Permanent pacemaker implantation rates following cardiac surgery in the modern era.

AIMS: The aim of this study was to evaluate the incidence of permanent pacemaker (PPM) implantation after cardiac surgery in our institution and investigate risk factors for PPM dependency to provide patients with accurate incidence figures at the time of consent for surgery. METHODS: Data was collected retrospectively from a single tertiary institution from October 2018 to April 2019 inclusive of 403 patients. Incidence of PPM implantation after various cardiac operations was evaluated. A univariate analysis was carried out to identify the independent risk factors related to PPM implantation. RESULTS: Ten patients required a PPM (2.48%). The most common indication for PPM implantation post-cardiac surgery was complete heart block (N = 7, 70%) followed by bradycardia/pauses (N = 2, 20%) and sick sinus syndrome (N = 1, 10%). PPM implantation after coronary artery bypass graft (CABG) surgery was the lowest (0.63%), while combined CABG and valve operations had the highest incidence (5.97%). Independent risk predictors for PPM implantation included female gender (p = 0.03), rheumatic heart disease (p = 0.008), pulmonary hypertension (p = 0.01), redo operations (p = 0.002), mitral valve procedures (p = 0.001), tricuspid valve procedures (p = 0.0003) and combined mitral and tricuspid valve procedures (p = 0.0001). Average length of intensive care unit (ICU)/high-dependency unit (HDU) stay was significantly prolonged for patients who required a PPM post-cardiac surgery. CONCLUSION: As clinicians, it can be challenging to provide our patients with accurate information on the risk of PPM implantation relative to their operation. A unit-specific data may be a more accurate method of informing our patients on this risk.

Implante de marcapasos transitorio en una terapia intensiva municipal / Implantation of temporary pacemaker in a municipal intensive care unit

Introducción: Las bradi-arritmias son cardiopatías graves que ocasionan trastornos hemodinámicos severos; llevar al paciente a un gasto cardiaco normal puede implicar que se implante un marcapasos. Objetivo: Describir algunos aspectos clínicos y epidemiológicos de pacientes que recibieron la técnica de implantar un marcapasos. Métodos: Se realizó un estudio descriptivo y transversal, con 36 pacientes que necesitaron marcapasos transitorio, ingresados en la unidad de cuidados intensivos del Hospital General Docente "Orlando Pantoja Tamayo" de Contramaestre, en el período desde octubre de 2015 hasta mayo de 2019. Las variables utilizadas fueron: grupo de edades y sexo, causas de arritmias y antecedentes patológicos personales, medicamentos más usados previos al ingreso, tiempo de uso del marcapasos transitorio y necesidad de implantación del permanente. Resultados: Predominó el sexo masculino y edades de 80 y más años, el trastorno de la conducción auriculoventricular más frecuente fue el bloqueo auriculoventricular de tercer grado; el tiempo promedio de uso de marcapaso transitorio fue entre 2 y 6 días. Conclusiones: La implantación precoz en esta entidad municipal mejoró notablemente la supervivencia de los pacientes(AU)

Introduction: Bradyarrhythmias are serious heart diseases that cause severe hemodynamic disorders. Bringing the patient to normal cardiac output may imply that a pacemaker be implanted. Objective: To describe some clinical and epidemiological aspects of patients who received the technique of implanting a pacemaker. Methods: A descriptive and cross-sectional study was carried out with 36 patients who needed a temporary pacemaker, admitted to the intensive care unit of Orlando Pantoja Tamayo General Teaching Hospital in Contramaestrem, in the period from October 2015 to May 2019. The variables used were age group and sex, causes of arrhythmias, and personal pathological history, most used medications prior to admission, time of usage of the temporary pacemaker, and the need for permanent implantation. Results: The male sex and ages 80 and older predominated, the most frequent atrioventricular conduction disorder was the third-degree atrioventricular block. The average time of temporary pacemaker usage was between two and six days. Conclusions: Early implantation in this municipal institution significantly improved patient survival(AU)

Radiation Therapy-Induced Dysfunction in Cardiovascular Implantable Electronic Devices.

PURPOSE: The prevalence of patients with cardiovascular implantable electronic devices (CIEDs) who receive radiation treatment for cancer is increasing. External beam radiation therapy (RT) can affect the electronic components. This study aimed to evaluate the incidence and predictors of new onset CIED dysfunction in patients treated with RT. METHODS AND MATERIALS: We retrospectively analyzed data from 230 patients with CIEDs who received radiation treatment at the Radiation Oncology Center of CHU de Québec - Université Laval between February 2007 and November 2013. The reviewed data included baseline characteristics, CIEDs, and RT treatment specifications. Patients with CIEDs were analyzed before, during, and at the end of radiation treatment. High- and low-energy photon or electron beam radiation from linear accelerators, orthovoltage machines, and high-dose rate brachytherapy delivery were used. Abnormal events could be one of the following: total or partial deprogramming of the CIED parameters, onset of new symptoms, or new arrhythmia. RESULTS: This study is based on one of the largest cohorts. A total of 18 events in 16 patients (7.8%) were recorded. Of the 18 events, 16 had at least part of the radiation treatment delivered with photo neutrons producing high-energy RT (neutron producing RT). Only 2 abnormal events occurred during non-neutron producing RT. Both the prescription dose and the dose estimated at the location of the pacemaker were correlated with the probability of an abnormal event (P = .0006 and P = .003, respectively). Among the 16 patients, clinical symptoms were noted in only 1 patient (6.3%). CONCLUSIONS: CIED malfunctions are relatively uncommon and do not seem to be life threatening. We recommend limiting the dose at the CIED and avoid neutron-producing RT to reduce the risk of CIED malfunction.

Electromagnetic Interference with Protocolized Electrosurgery Dispersive Electrode Positioning in Patients with Implantable Cardioverter Defibrillators.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Electromagnetic interference from monopolar electrosurgery may disrupt implantable cardioverter defibrillators.Current management recommendations by the American Society of Anesthesiologists and Heart Rhythm Society are based on expert clinical opinion since there is a paucity of data regarding the risk of electromagnetic interference to implantable cardioverter defibrillators during surgery. WHAT THIS ARTICLE TELLS US THAT IS NEW: With protocolized electrosurgery dispersive electrode positioning in patients with implantable cardioverter defibrillators, the risk of clinically meaningful electromagnetic interference was 7% in above-the-umbilicus noncardiac surgery and 0% in below-the-umbilicus surgery. In cardiac surgery, clinically meaningful electromagnetic interference with use of an underbody dispersive electrode was 29%.Despite protocolized dispersive electrode positioning, the risk of electromagnetic interference in above-the-umbilicus surgery is high, supporting recommendations to suspend antitachycardia therapy when monopolar electrosurgery is used above the umbilicus.With protocolized dispersive electrode positioning, the risk of electromagnetic interference in below-the-umbilicus surgery is negligible, implying that suspending antitachycardia therapy might be unnecessary in these cases.With an underbody dispersive electrode, the risk of electromagnetic interference in cardiac surgery is high. BACKGROUND: The goal of this study was to determine the occurrence of intraoperative electromagnetic interference from monopolar electrosurgery in patients with an implantable cardioverter defibrillator undergoing surgery. A protocolized approach was used to position the dispersive electrode. METHODS: This was a prospective cohort study including 144 patients with implantable cardioverter defibrillators undergoing surgery between May 2012 and September 2016 at an academic medical center. The primary objectives were to determine the occurrences of electromagnetic interference and clinically meaningful electromagnetic interference (interference that would have resulted in delivery of inappropriate antitachycardia therapy had the antitachycardia therapy not been programmed off) in noncardiac surgeries above the umbilicus, noncardiac surgeries at or below the umbilicus, and cardiac surgeries with the use of an underbody dispersive electrode. RESULTS: The risks of electromagnetic interference and clinically meaningful electromagnetic interference were 14 of 70 (20%) and 5 of 70 (7%) in above-the-umbilicus surgery, 1 of 40 (2.5%) and 0 of 40 (0%) in below-the-umbilicus surgery, and 23 of 34 (68%) and 10 of 34 (29%) in cardiac surgery. Had conservative programming strategies intended to reduce the risk of inappropriate antitachycardia therapy been employed, the occurrence of clinically meaningful electromagnetic interference would have been 2 of 70 (2.9%) in above-the-umbilicus surgery and 3 of 34 (8.8%) in cardiac surgery. CONCLUSIONS: Despite protocolized dispersive electrode positioning, the risks of electromagnetic interference and clinically meaningful electromagnetic interference with surgery above the umbilicus were high, supporting published recommendations to suspend antitachycardia therapy whenever monopolar electrosurgery is used above the umbilicus. For surgery below the umbilicus, these risks were negligible, implying that suspending antitachycardia therapy is likely unnecessary in these patients. For cardiac surgery, the risks of electromagnetic interference and clinically meaningful electromagnetic interference with an underbody dispersive electrode were high. Conservative programming strategies would not have eliminated the risk of clinically meaningful electromagnetic interference in either noncardiac surgery above the umbilicus or cardiac surgery.

Sarcoidosis of the medulla oblongata causing intractable hiccoughs and numbness of extremities: A case report.

RATIONALE: Sarcoidosis is a multisystem disorder characterized by noncaseating granulomas. The nervous system is involved in 5 to 16% of the patients. However, neurosarcoidosis in the medulla oblongata presenting as hiccough is remarkably rare. PATIENT CONCERN: A 55-year-old female was admitted to our hospital suffering from intractable hiccough and progressive numbness of extremities. DIAGNOSIS: The MR imaging revealed a circumscribed mass lesion located on the medulla oblongata. The mass was hyperintense on T2-weighted images and enhanced homogeneously with gadolinium-diethylenetriamine penta-acetic acid. The cerebrospinal fluid analysis showed a moderately elevated protein content and a significant lymphocytosis 86.5%. Electrocardiogram (ECG) showed complete atrioventricular block. Bilateral supraclavicular, hilar, and mediastinal lymphadenopathy was diagnosed in a CT scan. Transbranchial needle aspiration biopsy revealed noncaseating granuloma consisting of epithelioid cells, lymphocytes, and rare multinucleated giant cells which was consistent with sarcoidosis. The diagnosis of multisystemic sarcoidosis was made. INTERVENTIONS AND OUTCOMES: The patient underwent a permanent pacemaker insertion, and was successfully treated with corticosteroids. LESSONS: It is important to consider neurosarcoidosis in the differential diagnosis of intramedullary lesion, since a right recognition may lead to appropriate treatment with steroids and avoid needlessly extensive surgery.

Pericardial effusion as first presentation of disseminated non-Hodgkin's lymphoma.

A 46-year-old woman with quiescent lupus presented with worsening pleuritic chest pain and dyspnoea. Bedside echocardiogram confirmed large pericardial effusion with cardiac tamponade. Emergency bedside pericardiocentesis was performed. Pericardial fluid cytology confirmed diffuse large B cell lymphoma, stage four on positron emission tomography. Conventional rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone chemotherapy achieved good response in all sites except the pericardium. Progressive cardiac involvement was complicated by atrioventricular conduction block requiring permanent pacemaker. Second-line palliative chemotherapy was performed.

Management of cardiac implantable devices in patients undergoing radiotherapy.

The delivery of radiotherapy to patients with a cardiac implantable electronic device (CIED) is not an infrequent event. Consideration of the potential issues for patients is an important part of their care. An overview of CIEDs is provided, including the potential problems encountered and the steps that can be taken to mitigate this risk.

Management of patients with cardiac implantable electronic devices (CIED) undergoing radiotherapy: A consensus document from Associazione Italiana Aritmologia e Cardiostimolazione (AIAC), Associazione Italiana Radioterapia Oncologica (AIRO), Associazione Italiana Fisica Medica (AIFM).

The management of patients with a cardiac implanted electronic device (CIED) receiving radiotherapy (RT) is challenging and requires a structured multidisciplinary approach. A consensus document is presented as a result of a multidisciplinary working group involving cardiac electrophysiologists, radiation oncologists and physicists in order to stratify the risk of patients with CIED requiring RT and approaching RT sessions appropriately. When high radiation doses and beam energy higher than 6MV are used, CIED malfunctions can occur during treatment. In our document, we reviewed the different types of RT and CIED behavior in the presence of ionizing radiations and electromagnetic interferences, from the cardiologist's, radiation oncologist's and medical physicist's point of view. We also reviewed in vitro and in vivo literature data and other national published guidelines on this issue so far. On the basis of literature data and consensus of experts, a detailed approach based on risk stratification and appropriate management of RT patients with CIEDs is suggested, with important implications for clinical practice.

Transapical approach to optimize left ventricular resynchronization in patients with dilated cardiomyopathy.

An alternative to coronary sinus implantation for a left ventricular pacing lead is frequently needed for cardiac resynchronization therapy. We have developed a transapical approach to implant an endocardial pacing lead that will reach the most delayed segment of the left ventricle. This method is easily combined with other transapical heart surgeries. After some technological improvement our technique should offer easier access and better results than other currently available implantation methods.

Transapical approach to optimize left ventricular resynchronization in patients with dilated cardiomyopathy.

An alternative to coronary sinus implantation for a left ventricular pacing lead is frequently needed for cardiac resynchronization therapy. We have developed a transapical approach to implant an endocardial pacing lead that will reach the most delayed segment of the left ventricle. This method is easily combined with other transapical heart surgeries. After some technological improvement, our technique should offer easier access and better results than other currently available implantation methods.

Radiotherapy in patients with pacemakers and implantable cardioverter defibrillators: a literature review.

An increasing number of patients with implantable cardiac rhythm devices undergo radiotherapy (RT) for cancer and are thereby exposed to the risk of device failure. Current safety recommendations seem to have limitations by not accounting for the risk of pacemakers and implantable cardioverter defibrillators malfunctioning at low radiation doses. Besides scant knowledge about optimal safety measures, only little is known about the exact prevalence of patients with devices undergoing RT. In this review, we provide a short overview of the principles of RT and present the current evidence on the predictors and mechanisms of device malfunctions during RT. We also summarize practical recommendations from recent publications and from the industry. Strongly associated with beam energy of photon RT, device malfunctions occur at ∼3% of RT courses, posing a substantial issue in clinical practice. Malfunctions described in the literature typically consist of transient software disturbances and only seldom manifest as a permanent damage of the device. Through close cooperation between cardiologists and oncologists, a tailored individualized approach might be necessary in this patient group in waiting time for updated international guidelines in the field.

Initial Experience of an Anesthesiology-based Service for Perioperative Management of Pacemakers and Implantable Cardioverter Defibrillators.

BACKGROUND: Management of cardiovascular implantable electronic devices (CIEDs), including pacemakers and implantable cardioverter defibrillators, for surgical procedures is challenging due to the increasing number of patients with CIEDs and limited availability of trained providers. At the authors' institution, a small group of anesthesiologists were trained to interrogate CIEDs, devise a management plan, and perform preoperative and postoperative programming and device testing whenever necessary. METHODS: Patients undergoing surgery between October 1, 2009 and June 30, 2013 at the University of Washington Medical Center were included in a retrospective chart review to determine the number of devices actively managed by the Electrophysiology/Cardiology Service (EPCS) versus the Anesthesiology Device Service (ADS), changes in workload over time, surgical case delays due to device management, and errors and problems encountered in device programming. RESULTS: The EPCS managed 254 CIEDs, the ADS managed 548, and 227 by neither service. Over time, the ADS providers managed an increasing percentage of devices with decreasing supervision from the EPCS. Only two CIEDs managed by the ADS required immediate assistance from the EPCS. Patients who were unstable postoperatively were referred to the EPCS. Although numerous issues in programming were encountered, primarily when restoring demand pacing after programming asynchronous pacing for surgery, no patient harm resulted from ADS or EPCS management of CIEDs. CONCLUSIONS: An ADS can provide safe CIED management for surgery, but it requires specialized provider training and strong support from the EPCS. Due to the complexity of CIED management, an ADS will likely only be feasible in high-volume settings.

The use of 1.5 T magnetic resonance imaging for therapeutic decisions in patients with cardiac implantable electronic devices and significant neurological, neurosurgical and neuro-oncology diagnostic indications.

UNLABELLED: Between September 2009 and May 2014 the classification of 36 patients with cardiac implantable electronic devices (CIEDs) in terms of the feasibility of MRI scanning due to strong clinical indications was carried out. Finally MRI examinations were performed in 20 patients, of whom 27 studies were conducted and a total number of 35 anatomical regions were scanned. Neurological, neurosurgical and neuro-oncology indications for MRI were reported in 19 patients (95%) in whom 26 MRI studies (96.3%) were performed, and 34 anatomical regions (97.1%) were scanned. One patient had indications for MRI in the field of cardiology. Medical information obtained from 27 MRI studies allowed decisions to be made regarding the treatment in all patients. After 8 studies (29.6%), patients were classified into 9 different neurosurgical procedures. In the case of the remaining 19 studies (70.4%), there were no indications for surgical treatment and the decisions to implement conservative treatment were made. There were no complications related to the implanted CIEDs observed: neither immediate nor in the follow-up.

Preventing radiotherapy-induced side effects on deep brain stimulators: the need for a multidisciplinary management.

Brain pacemaker (BPM) systems are similar to cardiac pacemaker (CPM). On CPM, damage caused by ionizing radiation may lead to failure of the device. We report here a clinical situation of a patient treated with BPM and receiving cerebral radiotherapy. Strategies for protection of BPM from radiation damages are discussed.