Troubleshooting a pacemaker output failure: A case report.

The indications for permanent pacemaker (PM) implantation are rapidly expanding resulting in an increasing number of patients receiving PMs. Such PM patients need a good quality medical care. The follow up of these patients and their devices places a heavy burden on cardiology clinics with significant implications for the already stretched hospital resources. This has resulted in increased reliance on the options of automatic and continuous adjustments that the modern PMs offer. One such feature is the 'automatic sensitivity function' or 'AutoSense' which when turned on, monitors the amplitude of the intrinsic R wave and P wave and continuously adjusts the sensitivity, as a function of measured amplitudes, to avoid undersensing or oversensing. We are describing a case in which oversensing occurred even though the pacemaker's 'AutoSense' function was kept on and hence was misunderstood to be a lead problem and was advised ventricular lead replacement.

A Case of Delayed Non-infective Cystic Swelling at the Pacemaker Pocket Site.

With the expanding indications for device implantation, the number of cardiac implantable electrophysiological devices (CIED) being implanted has increased drastically. In a patient presenting with swelling at the pacemaker pocket site several years after the implantation, an infective collection due to device seeding by blood-borne microorganisms is the first diagnosis that is commonly considered. Once the diagnosis of CIED infection is made, complete removal of all the hardware is usually performed. We are describing an unusual case of a 70-year-old male with a permanent pacemaker implanted 8 years ago, who came with insidiously growing swelling at the pacemaker pocket site. He was afebrile. On examination, the swelling was soft and mobile and had no signs of inflammation. Blood cultures after 3 days of incubation did not show any growth. Ultrasound examination revealed a cystic swelling with thick septations. CT showed features suggestive of a seroma measuring 6.7 x 9.4 x 11 cm. Antibiotics were given empirically. A total of 100ml of serosanguinous fluid was drained and the pocket wall was excised. Pulse Generator (PG) was placed back into the pocket and the leads were reconnected. Culture and sensitivity testing of the drained fluid and excised tissue did not show any growth and microscopy revealed no abnormal cells. The patient was followed up on a regular basis for six months. There was no recurrence of swelling at the pacemaker site. Even though an infective abscess is the commonest cause of pacemaker pocket swelling, a non-infective swelling, however rare, must be considered as a non-infective swelling does not require complete removal of the hardware.

Thrombus-in-transit involving all four chambers of the heart in a patient presenting with acute pulmonary embolism.

A 43-year-old male with history of pulmonary embolism defaulted on anti-coagulation and presented with recurrent massive pulmonary embolism. Echocardiography revealed a serpiginous freely floating right atrial thrombus prolapsing through the tricuspid valve into the right ventricle. Thrombus was also seen crossing the interatrial septum into the left atrium and prolapsing into the left ventricle. Right-sided chambers were dilated with right ventricular dysfunction. Left ventricle was functioning normally. After evaluation by the pulmonary embolism response team, thrombolysis was done with alteplase which resulted in dramatic improvement of the symptoms and complete resolution of the intra-cardiac thrombus. Regular follow-up and counselling are advised henceforth to ensure drug compliance. Learning objectives: 1.In patients with right heart thrombus crossing an intracardiac communication into left-sided chambers carries an additional risk.2.Pulmonary embolism response team is essential for clinical decision-making.3.Echocardiography plays a critical role to diagnose and assess the extent of the intracardiac thrombus and ventricular function.4.On computed tomography, right ventricular (RV)/left ventricular diameter ratio of >0.9 and the presence of septal bowing signifies the presence of RV strain.5.Adequate counselling ensuring patient compliance and regular follow up is of utmost importance.

Personalized allocation of acetylsalicylic acid therapy for secondary prevention of coronary artery disease.

Background: A single-daily dose of 75 mg of acetylsalicylic acid inhibits 100% of thromboxane-B2 synthesis within 30-60 min. Thromboxane-B2 synthesis then recovers slowly as new platelets are released from the bone marrow. Normally, only 10% of the platelets are replaced daily by new platelets entering circulation. Hence, 24 h after a dose of acetylsalicylic acid, thromboxane-B2 synthesis is still suppressed by more than 90%. Hence, there is an adequate anti-platelet effect even after 24 h of acetylsalicylic acid intake. However, some patients treated with once-daily acetylsalicylic acid may have an incomplete 24-h suppression of thromboxane-B2 synthesis due to increased platelet turnover. The response could be improved in such patients by twice-daily acetylsalicylic acid administration. This study aimed to identify such a group of patients who would benefit from a twice-daily dose of acetylsalicylic acid. Materials and methods: Serum thromboxane-B2 levels were measured in 79 patients with coronary artery disease receiving 75 mg of acetylsalicylic acid for secondary prophylaxis. Serum levels of thromboxane-B2 were measured after 4 and 24 h of acetylsalicylic acid intake. Patients were then classified into three groups: steady suppression group (serum thromboxane B2 is adequately suppressed at 4 and 24 h), i.e., adequate response to acetylsalicylic acid; fast recovery group (more than 10% rise in serum thromboxane-B2 levels at 24-h when compared to at 4-h) and non-responders (serum thromboxane-B2 levels of >3,100 pg/ml after 4 h of acetylsalicylic acid intake). Patients in the fast recovery group were given twice-daily acetylsalicylic acid and thromboxane-B2 levels were re-measured. Results: A total of 20 patients (24.3%) had steady suppression of thromboxane-B2 and 11 patients (13.9%) belonged to the fast recovery group, i.e., thromboxane-B2 levels were adequately suppressed at 4 h but had recovered by more than 10% at 24 h; which was adequately suppressed by twice-daily acetylsalicylic acid (p 0.004). A total of 48 patients (60.8%) were non-responders. Conclusion: Twice-daily acetylsalicylic acid may be beneficial if serum thromboxane-B2 levels at 4 h are <3,100 and >3,100 pg/ml at 24 h. If thromboxane-B2 levels at 4 and 24 h is <3100 pg/ml but if there is a >10% rise in serum thromboxane B2 at 24 h as compared to that at 4 h, then twice-daily acetylsalicylic acid should be considered. However, if thromboxane-B2 at 4 and 24 h is >3,100 pg/ml consider switching over to a P2Y12 inhibitor.

An adult patient with previously undiagnosed sinus venosus atrial septal defect presenting with brain abscess: a case report.

BACKGROUND: Brain abscess is a common complication in children with cyanotic congenital heart disease. The presence of an underlying acyanotic congenital heart disease is usually not suspected in an adult patient presenting with brain abscess. CASE SUMMARY: A 51-year-old male patient with no known co-morbidities came with complaints of recent onset right lower limb weakness needing support while walking and on evaluation was found to have brain abscess. He underwent robotic endoscope assisted endoport excision of the brain abscess. Two-dimensional transthoracic echocardiography showed right atrial and right ventricular dilatation with mild low-pressure tricuspid regurgitation. Transoesophageal echocardiography (TOE) revealed sinus venosus atrial septal defect (ASD) with left-to-right shunt with the right upper pulmonary vein draining into superior vena cava. Contrast echocardiography revealed a small transient right-to-left shunt. He has been advised to undergo elective surgical closure of ASD with partial anomalous pulmonary venous connection repair. DISCUSSION: Right-to-left shunting in ASDs can occur in the early systole even in the absence of raised pressures in the right side of the heart, even when the predominant shunt is left to right, but the magnitude of such a shunt is small and transient and is easily missed. Contrast echocardiography and TOE should be done as a part of evaluation of patients presenting with brain abscess.