul, MN, USA), implanted in 2007.In 2000, the patient had coronaro-angiogra-phy due to a suspicion of coronary artery disease(CAD). This suspicion was based on clinicalsymptoms such as chest pain, shortness ofbreath during vigorous activities, and other typ-ical/atypical symptoms coexisting. The result ofexamination was a subcritical 30% stenosis inproximal left anterior descending artery. Afterten years (September 2010), we decided to per-form MSCT of the heart to evaluate progress ofthe CAD — insignificant intensification of CADclinical symptoms had been observed in the pre-vious few months. We were afraid that the co-existence of epicardial and endocardial leads88Cardiology Journal 2013, Vol. 20, No. 1www.cardiologyjournal.orgmight cause significant limitation of the useful-ness of MSCT.Computed tomography was performed usingan Aquilion 64 scanner (Toshiba Medical Systems,Japan). Scanning with retrospective ECG-gatingwas performed during a breath-hold using 64 sli-ces with a collimated slice thickness of 0.5 mm.A breath-hold examination was performed to ad-just the scanner settings. The helical pitch was12.8 in best mode and the rotation time was 0.4 s.The tube voltage was 135 kV at 380 mA. We useda pre-selected region of interest in the descend-ing aorta. Triggering started at 180 Hounsfieldunits; 90 mL of non-ionic contrast agent (Ultravist370, Schering, Germany) was given at a rate of4.5 mL/s. The contrast agent was given in threephases: 90 mL of contrast agent (average), then24 mL of contrast agent followed by 16 mL of sa-line flush (60%/40%), and finally 30 mL of saline.During scanning, the patient had native stablerhythm of 60 bpm.Reconstructions of data were performed onVitrea 2 workstations (Vital Images, Minnetonka, MN,USA; software version 5.1). Three-dimensional volu-me rendering reconstructions, and multi planar re-formatted reconstructions were created.The result of this examination did not showprogression of changes in the coronaries (Fig. 1).Artifacts occurred near the leads (Figs. 1B, D). Itwas possible to evaluate all coronary arteries with-out artifacts (Fig. 1C).An atrial lead (absent in this patient) could con-stitute a potential problem with right coronary ar-tery visualization in MSCT [4]. An important obser-vation is that it was possible to obtain diagnosticimages of coronary arteries despite the presenceof old patch defibrillation leads coexisting witha transvenous defibrillation lead.Figure 1. Multi-slice computed tomography (MSCT) images of patient with coexistence of transvenous (active) andepicardial (not active) leads; A, B. Three-dimensional images of the heart; *visible patch electrodes; C1, C2. Diagno-stic visualization of the coronaries (LAD — left anterior descending artery, RCA — right coronary artery) despite thepresence of both types of lead; D. Multi planar reformatted reconstruction with visible artifacts from the leads.89Agnieszka Młynarska et al., MSCT with epicardial leadswww.cardiologyjournal.orgIt is possible to perform MSCT of coronaryarteries despite the coexistence of transvenous andepicardial leads.Conflict of interest: none declaredReferences1. Mirowski M, Mower MM, Reid PR. The automatic implantabledefibrillator. Am Heart J, 1980; 100: 1089–1092.2. PCD Investigator Group. Clinical outcome of patients with ma-lignant ventricular tachyarrhythmias and a multiprogrammableimplantable cardioverter-defibrillator implanted with or withoutthoracotomy: An international multicenter study. J Am Coll Car-diol, 1994; 23:1521–1530.3. Taylor AJ, Cerqueira M, Hodgson JM et al. ACCF/SCCT/ACR//AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use cri-teria for cardiac computed tomography: A report of the Ameri-can College of Cardiology Foundation Appropriate Use CriteriaTask Force, the Society of Cardiovascular Computed Tomogra-phy, the American College of Radiology, the American HeartAssociation, the American Society of Echocardiography, theAmerican Society of Nuclear Cardiology, the North AmericanSociety for Cardiovascular Imaging, the Society for Cardiovas-cular Angiography and Interventions, and the Society for Car-diovascular Magnetic Resonance. J Am Coll Cardiol, 2010; 56:1864–1894.4. Sosnowski M, Mlynarski R, Wlodyka A, Brzoska J K, Kargul W,Tendera M. The presence of endocardial leads may limit appli-cability of coronary CT angiography. Scand Cardiovasc J, 2010;44: 31–36.

Can multi-slice computed tomography of the heart be useful in patients with epicardial leads?

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Can multi-slice computed tomography of the heart be useful in patients with epicardial leads?

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