Transvenous Lead Extraction for Cardiac Implantable Electronic Devices.

This article illustrates the important role that lead extraction plays in the management of patients with cardiac implantable electronic devices. Individualized care of the patient is paramount when considering lead management strategies. The critical care nurse must have a comprehensive understanding of the indications, procedural considerations, and preprocedural and postprocedural care for patients undergoing lead extraction procedures, thereby improving patient safety and maximizing patient outcomes.

Quality of life with atrial fibrillation: do the spouses suffer as much as the patients?

BACKGROUND: Atrial fibrillation (AF) can have a significant effect on quality of life (QoL). Other chronic diseases are known to not only affect the patient but to also impact the QoL of persons living with them. Scant data exist on the QoL effect of AF in spouses/significant others (SOs). METHODS: An anonymous survey regarding the perceived effect of AF on QoL was designed and distributed to both patients and spouses/SOs during an educational symposium about living with AF. Both were asked to fill out the survey independently according to how their life was affected by either their AF or their partner's AF. Questions included demographics, perceived impairment of overall QoL on a 5-point scale, as well as effect on subcategories of QoL, namely daily activity, work life, sex life, physical activity, psychological well-being, and social activity. RESULTS: Five hundred and sixty-eight subjects completed the survey of which 411 were AF patients and 129 were spouses/SOs. The perceived effect of AF on overall QoL (N = 527) was similar in patients and spouses (AF patients: mild 42.0%, moderate 26.0%, severe 32.0% vs. spouses: 44.1%, 25.2%, 31.7%; P = 0.917). This result did not change when adjusted for age and gender. There was also no significant difference between patients and spouses in the subcategories of QoL with the exception of the perceived effect on work life, which was greater in patients than spouses (P = 0.041). CONCLUSIONS: AF has a similar perceived impact on the QoL of spouses and patients. QoL improvement strategies for patients with AF should take spouses into account.

Practical considerations for remote monitoring.

The ability to remotely monitor important physiologic parameters will dramatically change how we care for patients. We are on the threshold of this era with currently available implantable cardiac devices. Current devices provide a plethora of important arrhythmia- and heart failure-related information. Dealing with this "flood" of information and a new "work flow" can be a challenge. Careful planning can reduce the stress and improve patient care. Electrophysiologists and heart failure practitioners are on the cutting edge of this revolution in health care and therefore are required to deal with the challenges this technology brings. However, they also have the opportunity to shape the future of heart failure management.

Quality of life issues in patients with implantable cardioverter defibrillators: driving, occupation, and recreation.

In the United States over 350,000 individuals die annually from sudden cardiac arrest due to ventricular tachyarrhythmias. Numerous large-scale clinical trials have consistently demonstrated that implantable cardioverter defibrillators (ICDs) reduce mortality among appropriately selected patients who have survived an episode of potentially life-threatening ventricular arrhythmia (secondary prevention) or are at risk for ventricular arrhythmia (primary prevention). Despite the demonstrated success of the ICD, many patients often experience unique physical, emotional, and psychosocial needs that can directly impact their overall quality of life (QOL). The most common psychological disturbances following ICD implantation include stress, anxiety, depression, or fear, typical of any chronic illness. Additionally, ICDs impose unique emotional pressures relating to altered body image, painful shocks, and the possibility of hardware failure. The random nature of shocks commonly induces feelings of isolation and powerlessness and the experience of shocks is directly linked to poor QOL outcomes. Lifestyle changes, such as restrictions on driving, eligibility for employment, marital and social relationships, sexual intimacy, or participation in recreational activities can significantly affect the ICD patient's psychological and emotional well-being. The purpose of this article is to review the QOL data from several large-scale clinical trials of ICD patients as well as to examine specific QOL issues such as driving restrictions, occupational, and recreational concerns.

Randomized pilot study of a new atrial-based minimal ventricular pacing mode in dual-chamber implantable cardioverter-defibrillators.

OBJECTIVE: We hypothesized that a new minimal ventricular pacing mode (MVP) that provides AAI/R pacing with ventricular monitoring and back-up DDD/R pacing as needed during AV block (AVB) would significantly reduce cumulative percent ventricular pacing compared to DDD/R. BACKGROUND: Conventional DDD/R mode often results in high cumulative percent ventricular pacing that may adversely affect ventricular function and increase risk of heart failure and atrial fibrillation. METHODS: MVP was made operational in 30 patients with DDD/R implantable cardioverter-defibrillators (ICDs) and no history of AVB. Patients were randomized to one week each in DDD/R and MVP. Holter monitor recordings (ECG, intracardiac electrograms, and event markers) and device diagnostics were analyzed for cumulative % atrial paced (Cum%AP), cumulative percent ventricular pacing, and frequency and duration of DDD/R pacing back-up. Diaries were used to report symptoms. RESULTS: Age of the study population was 61 years +/- 12 years and 83% were male. Baseline PR interval was 204 ms +/- 32 ms and programmed AV intervals (DDD/R) were 200 ms +/- 50 ms (paced)/167 ms +/- 54 ms (sensed). Cum%AP was similar between MVP and DDD/R (47.9 +/- 37 vs 46.3 +/- 36). Cumulative percent ventricular pacing was significantly lower in MVP vs DDD/R (3.79 +/- 16.3 vs 80.6 +/- 33.8, P < .0001). Back-up DDD/R pacing during MVP operation due to transient AVB occurred in 10% of patients (9.3 +/- 7.4 [range 1-15] episodes/patient-day, duration 39.7 minutes +/- 156 minutes). Fifteen percent of AV intervals during MVP operation exceeded 300 ms. No significant symptoms were reported during MVP operation. CONCLUSIONS: MVP dramatically reduced cumulative percent ventricular pacing compared to DDD/R while maintaining AV synchrony and providing sensor-modulated atrial pacing support. Intermittent oscillations between MVP and DDD/R during transient AV block appeared safe and well tolerated.

Upgrade of permanent pacemakers and single chamber implantable cardioverter defibrillators to pectoral dual chamber implantable cardioverter defibrillators: indications, surgical approach, and long-term clinical results.

The aim of this study was to describe the indications for upgrade of pacemakers (PMs) or single chamber (VVIR) ICDs to dual chamber (DDDR) ICDs, surgical approach, hardware hybridization, and clinical outcome. Patients with preexisting PMs or VVIR ICDs may develop indications for ICD therapy or dual chamber pacing, respectively, that can be served by DDDR ICDs that incorporate preexisting transvenous leads. Fifty-seven patients underwent upgrade from PMs (29/57) or VVIR ICDs (28/57) to pectoral DDDR ICDs. Preexisting transvenous atrial and/or ventricular leads suitable for continued use were incorporated into new DDDR ICDs in 88.5% and 100% of PM and VVIR ICD upgrades, respectively. Acceptable DFTs were achieved in 56 (98.2%) of 57 patients. Appropriate VT/VF therapies were registered among 33.3% of patients during follow-up. No shocks due to lead noise were observed in any patient with hybridized transvenous leads. Atrial far-field R wave (FFRW) oversensing occurred in 24% of DDDR ICD systems incorporating a preexisting atrial lead. FFRW was overcome by programming reduced atrial sensitivity without interfering with the normal ICD system performance in all instances. Upgrade of PMs and VVIR ICDs to pectoral DDDR ICDs is safe and technically feasible in most patients. Preexisting transvenous leads can be successfully incorporated into new DDDR ICDs, simplifying the surgical procedure, minimizing transvenous hardware, and eliminating the possibility of hazardous pacemaker-ICD interactions.