Rapid Ventricular Pacing Facilitates Transarterial Embolization in Vein of Galen Malformations
Jesse G A Jones1, Austin Kane1
19968University of Alabama, Birmingham.
Insights
Rapid ventricular pacing (RVP) is a safe and effective technique for embolizing mural type vein of Galen malformation (mVOGM). This method reduces cardiac output, simplifying embolization procedures for pediatric patients with this congenital heart defect.
Area of Science:
- Pediatric Neurology
- Interventional Neuroradiology
- Cardiology
Background:
- Mural type vein of Galen malformation (mVOGM) involves congenital arteriovenous shunts causing heart failure in children.
- Embolizing mVOGM is complex, often needing adjunctive techniques like induced hypotension or balloon-assisted flow control.
- Rapid ventricular pacing (RVP) offers a potentially simpler alternative to current embolization strategies.
Purpose of the Study:
- To evaluate the safety and efficacy of RVP as an adjunctive technique for embolizing mVOGM.
- To assess the feasibility of RVP in reducing cardiac output during embolization procedures.
Main Methods:
- RVP was performed in five pediatric patients with mVOGM between April 2020 and July 2021.
- The technique involved right ventricular catheterization and temporary external pacing to induce RVP before embolization.
- RVP was used in ten procedures across twenty-six pedicles.
Main Results:
- Successful ventricular capture was achieved in all cases without inducing arrhythmias.
- Effective arterial pedicle casting adjacent to or traversing the fistulous point was accomplished in 9 out of 10 cases.
- No procedural complications were reported; one case required a coil basket for a stable cast.
Conclusions:
- This study presents the largest case series to date on RVP for mVOGM.
- RVP appears to be a safe, well-tolerated, and effective adjunctive technique for embolizing mVOGM.
- The method simplifies embolization, potentially reducing procedural time and complexity.
Abstract:
Background: Mural type vein of Galen malformation (mVOGM) is a congenital high flow arteriovenous shunt between choroidal arteries and the prosencephalic vein of Markowski leading to heart failure and hydrovenous disorder in children. Embolizing fistulous connections can be challenging and typically requires adjunctive techniques such as induced hypotension, balloon-assisted flow control, and creation of a coil basket. These maneuvers add time, complexity, and unpredictability. Rapid ventricular pacing (RVP) has been proposed as an alternative strategy with fewer drawbacks, but has not been well studied. The approach involves catheterizing the right ventricle with a pacing catheter connected to a temporary external pacemaker. Prior to embolization, RVP is initiated to lower cardiac output. Following embolization, pacing is discontinued, and the heart returns to sinus rhythm. Methods: We performed RVP in five mVOGM patients from 4/2020 through 7/2021. Accounting for multiple procedures, RVP was utilized in ten cases and twenty-six pedicles. Results: Ventricular capture was achieved in all instances and was well tolerated, without arrhythmia. Casting the arterial pedicle with liquid embolic immediately adjacent to, or traversing, the fistulous point was achieved in 9/10 cases. There were no procedural complications. In 1 case, creation of a coil basket in the venous pouch was required to achieve a stable arterial cast Conclusions: This report describes the largest case series utilizing RVP in mVOGM. The technique appears safe and well tolerated.
