Clinical Images

Alpha-Loop for Permanent Pacemaker Implantation in Restrictive Cardiomyopathy

Yash Paul Sharma, MD;  Kewal Kanabar, MD;  Sagar Makode, MD;  Krishna Prasad, MD

Yash Paul Sharma, MD;  Kewal Kanabar, MD;  Sagar Makode, MD;  Krishna Prasad, MD

J INVASIVE CARDIOL 2020;32(4):E98.

Key words: cardiac imaging, high-grade atrioventricular block, permanent pacemaker implantation

A 22-year-old male patient, diagnosed with non-familial idiopathic restrictive cardiomyopathy on the basis of symptoms, transthoracic echocardiogram, cardiac magnetic resonance imaging, cardiac catheterization, and genetic testing, presented with recurrent episodes of syncope. A 24-hour ambulatory monitoring revealed high-grade atrioventricular block. A dual-chamber permanent pacemaker implantation with DDDR pacing was planned. After uneventful right axillary venous punctures, several attempts to place an active fixation ventricular lead (Biotronik) were unsuccessful (Figures 1B and 1C) as the lead failed to prolapse across the tricuspid valve due to the hugely dilated right atrium and a small right ventricle (Figure 1A). An alpha loop was made in the right atrium to negotiate the tricuspid valve and enhance the lead stability (Figure 1D). After the confirmation of appropriate thresholds and impedance, the lead was screwed at the ventricular apex. The positioning of the right atrial lead was uneventful. A postprocedure on-table fluoroscopy (Figures 1E and 1F) and x-ray after 24 hours depicted the alpha loop and appropriate lead position. At 3-month follow-up, the patient was symptomatically better and device interrogation showed stable lead parameters. High-grade and complete heart block commonly occurs in adult patients with restrictive cardiomyopathy, and requires aggressive monitoring and prophylactic pacemaker/defibrillator. There are limited data on the procedural details of pacemaker implantation in this group of patients, and as reported, special maneuvers may be required for ventricular lead placement.

From the Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted July 8, 2019.

Address for correspondence: Yash Paul Sharma, MD, DM, Professor & Head, Department of Cardiology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh-160012, India. Email: