RESUMO
The subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to transvenous ICD in patients who do not need cardiac pacing. We report the case of a young isometric athlete who received S-ICD for primary prevention of sudden death. Lead dislodgement and myopotential noise oversensing during isometric training led to inappropriate shock, and a surgical revision was performed. During the procedure, strong fibrous adhesions were found, requiring polytetrafluoroethylene dilator sheaths. The S-ICD was finally reimplanted. Despite continued isometric training, no more myopotential oversensing occurred after 1-year follow-up. The present case highlights the possible higher risks of lead complication in an isometric athlete and the uncommon effort in removing an old-generation subcutaneous defibrillator lead.
Assuntos
Síndrome de Brugada/terapia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis/efeitos adversos , Falha de Equipamento , Atletas , Síndrome de Brugada/fisiopatologia , Eletrocardiografia , Fluoroscopia , Humanos , Masculino , Prevenção Primária , Reoperação , Levantamento de Peso , Adulto JovemRESUMO
AIMS: A sub-analysis of the ESC-EHRA European Lead Extraction ConTRolled (ELECTRa) Registry to evaluate the clinical impact of antithrombotic (AT) on transvenous lead extraction (TLE) safety and efficacy. METHODS AND RESULTS: ELECTRa outcomes were compared between patients without AT therapy (No AT Group) and with different pre-operative AT regimens, including antiplatelets (AP), anticoagulants (AC), or both (AP + AC). Out of 3510 pts, 2398 (68%) were under AT pre-operatively. AT patients were older with more comorbidities (P < 0.0001). AT subgroups, defined as AP, AC, or AP + AC, were 1096 (31.2%), 985 (28%), and 317 (9%), respectively. Regarding AP patients, 1413 (40%) were under AP, 1292 (91%) with a single AP, interrupted in 26% about 3.8 ± 3.7 days before TLE. In total, 1302 (37%) patients were under AC, 881 vitamin K antagonist (68%), 221 (17%) direct oral anticoagulants, 155 (12%) low weight molecular heparin, and 45 (3.5%) unfractionated heparin. AC was 'interrupted without bridging' in 696 (54%) and 'interrupted with bridging' in 504 (39%) about 3.3 ± 2.3 days before TLE, and 'continued' in 87 (7%). TLE success rate was high in all subgroups. Only overall in-hospital death (1.4%), but not the procedure-related one, was higher in the AT subgroups (P = 0.0500). Age >65 years and New York Heart Association Class III/IV, but not AT regimens, were independent predictors of death for any cause. Haematomas were more frequent in AT subgroups, especially in AC 'continued' (P = 0.025), whereas pulmonary embolism in the No-AT (P < 0.01). CONCLUSIONS: AT minimization is safe in patients undergoing TLE. AT does not seem to predict death but identifies a subset of fragile patients with a worse in-hospital TLE outcome.
Assuntos
Remoção de Dispositivo/efeitos adversos , Eletrodos Implantados , Fibrinolíticos/administração & dosagem , Marca-Passo Artificial , Complicações Pós-Operatórias/epidemiologia , Fatores Etários , Idoso , Comorbidade , Falha de Equipamento , Europa (Continente)/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de RiscoRESUMO
AIMS: Female sex is considered an independent risk factor of transvenous leads extraction (TLE) procedure. The aim of the study was to evaluate the effectiveness of TLE in women compared with men. METHODS AND RESULTS: A post hoc analysis of risk factors and effectiveness of TLE in women and men included in the ESC-EHRA EORP ELECTRa registry was conducted. The rate of major complications was 1.96% in women vs. 0.71% in men; P = 0.0025. The number of leads was higher in men (mean 1.89 vs. 1.71; P < 0.0001) with higher number of abandoned leads in women (46.04% vs. 34.82%; P < 0.0001). Risk factors of TLE differed between the sexes, of which the major were: signs and symptoms of venous occlusion [odds ratio (OR) 3.730, confidence interval (CI) 1.401-9.934; P = 0.0084], cumulative leads dwell time (OR 1.044, CI 1.024-1.065; P < 0.001), number of generator replacements (OR 1.029, CI 1.005-1.054; P = 0.0184) in females and the number of leads (OR 6.053, CI 2.422-15.129; P = 0.0001), use of powered sheaths (OR 2.742, CI 1.404-5.355; P = 0.0031), and white blood cell count (OR 1.138, CI 1.069-1.212; P < 0.001) in males. Individual radiological and clinical success of TLE was 96.29% and 98.14% in women compared with 98.03% and 99.21% in men (P = 0.0046 and 0.0098). CONCLUSION: The efficacy of TLE was lower in females than males, with a higher rate of periprocedural major complications. The reasons for this difference are probably related to disparities in risk factors in women, including more pronounced leads adherence to the walls of the veins and myocardium. Lead management may be key to the effectiveness of TLE in females.
Assuntos
Dispositivos de Terapia de Ressincronização Cardíaca , Desfibriladores Implantáveis , Remoção de Dispositivo , Complicações Intraoperatórias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Infecções Relacionadas à Prótese/terapia , Idoso , Idoso de 80 Anos ou mais , Fontes de Energia Elétrica , Europa (Continente) , Feminino , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Marca-Passo Artificial , Sistema de Registros , Fatores Sexuais , Fatores de Tempo , Insuficiência da Valva Tricúspide/epidemiologia , Trombose Venosa/epidemiologiaRESUMO
Implantation of cardiac resynchronization therapy (CRT) devices can be challenging, time consuming, and associated with high-dose x-ray exposure. We present the technique in which an electromagnetic navigation system (MediGuideTM, St. Jude Medical) and an electroanatomical three-dimensional mapping system (EnSite NavX, St Jude Medical) are usefully combined for implanting implantable cardioverter defibrillator CRT devices with strong reduction of x-ray exposure, and for targeting the most delayed regions in the activation maps avoiding scars for optimal CRT response.
Assuntos
Dispositivos de Terapia de Ressincronização Cardíaca , Fenômenos Eletromagnéticos , Mapeamento Epicárdico , Implantação de Prótese/métodos , Eletrocardiografia , Desenho de Equipamento , Fluoroscopia , Humanos , Doses de RadiaçãoRESUMO
Use of cardiac implantable devices and catheter ablation is steadily increasing in Western countries following the positive results of clinical trials. Despite the advances in scientific knowledge, tools development, and techniques improvement we still have some grey area in the field of electrical therapies for the heart. In particular, several reports highlighted differences both in medical behaviour and procedural outcomes between female and male candidates. Women are referred later for catheter ablation of supraventricular arrhythmias, especially atrial fibrillation, leading to suboptimal results. On the opposite females present greater response to cardiac resynchronization, while the benefit of implantable defibrillator in primary prevention seems to be less pronounced. Differences on aetiology, clinical profile, and development of myocardial scarring are the more plausible causes. This review will discuss all these aspects together with gender-related differences in terms of acute/late complications. We will also provide useful hints on plausible mechanisms and practical procedural aspects.
Assuntos
Arritmias Cardíacas/terapia , Ablação por Cateter , Cardioversão Elétrica , Disparidades em Assistência à Saúde , Avaliação de Processos em Cuidados de Saúde , Idoso , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/fisiopatologia , Terapia de Ressincronização Cardíaca/efeitos adversos , Terapia de Ressincronização Cardíaca/mortalidade , Dispositivos de Terapia de Ressincronização Cardíaca , Ablação por Cateter/efeitos adversos , Ablação por Cateter/mortalidade , Congressos como Assunto , Desfibriladores Implantáveis , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/mortalidade , Feminino , Disparidades nos Níveis de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Sexuais , Resultado do TratamentoRESUMO
AIMS: Actual rates of lead vegetations (LVs) in cardiovascular device infections (CDI) are debated in this study. The aim of this study is to characterize prevalence and risk factors of LV in patients with CDI treated with lead extraction (LE). METHODS AND RESULTS: Between 2003 and 2011, 293 leads were extracted from 136 patients (age 70.5 ± 14.5 years, 109 male) with infective indications: 39.2% chronic draining sinus, 20.9% pocket infections, and 28.8% systemic infections/sepsis. All patients underwent transesophageal echocardiography (TEE) before LE. Lead vegetation prevalence was 40.4%: 62.2% in systemic infection, but noteworthy in local infection/chronic draining sinus (21.9/36.4%). Younger age, renal disease, ad dialysis were associated with systemic infection. Fever after last intervention, revision, previous reparative procedure, infection at wound/device site and infection >6 months were associated with local infection/chronic draining sinus. Cardiac resynchronization therapy device, fever after last intervention, infection <6 months, renal disease, dialysis, abnormal chest X-ray, fever at admission, pulmonary symptoms, white blood cell (WBC) count, erythrocyte sedimentation rate, C-reactive protein increase and positive blood samples were related to LV. Risk of vegetations was reduced by antibiotic prophylaxis. Multivariate analysis indicated that renal failure and increased WBC count were related to LV. CONCLUSION: Lead vegetations were frequently observed in patients with only local symptoms. Therefore, TEE should be mandatory in all patients undergoing LE for infective indications.
Assuntos
Desfibriladores Implantáveis/estatística & dados numéricos , Eletrodos Implantados/estatística & dados numéricos , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/prevenção & controle , Marca-Passo Artificial/estatística & dados numéricos , Infecções Relacionadas à Prótese/epidemiologia , Insuficiência Renal/epidemiologia , Idoso , Comorbidade , Feminino , Humanos , Incidência , Itália/epidemiologia , Contagem de Leucócitos/estatística & dados numéricos , Masculino , Fatores de RiscoRESUMO
Cardiac resynchronization therapy (CRT) was shown to improve cardiac function, reduce heart failure hospitalizations, improve quality of life and prolong survival in patients with severe left ventricular dysfunction and intraventricular conduction disturbances, mainly left bundle branch block, on optimal medical therapy with ACE-inhibitors, ß-blockers and mineralocorticoid receptor antagonists up-titrated to maximum tolerated evidence-based doses. CRT can be achieved by means of pacemaker systems (CRT-P) or devices with defibrillation capabilities (CRT-D). CRT-Ds offer an undoubted advantage in the prevention of arrhythmic death, but such an advantage may be of lesser degree in nonischemic heart failure etiologies. Moreover, the higher CRT-D hardware complexity compared to CRT-P may predispose to device/lead malfunctions and the higher current drainage may cause a shorter battery duration with consequent premature replacements and the well-known incremental complications. In a period of financial constraints, also device costs should be carefully evaluated, with recent reports suggesting that CRT-Ps may be favored over CRT-Ds in patients with nonischemic cardiomyopathy and no prior history of cardiac arrhythmias from a cost-effectiveness point of view. The choice between a CRT-P or a CRT-D device should be patient-tailored whenever straightforward defibrillator indications are not present. The Goldenberg score may facilitate this decision-making process in ambiguous settings. Age, comorbidities, kidney disease, atrial fibrillation, advanced functional class, inappropriate therapy risk, implantable device infections, and malfunctions are factors potentially reducing the expected benefit from defibrillating capabilities. In the future, prospective randomized controlled trials are warranted to directly compare the efficacy and safety of CRT-Ps and CRT-Ds.
Assuntos
Terapia de Ressincronização Cardíaca , Desfibriladores Implantáveis , Insuficiência Cardíaca , Humanos , Estudos Prospectivos , Qualidade de Vida , Resultado do TratamentoRESUMO
PURPOSE: Left atrial volume index (LAVI) is a predictor of heart failure and adverse events, irrespective of left ventricular systolic function. The role of LAVI in the prediction of appropriate implantable cardioverter-defibrillator (ICD) therapies is currently unclear and was the focus of this study. METHODS: Consecutive heart failure patients with ischaemic (ICM) or idiopathic (DCM) aetiology receiving ICD for primary prevention were included. The primary endpoint was the occurrence of appropriate ICD therapies (ATs): shocks or antitachycardia pacing (ATP). Inappropriate ICD shocks were also assessed as secondary endpoint. RESULTS: Among 198 included patients, severe left atrial dilatation (SLAE = LAVI ≥ 60 ml/m2) was present in 54 (27%). SLAE patients had a higher prevalence of NYHA class ≥ III, severe mitral regurgitation and atrial fibrillation history. During a median follow-up of 45 months (IQR 25-68), ATs occurred more frequently in SLAE group (33% vs. 15%, p = .007) as well as appropriate shocks (24% vs. 10%, p = .014). At multivariate analysis SLAE was an independent predictor of ATs (OR 3.19, 95% CI 1.38-7.38, p = .007). Inappropriate shocks were associated with AF during implantation (p = .03), but not with SLAE (p = .009). CONCLUSION: In DCM or ICM patients candidate to receive an ICD for primary prevention, a severely enlarged left atrium is a predictive factor for ATs (shocks or ATP). The risk of inappropriate shocks was increased in patients with atrial fibrillation, rather than SLAE.
Assuntos
Fibrilação Atrial , Desfibriladores Implantáveis , Insuficiência Cardíaca , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Desfibriladores Implantáveis/efeitos adversos , Humanos , Prevenção Primária , Prognóstico , Resultado do TratamentoRESUMO
In children, intracardiac loops are created to avoid a lead's fracture due to rapid body growth. Selective site pacing needs the insertion of two 4.1 Fr lumenless leads that do not allow direct manoeuvrability and should be extracted when tension on the lead occurs. We describe an easy, safe, and inexpensive technique to reposition the leads and generate new intracardiac loops.
Assuntos
Bloqueio Atrioventricular/terapia , Estimulação Cardíaca Artificial/métodos , Eletrodos Implantados , Átrios do Coração/crescimento & desenvolvimento , Marca-Passo Artificial , Pré-Escolar , Desenho de Equipamento , Feminino , Humanos , Resultado do TratamentoRESUMO
AIMS: In pacemaker patients with Gram-positive occult bacteremia, it is reasonable to remove the whole stimulation system, but therapeutic decision is sometimes very challenging. METHODS AND RESULTS: A young patient at 6 years of age underwent dual-chamber pacemaker implantation due to complete atrioventricular block after mitral valve replacement. He felt well until November 2008, when he suffered from febrile illness with blood cultures disclosing methicillin-resistant staphylococcus aureus strain. Repeated antibiotic courses were effective only in obtaining temporary remissions. Consecutive transoesophageal echocardiography examinations were inconclusive. A labelled leucocyte scintigraphy, showing increased captation along leads, was very helpful and critical in guiding our decision to extract leads. CONCLUSION: In equivocal cases, or when the hazard of extraction procedure is presumably high, every accessory diagnostic tool (like scintigraphy with labelled leucocytes) is helpful in establishing a definitive diagnosis and in strengthening a somewhat difficult decision.
Assuntos
Bacteriemia/etiologia , Bacteriemia/terapia , Eletrodos Implantados/efeitos adversos , Eletrodos Implantados/microbiologia , Próteses Valvulares Cardíacas/efeitos adversos , Próteses Valvulares Cardíacas/microbiologia , Marca-Passo Artificial/efeitos adversos , Marca-Passo Artificial/microbiologia , Antibacterianos/uso terapêutico , Bacteriemia/diagnóstico , Criança , Remoção de Dispositivo , Humanos , MasculinoRESUMO
BACKGROUND: 'Idiopathic' lead macrodislodgement may be due to Twiddler's syndrome depending on active twisting of pulse generator within subcutaneous pocket. All leads are involved, at any time from implantation, and frequently damaged. In the past few years, a reel syndrome was also observed: retraction of pacemaker leads into pocket without patient manipulation, owing to lead circling the generator. In other cases, a 'ratchet' mechanism has been postulated. Reel and ratchet mechanisms require loose anchoring, occur generally briefly after implantation, with non-damaged leads. We report the first case of an active-fixation coronary sinus lead selective macrodislodgement involving such ratchet mechanism. CASE SUMMARY: A 65-year-old man underwent biventricular defibrillator device implantation, with active-fixation coronary sinus lead. Eight months later, he complained of muscle contractions over device pocket. At fluoroscopy, coronary sinus lead was found near to pocket, outside of thoracic inlet. Atrial and ventricular leads were in normal position. After opening pocket, a short tract of coronary sinus lead appeared anteriorly dislocated to generator, while greater length of lead body twisted a reel behind. The distal part of lead was found outside venous entry at careful dissection. Atrial and ventricular leads were firmly anchored. DISCUSSION: Our case is a selective 'Idiopathic' lead macrodislodgement, possibly due to a ratchet mechanism between the lead and the suture sleeve, induced by normal arm motion; such mechanism incredibly, and for first time in literature involves a coronary sinus active-fixation lead. CONCLUSION: Careful attention should always be paid to secure anchoring even of active-fixation coronary sinus leads.
RESUMO
The original version of this article unfortunately contained a mistake.
RESUMO
BACKGROUND: Diuretic resistance portends a poor prognosis in acute heart failure, especially in advanced stages. Early identification of a poor response to diuretics may help to improve treatment and outcomes. Spot natriuresis (UNa+) at 2 h from the start of intravenous furosemide has been proposed as an early indicator of diuretic response. Our paper aimed to determine the role of early natriuresis in patients hospitalized with advanced chronic heart failure (ACHF) and high risk of diuretic resistance. METHODS AND RESULTS: We performed a sub-analysis of the DRAIN trial, a randomized clinical trial on 80 patients with acute decompensation of ACHF (NYHA IV, EF ≤ 30%) with low systolic blood pressure (≤ 110 mmHg) and dilutional hyponatremia (sodium ≤ 135 mMol/L) at admission. Patients were divided into two groups according to spot urinary sodium excretion (high: UNa+ > 50 or low: ≤ 50 mEq/L) at 2 h from furosemide administration. Twenty-eight patients (35%) showed a low natriuretic response. As compared to the other patients, this group showed lower daily urinary output (2275 ± 790 vs 3849 ± 2034 mL, p < 0.001), lower body weight reduction after 48 h (1.55 ± - 1.66 vs - 3.55 ± - 2.93 kg, p < 0.001), higher incidence of worsening renal function (32% vs 10%, p 0.02) and increasing rather than reducing NT-proBNP at 72 h (p 0.02). CONCLUSIONS: In patients with ACHF and dilutional hyponatremia, low natriuresis after furosemide is an early marker of poor diuretic response and correlates with higher NT-proBNP and higher incidence of worsening renal function at 72 h.
Assuntos
Diuréticos/administração & dosagem , Furosemida/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Sódio/urina , Administração Intravenosa , Idoso , Biomarcadores/metabolismo , Diuréticos/farmacologia , Método Duplo-Cego , Resistência a Medicamentos , Feminino , Furosemida/farmacologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Hiponatremia/epidemiologia , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Natriurese/efeitos dos fármacos , Peptídeo Natriurético Encefálico , Fragmentos de Peptídeos , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Diuretic resistance is a common issue in patients with acute decompensation of advanced chronic heart failure (ACHF). The aim of this trial was to compare boluses and continuous infusion of furosemide in a selected population of patients with ACHF and high risk for diuretic resistance. METHODS: In this single-centre, double-blind, double-dummy, randomized trial, we enrolled 80 patients admitted for acute decompensation of ACHF (NYHA IV, EF ≤ 30%) with criteria of high risk for diuretic resistance (SBP ≤ 110 mmHg, wet score ≥ 12/18, and sodium ≤ 135 mMol/L). Patients were assigned in a 1:1 ratio to receive furosemide by bolus every 12 h or by continuous infusion. Diuretic treatment and dummy treatment were prepared by a nurse unassigned to patients' care. The study treatment was continued for up to 72 h. Coprimary endpoints were total urinary output and freedom from congestion at 72 h. RESULTS: 80 patients were enrolled with 40 patients in each treatment arm. Mean daily furosemide was 216 mg in continuous-infusion arm and 195 mg in the bolus intermittent arm. Freedom from congestion (defined as jugular venous pressure of < 8 cm, with no orthopnea and with trace peripheral edema or no edema) occurred more in the continuous infusion than in the bolus arm (48% vs. 25%, p = 0.04), while total urinary output after 72 h was 8612 ± 2984 ml in the bolus arm and 10,020 ± 3032 ml in the continuous arm (p = 0.04). Treatment failure occurred less in the continuous-infusion group (15% vs. 38%, p = 0.02), while there was no significant difference between groups in the incidence of worsening of renal function. CONCLUSION: Among patients with acute decompensation of ACHF and high risk of diuretic resistance, continuous infusion of intravenous furosemide was associated with better decongestion. DRAIN TRIAL: ClinicalTrials.gov number NCT03592836.
Assuntos
Edema/prevenção & controle , Furosemida/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Inibidores de Simportadores de Cloreto de Sódio e Potássio/administração & dosagem , Idoso , Pressão Venosa Central/efeitos dos fármacos , Doença Crônica , Método Duplo-Cego , Esquema de Medicação , Resistência a Medicamentos , Edema/diagnóstico , Edema/fisiopatologia , Feminino , Furosemida/efeitos adversos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Infusões Intravenosas , Injeções Intravenosas , Itália , Masculino , Pessoa de Meia-Idade , Inibidores de Simportadores de Cloreto de Sódio e Potássio/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
AIM: Obesity is associated with an increased cardiovascular risk. This study aimed to assess the role of echocardiography in the early detection of subclinical cardiac abnormalities in a cohort of obese patients with a preserved ejection fraction (EF) undergoing bariatric surgery. METHODS AND RESULTS: Forty consecutive severely obese patients (body mass index≥35 kg/m2) referring to our center for bariatric surgery were enrolled in this prospective cohort study. Despite a baseline EF of 61% ± 3%, almost half patients (43%) had a systolic dysfunction (SD) defined as global longitudinal strain (GLS)>-18%, and most of them (60%) had left ventricular hypertrophy (LVH) or concentric remodeling (CR). At 10-months after surgery, body weight decreased from 120 ± 15 kg to 83 ± 12 kg, body mass index from 44 ± 5 kg/m2 to 31 ± 5 kg/m2 (both P < 0.001). Septal and left ventricular posterior wall thickness decreased respectively from 10 ± 1 mm to 9 ± 1 mm (P = 0.004) and from 10 ± 1 mm to 9 ± 1 mm (P = 0.007). All systolic parameters improved: EF from 61% ± 3% to 64% ± 3% (P = 0.002) and GLS from -17% ± 2% to -20% ± 1% (P < 0.001). Epicardial fat thickness reduction (from 4.7 ± 1 mm to 3.5 ± 0.7 mm, P < 0.001) correlated with the reduction of left atrial area (P < 0.001 R = 0.35) and volume (P = 0.02 R = 0.25). Following bariatric surgery, we observed a reduced prevalence of LVH/CR (before 60%, after 22%, P = 0.001) and a complete resolution of preclinical SD (before 43%, after 0%, P < 0.001). Moreover, a postoperative reduction of at least 30 kg correlated with regression of septal hypertrophy (P < 0.001). CONCLUSIONS: Obese patients candidate to bariatric surgery have an high prevalence of preclinical SD and LVH/CR, early detectable with echocardiography. Bariatric surgery is associated with reverse cardiac remodeling; it might also have a preventive effect on atrial fibrillation occurrence by reducing its substrate.
RESUMO
BACKGROUND: Recent studies suggest that atrioventricular (AV) conduction may recover after pacemaker (PM) implantation following transcatheter aortic valve replacement (TAVR), but little is known about long-term follow-up of such patients. OBJECTIVE: The purpose of this study was to evaluate the long-term percentage of right ventricular pacing in patients who underwent TAVR and required PM implantation stratified based on the indication for permanent pacing. METHODS: Retrospective analysis of all consecutive patients who underwent TAVR from February 2008 to August 2019 at 3 centers was performed. Patients already implanted with a PM/implantable cardioverter-defibrillator (ICD) before TAVR, implanted with a cardiac resynchronization therapy device, or implanted >30 days after TAVR were excluded. Eligible patients were divided into 2 groups based on the presence (persistent atrioventricular block [AVB] group) or absence (nonpersistent AVB group) of persistent third-degree AVB after TAVR. RESULTS: A total of 1594 patients underwent TAVR. Two hundred four patients were implanted with a PM or ICD after TAVR and 32 met exclusion criteria, so 172 patients were eligible (median time TAVR-PM implant 4 days) for a total of 352 follow-up visits analyzed. A significant difference in the percentage of ventricular pacing was observed at follow-up performed 7-90 days after implantation (98% persistent AVB group vs 8% nonpersistent AVB group; P <.001). This difference remained significant at follow-up performed 91-270 days (95% vs 3.5%; P <.001), 271-540 days (95.5% vs 3%; P = .006), and 541-900 days (97.4% vs 2.2%; P <.001) after implantation. CONCLUSION: Patients requiring PM implantation due to persistent third-degree AVB after TAVR were less likely to show AV conduction recovery, whereas patients implanted for other indications showed a low percentage of pacing during follow-up.
Assuntos
Valva Aórtica/cirurgia , Bloqueio Atrioventricular/terapia , Estimulação Cardíaca Artificial/métodos , Sistema de Condução Cardíaco/fisiopatologia , Doenças das Valvas Cardíacas/cirurgia , Complicações Pós-Operatórias , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso de 80 Anos ou mais , Bloqueio Atrioventricular/etiologia , Bloqueio Atrioventricular/fisiopatologia , Feminino , Seguimentos , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Fatores de TempoAssuntos
Síndrome de Brugada/terapia , Desfibriladores Implantáveis/efeitos adversos , Infecções Relacionadas à Prótese/diagnóstico por imagem , Infecções Relacionadas à Prótese/microbiologia , Infecções Estafilocócicas/diagnóstico por imagem , Infecções Estafilocócicas/microbiologia , Síncope/terapia , Idoso , Remoção de Dispositivo , Ecocardiografia , Contaminação de Equipamentos , Falha de Equipamento , Humanos , Leucócitos , Cintilografia , Staphylococcus epidermidis/isolamento & purificaçãoRESUMO
AIMS: Pacemaker and implantable-cardioverter defibrillator lead infections widely increased with consequent need to accurately recognize responsible bacteria. METHODS: Between May 2003 and December 2007, we extracted 118 leads, 104 (87.3%) due to infections (sepsis, lead-associated endocarditis, pocket infection) or chronic draining sinus (with negative local bacteriological analyses). Swabs and tissue specimens from pocket and fragments of pin and tip of each extracted lead were obtained during extraction and sent for bacteriological examination. RESULTS: Cultures from explanted lead pins returned positive results in 100% of the cases presenting with local infections and in 92.5% of those with chronic draining sinus. In cases of sepsis, positive results of blood samples are less common than lead samples (58.3 vs 86.7, P = 0.02), the latter being more sensitive for infection diagnosis. Concordance between bacterial isolates from pocket and lead is quite low, approaching 45%, seemingly due to contamination effect. Concordance between isolates within the lead (pin and tip) is quite high, close to 70%, reflecting a more accurate expression of the real infection. In cases of sepsis, concordance between lead and blood samples, and mainly from tip and blood, is very high, resembling 80-85%; consequently bacterial isolates from the lead, particularly from lead tip, are clearly associated with clinical infections. CONCLUSIONS: Our results strongly support the hypothesis that chronic draining sinus is often sustained by infection. Moreover, diagnostic accuracy of lead samples is higher not only than swabs and tissue samples, but also than blood samples to confirm an infection and to guide effective therapy.
Assuntos
Infecções Bacterianas/diagnóstico , Desfibriladores Implantáveis/microbiologia , Marca-Passo Artificial/microbiologia , Infecções Relacionadas à Prótese/diagnóstico , Idoso , Infecções Bacterianas/microbiologia , Remoção de Dispositivo , Feminino , Humanos , Masculino , Estudos Prospectivos , Infecções Relacionadas à Prótese/microbiologia , Sensibilidade e Especificidade , Infecções Estafilocócicas/diagnóstico , Técnicas de Cultura de TecidosRESUMO
: Cardiac implantable electronic device (CIED) implantation has greatly increased, with an associated exponential increase in CIED infections (CDIs). Cardiac device related infective endocarditis (CDRIE) has high morbidity and mortality: approximately 10-21%. Therefore, a prompt diagnosis and radical treatment of CDRIE are needed; transvenous lead extraction (TLE) is the mainstay for the complete healing, even if associated with wide logistic problems, high therapeutic costs and high mortality risk for patients. Some criticisms about the value of Duke criteria and their limitations for the diagnosis of CDRIE are known. The significance of classic laboratory data, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), considered in the Duke score, are reviewed and critically discussed in this article, with regard to the specific field of the diagnosis of CDI. The need for new techniques for achieving the diagnostic reliability has been well perceived by physicians, and additional techniques have been introduced in the new European Society of Cardiology (ESC) and British Heart Rhythm Society (BHRS) guidelines on infective endocarditis. These suggested techniques, such as 18-Fluorodeoxyglucose PET/computed tomography (FDG-PET/CT), white blood cell PET (WBC PET) and lung multislice CT (MSCT), are also discussed in the study. This short review is intended as an extensive summary of the diagnostic workflow in cases of CDI and will be useful for readers who want to know more about this issue.
Assuntos
Procedimentos Clínicos , Desfibriladores Implantáveis/efeitos adversos , Remoção de Dispositivo , Endocardite Bacteriana/diagnóstico por imagem , Endocardite Bacteriana/cirurgia , Marca-Passo Artificial/efeitos adversos , Infecções Relacionadas à Prótese/diagnóstico por imagem , Infecções Relacionadas à Prótese/cirurgia , Fluxo de Trabalho , Antibacterianos/uso terapêutico , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/mortalidade , Endocardite Bacteriana/microbiologia , Endocardite Bacteriana/mortalidade , Humanos , Valor Preditivo dos Testes , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Finding of intracardiac lead masses in patients with cardiac implantable electronic devices remains controversial, as such masses have been observed in cases of exclusively local infections whereas they have not been recognized in patients with positive cultures of intravascular lead fragments. In this study, we aim to describe the prevalence of intracardiac lead masses in true asymptomatic patients with cardiac implantable electronic devices, to identify their predictive factors and to define their prognostic impact at long-term follow-up. METHODS: Seventy-eight consecutive patients admitted over a 6-month period for elective generator replacement without clinical evidence of infection were evaluated by transthoracic and transesophageal echocardiography and prospectively followed at in-clinic follow-up visits. RESULTS: Lead masses were found in 10 patients (12.8%). These patients had more frequently right ventricular dysfunction at univariate analysis (OR 2.71, Pâ=â0.010) and after baseline variables adjustment (hazard ratio 6.25, Pâ=â0.012). At 5-year follow-up without any specific therapy, none of the patients suffered from any cardiac device infections, or developed clinical signs of infections. CONCLUSION: There is an evidence of clinical lead masses in asymptomatic patients with cardiac implantable electronic devices. The value of these findings is still debated for aetiological interpretation and for therapeutic strategy, but they are not necessarily associated with an infection.