Feasibility of complex transfemoral electrophysiology procedures in patients with inferior vena cava filters.

BACKGROUND: The presence of inferior vena cava filters (IVCFs) has been considered a relative contraindication to electrophysiology (EP) procedures that require transfemoral venous placement of multiple catheters and/or long sheaths. There are inadequate data related to complex EP procedures in this population. OBJECTIVE: The purpose of this study was to describe the experience of a single high-volume center with respect to complex EP procedures in patients with IVCFs. METHODS: Patients with IVCFs undergoing complex EP procedures between 2004 and 2018 were identified. Clinical characteristics, IVCF type, procedural findings, and complications were analyzed. RESULTS: Fifty complex ablation procedures were performed in 40 patients (mean age 63.8 ± 10.9 years; 68% men). The mean IVCF dwell time was 69.1 ± 19.1 months, and 48 patients (96%) were on chronic oral anticoagulation. Procedures included ablation of atrial fibrillation (n = 21), ventricular tachycardia (n = 20), supraventricular tachycardia (n = 3), cavotricuspid isthmus flutter (n = 3), supraventricular tachycardia and cavotricuspid isthmus flutter (n = 1), and transvenous lead extraction (n = 3). Twenty procedures included quadripolar catheters (mean 1.4 ± 0.75), and 33 procedures involved deflectable decapolar catheters (mean 1.7 ± 0.47). Long sheaths were used in 35 cases (mean 1.63 ± 0.49) and intracardiac echocardiography in 38. In 4 cases (involving 3 patients), the IVCF was occluded and could not be crossed. There were no procedural complications related to the IVCF. CONCLUSION: The substantial majority of IVCFs in patients presenting for complex EP procedures were patent and easily crossed under fluoroscopic guidance. The presence of an IVCF should not discourage operators from performing procedures that require transfemoral deployment of multiple catheters and/or sheaths.

First Locally Acquired Congenital Zika Syndrome Case in the United States: Neonatal Clinical Manifestations.

In the spring of 2017, a full-term infant with microcephaly was delivered in South Florida. During first trimester, the mother presented with fever, nausea, and vomiting. She reported no foreign travel for herself or her partner. The infant's neurologic, ophthalmologic, neuroradiologic, and audiologic findings were highly suggestive of congenital Zika syndrome (CZS), confirmed by IgM antibodies and plaque reduction neutralization test. New observations, including peripheral temporal retinal avascularity and peripapillary retinal nerve fiber layer thinning, are presented from this first known case of non-travel-associated CZS in the United States. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e93-e98.].

Simultaneous lead traction from above and below: A novel technique to reduce the risk of superior vena cava injury during transvenous lead extraction.

BACKGROUND: Superior vena cava (SVC) injury is a rare but dreaded complication during percutaneous transvenous lead extraction (TLE) that carries high morbidity and mortality. Despite technological advances and improved efficacy, complication rates remain unchanged. OBJECTIVE: We sought to develop and test a novel technique that could reduce the risk of SVC injury during TLE. METHODS: Fifteen patients referred for TLE of an implantable cardioverter-defibrillator lead were included. Patients underwent fluoroscopic and intracardiac echocardiographic (ICE) imaging of the lead-SVC interface with traction from above, below, and simultaneously. Clinical characteristics, fluoroscopic and ICE findings, and procedural outcomes were collected and analyzed. RESULTS: Fourteen of 15 patients were men (93%) with a mean age of 58 years. The mean lead dwell time was 8.09 ± 3.97 years (range 1.08-16.25 years), and 12 of 15 leads (80%) were dual-coil. Acceptable ICE imaging was not possible in 3 of 15 patients (20%). Simultaneous traction showed greater leftward fluoroscopic shift compared with traction from above (24.96 ± 8.82 mm vs 13.68 ± 6.86 mm; P < .01), created greater separation between the lead and the SVC wall upon ICE imaging (2.0 ± 0.52 mm vs 1.24 ± 0.38 mm; P < .01), and maintained a more parallel relationship of the lead with the SVC wall (24.41° ± 4.14° vs 27.91° ± 4.92°; P < .05). CONCLUSION: In patients presenting for TLE, simultaneous traction results in increased separation and a more parallel alignment of the lead and SVC wall, allowing the sheath to be better oriented in the desired cleavage plane. This improved sheath alignment is particularly critical when powered sheaths are to be used.

Utility of intracardiac echocardiography during transvenous lead extraction.

BACKGROUND: Transvenous lead extraction (TLE) carries a significant risk of intraprocedural complications. Phased-array intracardiac echocardiography (ICE) is widely used during cardiac procedures; however, its utility during TLE has not been well described. OBJECTIVE: We sought to define the utility of ICE imaging during TLE. METHODS: Fifty patients referred for TLE were included. Patients underwent ICE imaging before and throughout TLE. Clinical characteristics of the patients, ICE findings, and procedural outcomes were collected and analyzed. RESULTS: Of the 50 patients, 18 (36%) were found to have visible binding sites in the ICE field of view; 13 (26%) had intracardiac binding sites only, and 5 (10%) had both superior vena cava (SVC) and intracardiac binding sites. Lead-adherent echodensities (LAEs) were found in 36 patients (72%), of whom 7 (14%) had bacteremia. Patients with SVC and/or intracardiac binding sites were more likely to have a complex extraction, defined as that requiring the use of internal jugular or femoral venous access, advancement of extraction apparatus beyond the SVC, disruption of lead structure during the procedure, or resulting in major complications (56% vs 0%; P ≤ .0001). CONCLUSION: ICE imaging during TLE can be used to assess the presence of lead binding sites, LAEs, and procedural complications. LAEs were found in the majority of patients, mostly in the absence of bacteremia. The presence of ICE-detected lead binding sites is predictive of a more complex extraction procedure.

Outcomes of patients with definite and suspected isolated cardiac sarcoidosis treated with an implantable cardiac defibrillator.

PURPOSE: Cardiac sarcoidosis (CS) patients are at increased risk for sudden death. Isolated CS is rare and can be difficult to diagnose. METHODS: In this multicenter retrospective review, patients with CS and an implantable cardiac defibrillator (ICD) were identified. RESULTS: Of 235 patients with CS and ICD, 13 (5.5 %) had isolated CS, including 7 (3.0 %) with definite isolated CS (biopsy or necropsy-proven) and 6 (2.6 %) with suspected isolated CS based on a constellation of clinical, ECG, and imaging findings. Among 13 patients with isolated CS, 10 (76.9 %) were male, mean age was 53.8 ± 7.6 years, and mean left ventricular ejection fraction was 38.3 ± 16.5. Diagnosis was made by cardiac magnetic resonance (CMR) (n = 2), biopsy (n = 3), CMR and biopsy (n = 2), CMR and positron emission tomography (PET) (n = 2), PET (n = 1), late enhanced cardiac CT (n = 1), pathology at heart transplant (n = 1), and autopsy (n = 1). Eight of 13 (61.5 %) patients with isolated CS had a secondary prevention indication (VT in 6 and VF in 2) vs. 80 of 222 (36.0 %) with sarcoidosis in other organs (p = 0.04). Over a mean of 4.2 years, 9 of 13 (69.2 %) patients with isolated CS received appropriate ICD therapy, including anti-tachycardia pacing (ATP) and/or shock, compared with 75 of 222 (33.8 %) patients with cardiac and extracardiac sarcoidosis (p = 0.0150). Six of 7 (85.7 %) patients with definite isolated CS received appropriate ICD intervention, compared with 78 of 228 patients (34.2 %) without definite isolated CS (p = 0.0192.) CONCLUSIONS: In this retrospective study, patients with isolated CS had very high rates of appropriate ICD therapy. Prospective, long-term follow-up of consecutive patients with isolated CS is needed to determine the true natural history and rates of ventricular arrhythmias in this rare and difficult-to-diagnose disease.

Same-day contralateral implantation of a permanent device after lead extraction for isolated pocket infection.

AIMS: The purpose of this study is to examine the safety and outcomes of same-day reimplantation at the contralateral pectoral site in patients with device extraction for pocket infection but with negative blood cultures and no signs of systemic infection. METHODS AND RESULTS: Clinical and procedure-related data were retrospectively collected on 15 (11 male, mean age 77) device-dependent patients who underwent device and complete lead extraction (mean 2.5 leads per patient, mean implant duration 6.2 years) for local pocket infection, and who had a new contralateral device implanted on the same day. Temporary pacing via the femoral vein was used during extraction. The infected pocket was managed with an elliptical skin incision, debridement, full capsule resection, and primary wound closure with the end of the wound left open for a Penrose drain. Intravenous antibiotics were used prior to and through the procedure, and continued for a mean of 2 days post-procedure, with oral antibiotics used thereafter for a mean course of 2 weeks. No infections of the new device system occurred, with a mean follow-up of 39.6 months (range 12-74 months). CONCLUSION: In the setting of device erosion and isolated pocket infection without systemic or bloodstream involvement, a new contralateral device may be implanted on the same day as pocket debridement and system extraction without developing infection of the new permanent hardware. This strategy can be useful in patients with pacemaker-dependence, as an alternative to using a temporary pacing system.

Glove and gown effects on intraoperative bacterial contamination.

OBJECTIVE: Experiments were performed to determine the risk of bacterial contamination associated with changing outer gloves and using disposable spunlace paper versus reusable cloth gowns. BACKGROUND: Despite decades of research, there remains a lack of consensus regarding certain aspects of optimal aseptic technique including outer glove exchange while double-gloving and surgical gown type selection. METHODS: In an initial glove study, 102 surgical team members were randomized to exchange or retain outer gloves 1 hour into clean orthopedic procedures; cultures were obtained 15 minutes later from the palm of the surgeon's dominant gloved hand and from the surgical gown sleeve. Surgical gown type selection was recorded. A laboratory strike-through study investigating bacterial transmission through cloth and paper gowns was performed with coagulase-negative staphylococci. In a follow-up glove study, 251 surgical team members, all wearing paper gowns, were randomized as in the first glove study. RESULTS: Glove study 1 revealed 4-fold higher levels of baseline bacterial contamination (31% vs 7%) on the sleeve of surgical team members wearing cloth gowns than those using paper gowns [odds ratio (95% confidence interval): 4.64 (1.72-12.53); P = 0.0016]. The bacterial strike-through study revealed that 26 of 27 cloth gowns allowed bacterial transmission through the material compared with 0 of 27 paper gowns (P < 0.001). In glove study 2, surgeons retaining outer gloves 1 hour into the case had a subsequent positive glove contamination rate of 23% compared with 13% among surgeons exchanging their original outer glove [odds ratio (95% confidence interval): 1.97 (1.02-3.80); P = 0.0419]. CONCLUSIONS: Paper gowns demonstrated less bacterial transmission in the laboratory and lower rates of contamination in the operating room. Disposable paper gowns are recommended for all surgical cases, especially those involving implants, because of the heightened risk of infection. Outer glove exchange just before handling implant materials is also recommended to minimize intraoperative contamination.

Stemmed knee replacement in a patient with an irremovable tibial nail.

A patient with a cemented centrally located intramedullary tibial nail that occluded the proximal tibial canal underwent knee reconstruction with a total knee design utilizing a custom hollow tibial stem. In this oncology case, a rotating-hinge knee design was used that incorporates an intra-articular inverted post-in-channel central rotational post design. This design allowed for a rather straightforward reconstruction that functioned well for 3 years. Although rarely encountered, utilization of a hollow-stemmed tibial total knee component may allow salvage of an extremity with central occlusion of the proximal tibial canal.

Percutaneous epicardial ventricular tachycardia ablation after noncoronary cardiac surgery or pericarditis.

BACKGROUND: Patients with previous noncoronary cardiac surgery or pericarditis may require epicardial access to facilitate successful ventricular tachycardia (VT) ablation. Percutaneous pericardial access is known to be difficult in these patients owing to the presence of pericardial adhesions. OBJECTIVE: To examine the success and safety of percutaneous pericardial access as well as the ability to map and ablate epicardial VT targets. METHODS: We studied 10 consecutive patients with prior noncoronary cardiac surgery (8 patients) or prior pericarditis (2 patients) who required epicardial access for VT ablation. RESULTS: Percutaneous pericardial access was achieved by experienced operators, and dense adhesions interfering with catheter mapping were encountered in all patients. Using blunt dissection with a deflected ablation catheter, adhesions were divided over the course of 19-125 minutes (mean 57±38 minutes; median 47 minutes). This dissection allowed for sufficient epicardial mapping in 9 of 10 (90%) patients. The clinical targeted VTs were rendered noninducible in 8 (80%) patients. One patient had 70 cm(3) of bleeding with the initial puncture. No other complications occurred. During a long-term follow-up of 24±27 months (median 13 months), 5 patients have remained VT-free. CONCLUSIONS: Percutaneous pericardial access for epicardial VT ablation in patients with previous noncoronary cardiac surgery or pericarditis can usually be obtained. However, dense pericardial adhesions are often encountered and may limit the ability to map the entire epicardial space. Typically, appropriate targets can be reached and ablated by disrupting the adhesions with the ablation catheter and/or deflectable sheath, facilitating excellent long-term clinical outcome in half of the patients with no major complications.

Long-term follow-up of patients with cardiac sarcoidosis and implantable cardioverter-defibrillators.

BACKGROUND: Ventricular tachyarrhythmias are an important cause of morbidity and mortality in cardiac sarcoidosis. To date, the prevalence and incidence of ventricular tachycardia/ventricular fibrillation (VT/VF) in this population remain unknown. OBJECTIVES: To determine the prevalence and incidence of ventricular tachyarrhythmias in patients with cardiac sarcoidosis and to identify the clinical attributes associated with appropriate implantable cardioverter-defibrillator (ICD) therapies. METHODS: We studied 45 patients with ICDs, biopsy-proven systemic sarcoidosis, and cardiac involvement, as evidenced by histopathology, cardiac magnetic resonance imaging, and/or (18)F-fluoro-2-deoxyglucose-positron emission tomography imaging. Device logs and medical records were retrospectively reviewed. RESULTS: Appropriate ICD therapies for VT/VF were observed in 37.8% of the patients with an incidence of 15% per year. Inappropriate ICD therapies occurred in 13.3% of the patients. Longer ICD follow-up (4.5 ± 3.1 years vs 1.5 ± 1.5 years; P = .001), depressed left ventricular ejection fraction (35.5% ± 15.5% vs 50.9% ± 15.5%; P = .002), and complete heart block (47.1% vs 17.9%; P = .048) were associated with appropriate ICD therapy. While there was no significant difference in the total number of shocks/antitachycardia pacing-terminated events between primary (n = 29) and secondary (n = 16) prevention groups, there was a trend toward more events in the secondary prevention arm after 2 years. CONCLUSIONS: Ventricular tachyarrhythmias requiring ICD therapy were common in patients with cardiac sarcoidosis, with an estimated incidence rate of 15% per year. Longer follow-up, left ventricular systolic dysfunction, and complete heart block were associated with VT/VF. Patients with primary prevention ICDs had high rates of appropriate ICD therapy but not as high as did secondary prevention patients. In the absence of reliable risk stratification techniques, consideration should be given to prophylactic ICD implantation in patients with cardiac sarcoidosis.

Allergic reaction to suture material after an ICD procedure: device infection mimicry.

When an implanted device is infected, complete explantation of the device system, including lead extraction, is usually required. Superficial problems with wound healing may be managed more conservatively, but distinguishing between a surface process and deeper infection can pose a clinical challenge. We present a case of poor wound healing after an ICD pocket revision procedure, and an allergic reaction to the suture material was found to be the cause. Diagnosis, management, and future implications of suture allergy are discussed.

Tissue-specific variability in human epicardial impedance.

INTRODUCTION: Epicardial ablation can be employed to treat ventricular tachycardia. Voltage attenuation in regions of fat can mimic epicardial scar, limiting its specificity. Ablation over fat may not be as effective. Prior animal data have shown that infarcted myocardium has lower impedance than normal, and human bioimpedance studies suggest peripheral fat displays higher impedance. Therefore, we tested the hypothesis that human epicardial fat has higher impedance than myocardium when measured with standard ablation tools. METHODS: Patients undergoing elective surgery for coronary artery or valve disease were enrolled. A reference patch was placed on the patients' back between the scapulae and connected to a standard RF generator (Stockert, GmBH, Germany). Impedance was measured by passing a 1 µA, 50 kHz current from the catheter tip to the patch. After sternotomy but before initiation of cardiopulmonary bypass, an ablation catheter (Celsius, Biosense Webster, Diamond Bar, CA, USA) was placed onto the epicardial surface in ventricular regions visually identified as fat or myocardium. At each site, impedance was recorded from the generator. RESULTS: A total of 37 (7 patients) points were sampled. Impedance was significantly higher in regions of fat versus normal muscle (697 Ω vs. 301 Ω; P = 0.01). Moreover, normal sites from the LV had higher impedance than from the RV (381 Ω vs. 271 Ω; P = 0.01). CONCLUSIONS: Human epicardial fat has higher tissue impedance than normal muscle. Using epicardial impedance and voltage mapping in conjunction may improve differentiation of arrhythmia substrate from epicardial fat and improve the efficacy of epicardial ablation.

Severe venous and lymphatic obstruction after single-chamber pacemaker implantation in a patient with chest radiation therapy.

A 73-year-old woman with a history of paroxysmal atrial fibrillation, sinus node dysfunction, bilateral breast cancer, and extensive chest radiation developed progressive edema, dyspnea, and recurrent pleural effusions soon after single-chamber pacemaker implantation. Thoracentesis yielded a diagnosis of chylothorax, and progressive refractory anasarca developed. A computed tomography angiogram suggested obstruction of the superior vena cava and left subclavian vein despite outpatient therapeutic anticoagulation. Autopsy confirmed venous thrombosis, along with mediastinal fibrosis. The presumed etiology of the chylothorax and anasarca was obstruction of the atretic central venous structures following pacemaker implantation, critically impairing the already tenuous venous and lymphatic drainage. (PACE 2010; 520-524).

Abdominal panniculectomies: high patient satisfaction despite significant complication rates.

BACKGROUND: We reviewed our experience with 3 operative techniques for abdominal panniculectomies to determine differences in complication rates and levels of patient satisfaction. METHODS: This retrospective study included 92 consecutive patients who underwent abdominal panniculectomies over a 9-year period. Patients underwent one of 3 panniculectomy techniques: fleur-de-lis (n = 25), transverse incisions with minimal undermining (n = 30), or transverse incisions with extensive undermining (n = 37). Postoperatively, patient satisfaction surveys were completed. RESULTS: Median pannus weight was 4.4 kg (range, 1.6-20.5). Sixty-eight patients (73.9%) had a previous gastric bypass. Median body mass index (BMI) was 38 kg/m2 (range, 22-66.9). Median follow-up for complications was 8.1 week (range, 1-235). Forty of 92 patients (43%) suffered wound complications. The reoperation rate was 13%. Postoperative complication rates were higher among hypertensive patients (61% vs. 36%; P = 0.04). There was a trend towards increased complications among those with higher BMI and pannus weights. There was not a significant relationship between operative technique and overall complication rate. Mean length of follow-up for patient questionnaire completion was 2 years, 11 months (range, 1-9 years). Eighty-one percent of those responding to the mailed questionnaire were satisfied with their operative results. There were no statistically significant differences between the technique used and patient satisfaction level. Concomitant hernia repair was performed in 47% of patients without increased wound complications. CONCLUSIONS: Patients were satisfied with the results of their panniculectomy, although complications were common. Higher BMI, larger pannus size, and hypertension were correlated with increased complication rates. The minimal undermining, extensive undermining, and the fleur-de-lis panniculectomy techniques result in similar patient satisfaction rates and complication rates.

Sequential dual chamber extrastimulation: a novel pacing maneuver to identify the presence of a slowly conducting concealed accessory pathway.

BACKGROUND: Transient VA block can be created in the AV node (AVN) when an atrial extrastimulus is delivered at the AVN effective refractory period (ERP) due to anterograde concealed conduction. OBJECTIVE: We hypothesized that ventricular stimulation during pacing-induced AVN refractoriness could identify concealed accessory pathways (APs) that remain hidden with standard maneuvers. METHODS: Patients undergoing electrophysiological study for supraventricular tachycardia were screened for presence of an AP using standard pacing maneuvers and/or V pacing during adenosine infusion. The dual-chamber sequential extrastimulation maneuver consisted of an 8-beat drive train of simultaneous AV pacing at 600 msec, followed by an A2 delivered at AVN ERP, followed by a V2 delivered at the drive train cycle length (600 msec). Repeat drives were then performed with decrements of 10 msec for V2 until VA block was seen. Retrograde AVN and AP ERP were recorded with standard (V1, V2) and dual-chamber extrastimulation (A1/V1, A2, V2). Patients with an AP identified with standard pacing, manifest pre-excitation, or A ERP < AVN ERP were excluded. RESULTS: Fourteen patients with and 19 patients without an AP were studied. In all patients with an AP, exclusive VA conduction over the AP, without fusion, was seen with the described pacing maneuver. In patients without an AP, retrograde AV nodal ERP was extended by a mean of 138 +/- 46 msec (range 50 to 210 msec) with the A2. Anterograde concealed conduction into the AP was also seen in some patients who showed AP conduction during standard V1V2 pacing (mean retrograde extension of ERP 12 +/- 8 msec, range 0 to 20 msec). CONCLUSION: Dual-chamber sequential extrastimulation is a useful maneuver for identifying slowly conducting APs not revealed with standard pacing maneuvers because of an ERP and conduction time similar to the AVN. The maneuver uses anterograde concealed conduction to prolong AVN refractoriness much more than that of a concealed AP, thereby allowing the AP to become manifest with the V2.

Incidence and predictors of very late recurrence of atrial fibrillation after ablation.

INTRODUCTION: Radiofrequency catheter ablation can effectively treat patients with refractory atrial fibrillation (AF). Very late AF recurrence (> or = 12 months post-ablation) is uncommon and may represent a unique patient cohort. METHODS AND RESULTS: A nested case-control study was performed in the cohort who underwent AF ablation at the University of Pennsylvania to characterize patients who develop very late AF recurrence after ablation. The procedure consisted of isolation of pulmonary veins (PVs) demonstrating triggers and elimination of non-PV triggers initiating AF. Twenty-seven (7.9%) patients with very late recurrence were compared to 219 patients without recurrence and > or = 12 months of follow-up. The mean age was 54.6 +/- 11.3 years and 79% were men. Very late recurrence patients more likely weighed >200 lbs (70% vs 55%, P = 0.01); during initial ablation had fewer PVs isolated (2.8 +/- 1.1 vs 3.3 +/- 1.0, P = 0.03); and were less likely to have right inferior PV isolation (37% vs 61%, P = 0.02), less likely to have isolation of all PVs (30% vs 56%, P = 0.01), and more likely to have non-PV triggers (30% vs 11% OR 3.4(95% CI, 1.3-8.7), P = 0.01). PV reconnectivity and new triggers were found in the majority of patients with very late recurrence of AF who underwent repeat ablation. CONCLUSION: Very late recurrence of AF more likely occurred in patients >200 lbs who demonstrated non-PV triggers and did not undergo right inferior PV isolation. The majority of patients undergoing repeat ablation for very late recurrence demonstrated PV reconnectivity and new non-PV and PV triggers not observed during the initial ablation.

Primary and revision cleft lip repairs using octyl-2-cyanoacrylate.

The purpose of our retrospective review is to examine our method and outcomes for the application of octyl-2-cyanoacrylate for the repair of primary and revision cleft lips in both pediatric and adult patients. Records and photographs were reviewed and analyzed for patient age, type of cleft, revision or primary repair, complications, length of follow-up, and aesthetic outcomes. Eighteen patients, both children and adults, who underwent cleft lip repairs using tissue adhesive performed by a single surgeon between 1999 and 2003 were included. Twelve patients underwent primary repair and 6 patients underwent revision repair. Repairs were performed using the Millard rotation advancement technique and the Mohler variant. The lateral advancement flap was kept long and redundant in its transverse dimension to create a pressure fit everting the skin edges with minimal sutures to set up the closure for application of the tissue adhesive. Seventeen of eighteen patients had excellent cosmetic outcomes. One patient had minor necrosis of the tip of the advancement flap. No allergic reactions, wound infections, or dehiscences occurred. The use of octyl-2-cyanoacrylate for the skin closure of primary and revision cleft lip repairs in both children and adults results in excellent cosmetic outcomes. Employing our pressure-fit technique for skin eversion prior to application of the tissue adhesive may be advantageous. The lack of suture removal in the pediatric population and decreased operative time are additional benefits.