Coronary artery compression from epicardial leads: More common than we think

• Published in: Heart rhythm Vol. 15; no. 10; pp. 1439 - 1447
• Main Authors: Mah, Douglas Y., Prakash, Ashwin, Porras, Diego, Fynn-Thompson, Francis, DeWitt, Elizabeth S., Banka, Puja
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-10-2018
• Subjects: Congenital heart disease; Coronary artery; Defibrillator; Epicardial lead; Pacemaker; Pediatrics; Sudden death; Pediatrics; Pacemaker; Sudden death; Coronary artery; Congenital heart disease; Epicardial lead; Defibrillator
• ISSN: 1547-5271; 1556-3871
• DOI: 10.1016/j.hrthm.2018.06.038

A child with an epicardial pacemaker presented with sudden death at our institution, secondary to coronary artery compression. This case prompted enhanced surveillance of all patients with epicardial pacing or defibrillation systems.
The purpose of this study was to determine the incidence of coronary artery compression and the diagnostic yield of catheter angiography (CA) and computed tomography (CT).
All patients with epicardial leads who underwent CA or cine CT were retrospectively reviewed. A patient with postmortem diagnosis of coronary compression was also included.
Coronary compression was noted in 8 of 145 patients (5.5%) with epicardial leads. Median age at diagnosis was 11.4 years (range 3.0–29.6 years). Six patients had compression noted by CA, 6 by CT, and 1 by postmortem analysis. Chest radiography had sensitivity and specificity of 57% and 96%, respectively; CT 100% and 93%, respectively; and CA 86% and 100%, respectively. There was no difference in age or weight at the time of lead implant between those who did and those who did not have compression (age: median 1.3 vs 2.4 years; P = .36; weight: 9.5 vs 11.8 kg; P = .46). Among those with coronary compression, 6 of 8 (75%) had symptoms (1 sudden death, 3 chest pain [2 with associated troponin leak]), 2 unexplained fatigue). Seven patients had surgical repositioning of their lead.
We found a higher incidence of coronary artery compression by epicardial leads (5.5%) than previously reported in the literature. Chest radiography can serve as a good surveillance tool, with cine CT scans considered in those with concerning radiographs or with symptoms. Confirmatory CA can be performed before surgical intervention.