Cor Vasa 2025, 67(Suppl.3):31-36 | DOI: 10.33678/cor.2025.025

Epicardial Pacing Lead Implantation in Complete Heart Block as a Manifestation of Cardiac Mass: Case Report

Cornelia Ghea, Rerdin Julario, Budi Baktijasa Dharmadjati, Ragil Nur Rosyadi, Muhammad Rafdi Amadis, Ruth Irena Gunadi, Makhyan Jibril Al-Farabi

Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University, Dr. Soetomo General Hospital, Surabaya, Indonesia

Background: Atrioventricular (AV) conduction abnormalities can manifest with a wide spectrum of clinical presentations, ranging from asymptomatic cases to severe bradycardia-associated symptoms. While transvenous pacemaker implantation is widely regarded for its minimal invasiveness and clinical efficacy, this approach may be contraindicated in patients with anatomical anomalies or significant comorbidities. This report presents a rare case of an intracardiac mass obstructing the AV conduction pathway, where the conventional transvenous approach was not feasible. In such complex scenarios, epicardial pacemaker implantation emerges as the most suitable and effective intervention. Case description: A 48-year-old male presented with a six-month history of progressive weight loss and dyspnea, with symptom exacerbation over the preceding week. Transthoracic echocardiography revealed an intracardiac mass involving the right atrium, interatrial septum, and left atrium. Subsequent computed tomography (CT) imaging confirmed a malignant, enhancing solid mass occupying the interatrial septum, with extensions into the right atrium, left atrium, right pulmonary vein, and inferior vena cava, suggestive of a primary cardiac tumor. The mass exhibited irregular borders and measured approximately 6.0 × 6.0 × 8.2 cm. This mass disrupted the AV conduction pathway, leading to complete heart block and resulting in hemodynamic instability. Given the mass's size and its anatomical position within the right atrium, transvenous pacemaker lead placement was deemed unfeasible due to the potential risk of lead misplacement, tumor perforation, or embolization. Thus, surgical epicardial pacemaker implantation was performed. The procedure was completed successfully without complications, resulting in significant improvement in the patient's hemodynamic status. Postoperative recovery was uneventful, and the patient was discharged five days after surgery with marked clinical improvement.

Discussion: This case underscores a rare and complex presentation of a large intracardiac mass causing systemic symptoms such as weight loss and dyspnea, progressively worsening over six months. The involvement of multiple cardiac structures, including the right atrium, interatrial septum, and left atrium, posed significant diagnostic and therapeutic challenges. The mass's extensive involvement of cardiac and venous structures rendered transvenous pacemaker implantation impractical and potentially hazardous. In this context, epicardial lead placement provided a safe and effective alternative, circumventing the risks associated with transvenous approaches. This case highlights the critical role of epicardial pacemaker implantation in managing patients with obstructive cardiac masses, emphasizing its efficacy and safety in scenarios where conventional transvenous methods are not viable.

Conclusion: Epicardial lead placement should be considered when primary transvenous lead placement cannot be performed in challenging cases, such as in the case where a cardiac mass obstructs the AV conducting pathway.

Keywords: Cardiac mass obstruction, Complete atrioventricular block, Epicardial pacemaker, Intracardiac mass

Received: December 18, 2024; Revised: February 5, 2025; Accepted: February 8, 2025; Prepublished online: June 2, 2012; Published: September 1, 2025  Show citation