Persistence of ICD indication at the time of replacement in patients with initial implant for primary prevention indication: Effect on subsequent ICD therapies.

BACKGROUND: Indication to implantable cardioverter defibrillator (ICD) for primary prevention of sudden death relies on left ventricular ejection fraction (LVEF). We measured the proportion of patients in whom indication to ICD persisted at the time of generator replacement (GR) and searched for predictors of appropriate therapies after GR. METHODS: We identified all consecutive patients who had received an ICD at our hospital, for LVEF ≤35% and no previous arrhythmias or unexplained syncope. Then, we included the 166 patients who outlived their first device and underwent GR. RESULTS: At the time of GR (mean follow-up 59 ± 20 months), ICD indication (i.e. LVEF ≤35% or previously treated ventricular arrhythmias) persisted in 114 (69%) patients. After GR, appropriate ICD therapies were delivered in 30 (26%) patients with persistent ICD indication and in 12 (23%) of the remaining patients (p = 0.656). Nonetheless, the annual rate of therapies was higher in the first group (1.08 versus 0.53 events/year; p < 0.001), as well as the rate of inappropriate therapies (0.03 versus 0 events/year; p = 0.031). The only independent predictor of appropriate ICD therapies after GR was the rate of shocks received before replacement (Hazard Ratio: 1.41; 95% confidence interval: 1.01-1.96; p = 0.041). CONCLUSION: In heart failure with reduced LVEF, ICD indication persisted at the time of GR in 69% of patients. However, even in the absence of persistent ICD indication at GR, the risk of recurrence of arrhythmic events was not null.

Right ventricular septal pacing: Safety and efficacy in a long term follow up.

AIM: To evaluate the safety and efficacy of the permanent high interventricular septal pacing in a long term follow up, as alternative to right ventricular apical pacing. METHODS: We retrospectively evaluated: (1) 244 patients (74 ± 8 years; 169 men, 75 women) implanted with a single (132 pts) or dual chamber (112 pts) pacemaker (PM) with ventricular screw-in lead placed at the right ventricular high septal parahisian site (SEPTAL pacing); (2) 22 patients with permanent pacemaker and low percentage of pacing (< 20%) (NO pacing); (3) 33 patients with high percentage (> 80%) right ventricular apical pacing (RVA). All patients had a narrow spontaneous QRS (101 ± 14 ms). We evaluated New York Heart Association (NYHA) class, quality of life (QoL), 6 min walking test (6MWT) and left ventricular function (end-diastolic volume, LV-EDV; end-systolic volume, LV-ESV; ejection fraction, LV-EF) with 2D-echocardiography. RESULTS: Pacing parameters were stable during follow up (21 mo/patient). In SEPTAL pacing group we observed an improvement in NYHA class, QoL score and 6MWT. While LV-EDV didn't significantly increase (104 ± 40 mL vs 100 ± 37 mL; P = 0.35), LV-ESV slightly increased (55 ± 31 mL vs 49 ± 27 mL; P = 0.05) and LV-EF slightly decreased (49% ± 11% vs 53% ± 11%; P = 0.001) but never falling < 45%. In the RVA pacing control group we observed a worsening of NYHA class and an important reduction of LV-EF (from 56% ± 6% to 43% ± 9%, P < 0.0001). CONCLUSION: Right ventricular permanent high septal pacing is safe and effective in a long term follow up evaluation; it could be a good alternative to the conventional RVA pacing in order to avoid its deleterious effects.

Twiddler's syndrome and pectoral stimulation in a patient with dual-site unipolar atrial pacing.

Twiddler's syndrome is a rare condition of pacemaker rotation; when associated with unipolar pacing it could provoke extracardiac muscular stimulation. We report a case of an obese woman who unintentionally reversed her triple-chamber, dual-site unipolar atrial pacemaker, implanted for the prevention of paroxysmal atrial fibrillation. The extracardiac pectoral stimulation was due to unipolar atrial stimulation. The polarity mode was not programmable and output reduction was unsuccessful. Thus, the problem was resolved noninvasively by means of external manual rotation of the pacer. At 24 months of follow-up, the patient was still free of symptoms.

Cardiac dyssynchrony quantitated by time-to-peak or temporal uniformity of strain at longitudinal, circumferential, and radial level: implications for resynchronization therapy.

BACKGROUND: The standard deviation of time to peak strain (TPS-SD) has been proposed as an index of left ventricular (LV) dyssynchrony in patients to be resynchronized. However, TPS-SD is sensitive to noise, and the influence of outliers on TPS-SD is also relevant. Alternatively, dyssynchrony can be indexed by temporal uniformity of strain (TUS), whereby a time plot of regional strains, arranged for LV location, is subjected to Fourier analysis. If segments shorten simultaneously (synchronously), the plot appears as a straight line, with power only in the zero-order Fourier term, whereas regionally clustered dyssynchrony generates an undulating plot with higher power in the first-order term. TUS index reflects zero-order relative to first-order plus zero-order power. METHODS: In this study, TUS and TPS-SD were computed in 68 patients (QRS duration >/= 120 ms; ejection fraction

Left ventricular torsion in paced patients.

BACKGROUND: In healthy people the left ventricle presents a counter-clockwise apical rotation and a clockwise basal rotation ending in late systole. In early systole (during isovolumic contraction) there is a fast and inverse rotation (counter-clockwise at the base and clockwise at the apex). This opposite rotation between apex and base produces the systolic torsion of the left ventricle. The effect of permanent conventional pacing on this torsion is little known. OBJECTIVES: The aim of this study was to assess, by speckle tracking echocardiography, left ventricular rotation and torsion in patients conventionally paced at the apex of the right ventricle. METHODS: Left ventricular apical and basal rotation and the consequent torsion were evaluated by means of speckle tracking echocardiography, in 13 paced patients, without ischemic or valvular disease, and in 17 healthy participants. Left ventricular dyssynchrony was evaluated by means of temporal uniformity of strain. RESULTS: In the paced group there was a significant reduction in early-systolic clockwise torsion (-0.4 degrees +/- 1.2 vs. -1.5 degrees +/- 1.6; P = 0.04), and in late-systolic counter-clockwise torsion (15.1 degrees +/- 4.3 vs. 19.1 degrees +/- 5.5; P = 0.03). Circumferential temporal uniformity of strain averaged significantly lower in paced patients. CONCLUSIONS: Conventional pacing from the apex of the right ventricle alters both the torsional mechanic and the synchrony of the left ventricle.

Inappropriate implantable cardioverter-defibrillator discharges unrelated to supraventricular tachyarrhythmias.

AIMS: The development of implantable cardioverter-defibrillators (ICDs) with QRS morphology discrimination and dual-chamber sensing capabilities has improved the differentiation of supraventricular from ventricular tachycardias (VTs). Inappropriate ICD discharges may result from extracardiac signals caused by electromagnetic interference (EMI), because of electric fields and leakage currents from domestic or medical electrical devices, damaged sensing leads, and various cardiac and extracardiac signals that mimic VT and/or ventricular fibrillation. The aim of our study was to determine retrospectively the incidence and clinical relevance of these ICD behaviours and offer possible therapeutic solutions. METHODS AND RESULTS: We have observed inappropriate discharges unrelated to supraventricular arrhythmias in 13 (3.9%) of the 336 patients implanted with ICDs in our centre from 1989 to 2005. Seven patients received inappropriate shocks following exposure to external EMI: improperly grounded electric stove, electrically powered watering system, hydro-massage bath, electrical pruner, electrocautery current during cardiac surgery, transcutaneous electric nerve stimulation. In four patients, spurious discharges were related to internal noise of the ICD system from inappropriate lead connections. In two cases, erroneous antitachycardia therapy was delivered following different body signals oversensing (T-wave oversensing, wide QRS double-counting and myopotentials). In nine patients, non-invasive solutions prevented further inappropriate therapies (avoidance of EMI, malfunctioning atrial lead exclusion, ventricular sensing reprogramming). In four patients, surgical revision of the system was required (lead connections or position revision). CONCLUSION: In our experience, inappropriate ICD discharges unrelated to supraventricular arrhythmias occurred in about 4% of ICD patients. A careful evaluation of clinical data and telemetric information (lead impedance, sensed R-wave, stored electrograms) is essential in order to understand the nature of inappropriate ICD discharges and to select the most appropriate solution.

[Electrical storms in patients with implantable cardioverter-defibrillator: incidence and clinical management]. / La tempesta aritmica nel paziente con defibrillatore automatico impiantabile: incidenza e problematiche terapeutiche.

BACKGROUND: Electrical storm in implantable cardioverter-defibrillator (ICD) recipients is a dramatic experience for the patient and a hard emergency for the cardiology team. The aim of our study was to evaluate the incidence and the clinical significance of electrical storm in a standard population of ICD patients. METHODS: We considered retrospectively 262 consecutive ICD patients (86% males, mean age 65+/-10.7 years). Patients were divided into three groups: 88 patients without appropriate ICD therapy (group A); 140 patients with isolated ICD therapies (group B); 34 patients with electrical storm episodes (> or = 3 appropriate ICD therapies/24 h) (group C). Survival study (endpoint death) was performed for each group of patients. RESULTS: There was no difference in age, sex, heart disease, ejection fraction or NYHA functional class among the three groups. ICD implant was performed for secondary prevention in 79% of group C patients and in 74.3 % of group B patients, but only in 39.8 % of group A patients (p < 0.0001). Mean follow-up was 31.1+/-29.8 months in group A, 55.1+/-38 months in group B, and 71.1+/-51.7 months in group C. The endpoint was reached by 16 patients (18%) of group A, by 53 patients (38%) of group B, and by 20 patients (58%) of group C. Comparison of the survival curves of the three groups did not show significant differences. In group C patients, 54 electrical storm episodes were recorded (mean 1.5/patient). CONCLUSIONS: In our population of ICD patients, we observed electrical storm in 34 patients (12.9%). Survival in group with episodes of electrical storm was comparable to patients without electrical storm; thus, in our experience, electrical storm could not represent a negative prognostic factor.

Prevention of ventricular desynchronization by permanent para-Hisian pacing after atrioventricular node ablation in chronic atrial fibrillation: a crossover, blinded, randomized study versus apical right ventricular pacing.

OBJECTIVES: The aim of our study was to evaluate the feasibility, the safety, and hemodynamic improvements induced by permanent para-Hisian pacing in patients with chronic atrial fibrillation and narrow QRS who underwent atrioventricular (AV) node ablation. BACKGROUND: Right ventricular apical pacing, inducing asynchronous ventricular contraction, may impair cardiac function; permanent para-Hisian pacing could preserve interventricular synchrony and improve left ventricular function. METHODS: After AV node ablation, 16 patients were implanted with a dual-chamber pacemaker connected to a screw-in lead positioned in close proximity to the His bundle and to a right ventricular apical lead. Clinical and echocardiographic data were collected at baseline and after two randomized six-month periods (with para-Hisian and conventional pacing). RESULTS: During para-Hisian pacing, the interventricular electromechanical delay improved as well (34 +/- 18 ms) as during right apical pacing (47 +/- 19 ms), p < 0.05. Para-Hisian pacing allowed an improvement in New York Heart Association functional class (1.75 +/- 0.4 vs. 2.33 +/- 0.6 at baseline and 2.5 +/- 0.4 during apical pacing, p < 0.05 for both), in quality-of-life score (16.2 +/- 8.7 vs. 32.5 +/- 15.0 at baseline, p < 0.05), and in the 6-min walk test (431 +/- 73 m vs. 378 +/- 60 m at baseline and 360 +/- 71 m during apical pacing, p < 0.5 for both). Mitral and tricuspid regurgitation improved during para-Hisian pacing (1.22 +/- 0.8 and 1.46 +/- 0.5 index, respectively, vs. 1.68 +/- 0.6 [p < 0.05] and 1.62 +/- 0.7 [p = NS] index at baseline, respectively), with a slight worsening during apical pacing (1.93 +/- 1 and 1.93 +/- 0.7 index, respectively, p < 0.05 for both). CONCLUSIONS: Permanent para-Hisian pacing is feasible and safe. Compared with conventional right apical pacing, it allows an improvement in functional and hemodynamic parameters over long-term follow-up.

Primary hyperparathyroidism and arrhythmic storm in a patient with an implantable cardioverter defibrillator for primary prevention of sudden death.

A case of a patient with an automatic cardioverter defibrillator (ICD) and recurrent ventricular arrhythmic storms related to primary hyperparathyroidism and hypercalcaemia is reported: medical therapy was ineffective and only surgical resection of the parathyroid adenoma resolved this complex clinical condition.