Epicardial cardiac rhythm devices for dialysis patients: minimizing the risk of infection and preserving central veins.

Transvenous leads of cardiac rhythm devices (CRDs) are known to cause central stenosis and are vulnerable to contamination during hemodialysis access-related bacteremia. In this retrospective study, nine consecutive chronic hemodialysis patients with transvenous CRD infection due to dialysis access-related bacteremia and recurrent central stenosis are presented. Four patients with tunneled hemodialysis catheters (TDCs) and three with arteriovenous grafts experienced access-related bacteremia that spread to the transvenous CRD. Two patients required repeated angioplasty procedures (less than 3 months apart) for central venous stenosis. Transvenous CRD was removed and replaced with an epicardial system in all. One patient with TDC switched to peritoneal dialysis and did not experience infection of the epicardial system despite two episodes of peritonitis. The remaining TDC (n=3) and graft patients (n=3) received a new TDC after the resolution of bacteremia. While all six experienced on average 1.5 episodes of catheter-related bacteremia (average follow-up = 14.5 months), none developed infection of the epicardial system. The patients with central stenosis have required only one angioplasty each for the past 8 and 6 months. To the best of our knowledge this is the first study to suggest that an epicardial approach might be a preferred method over transvenous leads for chronic hemodialysis patients.

High brachial artery bifurcation: clinical considerations and practical implications for an arteriovenous access.

High brachial artery bifurcation (HiBAB) is not a rare occurrence. Recent data have emphasized that HiBAB can have major clinical implications including high failure rate and decreased functional patency of an arteriovenous (AV) fistula. In this retrospective study, we investigated the incidence of HiBAB. Patients with advanced chronic kidney disease and end-stage renal disease on chronic hemodialysis undergoing preoperative vascular mapping for the creation of an AV access were included in this analysis. Ultrasound examination was used to map the arteries of the upper extremities. Four hundred and eighty-one arms in 340 patients were examined (right arm = 181, left arm = 300). Sixty-nine of the 481 (12.3%) demonstrated HiBAB. The internal diameter of the radial and ulnar arteries measured at the elbow region was found to be 2.9 ± 0.8 and 3.6 ± 1.0 mm, respectively (p = 0.0001). There were no statistically significant differences in terms of race, gender, and right versus left arms regarding the incidence of HiBAB. As HiBAB can be present in a significant number of patients and have an impact on the AV access, its presence should be evaluated during vascular mapping prior to an AV access creation.

Stent graft infection and protrusion through the skin: clinical considerations and potential medico-legal ramifications.

Stent grafts have been used for a variety of arteriovenous access associated issues. This article presents three cases of stent graft infection and a case of protruded metal piece of the stent graft through the skin. All four required surgical treatment and three cases required a tunneled dialysis catheter to provide long-term dialysis therapy. This report highlights that stent graft problems can occur that may result in loss of the access. Additionally, strut protrusion can pose a medical hazard to those performing preparation and cannulation of the arteriovenous access.

Remodeling of the mitral valve using radiofrequency energy: review of a new treatment modality for mitral regurgitation.

Mitral regurgitation (MR) is a common valvular pathology with significant morbidity and mortality implications. Mechanical treatment of this condition is more effective than medical treatment and surgical correction has traditionally been the mechanical method of choice. Following major advances and wide acceptance of percutaneous interventions for coronary artery diseases, the field of valvular heart disease became an attractive target for transcatheter treatment modalities. Significant steps have been achieved in the field of percutaneous treatment of mitral stenosis as well as aortic stenosis, and lately, mitral regurgitation has been the focus of interest for many investigators looking for transcatheter solutions. Percutaneous edge-to-edge techniques and annuloplasty are innovative but have many disadvantages including the inability to reintervene and leaving a foreign body behind, respectively. Since the mitral and tricuspid annuli have dense collagen, a treatment modality targeting that collagen is logical. Observing the thermal effect on collagen, which causes conformational changes and shrinkage, radiofrequency energy was tested to evaluate its effect on the collagen-rich structure that is the mitral valve annulus. The potential of shrinking the mitral annulus by applying direct thermal source could be a promising modality for the treatment of mitral regurgitation with potential open and percutaneous applications. This paper presents an overview of the recent advances in transcatheter treatment of mitral regurgitation focusing on a new treatment modality that aims at reducing the mitral valve annulus diameter through the direct application of thermal energy using a radiofrequency energy probe.