Role of routine investigations post cardiac devices implants in detecting peri-procedural complications: A retrospective analysis from a tertiary UK center.

BACKGROUND: Peri-procedural complications associated with cardiac implantable electronic devices are not uncommon. European Society of Cardiology guidelines recommend device checks of all devices within 72 h of implant. European Heart Rhythm Association expert practical guide on Cardiac implantable electronic devices (CIEDs) recommend that a chest x-ray (CXR) should be performed within 24 h to rule out pneumothorax and document lead positions. First, the rate of peri-procedural complications associated with CIED implants at our center, as well as patient and/or procedural-related factors that are associated with higher rates of complications, is analyzed. Second, the yield of the guideline-recommended measures in the early detection of peri-procedural complications is examined. MATERIALS AND METHODS: Consecutive de novo transvenous device implants at our center in 2019 were retrospectively analyzed. Patients' demographics, types and indications for device therapy, procedural reports, device checks, and CXRs were obtained from the hospital electronic records. RESULTS: A total of 578 patients (Age 74 ± 16 years, 68% male) were included. All patients had routine post-procedure CXRs and device checks. There were 16 (2.8%) complications; 7 (1.2%) pneumothoraxes, 6 (1%) pericardial effusions, and 3 (0.5%) lead displacements. Procedure time correlated significantly with complications; in uncomplicated cases it was 99 ± 43 min versus 127 ± 50 min in procedures associated with complications (p = .02). CONCLUSIONS: Routine post CIED implantation CXRs can detect early peri-procedural complications, while repeat post mobilization device checks has low yield of detection of complications. The only statistically significant predictor of peri-procedural complications is the duration of the procedure; longer procedures were associated with higher rates of complications.

A cluster of inappropriate shocks in a pediatric S-ICD patient - how to troubleshoot?

We present the case of a 16-year-old male pediatric patient diagnosed with hypertrophic cardiomyopathy (HCM, identified as having a high risk of sudden cardiac death (SCD), who underwent a successful subcutaneous implantable cardiac defibrillator (S-ICD) implantation as a primary prevention measure in 2018. His past medical history included ADHD, Autism, and panic attacks. The patient experienced appropriate shocks that successfully terminated VF episodes. However, he also experienced multiple inappropriate shocks from the S-ICD, triggered by anxiety-induced tachycardia during panic episodes. Meticulous assessment of S-ICD tracings and electrocardiograms (ECGs) revealed the erroneous classification of sinus tachycardia as sustained ventricular tachycardia, leading to unwarranted therapeutic interventions. Clinical intervention involved reprogramming of the S-ICD, emphasizing the pivotal role of personalized device configuration in pediatric cases where fine margins matter. While literature on S-ICD use in pediatric populations remains limited, emerging registries underscore the efficacy and safety of S-ICDs in preventing sudden cardiac death while reducing complications associated with intravascular leads. This case underscores the critical nature of customized device programming in pediatric patients, underscoring S-ICDs as a practical defibrillation alternative that addresses distinct concerns within this cohort of patients.

Outcome of left main stem percutaneous coronary intervention in a UK nonsurgical center: A 5-year clinical experience.

OBJECTIVES: To evaluate the outcome of unprotected left main stem (LMS) percutaneous coronary intervention (PCI) in a large UK nonsurgical center. BACKGROUND: PCI on unprotected LMS is increasingly regarded as a viable alternative to coronary artery bypass grafting (CABG) with comparable outcome and safety profile in select groups. The safety and efficacy of unprotected LMS PCI without on-site surgical back up has not been reported. METHODS: Data on all unprotected LMS PCI performed between January 2011 and December 2015, was collected from the local PCI database and electronic patient records. In hospital and 1-year major adverse cardiovascular events (MACE) (all-cause mortality, myocardial infarction [MI], stroke, and target vessel revascularization [TVR]) was recorded. RESULTS: 249 patients had unprotected LMS intervention during the study period. 77% of patients (n = 192) were male and mean age was 70 ± 12 years. 31% (n = 78) of cases were elective, 44% (n = 109) NSTEMI, and 25% (n = 62) STEMI. Anatomical distribution: 19% (n = 47) ostial left main, 31% (n = 77) shaft, and 50% (n = 125) bifurcation. The mean SYNTAX score was 24.4 ± 10.6. 22% (n = 55) of patients had severe LV impairment preprocedure and 13% (n = 33) were in cardiogenic shock at presentation. 35% (14%) required IABP support. The vast majority (98.4%) of procedures were successful. No patients required emergency transfer for CABG surgery. There were 25 (10%) in-hospital deaths. 68% of in-hospital deaths occurred in patients undergoing primary PCI for STEMI. 72% of patients who died were in cardiogenic shock at presentation. The 12-month MACE rate was 17.2%. Death occurred in 11.6%, MI in 2.4%, TVR in 2.4%, and stroke in 0.8% of patients. CONCLUSION: These results highlight the safety and efficacy of unprotected LMS PCI in a high volume non-surgical center.

A leadless pacemaker matched with a vasovagal syncope: how long can it last?

BACKGROUND: Guidelines recommend that cardiac pacing should be considered in patients suffering from frequent vasovagal syncopal (VVS) episodes. Studies have demonstrated the safety and efficacy of leadless pacemakers (LP) in cardioinhibitory vasovagal populations specifically, rendering them a reasonable alternative to transvenous pacing in these patients. However, due to the paucity of data on extraction and the number of concomitant LPs that can be safely implanted, there are concerns regarding LPs' battery longevity, especially in younger patients who may require decades of pacing therapy. METHODS: This is a retrospective analysis of the first 100 LPs implanted at a tertiary cardiac centre in the UK. Demographical data and device parameters at implant and follow-ups were obtained from the hospital's medical records. The battery life of the LPs in the VVS patients was compared to that of patients with other pacing indications. RESULTS: Ninety patients were included in the analysis. 14 patients (15.6%) had VVS, and 76 patients (84.4%) had other indications for pacing. Mean ages were 34 ± 13 years and 62 ± 20 years for the VVS and the other group, respectively. The estimated total battery life was 15.22 ± 0.35 and 13.65 ± 2.97 years in the VVS and the other indications group respectively (p = .04). There were no complications in the VVS group. CONCLUSION: LPs provide a promising treatment for patients with vasovagal syncope with reassuring battery performance at the short/intermediate term. Further longer-term follow-up data are needed to identify the true battery potential in this patient cohort.

The application of fluoroscopic criteria to define leadless pacemakers implant position and the effect of location on device performance.

OBJECTIVE: Leadless pacemakers (LPs) were designed to avoid complications associated with transvenous pacing. To minimise risk of perforations, there is preference towards implanting LPs into the septum rather than the apex or free wall.An objective yet feasible way of characterising the LP location is currently lacking. We report a simple radiological method of defining LP position and our analysis of the impact of implantation site on performance of LPs. METHODS: The first 100 LPs implanted at our UK centre were reviewed and the devices' positions in fluoroscopy images and X-rays based on conventional criteria for lead positions and conventional practice for LPs positioning were assessed. The devices' electrical parameters at implant and at the latest device follow-up were used to compare performance between implantation sites. RESULTS: 35.6% of implants were in the apex. 31.1% in mid-septum, 16.7% in apical septum, 15.5% on the septal right ventricular inflow and 1.1% in the septal RV outflow tract. We had no major complications.Thresholds, R-wave amplitudes, and impedance averaged at 0.67 ± 0.41 V, 10.64 ± 5.30 mV, and 777.67 ± 201.67 Ohms, respectively, at the time of implantation, and 0.66 ± 0.39 V, 14.08 ± 6.14 mV, and 564.29 ± 96.76 Ohms at the last device check. There was no difference in the pacing thresholds or impedance between implant sites. CONCLUSIONS: We propose a simple, reproducible way of defining the LP location which can help standardise the assessment of the device location sites across LP implantation centres. ADVANCES IN KNOWLEDGE: Emphasis on the safety and reliability of the leadless pacemakers in a real-world setting.Establishing the variation in the implantation sites for leadless pacemakers and reporting the effect of the implantation sites on the devices' performance.We propose a simple, reproducible way of defining the LP location which can help standardise the assessment of the device location sites across LP implantation centres.

Impact of right ventricular pacing site on the subcutaneous ICD sensing-a step towards personalised device therapy?

BACKGROUND: Patients with an existing subcutaneous implantable cardiac defibrillator (S-ICD) may develop a pacing indication. When transvenous pacing is not feasible, combining an S-ICD and a leadless pacemaker (LP) can be a reasonable option. There are reports of concomitant use of both devices. However, the effect of pacing on the S-ICD sensing is not well studied. We hypothesise that pacing changes R and T-wave amplitudes, causing changes in R:T ratios as perceived by a S-ICD, increasing the risk for T wave oversensing (TWO) during paced rhythm with a subsequent risk of inappropriate shocks. METHODS: This is a prospective study in patients undergoing electrophysiological studies. Participants were fitted with a Holter®, and the leads were placed to correspond to the vectors of an S-ICD. The right ventricle was paced at four positions for 10 beats each at 8 mA/2 ms. The Holter® traces were analysed, using two-way analysis of variance (ANOVA) to assess the effect of pacing on the R:T ratio. RESULTS: Forty-seven patients (age 56.02 ± 16.02, 72% male) were enrolled (81% structurally normal heart, 15% dilated cardiomyopathy, 2% ischaemic cardiomyopathy, and 2% adult congenital heart disease). Age, sex, and aetiology had no effect on the R:T ratio. Pacing caused significant changes in the R:T ratio. There was no significant difference in the R:T ratios between the pacing sites (p < 0.001). CONCLUSIONS: Pacing alters the R:T ratio significantly in most patients, theoretically increasing the risk for TWO and inappropriate shocks. Tailored programming for both devices is important for concomitant use of LPs and S-ICDs.

Clinical and echocardiographic follow-up of patients following surgical heart valve repair or replacement: a tertiary centre experience.

International best practice guidelines recommend lifelong follow-up of patients that have undergone valve repair or replacement surgery and provide recommendations on the utilization of echocardiography during follow-up. However, such follow-up regimes can vary significantly between different centres and sometimes within the same centre. We undertook this study to determine the patterns of clinical follow-up and use of transthoracic echocardiography (TTE) amongst cardiologists in a large UK tertiary centre. In this retrospective study, we identified patients that underwent heart valve repair or replacement surgery in 2008. We used local postal codes to identify patients within our hospital's follow-up catchment area. We determined the frequency of clinical follow-up and use of transthoracic echocardiography (TTE) during the 9-year follow-up period (2009-2016 inclusive). Of 552 patients that underwent heart valve surgery, 93 (17%) were eligible for local follow-up. Of these, the majority (61/93, 66%) were discharged after their 6-week post-operative check-up with no further follow-up. Of the remaining 32 patients, there was remarkable heterogeneity in follow-up regimes and use of TTE. This variation did not correlate with the prosthesis type. In summary, the frequency of clinical follow-up and use of echocardiography is highly variable in contemporary practice. Many patients are inappropriately discharged back to their family doctor with no plans for hospital follow-up. These data further support the creation of dedicated specialist heart valve clinics to optimize patient care, ensure rational use of TTE and optimize adherence with best practice guidelines.