Letter to the Editor Implantation of a defibrillator in a pregnant woman with hypertrophic cardiomyopathy under echocardiographic guidance: A case report Skevos Sideris a, ⁎ ,1 , Alexandros Kasiakogias a,1 , Constantina Aggeli b,1 , Kostas Manakos a,1 , George Trantalis a,1 , Konstantinos Gatzoulis b,1 , Dimitrios Tousoulis b,1 , Ioannis Kallikazaros a,1 a State Cardiology Division, Hippokration Hospital, Athens, Greece b First Cardiology Clinic, University of Athens, Hippokation Hospital, Athens, Greece article info Article history: Received 6 November 2014 Accepted 8 November 2014 Available online 11 November 2014 Keywords: Electronic device Ventricular tachycardia Pregnancy Hypertrophic cardiomyopathy (HCM) is a predominantly inherited disease with an estimated annual incidence of cardiac mortality of 1– 2% [1]. The presence of episodes of non-sustained ventricular tachycar- dia (NSVT) is considered as an independent predictor of sudden cardiac death. During pregnancy, episodes of arrhythmias may become more often while implantation of an implantable cardioverter-defibrillator (ICD) may be needed. Concerns of performing such a procedure under fluoroscopic guidance during pregnancy have been variably posed. The purpose of this report is to describe the case of a pregnant patient with hypertrophic cardiomyopathy in whom an ICD with the guidance of transesophageal echocardiography was implanted. A 26 year old woman at 24 weeks of gestation referred to our clinic because of increasing episodes of palpitations. The patient had been di- agnosed with HCM at the age of 13 years, had an ejection fraction over 60% and did not report any symptoms of heart failure. She was a high risk patient as she had a positive family history of sudden cardiac death, an abnormal response to exercise and recorded episodes of NSVT. Implantation of an ICD had been consistently advised but the pa- tient had refused due to the invasive nature of the treatment. At the age of 24 years she became pregnant for the first time and was closely mon- itored by her cardiologist. That pregnancy was completed without com- plications and no arrhythmias were recorded during that time. After presentation at our clinic, the patient underwent several 24-hour ambu- latory rhythm monitorings that confirmed multiple episodes of NSVT with an increasing frequency. The estimated risk of sudden cardiac death was more than 10% [2]. Accordingly, after a thorough consultation when the risks for the patient and the fetus were again clearly present- ed, the patient eventually accepted to undergo ICD implantation. The patient was informed about the possible dangers of fluoroscopy in the setting of pregnancy, and the alternative of transesophageal echocardi- ography during the procedure was decided to be followed. Implantation of the ICD was performed under general anesthesia by using medications which would not adversely affect the fetus. Midazo- lam 5 mg and Propofol 100 mg were introduced once for induction of anesthesia while a Propofol infusion at the rate of 60 mg/h was applied for maintenance. An ICD pocket was formed in the region of the left pec- toral muscle and a defibrillator lead was inserted into the left subclavian vein by percutaneous puncture and then advanced through the superior vena cava to the right heart chambers. Transesophageal ultrasound (Phillips iE33, 2.5 MHz s5-1 transducer) was used to guide implantation of the lead in the right ventricle. By ap- plying the four chamber view (Fig. 1), the transgastric view (Figs. 2 and 3) and the short axis view at the level of the aortic valve, the electrode was inserted in the right ventricular apex. At the final positioning, the ICD lead tip was clearly visualized in place and there was no need to perform further visualization with fluoroscopy. Appropriate parameters regarding impedance, sensing, pacing threshold and defibrillation threshold were then tested. The duration of the procedure was approx- imately 65 min. The post-operative check did not identify any pericardi- al effusion or other intraoperative or postoperative complications. The patient was discharged after two days of hospitalization. In a 6 month follow-up visit, no episodes of ventricular tachycardia or defibrillator discharge were recorded during ICD interrogation. A chest X-ray was also performed where the right position of the elec- trode was clearly observed. As echocardiography is now a widely available diagnostic method, and genetic as well as family screening are being more often performed, an increasing number of women of child-bearing potential are diagnosed with HCM. In the pregnant patient, apart from the possible development or progression of symptoms or clinical heart failure that are attributed partly to the hemodynamic changes during this period, a risk of sudden cardiac death is also to be considered [3]. A previous out-of-hospital ar- rest, non-sustained or sustained ventricular tachycardia, family history International Journal of Cardiology 179 (2015) 323–324 ⁎ Corresponding author at: State Cardiology Division, Hippokration Hospital, 114 Vasilissis Sofias St., 115 28 Athens, Greece. E-mail address: skevos1@otenet.gr (S. Sideris). 1 All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. http://dx.doi.org/10.1016/j.ijcard.2014.11.091 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard