Transcaval access for the emergency delivery of 5.0 liters per minute mechanical circulatory support in cardiogenic shock.

OBJECTIVES: The purpose of this study was to describe the feasibility and early outcomes of transcaval access for delivery of emergency mechanical circulatory support (MCS) in cardiogenic shock. BACKGROUND: Vascular access for implantation of MCS in patients with cardiogenic shock is often challenging due to peripheral arterial disease and vasoconstriction. Transcaval delivery of MCS may be an alternative. We describe a series of patients we implanted an Impella 5.0 device, on-table without CT planning, through a percutaneous transcaval access route. METHODS: Ten patients with progressive or refractory cardiogenic shock underwent Impella 5.0 implantation via transcaval access. Demographic, clinical and procedural variables and in-hospital outcomes were collected. RESULTS: All ten underwent emergency implantation of the 7 mm diameter Impella 5.0 device via transcaval access. Six were women, with median age of 55.5 years (range, 29-69). Cardiogenic shock was attributed to idiopathic nonischemic cardiomyopathy (n = 4), myocarditis (n = 2), ischemic cardiomyopathy (n = 2), heart transplant rejection (n = 1), and unknown etiology (n = 1). Median duration of support was 92.1 hr (range, 21.2-165.4). Seven (70%) survived to device explant, with six (60%) surviving to access port closure and discharge. Among survivors, five recovered heart function and one received destination therapy left ventricular assist device. CONCLUSIONS: Transcaval access is feasible for emergency nonsurgical implantation of the Impella 5.0 device in cardiogenic shock with small or diseased iliofemoral arteries. This allows early institution of higher-flow MCS than conventional femoral artery implantation of the 3.5 L Impella CP device, and enables a bridge-to-recovery or bridge-to-destination strategy.

Dual-chamber pacing using a hybrid transvenous and leadless pacing approach.

An elderly gentleman with a dual-chamber pacemaker presented to our institution with symptoms of symptomatic bradycardia and high-grade atrioventricular (AV) block. Device interrogation revealed failure to capture in the right ventricle (RV) lead with bipolar pacing, high RV pacing threshold with unipolar pacing, and high impedance suggesting lead fracture. The atrial lead function was normal. Given his advanced age, gait instability, and dementia, the decision was made to proceed with Micra AV pacemaker implantation, while programming his dual-chamber pacemaker to AAIR mode, thus maintaining AV synchrony by tracking paced atrial impulses and providing ventricular pacing.

Lifestyle Therapy for the Management of Atrial Fibrillation.

Atrial fibrillation (AF) is a common arrhythmia associated with increased risk of morbidity and mortality. There is evidence that lifestyle interventions may serve as complementary treatments to reduce AF burden. The objective of this review was to summarize the efficacy of lifestyle interventions for the management of AF. Studies which included patients with systolic heart failure (ejection fraction ≤40%), and those limited to an examination of vigorous physical activity were excluded from our search. Studies were identified through a search of the following databases: MEDLINE, EMBASE, CINAHIL, and PubMed, run from inception through August 2016. All studies were graded for quality using the Oxford Centre for Evidence-based Medicine recommendations. Meta-analyses of the studies were not performed due to the heterogeneity of the studies. From a total of 1,811 publications, 10 articles were identified and included. Selected publications included 1 study on yoga, 2 studies on acupuncture, 3 studies that examined weight loss programs, and 4 studies that evaluated the impact of moderate physical activity. Yoga was associated with less symptomatic AF episodes and improved quality of life. Acupuncture was associated with reduced AF occurrence in patients with persistent and paroxysmal AF. Weight loss was associated with a significant reduction AF burden and symptoms. Moderate exercise resulted in greater arrhythmia free survival and a mean reduction in AF burden. In conclusion, evidence exists to suggest that yoga, weight loss, and moderate exercise are associated with reductions in AF burden and symptoms. Evidence is greatest for weight loss and moderate exercise.