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We report the case of a 63-year-old woman presenting with progressive dyspnea of insidious onset culminating in severe central cyanosis. Conventional studies including M-mode echocardiography did not point to the diagnosis. At cardiac catheterization a large right atrial myxoma producing partial dynamic tricuspid obstruction was discovered along with an atrial septal defect with a right to left shunt. After successful surgical excision of the tumor and repair of the atrial septal defect, the patient has been totally relieved of her presenting symptoms.

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BOGNOLO. D.A., ET AL.: Two leads in one introducer technique for A-V sequential implontations. Thirty-six [36} consecutive patients underwent implantation of transvenous atrioventricuJar sequential pacing systems by inserting the atriaJ and ventricuJar Jeads together tJirough one §14 French subclavian introducer. This technique has been easy, reliable and free of complications. (PACE, Vol. 5, March-April, 1982} sequential pacing, atriai leads, ventricular Jeads, subcJavian introducers This report describes our experience with the use of a single #14 French subclavian introducer for simultaneous passage of alrial and ventricular leads in thirty-six consecutive A-V sequential pacemaker implants. Material, Method and Operative TechniqueThe patient is placed on the operating table modified with the use of a plywood board, as previously described.' in marked Trendelenburg position in order to distend the suhclavian vein and prevent air embolism. A standard infraclavicular incision is made, and the suhclavian vein is punctured hy standard technique through the incision using a thin-walled #18 gauge needle. A flexible pigtail guide wire is advanced through the needle into the superior vena cava. By steady forceful pushing, a #14 French introducer with a tapered vessel dilator is advanced into the subclavian vein. After removing the dilator and guide wire, the exposed portion of the peel-away introducer sheath is pinched in order to prevent blood loss and air aspiration. A tined atriai "J" lead with a polyurethane insulator (Medtronic* 6990U) is first introduced and advanced far enough to reach the right atrium; the second lead, a ventricular tined polyurethane lead (Medtronic 6972], is Address for reprints: Diego A.

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A new permanent lead has been developed for atrial epicardial use. Early clinical evaluation (26 human implants) following thorough canine studies indicates that the new lead is safe, effective, and reliable. Canine thresholds and P-wave amplitudes as a function of implant time are similar to those of transvenous atrial "J" leads. Human thresholds at implant are higher than canine, but change less with time. Implant and acute repositioning were found to be easy. There have been no lead-related operations.

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