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Archives of cardiovascular diseases
Volume 105, n° 4
pages 256-257 (avril 2012)
Doi : 10.1016/j.acvd.2011.04.012
Received : 29 December 2010 ;  accepted : 8 April 2011
Right phrenic stimulation due to defibrillator implantation: A rare cause
Stimulation diaphragmatique droite suite à l’implantation d’un défibrillateur : une étiologie rare
 

François Roubille a, , c , François Massin a, b, Jean-Marc Davy a, b
a Département de cardiologie et maladies vasculaires, hôpital Arnaud de Villeneuve, CHRU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier, France 
b U1046, Inserm, CHU Arnaud de Villeneuve, université Montpellier 1 et 2, 371, avenue du Doyen-Gaston-Giraud, bâtiment Inserm Crastes-de-Paulet, 34295 Montpellier, France 
c CNRS, UMR-5203, Inserm, U661, institut de génomique fonctionnelle, universités de Montpellier 1 et 2, 141, rue de La-Cardonille, 34396 Montpellier cedex, France 

Corresponding author.

Keywords : Phrenic stimulation, Defibrillator, Lead displacement

Mots clés : Stimulation diaphragmatique, Défibrillateur, Déplacement de sonde


We report the case of a 68-year-old man admitted for acute heart failure with troponin I elevation. His medical history was mainly pulmonary adenocarcinoma treated with surgery (left superior lobectomy) a few months previously. He was also known to have had a coronary stenosis on the little branch of the left descending coronary artery on a coronary angiogram 3 years earlier.

After medical treatment, a new coronary examination revealed no additional lesions on the coronary tree. During hospitalization, ventricular tachycardia was observed. His left ventricular ejection fraction had been already evaluated at 30% despite adapted treatment. An automatic implanted cardiac defibrillator (ICD) was then required. Implantation of a single-chamber ICD was performed without any problem, with a single-coil defibrillator lead screwed at the apex of the right ventricle (Figure 1, Panel A). Four days after implantation, the patient presented with diaphragmatic stimulation. Lead displacement was suspected, as the patient had not complied with the recommended rest. Surprisingly, there were right and not left diaphragmatic contractions. The lead had moved towards the superior vena cava (Figure 1, Panels B and C). As shown in the schematic drawing (Figure 1, Panel D), the lead could have moved close to the right phrenic nerve, explaining this rare complication. Unfortunately, this tight nerve structure could not be seen on a computed tomography scan.



Figure 1


Figure 1. 

Chest X-ray (A) before lead displacement and (B, C) after lead displacement, and (D) proposed explanation.

Zoom

Lead displacement after pacemaker or ICD implantation is not infrequent. Left diaphragmatic contraction is usually due to a lead being over its target. However, right diaphragmatic contractions are rarely reported.


Acknowledgements

The authors acknowledge Dr Antoine Micheau, MD (Cardiovascular Imagery Department, Arnaud de Villeneuve University Hospital, Montpellier, France), for providing the image, which is available at www.imaios.com/. F. Roubille and F. Massin contributed equally to this work.



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