Recurrent Transient Ischemic Attacks in a Patient with Multiple Pacemaker Leads

Figures

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  Figure 1:. Chest X-ray showing right-sided pacemaker with 3 right-sided leads and 2 left-sided leads, including 1 tunneled across the chest over to the device on the right; also, note that a total of 5 leads pass through the superior vena cava.

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  Figure 2:. Apical 4-chamber transthoracic echocardiogram showing how agitated saline contrast bubbles initially appeared in the LA (as shown by the dashed circle) on the left image, followed by the left ventricle (shown by the dashed oval) on the right image. In normal anatomy, the bubbles will appear in the right atrium first, followed by the right ventricle right after injection. Abbreviations: RA, right atrium; RV, right ventricle.

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  Figure 3:. On top, biplane images can be seen. On bottom is a 3-dimensional transthoracic echocardiogram with color flow Doppler of the intact intra-atrial septum (red arrows surrounding the fossa ovalis) without evidence of shunt at the interatrial level. Abbreviations: AO, aorta; CS, coronary sinus; SVC, superior vena cava.

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  Figure 4:. From left to right, axial and coronal segments of computed tomography angiography imaging of the heart; dashed red arrows indicate the network of collaterals directed toward bilateral pulmonary veins that had developed extensively across the chest. Abbreviations: AO, aorta; LA, left atrium; LPA, left pulmonary artery; LPV, Left pulmonary vein; LV, left ventricle; RPV, right pulmonary vein.

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  Figure 5:. From left, a venogram from simultaneous upper-extremity injection of contrast dye shows the existence of a major collateral from the left brachiocephalic vein to the left pulmonary vein highlighted by a red arrow, which is subsequently coiled on the right image.

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  Figure 6:. Follow-up transthoracic echocardiogram with agitated saline contrast injected from bilateral upper extremities and through the lower extremity to reassess shunting after coil embolization of a large collateral. A: A large number of agitated saline bubbles appeared in the left atrium and left ventricle before the right side with the left-sided injection in a manner suggestive of persistent extracardiac shunting. B: With the right upper-extremity injection, the density of the bubbles was reduced, following the same route in a manner suggestive of a lesser degree of shunt on the right compared to the left. C: An absence of agitated saline bubbles was seen with the lower-extremity injection through multiple cardiac cycles. Abbreviations: IV, intravenous; LT, left; RT, right; TTE, transthoracic echocardiogram.