1. Deepak Talreja, MD, FACC, FSCAI
Nurses Week Celebration
CRT 2013 Source of Embolus?
                                                                              
Deepak Talreja, MD, FACC, FSCAI

2. Deepak Talreja, MD Honoraria: Abbott Vascular GlaxoSmithKline
Bristol-Myers Squibb
Sanofi Pharmaceuticals Partnership
AstraZeneca
Merck and Company, Inc.
Sanofi-Aventis
St. Jude Medical, Inc.

3. History
70 yo female transferred from OSH with sudden onset complete bilateral blindness.

4. History (cont)
70 yo female transferred from OSH with sudden onset complete bilateral blindness.
Head CT scan – multiple areas of cortical infarct bilaterally and encephalopmalasia

5. Source of Embolus?

6. Past Medical History Hypertension Diabetes Mellitus on insulin
Dyslipidemia
Hypothyroidism
Obesity

7. Past History
H/O Syncope with 3rd degree CHB treated with PPM (2007, OSH)
Two separate prior CVA:
Cryptogenic ischemic CVA 2006
Postoperative CVA (2007) with hemorrhagic transformation – left frontal lobe infarct with hemiparesis; SNF rehab.

8. PPM Implant 2007 Complicated procedure (5 hours)
Initial question of arterial access – venograms performed by implanting EP and surgeon called in consultation
Transient asystole
Two atrial leads failed to capture with severe TR, question of crossing PFO entertained; but third lead did capture with good thresholds

9. CXR

10. CT Chest

11. Echocardiogram Normal EF 45-50% without WMA
C/w Left sided implant with leads seen in Ao and LV
Moderate AI around LV lead

12. Cardiac Catheterization

13. DX: Left sided PPM Implant via Left Subclavian artery with LV apical Lead and atrial lead inserted in distal LM/LCX
So what now?

14. Options On-Pump, Lead and device extraction and repair
Minimally invasive options?

15. 1. New Pacer Implant on R given CHB

17. 2. Operation:
Draped in OR – ready to crack chest – pacer pocket opened and left sided PPM explanted.
Vasc Surgery obtained brachial access with cutdown. Balloon used to tamponade while pacer leads extracted.
Covered stent deployed in LSCA to cover access site
Repeat angiography showed patent cors