Desfibrilador subcutáneo. Primeros casos en el Instituto Nacional de Cardiología, incluyendo dos pacientes pediátricos / Use of subcutaneous cardioverter-defibrillator. First cases reported from National Institute of Cardiology Ignacio Chávez-Mexico

Resumen Introducción: El desfibrilador automático implantable (DAI) transvenoso es el tratamiento de elección para la prevención de muerte súbita (MS) cardiaca por arritmias ventriculares malignas. Su uso se puede ver limitado cuando existe infección del sistema de estimulación o en población pediátrica donde representa un reto por diversas razones, incluyendo: las mínimas dimensiones del sistema venoso de los niños, la longitud de los electrodos, el tamaño del generador, así como por la complejidad anatómica en casos de cardiopatía congénita asociada. Objetivo: El presente artículo tiene por objetivo presentar la primera serie de casos de pacientes mexicanos a los cuales se les implantó un DAI subcutáneo (DAI-SC) como terapia para la prevención de MS. Métodos: Se presentan los cuatro primeros casos que fueron implantados en el Instituto Nacional de Cardiología Ignacio Chávez con un DAI-SC (Emblem, Boston Scientific, EE.UU.), tres de ellos eran pacientes pediátricos, incluyendo el primer implante de este tipo de dispositivo en un paciente pediátrico en América Latina. Las técnicas de tres y dos incisiones fueron empleadas bajo anestesia general. Resultados: Se realizó el implante exitoso con técnica de tres incisiones en los dos primeros casos y con técnica de dos incisiones en los dos últimos casos. Se corroboró el adecuado funcionamiento del dispositivo en sala, con la verificación de terapia apropiada (65 J) de la fibrilación ventricular inducida mediante estimulación a 50 Hz. No hubo complicaciones inmediatas. Un paciente presentó descargas apropiadas a los dos meses del implante. En el seguimiento, un niño desarrolló erosión de la piel a nivel de la curva del electrodo en el esternón, sin datos de infección. En quirófano se resecó la piel dañada, se retiró el barril y la seda de fijación, se realizó lavado quirúrgico y se volvió a cerrar la piel, logrando así evitar el retiro del sistema. Conclusiones: El DAI-SC es una terapia alternativa al DAI endovenoso y puede ser considerado de primera elección en aquellos casos que no requieran de estimulación ventricular, incluyendo pacientes pediátricos. Pueden ocurrir complicaciones cutáneas, pero no representan una amenaza como las complicaciones venosas de los DAI convencionales.

Abstract Introduction: The transvenous implantable cardioverter defibrillator (ICD) is the treatment of choice for the prevention of sudden cardiac death (SCD). Its use could be restricted when device-related infections occurs or in the pediatric population. In the later, an ICD represents a challenge, due to the minimal dimensions of the venous system in children, the length of the electrodes, the size of the generator, as well as the anatomical complexity in cases with associated congenital heart disease. Objective: This article presents the first Mexican patients with a subcutaneous ICD (SC-ICD) implant as a therapy for the prevention of SCD. Methods: The first four cases were implanted at the Ignacio Chávez National Institute of Cardiology with a SC-ICD (Emblem, Boston Scientific, USA), three of them were pediatric patients, including the first implant of this type of device in a pediatric patient in Latin America. The 3-incision and 2-incision techniques were used under general anesthesia. Results: A successful implantation was obtained with the 3-incision technique in the first 2 cases and the last 2 with the 2-incision technique. Proper functioning of the device was corroborated in the operating room with proof of appropriate therapy (65 J) for ventricular fibrillation induced with 50 Hz stimulation. No immediate complications were observed. One patient had appropriate shocks two months after the implant. During follow-up, one child developed skin erosion at the level of the curve of the electrode on the sternum, with no signs of infection. In the operating room, the damaged skin was resected, the barrel and the fixation silk were removed, surgical lavage was performed, and the skin was closed again, thus avoiding removal of the system. Conclusions: The SC-ICD is an alternative therapy to the transvenous ICD. It can be considered first choice in subjects who do not require ventricular pacing, including pediatric patients. Skin complications can occur but do not pose a threat as venous complications of conventional ICDs.

Dispositivos cardíacos implantables y uso de resonancia magnética / Cardiac implantable devices and use of magnetic resonance / Dispositivos cardíacos implantáveis e utilização da ressonância magnética

El uso de la resonancia magnética (RM) en las distintas áreas de la medicina se ha expandido de manera significativa y de forma diaria se solicitan numerosos estudios. El hecho de que los resonadores pueden interaccionar con algunos objetos ha llevado a que históricamente se les niegue la realización de este estudio a pacientes portadores de dispositivos cardíacos porque se entiende que existen contraindicaciones absolutas. El avance de la tecnología de los dispositivos y la creciente evidencia publicada han cambiado este concepto. Nos proponemos revisar los mecanismos por los cuales un dispositivo implantable puede interactuar con el resonador y las implicancias clínicas que esto podría tener si las hubiera. La mayoría de los pacientes portadores de dispositivos cardíacos de estimulación podrán realizarse una RM, pero para que este procedimiento sea seguro es importante conocer las características y el tipo específico de dispositivo implantado. Proponemos finalmente puntos clave y algoritmos para tener en cuenta para el manejo adecuado de estos pacientes.

The use of magnetic resonance imaging (MRI) in different areas of medicine has expanded significantly and numerous procedures are indicated daily. The fact that resonators could interact with some objects has historically led to patients with cardiac devices being denied an MRI on the understanding that they suppose an absolute contraindication. Advances in device technology and the increasing evidence have changed this concept. We intend to review the mechanisms by which an implantable device could interact with the resonator and the clinical implications that this could have if any. Most patients will be able to undergo these studies, but to determine the safety of performing an MRI it is important to know the characteristics and specific type of implanted device. Finally, we provide key points and algorithms to take into account for these patients.

O uso da ressonância magnética em diferentes áreas da medicina tem se expandido significativamente e inúmeros exames são indicados diariamente. A possibilidade de que os ressonadores interajam com alguns objetos historicamente levou os pacientes com dispositivos cardíacos a terem a ressonância magnética negada por entender que existem contraindicações absolutas. Os avanços na tecnologia de dispositivos e o aumento das evidências publicadas mudaram esse conceito. Pretendemos revisar os mecanismos pelos quais um dispositivo implantável pode interagir com o ressonador e as implicações clínicas que isso pode ter, se houver. A grande maioria dos pacientes poderá se submeter a esses estudos, mas para determinar a segurança de realizar uma ressonância magnética é importante conhecer as características e o tipo específico de dispositivo implantado. Por fim, propomos pontos e algoritmos para a gestão dos pacientes.

Síndrome de Andersen Tawil en una embarazada con alto riesgo de muerte súbita. Reporte de caso / Andersen Tawil syndrome in a pregnant woman at high risk of sudden death

Resumen ANTECEDENTES: El síndrome de Andersen Tawil es una canalopatía multisistémica genética, muy rara, sin alteración cardiaca estructural, heredada de manera autosómica dominante y causada por mutación en el gen KCNJ2. Este síndrome se caracteriza por una triada de parálisis muscular periódica, cambios en el electrocardiograma y estructurales corporales. El rasgo distintivo es la taquicardia ventricular bidireccional, las contracciones ventriculares prematuras y raramente taquicardia polimórfica tipo torsade de pointes. En la actualidad se carece de guías para el peri y postparto y para la prevención de arritmias. CASO CLÍNICO: Paciente de 21 años, embarazada, con síndrome de Andersen Tawil diagnosticado a esta edad, con base en los antecedentes de síncope de repetición y debilidad en las extremidades desde los 11 años. Recibía tratamiento con un beta-bloqueador y un desfibrilador automático implantable. La ecocardiografía fetal a las 23 y 33 semanas de gestación reportó una comunicación interventricular apical de 1.6 mm. A las 39 semanas de embarazo se practicó una cesárea electiva, con evolución posoperatoria satisfactoria. El estudio molecular dirigido al recién nacido descartó el síndrome de Andersen Tawil congénito. CONCLUSIÓN: En pacientes con síndromes de arritmia congénita, el embarazo puede ser seguro siempre y cuando un grupo de especialistas esté pendiente para tomar decisiones de atención y tratamiento durante todo el proceso del embarazo y puerperio.

Abstract BACKGROUND: Andersen Tawil syndrome is a very rare genetic multisystemic channelopathy without structural cardiac alteration, inherited in an autosomal dominant manner and caused by mutation in the KCNJ2 gene. This syndrome is characterised by a triad of periodic muscle paralysis, electrocardiogram and body structural changes. The hallmark is bidirectional ventricular tachycardia, premature ventricular contractions and rarely polymorphic torsade de pointes tachycardia. Currently there is a lack of guidelines for peri- and postpartum and arrhythmia prevention. CLINICAL CASE: 21-year-old pregnant patient with Andersen-Tawil syndrome diagnosed at this age, based on a history of repeated syncope and weakness in the extremities since the age of 11. She was being treated with a beta-blocker and an implantable cardioverter defibrillator. Fetal echocardiography at 23 and 33 weeks gestation reported an apical ventricular septal defect of 1.6 mm. Elective caesarean section was performed at 39 weeks of pregnancy, with satisfactory postoperative evolution. Molecular study of the newborn ruled out congenital Andersen-Tawil syndrome. CONCLUSION: In patients with congenital arrhythmia syndromes, pregnancy can be safe as long as it is managed by a group of experts to make decisions and optimise care throughout the pregnancy and postpartum period.

Effect of ivabradine on ventricular arrhythmias in heart failure patients with reduced ejection fraction

SUMMARY BACKGROUND/INTRODUCTION: Heart failure patients with reduced ejection fraction are at high risk for ventricular arrhythmias and sudden cardiac death. Ivabradine, a specific inhibitor of the If current in the sinoatrial node, provides heart rate reduction in sinus rhythm and angina control in chronic coronary syndromes. OBJECTIVE: The effect of ivabradine on ventricular arrhythmias in heart failure patients with reduced ejection fraction patients has not been fully elucidated. The aim of this study was to investigate the effect of ivabradine use on life-threatening arrhythmias and long-term mortality in heart failure patients with reduced ejection fraction patients. METHODS: In this retrospective study, 1,639 patients with heart failure patients with reduced ejection fraction were included. Patients were divided into two groups: ivabradine users and nonusers. Patients presenting with ventricular tachycardia, the presence of ventricular extrasystole, and ventricular tachycardia in 24-h rhythm monitoring, appropriate implantable cardioverter-defibrillator shocks, and long-term mortality outcomes were evaluated according to ivabradine use. RESULTS: After adjustment for all possible variables, admission with ventricular tachycardia was three times higher in ivabradine nonusers (95% confidence interval 1.5-10.2). The presence of premature ventricular contractions and ventricular tachycardias in 24-h rhythm Holter monitoring was notably higher in ivabradine nonusers. According to the adjusted model for all variables, 4.1 times more appropriate implantable cardioverter-defibrillator shocks were observed in the ivabradine nonusers than the users (95%CI 1.8-9.6). Long-term mortality did not differ between these groups after adjustment for all covariates. CONCLUSION: The use of ivabradine reduced the appropriate implantable cardioverter-defibrillator discharge in heart failure patients with reduced ejection fraction patients. Ivabradine has potential in the treatment of ventricular arrhythmias in heart failure patients with reduced ejection fraction patients.

Primer choque apropiado del desfibrilador automático implantable en pacientes con cardiopatía chagásica / First appropriate implantable defibrillator shocks in patients with Chagasic heart disease

Resumen Objetivos: Determinar si los pacientes con cardiopatía chagásica (CCh) presentaron choques apropiados del desfibrilador automático implantable (DAI) de manera más precoz que los pacientes con cardiopatía isquémica (CI). Métodos: Estudio de cohorte retrospectivo que incluyó los pacientes con CCh y CI en quienes se implantó un DAI entre los años 2009 y 2018 en un hospital de alta complejidad. El seguimiento se realizó hasta los 36 meses, evaluándose el momento del primer choque apropiado del dispositivo. Resultados: Se incluyeron 64 pacientes, 20 con CCh y 44 con CI. Se observó que una mayor proporción de pacientes con CCh presentaron choques apropiados durante el primer año (hazard ratio [HR]: 8.4; intervalo de confianza del 95% [IC95%]: 2.09-34.02; p = 0.0027) y a 3 años (HR: 4.61; IC95%: 1.51-14.07; p = 0.0072). El 100% de la población con CCh e implante del DAI como prevención secundaria de muerte súbita presentaron choques apropiados durante los primeros 26 meses de seguimiento. Conclusiones: Los pacientes con CCh presentaron choques apropiados del DAI de manera más precoz que los pacientes con CI. Todos los pacientes con CCh y DAI como prevención secundaria presentaron choques apropiados, representando una población de mayor riesgo. Esta información apoya la indicación del DAI en estos pacientes a pesar de la escasa evidencia en ensayos aleatorizados.

Abstract Objetives: To assess if patients with Chagasic heart disease (CHD) received effective automatic implantable defibrillator (AID) shocks earlier than patients with ischemic heart disease (IHD). Methods: Retrospective cohort of patients with CHD and IHD who received an implantable cardioverter defibrillator (ICD) between 2009 and 2018, in a tertiary hospital. We evaluated the time between the implant of ICD and the first effective shock in patients with CHD and compared it with the IHD control population. Results: We included a total of 64 patients, 20 with CHD and 44 with IHD. CHD patients presented earlier an effective shock than patients with IHD during the first year (hazard ratio [HR]: 8.4; 95% confidence interval [95% CI]: 2.09-34.02; p = 0.0027), and at three years (HR: 4.61; 95% CI: 1.51-14.07; p = 0.0072). 100% of CHD patients who received the ICD as secondary prevention of sudden cardiac death presented an effective shock during the first 26 months of follow-up. Conclusions: Patients with CHD received effective ICD shocks earlier than the IHD patients. All patients with CHD and ICD as secondary prevention had an appropriate ICD shock at short term, representing the highest risk population, and supporting the indication of the device in a setting where randomized clinical trials are lacking.

ICD indication in hypertrophic cardiomyopathy: which algorithm to use?

SUMMARY OBJECTIVE: This study aimed to evaluate the agreement in the indication of implantable cardioverter-defibrillators in patients with Hypertrophic cardiomyopathy, as per the 2014 European Society of Cardiology and 2020 American Heart Association recommendations, and evaluate fragmented QRS as a predictor of cardiovascular outcome. METHODS: Retrospective cohort with 81 patients was evaluated between 2019 and 2021. Patients with hypertrophic cardiomyopathy ≥16 years old were included. Exclusion criteria include secondary myocardiopathy and follow-up <1 year. Kappa coefficient was used to determine the agreement. Survival and incidence curves were determined by Kaplan-Meier method. A p<0.05 was considered significant. RESULTS: The fragmented QRS was identified in 44.4% of patients. There were no differences between patients with and without fragmented QRS regarding clinical parameters, echocardiography, fibrosis, and sudden cardiac death risk. During follow-up of 4.8±3.4 years, there was no sudden cardiac death, but 20.6% patients with implantable cardioverter-defibrillator had at least one appropriate shock. Three of the seven appropriate shocks occurred in European Society of Cardiology low- to moderate-risk patients. Three shocks occurred in moderate-risk patients and four in American Heart Association high-risk patients. Overall recommendations agreement was 64% with a kappa of 0.270 (p=0.007). C-statistic showed no differences regarding the incidence of appropriate shock (p=0.644). CONCLUSION: sudden cardiac death risk stratification algorithms present discrepancies in implantable cardioverter-defibrillator indication, both with low accuracy.

Predictors for early mortality in patients with implantable cardiac defibrillator for heart failure with reduced ejection fraction

Implantable cardioverter defibrillators (ICD) are recommended in heart failure with reduced ejection fraction (HFrEF) patients to reduce arrhythmic deaths. This study aimed to identify risk factors associated with mortality within one-year following the ICD. The data from our hospital's electronic database system was extracted for patients who were implanted ICD secondary to HFrEF between 2009 and 2019. Overall, 1107 patients were included in the present analysis. Mortality rate at one-year following the device implantation was 4.7%. In multivariate analysis; age, atrial fibrillation, New York Heart Association classification >2, blood urea nitrogen, pro-brain natriuretic peptide and albumin independently predicted one year mortality

Layperson’s performance on an unconversant type of AED device: A prospective crossover simulation experimental study / 世界急诊医学杂志（英文）

@#BACKGROUND: Diverse models of automated external defibrillators (AEDs) possess distinctive features. This study aimed to investigate whether laypersons trained with one type of AED could intelligently use another initial contact type of AED with varying features. METHODS: This was a prospective crossover simulation experimental study conducted among college students. Subjects were randomly trained with either AED1 (AED1 group) or AED2 (AED2 group), and the AED operation performance was evaluated individually (Phase I test). At the 6-month follow-up AED performance test (Phase II test), half of the subjects were randomly switched to use another type of AED, which formed two switches (Switch A: AED1-1 group vs. AED2-1 group; Switch B: AED2-2 group vs. AED1-2 group). RESULTS: A total of 224 college students participated in the study. In the phase I test, a significantly higher proportion of successful defibrillation and shorter shock delivery time to achieve successful defibrillation was observed in the AED2 group than in the AED1 group. In the phase II test, no statistical differences were observed in the proportion of successful defibrillation in Switch A (51.4% vs. 36.6%, P=0.19) and Switch B (78.0% vs. 53.7%, P=0.08). The median shock delivery time within participants achieving successful defibrillation was significantly longer in the switched group than that of the initial group in both Switch A (89 [81–107] s vs. 124 [95–135] s, P=0.006) and Switch B (68 [61.5–81.5] s vs. 95.5 [55–131] s, P<0.001). CONCLUSION: College students were able to effectively use AEDs different from those used in the initial training after six months, although the time to shock delivery was prolonged.

Discussion on automated external defibrillator configuration optimization strategy of rapidly developing city: a case study of Bao'an, Shenzhen / 中华危重病急救医学

Objective:To explore the automated external defibrillator (AED) configuration optimization strategy in line with the characteristics of the rapidly developing cities by analyzing the actual coverage of AED in Bao'an District based on the real world data of out-of-hospital cardiac arrest (OHCA) in Bao'an District, Shenzhen City.Methods:The data of cardiac arrest database registered in Bao'an District of Shenzhen City from March 1, 2019 to February 29, 2020 were included in a retrospective observational study. The AED coverage of public and non-public areas was analyzed by calculating the minimum distance between the occurrence place of each OHCA event and the nearest AED. The minimum distance ≤100 m was set as AED coverage, and the minimum distance > 100 m was set as non-AED coverage. It was assumed that one AED was configured for each OHCA hotspot area, then the AED coverage changes were analyzed. Based on the actual situation that the AED in schools, governments, sports venues, subways, tourist attractions and parks of public areas in Bao'an District could not be obtained at any time within 24 hours, it was assumed that all AED in the public areas could be obtained at any time within 24 hours, the impact of AED available at any time on AED coverage was analyzed.Results:A total of 525 cases of OHCA were enrolled. The highest incidence of OHCA was found in residential and industrial areas [54.5% (286/525) and 14.3% (75/525), respectively]. There were 252 AED in Bao'an District, Shenzhen, and 115 OHCA events occurred within the coverage area of AED. Even if all AED met the ideal state that could be obtained at any time within 24 hours, the coverage rate was only 21.9% (115/525). The AED coverage rate of the public areas and non-public areas was 31.6% (37/117) and 19.1% (78/408) respectively, with uneven distribution, and the AED coverage rate of non-public areas was low. Assuming that the residential community and industrial zone with more than 2 OHCA cases were respectively equipped with one AED, the coverage rate of AED in the non-public areas increased from 19.1% (78/408) to 28.2% (115/408), basically meeting the requirement that AED could be obtained at any time when OHCA events occurred. Some AED in the public areas of Bao'an District were not available at any time within 24 hours. If the ideal state that all AED in the public area could be obtained at any time within 24 hours could be achieved, the AED coverage rate of all regions increased from 16.8% (88/525) to 21.9% (115/525), the AED coverage rate of the public areas increased from 29.1% (34/117) to 31.6% (37/117), the AED coverage rate of the non-public areas increased from 13.2% (54/408) to 19.1% (78/408).Conclusions:AED configuration in Bao'an District was unevenly distributed, and the coverage rate of AED in non-public areas was low. The allocation strategy for AED in fast-growing cities like Shenzhen should be as follows: on the premise of ensuring AED availability for 24 hours, priority should be given to covering the number of AED in the non-public areas including residential communities and industrial zones; AED is available in the public areas for 24 hours.

Submammary placement of implantable cardioverter defibrillators: a Singapore plastic surgeon experience

The use of implantable cardioverter defibrillators (ICDs) in young women has been increasing in recent years owing to greater awareness about inherited cardiac conditions that increase the risk of sudden death. Traditional placement of ICDs in the infraclavicular region among young women often leads to visible scars, a constant prominence that causes irritation from purse or bra straps and can result in body image concerns and device-related emotional distress. In this case series, two women with long QT syndrome required placement of ICDs for prevention of sudden cardiac death. Submammary placement of ICDs was performed in collaboration with electrophysiologists. We describe our local experience and technique in submammary placement of ICDs as well as the challenges faced.

Registro Costarricense de Resincronizadores, Desfibriladores Automáticos y Marcapasos Endovasculares (RECORDAME). I Informe oficial de la Comisión de Electrofisiología de la Asociación Costarricense de Cardiología (2019-2020) / Costa Rican Registry of Resynchronizers, Automatic Defibrillators and Endovascular Pacemakers (RECORDAME). I Official Report of the Electrophysiology Commission of the Costa Rican Cardiology Association (2019-2020)

Resumen Introducción y objetivo: Comunicar el primer informe del del registro nacional de dispositivos de estimulación cardíaca de agosto 2019 a agosto 2020, registro prospectivo de participación voluntaria. Métodos: Se analiza la información registrada, en forma voluntaria, por los centros implantadores con respecto a la población de pacientes a quienes se implantó un marcapaso, un desfibrilador o un resincronizador entre el 22 de agosto de 2019 hasta setiembre de 2020. Resultados: Se registraron un total de 317 procedimientos de marcapasos, por 10 centros implantadores, lo que corresponde a una participación en el registro de un 40%. La tasa de uso de marcapasos de 6,27 x 100 mil habitantes. Un 83% de los marcapasos fueron implantados en centros públicos, un 70% correspondió a dispositivos bicamerales. La edad media de la población fue de 73,7 años. La indicación más frecuente fue el trastorno de conducción AV (70,3%). Los electrodos de fijación activa fueron los más utilizados (97,8%). Un 83,3% de los sistemas implantados tuvieron compatibilidad con resonancia magnética. El uso de marcapasos unicamerales fue más frecuente en pacientes con 80 o más años. Con respecto a la terapia DAI se registraron un total de 63 procedimientos, por 5 centros implantadores, con una participación del 41%. La tasa total de implantes durante el período fue de 1,25 x 100 mil habitantes. La cardiomiopatía dilatada no isquémica fue la cardiopatía más frecuente en la población registrada. Conclusiones: El registro permite conocer la dinámica de procedimientos e indicaciones más usuales para el uso de dispositivos electrónicos cardíacos así como establecer la tasa de uso de las terapias en nuestro país. El porcentaje de participación en el registro puede mejorar. La implantación de dispositivos de estimulación cardíaca es financiada predominantemente por el sistema de seguridad social. La tasa de implantación es baja con respecto a otras regiones.

Abstract Costa Rican Registry of Resynchronizers, Automatic Defibrillators and Endovascular Pacemakers (RECORDAME). I Official Report of the Electrophysiology Commission of the Costa Rican Cardiology Association (2019-2020) Introduction and objective: To communicate the results of the first national registry of cardiac stimulation devices from August 2019 to August 2020. Methods: We analyze the information recorded prospectively, on a voluntary basis, by the implant centers with respect to the population of patients who were implanted with a pacemaker, a defibrillator or a resynchronizer between August 22, 2019 and September 2020. Results: A total of 317 pacemaker procedures were registered from 10 centers participated. Participation was 40% of total procedures reported by companies. The pacemaker implantation rate was 6.27 per hundred thousand. A 83% of pacemakers were implanted in public centers, 70% corresponded to dual chamber devices. Mean age of the population was 73.7 years. Most frequent indication was AV conduction disorder (70.3%). Active fixation electrodes were the most used (97.8%). A 83.3% were MRI conditional. Use of single chamber pacemakers was more frequent in patients aged 80 years or older. Regarding ICD therapy, a total of 63 procedures were registered. from 5 centers, with a participation of 41%. Rate of ICD use was 1.25 per hundred thousand. Non-ischemic dilated cardiomyopathy was the most common heart disease in the recorded population. Conclusions: The registry allowed to know the frequency of procedures and more usual indications as well as to establish the rate of use of therapies in our country. The percentage of participation in the registration can be improved. The implementation of cardiac stimulation devices is predominantly financed by the social security system. The implantation rate is low compared to other regions.

Muerte súbita cardíaca por fibrilación ventricular asociada a isquemia miocárdica, tratada por desfibrilador automático implantable / Sudden cardiac death due to ventricular fibrillation associated with myocardial ischemia, treated by implantable cardioverter defibrillator

Resumen: Reportamos el caso de un hombre de 67 años, con múltiples factores de riesgo cardiovascular, quien en el año 2015 presentó muerte súbita por fibrilación ventricular sin lesiones coronarias significativas, tras lo cual se implantó un desfibrilador automático. En el año 2019 presentó un nuevo episodio de fibrilación ventricular en relación con síndrome coronario agudo con supradesnivel del ST localizado en pared anterior, registrado y adecuadamente resuelto por el dispositivo. Se demostró una oclusión aterotrombótica en la porción proximal de la arteria descendente anterior. Fue precoz y exitosamente manejado con angioplastía coronaria percutánea e implante de stent fármaco activo, guiado por tomografía por coherencia óptica intracoronaria. A las 48 horas post angioplastía, presentó episodio de taquicardia ventricular polimorfa reconocido y tratado por el cardiodesfibrilador, sin consecuencias. Electivamente se efectuó angioplastía e implante de stent metálico en arteria coronaria derecha distal, con buen resultado angiográfico. La posterior evolución del paciente fue satisfactoria, sin manifestaciones de insuficiencia cardíaca, angina ni arritmias.

Abstract: A 67-year-old man, with multiple cardiovascular risk factors who in 2015 presented sudden death due to ventricular fibrillation without significant coronary lesions, after which an implantable automatic defibrillator (ICD) was implanted. In 2019, he presented a new episode of ventricular fibrillation adequately resolved by the device, in relation to an acute coronary syndrome with ST elevation in the anterior wall of the left ventricle, due to atherothrombotic occlusion in the proximal portion of the anterior descending artery. He was early and successfully managed with percutaneous coronary angioplasty by the insertion of a drug eluting stent, implanted guided by intracoronary optical coherence tomography. Forty eight hours later, he presented an episode polymorphic ventricular tachycardia recognized and treated by the ICD. Angioplasty with a bare metal stent implantation were performed in the distal right coronary artery, with good angiographic results. The subsequent course was satisfactory, with no manifestations of heart failure, angina or arrhythmias.

Supervivencia en pacientes con falla cardiaca y desfibrilador automático implantable en una unidad de electrofisiología de Pereira, Colombia / Survival in patients with heart failure and implantable cardioverter-defibrillator in an electrophysiological unit in Pereira, Colombia

Objetivo: identificar las variables clínicas que impactan en la mortalidad de los pacientes con falla cardiaca implantados con desfibrilador automático. La terapia con cardiodesfibrilador implantable busca prevenir la muerte súbita cardiaca por arritmias malignas colapsantes. Material y métodos: estudio de cohorte retrospectiva. Se incluyó a pacientes con implante de desfibrilador entre los años 2010-2012, con dispositivo funcional, historia clínica y disponibilidad de seguimiento hasta el primer trimestre del 2014. Resultados: un total de 30 pacientes fueron incluidos, con una supervivencia del 77% a los cuatro años de seguimiento. El 82,7% de los pacientes presentó cardiopatía isquémica y el promedio de la fracción de eyección ventricular izquierda fue 27,8 ± 6,3. El tiempo promedio de uso del desfibrilador fue de 2,1 años, la tasa de peligro mayor reportada fue del 6% para los días 759 y 760. Se encontró una asociación entre una duración del QRS mayor a 120 ms (HR= 7,7, IC 90%= 1,77- 33,6; p=0,022), fibrilación auricular (HR= 4,2, IC 90%=1,13-15,68; p=0,072) y el uso de beta-bloqueadores (HR= 0,15, IC 90%= 0,03 ­ 0,64; p=0,031) con el tiempo de supervivencia. Discusión: la prevención de muerte súbita está condicionada por la optimización farmacológica, así como las anomalías estructurales y de la conducción eléctrica, por lo cual se debe aumentar el seguimiento en estos casos y el ajuste de la terapia farmacológica. Conclusiones: el uso de beta bloqueadores en pacientes con falla cardiaca con fibrilación auricular y duración del QRS mayor de 120 ms es un factor protector..Au

Objective: to identify the clinical variables that impact on the mortality of patients with heart failure implanted with cardioverter defibrillator. Implantable cardioverter defibrillator therapy seeks to prevent sudden cardiac death by collapsing malignant arrhythmias. Material y methods: retrospective cohort study. Patients with a defibrillator implant from the year 2010 to the year 2012 were included, with functional device, clinical history and availability of follow-up until the first quarter of 2014. Results: a total of 30 patients were included, with a 77% survival at four years of follow-up. 82.7% of the patients presented with ischemic heart disease and the mean left ventricular ejection fraction was 27.8 ± 6.3. The mean time of use of the defibrillator was 2.1 years, the reported mayor danger rate was 6% for days 759 and 760. An association was found between a QRS mayor duration at 120 ms (HR = 7.7, 90% CI = 1.77-33.6, p = 0.022), atrial fibrillation (HR = 4.2, 90% CI = 1.13-15.68, p = 0.072), and beta- blockers (HR = 0.15, 90% CI = 0.03-0.64, p = 0.031) with survival time. Discussion: the prevention of death is conditioned by pharmacological optimization, as well as structural and electrical conduction anomalies, so the monitoring and adjustment of pharmacological therapy should be increased. Conclusions: the use of beta-blockers in patients with atrial fibrillation and QRS duration greater than 120 ms is a protective factor..Au

Implantable cardioverter-defibrillator prevents sudden death in patients with Chagas cardiomyopathy in the Brazilian Amazon

Abstract Chagas disease (CD), with approximately 10,000 deaths annually, has become a worldwide health problem. Approximately 35% of cases may show cardiac manifestations such as arrhythmias and/or conduction disorders, heart failure, thromboembolic accidents, and sudden death. The Amazon region has long been considered a non-endemic area for CD; however, in the last decades, with an increase in the number of acute and chronic cases, disease evolution has received greater attention. Here, we report the successful implementation of a cardioverter-defibrillator for the prevention of sudden death in a patient with autochthonous Chagas cardiomyopathy in the Brazilian Amazon.

Preparación de los colegios y profesores de educación física en prevención de muerte súbita y soporte vital básico / Competence of schools and physical education teachers for sudden death prevention and basic life support

OBJETIVO: Conocer el nivel de preparación de colegios y profesores de educación física en prevención de muerte súbita (MS) y soporte vital básico, incluyendo disponibilidad y uso del desfibrilador externo automático (DEA). MÉTODOS: Estudio descriptivo de corte transversal, en profesores de educación física de establecimientos educacionales de distintos tipos de sostenedores (municipales, subvencionados y particulares) de Santiago, Chile, a través de un cuestionario online. Se analizaron datos demográficos del profesor, antecedentes de preparación y disposición de reanimación cardiopulmonar (RCP), presencia y uso de DEA y preparación del establecimiento ante un caso de MS. RESULTADOS: De 97 profesores encuestados, 71,1% no se siente capacitado para realizar RCP a pesar que un 70% del total ha realizado un curso. La disposición para realizar reanimación en aquellos que han realizado un curso, es 99%, comparado con 83% en quienes no lo han realizado (p=0,003). Existe una marcada diferencia en disponibilidad de DEA según tipo de sostenedor (52,4% en particulares, 29,6% en municipales y 15% en subvencionados, p=0,001), pero transversalmente no saben cómo utilizarlo (42,9 %, 40,7% y 25%, p=0,43). La mayoría de los colegios no cuenta con un plan de acción ante MS. CONCLUSIONES: Los colegios y profesores de educación física tienen una preparación insuficiente y desactualizada en prevención de muerte súbita y soporte vital básico, con una distribución heterogénea de DEA en establecimiento según tipo de sostenedor.

OBJECTIVE: To assess the competence of schools and physical education teachers in the prevention of sudden death (SD) and basic life support meassures, including availability and use of the automatic external defibrillator (AED). METHODS: A descriptive cross-sectional study included physical education teachers from different Schools (public, subsidized and private) in Santiago, Chile. An online questionnaire was applied including demographic data of the teacher, comentence and willingness to perform cardiopulmonary resuscitation (CPR), presence and use of AED and school preparation in case of a SD. RESULTS: From a total of 97 teachers surveyed do not feel capable of performing CPR, in spite of the fact that 70% of them completed a CPR course. Among those who took a course, their willingness to perform resuscitation was 99%, compared to 83% en those not having taken the course (p = 0.003). There was a marked difference in DEA availability according to class of school (private 52,4%, public 29,6 subsidized 15%, p=0,001), but the knowledge on how to use de DEA was uniformly insufficient (42,9 %, 40,7% and 25%, p=0,43) Most schools do not have a protocol to face SD. CONCLUSIONS: We observed that schools and physical education teachers have an insufficient and outdated preparation in sudden death prevention and basic life support. The availability of AED differed according to the class of establishment.

Complications related to cardiac implantable electronic devices / Complicaciones asociadas al implante de dispositivos cardiacos electrónicos

Abstract Introduction: complications due to cardiac implantable electronic devices have been sparsely studied despite the increased number and complexity of these procedures in a population with multiple comorbidities. Objective: to determine the complication rate and associated risk factors at a reference center in Colombia. Methods: retrospective cohort study, which included patients who had a cardiac electronic device implanted between 2012 and 2015. Clinical records were reviewed to determine if patients developed complications during the year after the procedure, and, if so, which type and which clinical variables could be related to. Results: a total of 897 patients were included, 620 with pacemaker implants and 277 with other devices. The average age was 71.4 years, 63.9% were men, almost all the patients had a chronic disease, and 70% were de novo implants. The global complication rate was 10.9%; Lead displacement (3.6%) and pocket hematoma (3.3%) were the most frequent complications; 7.5% were major complications, and 73.5% occurred in the first month after procedure. The hospitalization rate associated with complications was 9.5%, and the median hospital stay was seven days, with 66.3% of these patients requiring new interventions. The mortality rate was 0.2% Conclusions: complications associated with cardiac implantable electronic devices occur red mainly in the first trimester after the initial intervention, were more frequent in patients under 80 years old, increased according to device complexity, and were not related to with the studied comorbidities.

Resumen Introducción: las complicaciones secundarias al implante de dispositivos cardiacos electrónicos han sido poco estudiadas a pesar del aumento en número y complejidad de estos procedimientos en población con múltiples comorbilidades. Objetivo: determinar la tasa de complicaciones del implante de dispositivos y los factores de riesgo asociados, en un centro de referencia en Colombia. Métodos: estudio de cohorte retrospectiva, que incluyó pacientes a quienes se les implantó dispositivo electrónico cardiaco entre 2012 y 2015. Se revisó la historia clínica para determinar si durante un año posterior al procedimiento, presentaron complicaciones, de qué tipo y con qué variables clínicas podría asociarse. Resultados: se incluyeron 897 pacientes, 620 con implante de marcapaso y 277 otros dispositivos. La edad promedio fue 71.4 años, 63.9% hombres, con múltiples enfermedades crónicas, 70% fueron implantes de novo. Se observó una tasa de complicaciones del 10.9%, la cual varía de acuerdo con el tipo de dispositivo. El desalojo del electrodo (3.6%) y el hematoma del bolsillo (3.3%) fueron las complicaciones más frecuentes, 7.5% fueron complicaciones mayores y 73.5% se presentaron en el primer mes postoperatorio. La tasa de hospitalización asociada a complicación fue 9.5%, mediana de estancia de 7 días, con un 66.3% de los pacientes en requerimiento de reintervención. La tasa de mortalidad fue del 0.2%. Conclusiones: las complicaciones asociadas al implante de dispositivos eléctricos cardiacos se presentaron principalmente en el primer trimestre, fueron más frecuentes en menores de 80 años, aumentaron con la complejidad del dispositivo y no se relacionaron con las comorbilidades estudiadas.

Seguimiento del paciente con cardiodesfibrilador automático implantable / Follow-up of the patient with automatic implantable cardioverter-defibrillator

RESUMEN Introducción: Los cardiodesfibriladores mejoran la supervivencia de los pacientes con riesgo de muerte súbita cardíaca. Existen escasos datos en nuestro país acerca de su eficacia en el seguimiento. Objetivo: Describir la evolución en el seguimiento de los pacientes con primoimplante de un cardiodesfibrilador automático. Método: Estudio ambispectivo, longitudinal, en 47 pacientes con primoimplante de un cardiodesfibrilador en el período septiembre de 2007 a diciembre de 2016, con cierre el 31 de diciembre de 2017. La probabilidad acumulada de supervivencia se estimó a través de las curvas de Kaplan-Meier. Resultados: La edad media fue de 57 ± 14,6 años, con predominio del sexo masculino (74,5%) y la indicación en prevención secundaria (83%). Presentaron terapias apropiadas el 57,4% de los pacientes, terapias inapropiadas un 23,4%, proarritmia del cardiodesfibrilador un 14,9% y tormenta arrítmica el 12,8% de los pacientes. Las terapias apropiadas se relacionaron con la fracción de eyección ≤ 35% (p=0,022) y la edad (p=0,031). La supervivencia acumulada libre del primer evento a los cuatro años fue 34,7%. La mortalidad cardiovascular se relacionó con: existencia de cardiopatía estructural (p=0,044), fracción de eyección ≤ 35% (p<0,001), clase funcional III-IV (p=0,046), terapias apropiadas (p=0,014) y tormenta arrítmica (p=0,002). La supervivencia acumulada libre de mortalidad cardiovascular fue de 70,7% al cuarto año. Conclusiones: La supervivencia de los pacientes con cardiodesfibrilador es buena. La mortalidad se asocia a un mayor deterioro del estado cardiovascular y a las terapias del dispositivo.

ABSTRACT Introduction: Implantable cardioverter-defibrillators improve the survival of patients at risk of sudden cardiac death. There is relatively little data in our country about their follow-up effectiveness. Objective: To describe the outcome of patients with primo-implantation of an automatic cardioverter-defibrillator during follow-up. Methods: An ambispective longitudinal cohort study was conducted in 47 patients with primo-implantation of a cardioverter-defibrillator in the period September 2007 to December 2016, ending on December 31, 2017. The cumulative probability of survival was estimated through the Kaplan-Meier curves. Results: Mean age was 57 ± 14.6 years, with male predominance (74.5%) and indication in secondary prevention (83%). Adequate therapies were found in 57.4% of patients, inadequate therapies in 23.4%, implantable cardioverter-defibrillator proarrhythmia in 14.9% and arrhythmic storm in 12.8% of patients. Adequate therapies were related to an ejection fraction ≤ 35% (p=0.022) and age (p=0.031). Cumulative free survival from the first event at four years was 34,7%. Cardiovascular mortality was related to: existence of structural heart disease (p=0.044), ejection fraction ≤ 35% (p<0.001), functional class III-IV (p=0.046), adequate therapies (p=0.014) and arrhythmic storm (p=0.002). Cumulative free survival of cardiovascular mortality was 70.7% at the fourth year. Conclusions: The survival of patients with implantable cardioverter-defibrillator is satisfactory. Mortality is associated with further deterioration of cardiovascular status and with device therapies.

Anaesthetic management of a patient with non compaction cardiomyopathy for implantable cardioverter defibrillator lead replacement

Non compaction cardiomyopathy (NCM) is a rare, primary genetically derived cardiomyopathy with a variable clinical presentation ranging from absence of symptoms to congestive heart failure, systemic thromboembolism, arrythmias and sudden cardiac death. Being an uncommon condition, the perioperative concerns in a patient with NCM have not been studied much. With increasing awareness and improved diagnostic tools including high resolution echocardiography and cardiac MRI, there has been an increase in the reporting of cases which stresses on the need for a complete understanding of this form of cardiomyopathy and its perioperative anaesthetic management. Authors report the case of a 24 years old female, with NCM who underwent prophylactic Implantable cardioverter defibrillator (ICD) insertion 5 years ago and was now posted for ICD removal and replacement in view of inappropriate ICD functioning.