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    • br Discussion Studies have reported that

    2019-04-16


    3. Discussion Studies have reported that permanent PMI using the conventional pectoral approach is impossible or contraindicated in 1–6% of patients [1–5]. In such patients, PMI via the iliac vein is considered an effective alternative. The advantages of this approach are that the wound size and bleeding amount are very small and that it trospium chloride can be performed under local anesthesia [5]. Therefore, this approach can be used in patients with a poor general condition. Another advantage is the low possibility of late threshold increases in the epicardial leads. However, this procedure has several limitations, including retroperitoneal hematoma due to erroneous arterial puncture, a high rate of atrial lead dislodgement, and lead fracture with hip joint movement [1–5]. Retroperitoneal hematoma can be avoided with puncture under visual guidance as in the present case. The atrial lead dislodgement rate is reportedly 7–21% [1–4], and the anatomical morphology and gravitational forces acting upon the implanted generator are the main causes [2–5]. Our primary aim in the current study was to save the patient’s life; therefore, atrial leads were not used and the procedure could be completed in little time without any complications. Lead fracture induced by hip joint movement was reported previously [1,3]. However, no study has reported that lead fracture occurs more frequently after the iliac vein approach than after the conventional pectoral approach. To monitor for lead fracture, our patient has been followed up intensively. More than 3 years have passed since the procedure, lead fracture has not occurred, and the patient remains in good condition.
    Conflict of interest
    Acknowledgments
    Case report
    Conflict of interest
    We examined the report by Hori et al. with specific interest in their description of a Brugada ECG (electrocardiogram) pattern observed during ablation of ventricular tachycardia (VT) . Their case provides an important contribution to an expanding database of ischemic Brugada phenocopies (BrP) . BrP are characterized by ECG patterns identical to those of Brugada syndrome (BrS), but are elicited under various circumstances . They are classified according to six etiological categories: (i) metabolic conditions; (ii) mechanical compression; (iii) myocardial ischemia & pulmonary embolism; (iv) myocardial & pericardial disease; (v) ECG modulations; and (vi) miscellaneous. See www.brugadaphenocopy.com. The authors presented the case of a 63-year-old man undergoing catheter ablation of ischemic VT. The patient developed a Type-1 Brugada ECG pattern during the procedure, resolving upon observation within two minutes. During this time, the mapping catheter appeared to have been pushed against the left ventricular wall. The patient was subjected to provocative testing with pilsicainide, the results of which were negative. We believe that this patient developed BrP in the context of ischemia, resulting from direct compression of a coronary artery or vasospasm. Ischemic causes of BrP are not uncommon; however, this is the first confirmed case to observe a BrP during ablation of VT .
    Case presentation A 57-year-old woman with a history of dizziness due to episodes of complete heart block and bradycardia was referred to the electrophysiology ward for pacemaker implantation. A dual chamber pacemaker (Medtronic, Relia, Medtronic, Minneapolis, USA) was implanted. Its analysis showed normal function (atrial lead capture threshold 0.5V at 0.4ms, ventricular lead capture threshold 0.75V at 0.4ms, and P-wave and R wave amplitude sensing 2mV and 8mV, respectively). The pacemaker was programmed in the DDDR mode with a lower rate limit of 60bpm, atrial and ventricular output of 3.5V and 3.5V at 0.4ms respectively, atrial and ventricular sensitivity of 0.5mV and 2.8mV respectively, a paced atrioventricular interval (pAVI) of 180ms, and a sensed atrioventricular interval of 150ms. The post atrioventricular blanking period (PAVBP) was 60ms. In the first day after implantation, 12-lead electrocardiography showed episodes of pseudofusion, leading to suspicion of pacemaker malfunction (Fig. 1).