Implantable cardioverter-defibrillator in the elderly: Predictors of appropriate interventions and mortality at 12-month follow-up.

BACKGROUND: The effectiveness of implantable cardioverter-defibrillator (ICD) in the elderly is uncertain, given their competing risk of nonarrhythmic death. Guidelines state that an ICD should be implanted if the expectation of survival is at least 1 year. However, survival is not easy to predict in elderly patients with severe cardiac disease. AIM: To assess 12-month survival after ICD implantation in patients aged ≥75 years, to identify predictors of 12-month mortality, and to evaluate the incidence of ICD therapy during follow-up. METHODS: We retrospectively analyzed all clinical, instrumental, and survival data of patients ≥75 years old who received an ICD in our center from 2000 to 2013. RESULTS: We included 127 patients (mean age 78 years). ICD was implanted for primary prevention in 61%. The 12-month survival rate was 87.4%. At both univariate and multivariate analyses, left ventricular ejection fraction (EF) ≤ 25%, and moderate to severe impaired renal function (IRF) independently predicted 12-month mortality that was as high as 45.5% in patients with both risk factors. During a median follow-up of 38 months, 30 patients (23.6%) received ≥1 appropriate ICD interventions, but only 3.1% of shocks occurred during the first year, and none in the subgroup of patients with EF ≤ 25% and IRF. CONCLUSION: Twelve-month survival in elderly patients after ICD implantation is good and the indication for ICD should not be based on age alone. However, the subgroup with EF ≤ 25% and IRF showed a high 12-month nonarrhythmic mortality and did not benefit from ICD implantation.

Interventricular conduction disorders after orthotopic heart transplantation: risk factors and clinical relevance.

BACKGROUND: Causes and significance of interventricular conduction disorders (IVCDs) after orthotopic heart transplantation (OHT) are still unknown. METHODS: We retrospectively researched the presence of IVCDs in 240 patients who underwent bicaval OHT in three time periods: at day 1, after 1 year, and after 3 years from OHT. To evaluate the impact of the surgical technique, a control population treated with biatrial anastomosis was used. RESULTS: The most common IVCD was right bundle branch block (RBBB). Its presence at day 1 correlated with transpulmonary gradient before OHT. Its presence after 1 year and its development correlated with a 1-month acute rejection score≥2 (p = .050 and p = .006). The incidence of RBBB was higher in the biatrial control population (40.7% vs 23.8%, p < .001). CONCLUSIONS: RBBB is the most common IVCD. Its presence can be explained by a susceptibility of the right branch to heart positioning, pressure overload, and acute rejection. IVCDs do not affect prognosis.

Pacemaker remote monitoring in the pediatric population: is it a real solution?

BACKGROUND: Clinical utility of remote monitoring of implantable cardiac devices has been previously demonstrated in several trials in the adult population. The aim of this study was to assess the clinical utility of remote monitoring in a pediatric population undergoing pacemakers implantation. METHODS: The study population included 73 consecutive pediatric patients who received an implantable pacemaker. The remote device check was programmed for every 3 months and all patients had a yearly out-patient visit. Data on device-related events, hospitalization, and other clinical information were collected during remote checks and out-patient visits. RESULTS: During a mean follow-up of 18 ± 10 months, 470 remote transmissions were collected and analyzed. Two deaths were reported. Eight transmissions (1.7%) triggered an urgent out-patient visit. Twenty percent of transmissions reported evidence of significant clinical or technical events. All young patients and their families were very satisfied when using remote monitoring to replace out-patient visits. CONCLUSIONS: The ease in use, together with satisfaction and acceptance of remote monitoring in pediatric patients, brought very good results. The remote management of our pediatric population was safe and remote monitoring adequately replaced the periodic out-patient device checks without compromising patient safety.

Atrial fibrillation after orthotopic heart transplantatation: Pathophysiology and clinical impact.

BACKGROUND: Atrial fibrillation (AF) is a well-established post-cardiac surgery complication. Orthotopic heart transplantation (OHT) represents a peculiar condition where surgical thoracic veins isolation and autonomic denervation occur. This study aims at investigating AF incidence in OHT in order to define its risk factors and to evaluate its prognostic impact. METHODS: 278 patients affected by OHT were recruited in our Cardiac Surgery Unit and retrospectively analyzed, using clinical, surgical and instrumental data. RESULTS: The patients cohort showed 45 post-operative (16.5%) and 20 late AF cases (7.2%). Only paroxysmal AF episodes were observed. Elderly donors and acute rejection resulted as risk factors in patients with post-operative AF episodes, who presented higher all-cause mortality at 11 years post-OHT (p < 0.001, Kaplan Meier analysis). The majority of late AF episodes occurred during hospitalization, due to renal failure or infections and more frequently in male patients; no significant correlation was observed with acute or chronic rejection or other characteristics. CONCLUSION: Pulmonary vein isolation and vagal denervation lead to low AF incidence in OHT recipients. Acute rejection and graft status are the main risk factors for post-operative AF episodes, while other systemic conditions act as late AF triggers. The occurrence of AF episodes is associated with poor outcome and AF should be considered as a marker of clinical frailty.

Clinical predictors of pocket hematoma after cardiac device implantation and replacement.

AIMS: Pocket hematoma is a common complication of cardiac implantable electronic device (CIED) procedures. the aim of the study was to research the clinical factors associated with pocket hematoma formation after CIED implantation or replacement and to identify the best perioperative antithrombotic management. METHODS: We retrospectively analyzed 500 consecutive patients who underwent to CIED implantation or replacement at our center from November 2014. RESULTS: Among our population, 206 patients (41.2%) were on anticoagulant therapy at the time of the intervention: 68 (13.6%) on ongoing Warfarin; 111 (22.2%) on low-molecular-weight heparin (LMWH); and 27 (5.4%) on ongoing direct oral anticoagulants. Antiplatelet therapy was present in 262 (52.4%) patients: in particular, 50 (10%) were on dual antiplatelet therapy, 64 (12.8%) were on single antiplatelet therapy and anticoagulant therapy, whereas 12 (2.4%) were on anticoagulant with dual antiplatelet therapy.Incidence of pocket hematoma after CIEDs implantation was of 4.6%. Considering the different perioperative anticoagulant strategies, patients on LMWH presented the higher hematoma rate [11/100 patients (11.0%), P < 0.001]. At the multivariate analysis, anticoagulant with dual antiplatelet therapy (P = 0.021, OR 6.3, IC 1.3-30.8), left ventricular ejection fraction (LVEF) less than 30% (P < 0.001, OR 7.4, IC 2.7-20.4), and use of LMWH (P = 0.008, OR 3.8, IC 1.4-10.6) resulted the strongest predictors of pocket hematoma (Hosmer test = 0.899).Considering replacement procedures, incidence of pocket hematoma was of 4.4%. The incidence was higher after ICD/CRT-D replacement. The majority of pocket hematoma occurred in patients with mechanical valve prosthesis (3/4 cases, 75%, P < 0.001). CONCLUSION: The use of LMWH and a low LVEF expose patients to a higher risk of pocket hematoma after CIED procedures. Anticoagulant with dual antiplatelet therapy and LMWH should be avoided.

Inappropriate implantable cardioverter defibrillator shocks due to atrial far-field on the tip-to-ring channel for lead dislodgement.

We reported a case of inappropriate implantable cardioverter defibrillator shocks, due to atrial far-field on the tip-to-ring channel of the fast electrical activity during atrial fibrillation, caused by lead dislocation in the right ventricle outflow tract. During these episodes the can-to-right ventricle coil signal correctly recorded the ventricular activity. The shock storm stopped when an antitachycardia pacing restored sinus rhythm.

Effective and safe lead extraction using the bidirectional rotational Evolution® sheath in a child with congenital heart disease.

We reported a challenging transvenous lead extraction procedure for lead failure in a child with congenital heart disease. Our report demonstrates that the new hand-powered bidirectional rotational Evolution RL (Cook Medical, USA) mechanical extraction sheath is an effective and safe tool for the extraction of chronically implanted leads in children.

Twelve-year follow-up of catheter ablation for atrial fibrillation: A prospective, multicenter, randomized study.

BACKGROUND: Randomized and controlled studies have reported the effect of catheter ablation (CA) for atrial fibrillation (AF) over a follow-up of 12-24 months. OBJECTIVE: We report on the effect of CA plus antiarrhythmic drugs in comparison with antiarrhythmic drugs alone on the maintenance of sinus rhythm over 12-year follow-up. METHODS: We extended the follow-up duration of the 137 patients who were enrolled in the Catheter Ablation for the Cure of Atrial Fibrillation Study between February 1, 2002, and June 30, 2003, and randomized to antiarrhythmic drugs (control group) or antiarrhythmic drugs plus CA (ablation group). The primary end point was time to first symptomatic or asymptomatic recurrence of atrial arrhythmia lasting >30 seconds during follow-up. RESULTS: During follow-up, 19 of 68 (27.9%; 95% confidence interval [CI] 18.7%-39.6%) ablation group patients and 3 of 69 (4.3%; 95% CI 1.49%-12.0%) control group patients did not experience any relapse of atrial tachyarrhythmia (P < .001). The Kaplan-Meier analysis performed to determine the probability of survival free from atrial arrhythmias showed a statistical difference in favor of the ablation group (log-rank, P < .001). The effect of CA was consistent in both patients with paroxysmal AF and those with persistent AF. In the multivariate Cox regression analysis, belonging to the control group (hazard ratio 2.95; 95% CI 1.896-4.726; P < .001) and longer time since first AF episode (hazard ratio 1.004; 95% CI 1.002-1.084; P = .041) were predictors of atrial tachyarrhythmia recurrence. CONCLUSION: In patients with paroxysmal and persistent AF, CA significantly increased time to first recurrence of atrial arrhythmias during 12-year follow-up.

Successful transvenous mechanical lead extraction and stent implantation in a patient after Mustard palliation for D-transposition of great arteries and superior vena cava syndrome.

: We report a successful combined approach of transvenous mechanical pacing lead extraction and stent angioplasty for superior baffle occlusion in a young woman with D-transposition of great artery after Mustard procedure. After having extracted the pacing leads, the baffle was easily stented, thanks to the channel left by the extracted leads. Eventually, a new pacing lead was implanted into the pulmonic ventricle through the stented baffle. Our report demonstrates the safeness and feasibility of a combined interventional approach in avoiding the need for surgery.

Axillary vein puncture using fluoroscopic landmarks: a safe and effective approach for implantable cardioverter defibrillator leads.

PURPOSE: Axillary vein puncture is an effective method for pacemaker lead insertion with less complications compared with subclavian vein puncture; however, there are limited data on implantable cardioverter defibrillator (ICD) implantation with this technique. We reported our experience with a blind axillary vein puncture using fluoroscopic landmarks consisting of the outer edge of the first rib and the body surface of the second rib for ICD lead implantation. METHODS: The study population included 103 consecutive patients (mean age 59 ± 9 years) referred for ICD implantation using axillary vein puncture without contrast venography. An 18-gauge needle was advanced toward the outer edge of the fist rib below the clavicle or the body surface of the second rib. If the vein was not entered, the needle was withdrawn and the puncture was repeated with slight variations of needle direction for a maximum of four times, then contrast-guided vein puncture was performed. RESULTS: The total implanted leads were 152 including 103 right ventricular leads, 35 right atrial leads, and 14 left ventricular epicardial leads. Blind axillary vein puncture was successful obtained in 96 (93.2 %) patients. The rate of success was higher using the body surface of the second rib compared with the outer edge of the first rib (88.7 vs. 100 %; p = 0.04).Contrast venography was required in seven (6.8 %) patients because of vein course abnormality (n = 5) or vasospasm (n = 2). No acute complications or device-related complications were recorded during a mean follow-up of 12 ± 5 months. CONCLUSIONS: Axillary vein access using fluoroscopic landmarks, especially the body surface of the second rib, is an effective approach for ICD implantation and offers the potential to avoid complications usually observed with traditional subclavian vein approach.

In-hospital management of heart failure: in 10 years we have improved, but not enough.

It is well recognized that the majority of patients with heart failure (HF) are admitted to General Medicine Departments (GMDs), and that the recommendations of the international guidelines for the treatment of HF are often incorrectly applied in hospital practice. We evaluated the treatment of patients with HF discharged from a single hospital over a period of 10 years. The study population comprised two series of patients who were discharged from six GMDs of a single hospital with the diagnosis of HF in the first 2 months of 1998 and 2008. The patients were also divided in two groups on the basis of the type of HF, systolic or diastolic. In 10 years, the number of patients who were discharged with the diagnosis of HF increased, the median age rose from 79 to 82 years and diastolic has become the more common type of HF. The prevalence of comorbidities rose significantly. There was an increased use of ACE-inhibitors and betablockers, and a reduction of digoxin and nitrates. The mortality decreased from 16.7% in 1998 to 9.6% in 2008 (p < 0.02) and hospitalizations became shorter (p < 0.05) considering patients with systolic HF (EF ≤ 45%) the median age rose from 74 to 79 years old (p < 0.01). We recorded an increasing use of betablockers, a reduction in the prescription of digoxin. The percentage of Diastolic HF rose from 55.7% in 1998 to 65.0% in 2008 (p < 0.001). The median age of these patients changed from 79 to 82 years old (p < 0.05). In 10 years, the clinical characteristics and management of HF patients who are hospitalized have changed. Pharmacological treatment has improved, but it still remains far from being adequately compliant with guideline recommendations.