27/09/2024
āļøCASE OF THE WEEKāļø
Pacemaker associated cranial caval syndrome
Video image left before stent, right after stent. Image 1 Chester at home
Images 2-3 Chester in the clinic
āļøChesterās Storyāļø
Chester was brought in as an emergency after he had been coughing and his vets identified fluid in his chest (pleural effusion). Three years previously, Chester had a pacemaker fitted to manage an electrical conduction problem in his heart.
On admit to the SATH we checked Chesterās pacemaker and confirmed that this was working appropriately. A heart scan (echocardiogram) showed faster than expected blood flow passing from one of his major veins (the cranial vena cava) into his right atrium (heart chamber), raising the suspicion of an obstruction to normal flow.
We performed an angiogram of Chesterās heart, which is where contrast is injected in to his vein which then shows up on a moving X-ray. This showed a narrowing (stenosis) of the cranial vena cava at its junction with the right atrium, causing obstruction to flow. The obstruction was deemed secondary to the presence of the pacemaker lead passing through this region. The build up of pressure behind the obstruction was the suspected cause for the pleural effusion and Chesterās abnormal breathing.
This pacemaker lead complication has been reported only 5 times in dogs and is a rare complication in humans following pacemaker implantation.
We decided to position a stent (a mesh tube) at the level of the obstruction to āopen it upā and allow blood to flow more freely. This procedure to manage this pacemaker related complication has never been done in veterinary medicine to our knowledge.
Chester went home the following day and following his check up a month later he has returned to his normal bouncy self. Our heart scan showed that normal blood flow has resumed and we hope Chester will continue to feel better
āļøChesterās Story by his mumāļø
Chesterās always been full of energy, the kind of dog who lights up the room just by being his wild, quirky self. He loves hugs and snuggles and expects plenty of attention from pretty much everyone. Yet at just five years old, heās required more veterinary visits than most dogs see in a lifetime.
3 years after his pacemaker implantation he started slowing down again. At first, we chalked it up to him getting older, but his breathing seemed different, faster, like something was wrong. A visit to our local vets revealed a devastating finding - 800ml of fluid had built up in his chest cavity! They were concerned it could be heart failure or even cancer. We were devastated, facing the unthinkable, again.
Chester was referred to the cardiology team at Liverpool small animal teaching hospital (SATH), the only place that could see him quickly. It was a long 4.5-hour drive, and by the time we got there, we were exhausted, emotionally drained, and scared out of our minds. But the moment we walked in the staff made us feel at ease. They took care of everything, from insurance to offering us phone chargers. Even the small things like appropriate and clean toilet facilities, a water fountain and vending machines were easily accessible.
Then the dreaded anticipated consultation. Apologies I can't remember the names of the team we saw on the first day but they were incredible. They were very welcoming, empathetic and thorough. Chester was admitted for tests which sadly revealed no clear answers; fluid was beginning to build up in his chest cavity again. Despite the bleak outlook the team wasnāt ready to give up. They suggested one more test, and given how far we were from home, we agreed to leave him overnight. That evening, we got a callāthe test showed something incredibly rare: a severe narrowing of the vessel where Chesterās pacemaker lead was. Itās a complication thatās almost unheard of in dogs, so unusual that many veterinarians never encounter it in their entire careers. The team however was determined. They devised a plan, and despite the anxiety that comes with such uncertainty, we felt a deep trust in them. Losing Chester was not an option, so we gave our consent.
The next morning, we met with Chesterās new cardiologist, Will Davies. From the moment Will introduced himself we knew Chester was in the best possible hands. To our relief the surgery was a success. The team at Liverpool made sure we were never alone, offering tissues for our tears and answering every question with compassion and clarity. They cared for Chester as if he were their own, and that made all the difference.
A month later, Chester had his post-op checkup - once again at Liverpool, where we felt a strong connection to the team who had saved his life. The stent was still in place with no further complications. Our boy is now back home, back to his wild, loving, quirky self.
Itās hard to put into words how thankful we are to Will and everyone at SATH. Chester isnāt just a pet, heās our family, our third child. And in the darkest of times, they gave us our boy back, and for that, weāll be forever grateful.
