Preditores de Qualidade de Vida, Ansiedade e Aceitação em Pacientes com Cardioversor-Desfibrilador Implantável / Predictors of Quality of Life, Anxiety and Acceptance in Patients with Implantable Cardioverter-Defibrillator

Resumo Fundamento O cardioversor-desfibrilador implantável (CDI) pode causar níveis elevados de ansiedade e depressão, resultando em efeitos negativos na qualidade de vida. Objetivos Avaliar a qualidade de vida, a ansiedade e a aceitação do CDI por meio de instrumentos de medida padronizados e identificar preditores de melhores respostas para cada um dos desfechos estudados. Método Coorte prospectiva com pacientes submetidos a implante inicial de CDI ou reoperação para a manutenção do dispositivo. Os desfechos do estudo incluíram: qualidade de vida, ansiedade e aceitação do CDI. A mudança nos escores (30 e 180 dias) foi avaliada por meio da diferença mínima importante (DMI). Foi utilizada a análise univariada e o modelo de regressão logística multivariada para a identificação de preditores de melhores respostas, adotando-se o nível de significância de 5%. Resultados De janeiro/2020 a junho/2021 foram incluídos 147 pacientes, com idade média de 55,3 ± 13,4 anos e predomínio do sexo masculino (72,1%). A DMI para qualidade de vida, a ansiedade e a aceitação do CDI foram observadas em 33 (22,4%), 36 (24,5%) e 43 (29,3%) pacientes, respectivamente. Idade igual ou maior que 60 anos (OR=2,5; IC 95%=1,14-5,53; p=0,022), ausência de fibrilação atrial (OR=3,8; IC 95%=1,26-11,63; p=0,017) e sexo feminino (OR=2,2; IC 95%=1,02-4,97; p=0,045) foram preditores independentes de melhores respostas para qualidade de vida, ansiedade e aceitação do CDI, respectivamente. Conclusão A identificação de preditores para melhores escores de qualidade de vida, ansiedade e aceitação do dispositivo pode subsidiar a implementação de cuidados específicos para os pacientes com maiores chances de apresentar resultados desfavoráveis.

Abstract Background An implantable cardioverter-defibrillator (ICD) can cause high levels of anxiety and depression, resulting in negative effects on quality of life. Objectives To evaluate the quality of life, anxiety, and acceptance of the ICD using standardized measurement instruments and identify predictors of better responses for each of the outcomes studied. Method This is a prospective cohort study with patients undergoing initial ICD implantation or reoperation to maintain the device. The study outcomes included quality of life, anxiety, and acceptance of the ICD. The change in scores (30 and 180 days) was assessed using the minimal important difference (MID). Univariate analysis and the multivariate logistic regression model were used to identify predictors of better responses, adopting a significance level of 5%. Results A total of 147 patients were included between January/2020 to June/2021, with a mean age of 55.3 ± 13.4 years and a predominance of males (72.1%). The MID for quality of life, anxiety, and ICD acceptance were observed in 33 (22.4%), 36 (24.5%) and 43 (29.3%) patients, respectively. Age equal to or greater than 60 years (OR=2.5; 95%CI=1.14-5.53; p=0.022), absence of atrial fibrillation (OR=3.8; 95%CI=1.26-11.63; p=0.017) and female gender (OR=2.2; 95%CI=1.02-4.97; p=0.045) were independent predictors of better responses to quality of life, anxiety and acceptance of the ICD, respectively. Conclusion The identification of predictors for better quality of life scores, anxiety, and acceptance of the device can support the implementation of specific care for patients with a greater chance of presenting unfavorable results.

Factors of mortality in patients with cardiac implantable electronic device: 5-year experience

SUMMARY OBJECTIVE: The use of cardiac implantable electronic devices has increased in recent years. It has also brought some issues. Among these, the complications of cardiac implantable electronic devices infection and pocket hematoma are difficult to manage. It can be fatal with the contribution of patient-related risk factors. In this study, we aimed to find mortality rates in patients who developed cardiac implantable electronic devices infection and pocket hematoma over 5 years. We also investigated the risk factors affecting mortality in patients with cardiac implantable electronic devices. METHODS: A total of 288 cardiac implantable electronic devices patients were evaluated. Demographic details, history, and clinical data of all patients were recorded. Cardiac implantable electronic devices infection was defined according to the modified Duke criteria. The national registry was used to ascertain the mortality status of the patients. The patients were divided into two groups (exitus and survival groups). In addition, the pocket hematoma was defined as significant bleeding at the pocket site after cardiac implantable electronic devices placement. RESULTS: The cardiac implantable electronic devices infection was similar in both groups (p=0.919), and the pocket hematoma was higher in the exitus group (p=0.019). The exitus group had higher usage of P2Y12 inhibitors (p≤0.001) and novel oral anticoagulants (p=0.031). The Cox regression analysis, including mortality-related factors, revealed that renal failure is the most significant risk factor for mortality. Renal failure was linked to a 2.78-fold higher risk of death. CONCLUSION: No correlation was observed between cardiac implantable electronic devices infection and mortality, whereas pocket hematoma was associated with mortality. Furthermore, renal failure was the cause of the highest mortality rate in patients with cardiac implantable electronic devices.

Preditores de Terapias Apropriadas e Óbito em Pacientes com Cardiodesfibrilador Implantável e Cardiopatia Chagásica Crônica / Predictors of Appropriate Therapies and Death in Patients with Implantable Cardioverter-Defibrillator and Chronic Chagas Heart Disease

Resumo Fundamento: Existem poucos estudos retrospectivos e prospectivos sobre cardiodesfibrilador implantável (CDI) na prevenção primária e secundária de morte súbita na cardiopatia chagásica crônica (CCC). Objetivos: Descrever a evolução a longo prazo dos portadores de CCC com CDI e identificar e analisar os preditores de mortalidade e de terapia apropriada do dispositivo nessa população. Métodos: Trata-se de um estudo prospectivo histórico com 117 pacientes portadores de CDI e CCC. Dispositivos foram implantados de janeiro de 2003 a dezembro de 2021. Fatores preditores de terapias apropriadas e mortalidade a longo prazo foram identificados e analisados. O nível de significância estatística é de p < 0,05. Resultados: Pacientes (n = 117) tiveram mediana de seguimento de 61 meses (25 a 121 meses), sendo o gênero masculino (74%) predominante e a mediana de idade de 55 anos (48 a 64 anos). Houve 43,6% de choques apropriados, 26,5% de estimulação cardíaca antitaquicardia (ATP) e 51% de terapias apropriadas. Durante o seguimento, 46 pacientes (39,7%) foram a óbito. A mortalidade foi de 6,2% pessoas-ano (intervalo de confiança [IC] 95%: 4,6 a 8,3), com 2 mortes súbitas durante o seguimento. A prevenção secundária (hazard ratio [HR] 2.1; IC 95%: 1,1 a 4,3; p = 0,029) e a fração de ejeção menor que 30% (HR 1.8; IC 95%: 1,1 a 3,1; p < 0,05) foram preditores de terapias apropriadas. Escore de Rassi intermediário apresentou uma forte associação com ocorrência de ATP isoladamente (p = 0,015). A classe funcional IV (p = 0,007), fração de ejeção do ventrículo esquerdo < 30 (p = 0,010) e a idade maior que 75 anos (p = 0,042) foram preditores de mortalidade total. Conclusão: Os desfibriladores na CCC apresentaram elevada incidência de acionamento apropriado especialmente naqueles pacientes de prevenção secundária, fração de ejeção do ventrículo esquerdo baixa e escore de Rassi intermediário. Os pacientes com insuficiência cardíaca congestiva, classe funcional avançada e idade maior que 75 anos apresentaram elevada mortalidade.

Abstract Background: There are few retrospective and prospective studies on implantable cardioverter-defibrillators (ICD) in primary and secondary prevention of sudden death in chronic Chagas heart disease (CCHD). Objectives: To describe the long-term evolution of patients with CCHD and ICD and to identify and analyze predictors of mortality and appropriate device therapy in this population. Methods: This was a historical prospective study with 117 patients with ICD and CCHD. Devices were implanted from January 2003 to December 2021. Predictors of appropriate therapies and long-term mortality were identified and analyzed. The level of statistical significance was p < 0.05. Results: Patients (n = 117) had a median follow-up of 61 months (25 to 121 months); they were predominantly male (74%), with a median age of 55 years (48 to 64 years). There were 43.6% appropriate shocks, 26.5% antitachycardia pacing (ATP), and 51% appropriate therapies. During follow-up, 46 patients (39.7%) died. Mortality was 6.2% person-years (95% confidence interval [CI]: 4.6 to 8.3), with 2 sudden deaths during follow-up. Secondary prevention (hazard ratio [HR] 2.1; 95% CI: 1.1 to 4.3; p = 0.029) and ejection fraction less than 30% (HR 1.8; 95% CI: 1.1 to 3.1; p < 0.05) were predictors of appropriate therapies. Intermediate Rassi score showed a strong association with the occurrence of ATP alone (p = 0.015). Functional class IV (p = 0.007), left ventricular ejection fraction < 30 (p = 0.010), and age above 75 years (p = 0.042) were predictors of total mortality. Conclusion: ICDs in CCHD showed a high incidence of appropriate activation, especially in patients with secondary prevention, low left ventricular ejection fraction, and intermediate Rassi score. Patients with congestive heart failure, elevated functional class, and age over 75 years showed elevated mortality.

Desfibriladores automáticos implantables y su desactivación, una conversación necesaria. Revisión de la literatura y propuesta multidisciplinaria / Implantable automatic defibrillators and their deactivation, a necessary conversation. Literature review

El uso de desfibriladores automáticos implantables (DAI) ha ido en aumento. Los pacientes usuarios de DAI inevitablemente transitan hacia el fin de la vida en algún momento, incluyendo la concurrencia de patologías terminales. En dicho contexto se hace relevante discutir y evaluar la desactivación de estos dispositivos en búsqueda del confort del paciente y evitar descargas en la fase de fin de vida. Hay múltiples barreras comunicacionales y operacionales a la hora de considerar la desactivación del DAI. En primer lugar, un gran porcentaje de pacientes no lo ha discutido con su tratante pese a las recomendaciones de guías internacionales de realizarlo previo a la instalación del dispositivo. En segundo lugar, existe un importante desconocimiento de pacientes, familiares e incluso médicos sobre los beneficios de DAI así como del proceso de desactivación y la discusión ética que incluso los lleva a pensar que ocurrirá una muerte inmediata, considerándolo como eutanasia o suicidio asistido. Finalmente, el manejo de pacientes en hospicios o el manejo de fin de vida en usuarios de DAI está escasamente protocolizado, con bajos porcentajes de desactivación, lo que se traduce en descargas en los últimos minutos de vida que producen angustia marcada a pacientes y familiares. Es necesario abordar estas barreras y discutir dichas temáticas con los pacientes para informarlos y educarlos en el funcionamiento de su dispositivo, con el objetivo final de permitir la toma de una decisión informada y compartida, en línea con el bienestar de los pacientes.

The use of implantable cardioverter-defibrillators (ICDs) has been on the rise. Patients using ICDs inevitably transit towards the end of life at some point, including some who develop terminal illnesses. In this context, it is relevant to discuss and evaluate the deactivation of these devices with the aim of addressing patients' comfort and avoiding shocks during the end-of-life phase. There are multiple communicational and operational barriers when considering ICDs deactivation. Firstly, many patients have not discussed this issue with their physicians despite international guidelines recommending such discussions before device installation. Secondly, there is a significant lack of knowledge among patients, family members, and even doctors about the benefits of ICDs, as well as the deactivation process and ethics considerations, which leads them to believe that immediate death will occur, considering it as euthanasia or assisted suicide. Finally, the management of hospice patients or end-of-life ICDs users is poorly standardized, with low rates of deactivation, resulting in shocks in the last minutes of life, which can cause marked distress to patients and families. It is necessary to address these barriers and discuss these issues with patients to inform and educate them about the functioning of their devices, with the ultimate goal of enabling informed and shared decision-making for patient well-being.

Cardioverter-defibrillator reduces mortality risk in eligible ischemic and non-ischemic cardiomyopathy patients: Sub-analysis of the multi-center Improve SCA study

Background & Objective: Despite the burden of sudden cardiac arrest (SCA) worldwide, implantable cardioverter-defibrillators (ICDs) are underutilized, particularly in Asia, Latin America, Eastern Europe, the Middle East, and Africa. The Improve SCA trial demonstrated that primary prevention (PP) patients in these regions benefit from an ICD or a cardiac resynchronization therapy defibrillator (CRT-D). We aimed to compare the rate of device therapy and mortality among ischemic and non-ischemic cardiomyopathy (ICM and NICM) PP patients who met guideline indications for ICD therapy and had an ICD/CRT-D implanted. Methods: Improve SCA was a prospective, non-randomized, non-blinded multicenter trial that enrolled patients from the above-mentioned regions. All-cause mortality and device therapy were examined by cardiomyopathy (ICM vs NICM) and implantation status. Cox proportional hazards methods were used, adjusting for factors affecting mortality risk. Results: Of 1848 PP NICM patients, 1007 (54.5%) received ICD/CRT-D, while 303 of 581 (52.1%) PP ICM patients received an ICD/CRT-D. The all-cause mortality rate at 3 years for NICM patients with and without an ICD/CRT-D was 13.1% and 18.3%, respectively (HR 0.51, 95% CI 0.38e0.68, p < 0.001). Similarly, all-cause mortality at 3 years in ICM patients was 13.8% in those with a device and 19.9% in those without an ICD/CRT-D (HR 0.54, 95% CI 0.33e.0.88, p ¼ 0.011). The time to first device therapy, time to first shock, and time to first antitachycardia pacing (ATP) therapy were not significantly different between groups (p 0.263). Conclusions: In this large data set of patients with a guideline-based PP ICD indication, defibrillator device implantation conferred a significant mortality benefit in both NICM and ICM patients. The rate of appropriate device therapy was also similar in both groups.

Reprocessamento de Marca-Passos em Países de Língua Portuguesa: Uma Reflexão Clínica / Pacemaker Reuse in Portuguese Speaking Countries: A Clinical Reflection

Resumo Há uma enorme disparidade entre os países de alta renda e outros em termos de acesso a dispositivos médicos cardíacos, como marca-passos e desfibriladores implantáveis. Os custos são uma das principais barreiras ao uso de dispositivos cardíacos nesses países. Existem iniciativas internacionais que visam reduzir essa disparidade, e o reuso de marca-passos tem sido discutido como uma possível alternativa. O conceito de reutilização de marca-passos não é novo; entretanto, estudos recentes têm se mostrado seguros, éticos e eficazes para aqueles que precisam de dispositivos eletrônicos cardíacos implantáveis e não tem como adquiri-los. Parte dos países de língua portuguesa, especialmente na África, precisam de uma resposta imediata que beneficie seus inúmeros pacientes que sofrem de arritmias tratáveis.

Abstract There is a gap between high-income countries and others in terms of access to medical cardiac devices, such as pacemakers and implantable cardioverter defibrillators. Costs are one of the main barriers to the use of cardiac devices in these countries. There are international initiatives that aim to reduce the gap. The reuse of pacemakers has been discussed as a possible alternative to this problem. The concept of reusing pacemakers is not new; however, recent studies have proven to be safe, ethical, and effective for those who need cardiac implantable electronic devices and cannot afford them. Part of the Portuguese-speaking countries, especially in Africa, need an immediate response that benefits their countless patients who suffer from treatable arrhythmias.

Estratégias Percutâneas em Doenças Estruturais: Foco em Insuficiência Cardíaca Crônica / Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure

Resumo As inovações em dispositivos ao longo das últimas décadas proporcionaram uma melhora no diagnóstico e tratamento de pacientes com insuficiência cardíaca. Essas novas ferramentas progressivamente adaptaram-se a estratégias minimamente invasivas e as opções percutâneas multiplicaram-se de forma rápida. No presente artigo revisamos as direções atuais e futuras dos dispositivos utilizados como opções adjuvantes para o diagnóstico e tratamento adjuvante na insuficiência cardíaca crônica, o seu desenvolvimento, mecanismos e estudos mais recentes

Abstract Innovations in devices during the last decade contributed to enhanced diagnosis and treatment of patients with cardiac insufficiency. These tools progressively adapted to minimally invasive strategies with rapid, widespread use. The present article focuses on actual and future directions of device-related diagnosis and treatment of chronic heart failure.

Favorable Safety Experience of Local Dental Anesthesia in ICD Recipients with Cardiac Channelopathies

Abstract Background Dental anesthetic management in implantable cardioverter defibrillator (ICD) recipients with cardiac channelopathies (CCh) can be challenging due to the potential risk of life-threatening arrhythmias and appropriate ICD therapies during procedural time. Objectives The present study assessed the hypothesis that the use of local dental anesthesia with 2% lidocaine with 1:100,000 epinephrine or without a vasoconstrictor can be safe in selected ICD and CCh patients, not resulting in life-threatening events (LTE). Methods Restorative dental treatment under local dental anesthesia was made in two sessions, with a wash-out period of 7 days (cross-over trial), conducting with a 28h - Holter monitoring, and 12-lead electrocardiography, digital sphygmomanometry, and anxiety scale assessments in 3 time periods. Statistical analysis carried out the paired Student's t test and the Wilcoxon signed-rank test. In all cases, a significance level of 5% was adopted. All patients were in stable condition with no recent events before dental care. Results Twenty-four consecutive procedures were performed in 12 patients (9 women, 3 men) with CCh and ICD: 7 (58.3%) had long QT syndrome (LQTS), 4 (33.3%) Brugada syndrome (BrS), and 1 (8.3%) Catecholaminergic polymorphic ventricular tachycardia (CPVT). Holter analysis showed no increased heart rate (HR) or sustained arrhythmias. Blood pressure (BP), electrocardiographic changes and anxiety measurement showed no statistically significant differences. No LTE occurred during dental treatment, regardless of the type of anesthesia. Conclusion Lidocaine administration, with or without epinephrine, can be safely used in selected CCh-ICD patients without LTE. These preliminary findings need to be confirmed in a larger population with ICD and CCh.

Avaliação Prognóstica da Microalternância da onda T na Cardiomiopatia Hipertrófica em um Seguimento Clínico de 9 anos / Prognostic Evaluation of Microvolt T-Wave Alternans in Hypertrophic Cardiomyopathy: 9-year Clinical Follow-up

Resumo Fundamento: A morte súbita cardíaca (MSC), decorrente de arritmias ventriculares, é a principal complicação da cardiomiopatia hipertrófica (CMH). A microalternância da onda T (MAOT) está associada à ocorrência de arritmias ventriculares em diversas cardiopatias, mas seu papel na CMH permanece incerto. Objetivo: Avaliar associação da MAOT com a ocorrência de MSC ou arritmias ventriculares malignas em pacientes com CMH. Método: Pacientes com diagnóstico de CMH e classe funcional I-II (NYHA) foram selecionados de forma consecutiva. No início do seguimento os participantes realizaram a avaliação da MAOT pela metodologia da média móvel modificada no teste de esforço. Os resultados foram classificados em alterado ou normal. O desfecho foi composto por MSC, fibrilação ventricular, taquicardia ventricular sustentada (TVS) e terapia apropriada do cardioversor desfibrilador implantável (CDI). O nível de significância estatística foi de 5%. Resultados: Um total de 132 pacientes (idade média de 39,5±12,6 anos) foram incluídos, com tempo de seguimento médio de 9,5 anos. A MAOT foi alterada em 74 (56%) participantes e normal em 58 (44%). Durante o seguimento, nove (6,8%) desfechos ocorreram, com prevalência de 1,0%/ano, sendo seis casos de MSC, dois choques apropriados do CDI e um episódio de TVS. MAOT alterada foi associada à taquicardia ventricular não sustentada no Holter (p=0,016), espessura septal≥30 mm (p<0,001) e resposta inadequada da pressão arterial ao esforço (p=0,046). Cinco pacientes (7%) e quatro pacientes (7%) com MAOT alterada e normal, respectivamente, apresentaram desfecho primário [OR=0,85(IC95%: 0,21-3,35, p=0,83)]. Curvas de eventos de Kaplan-Meir não apresentaram diferenças entre MAOT normal e alterada. Conclusão: A MAOT alterada não foi associada à ocorrência de MSC ou arritmias ventriculares potencialmente fatais em pacientes com CMH, e a baixa taxa desses eventos em um seguimento em longo prazo sugere o bom prognóstico dessa cardiopatia.

Abstract Background: Sudden cardiac death (SCD) resulting from ventricular arrhythmia is the main complication of hypertrophic cardiomyopathy (HCM). Microvolt T-wave alternans (MTWA) is associated with the occurrence of ventricular arrhythmias in several heart diseases, but its role in HCM remains uncertain. Objective: To evaluate the association of MTWA with the occurrence of SCD or potentially fatal ventricular arrhythmias in HCM patients in a long-term follow-up. Methods: Patients diagnosed with HCM and NYHA functional class I-II were consecutively selected. At the beginning of the follow-up, the participants performed the MTWA evaluation using the modified moving average during the stress test. The results were classified as altered or normal. The composite endpoint of SCD, ventricular fibrillation, sustained ventricular tachycardia (SVT) or appropriate implantable cardiac defibrillation (ICD) therapy was assessed. The level of significance was set at 5%. Results: A total of 132 patients (mean age of 39.5 ± 12.6 years) were recruited and followed for a mean of 9.5 years. The MTWA test was altered in 74 (56%) participants and normal in 58 (44%). Nine events (6.8%) occurred during the follow-up, with a prevalence of 1.0%/year - six SCDs, two appropriate ICD shocks and one episode of (SVT). Altered MTWA was associated with non-sustained ventricular tachycardia on Holter (p = 0.016), septal thickness ≥30 mm (p < 0.001) and inadequate blood pressure response to effort (p = 0.046). Five patients with altered MTWA (7%) and four patients with normal MTWA (7%) had the primary outcome [OR = 0.85 (95% CI: 0.21 - 3.35, p=0.83)]. Kaplan-Meir event curves showed no differences between normal and altered MTWA. Conclusion: Altered MTWA was not associated with the occurrence of SCD or potentially fatal ventricular arrhythmias in HCM patients, and the low rate of these events during long-term follow-up suggests the good prognosis of this heart disease.

Teste de Limiar de Desfibrilação e Seguimento a Longo Prazo de Pacientes com Cardiopatia Crônica da Doença de Chagas / Defibrillation Threshold Testing and Long-term Follow-up in Chagas Disease

Resumo Fundamento A morte súbita cardíaca (MSC) é a causa mais comum de óbito na cardiomiopatia crônica da doença de Chagas (CCDC). Visto que muitos pacientes com CCDC que são candidatos a receber um cardioversor desfibrilador implantável (CDI) atendem a critérios que sugerem alto risco de apresentarem limiares de desfibrilação elevados, sugere-se realizar um teste de limite de desfibrilação (LDF). Objetivos Investigamos o uso do teste de LDF em pacientes com CCDC, com enfoque nos óbitos relacionados ao implante do CDI e na ocorrência de eventos arrítmicos e o tratamento oferecido durante o seguimento de longo prazo. Métodos Avaliações retrospectivas de 133 pacientes com CCDC que receberam CDI, principalmente para prevenção secundária. Foram coletados dados demográficos, clínicos e laboratoriais, escore de Rassi e dados do teste de LDF. Adotou-se p<0,05 como estatisticamente significativo. Resultados A média de idade foi 61±13 anos, e 72% da amostra era do sexo masculino. A fração de ejeção basal do ventrículo esquerdo foi 40±15%, e o escore de Rassi médio foi 10±4 pontos. Não ocorreram óbitos durante o teste de LDF, e não foram documentadas falhas do CDI. Foi identificada relação entre escore de Rassi basal mais elevado e LDFs mais elevados (ANOVA =0,007). O tempo médio até o primeiro choque foi de 474±628 dias, mas a aplicação de choque foi necessária em apenas 28 (35%) pacientes com TV, visto que a maioria dos casos se resolveu espontaneamente ou através da programação de ATP. Após seguimento clínico de 1728±1189 dias, em média, ocorreram 43 óbitos, relacionados principalmente a insuficiência cardíaca progressiva e sepse. Conclusões Um teste de LDF de rotina pode não ser necessário para pacientes com CCDCs que receberam CDI para prevenção secundária. LDFs elevados parecem ser incomuns e podem estar relacionados a escore de Rassi elevado.

Abstract Background Sudden cardiac death is the most common cause of death in chronic Chagas cardiomyopathy (CCC). Because most CCC patients who are candidates for implantable cardioverter-defibrillators (ICD) meet criteria for high defibrillation threshold values, a defibrillator threshold test (DTT) is suggested. Objectives We investigated the use of DTT in CCC patients, focusing on deaths related to ICD and arrhythmic events, as well as treatment during long-term follow-up. Methods We retrospectively evaluated 133 CCC patients who received an ICD mainly for secondary prevention. Demographic, clinical, laboratory data, Rassi score, and DTT data were collected, with p < 0.05 considered significant. Results The mean patient age was 61 (SD, 13) years and 72% were men. The baseline left ventricular ejection fraction was 40 (SD, 15%) and the mean Rassi score was 10 (SD, 4). No deaths occurred during DTT and no ICD failures were documented. There was a relationship between higher baseline Rassi scores and higher DTT scores (ANOVA = 0.007). The mean time to first shock was 474 (SD, 628) days, although shock was only necessary for 28 (35%) patients with ventricular tachycardia, since most cases resolved spontaneously or through antitachycardia pacing. After a mean clinical follow-up of 1728 (SD, 1189) days, 43 deaths occurred, mainly related to progressive heart failure and sepsis. Conclusions A routine DTT may not be necessary for CCC patients who receive an ICD for secondary prevention. High DTT values seem to be unusual and may be related to high Rassi scores.

Selvester Score May Be a Predictor of ICD Therapies in Patients with Non-Ischemic Dilated Cardiomyopathy

ABSTRACT Introduction: The benefit of implantable cardioverter-defibrillator (ICD) in patients with non-ischemic dilated cardiomyopathy (DCM) is still an issue under discussion. Studies examining the relationship between ventricular scar tissue and ICD shock with cardiac magnetic resonance (CMR) are promising. CMR studies have shown that ventricular scar tissue size and Selvester score show a correlation. In the light of this information, this study aimed to investigate the potential relationship between Selvester score and ICD therapies. Methods: The study included 48 patients who had undergone ICD implantation with a diagnosis of DCM and who had undergone routine 6-month ICD control in outpatient clinic controls between December 2018 and October 2019. Selvester score and other data were compared between patients who received ICD therapy (n=10) and those who did not (n=38). Results: Selvester score (P<0.001) was higher in ICD therapy group. Positive correlation was found between ICD shock therapy and Selvester score (P=0.002, r=0.843). Selvester score was detected as an independent predictor for ICD therapy after multiple linear regression analysis (P=0.004). Receiver operating characteristic curve analysis showed that Selvester score (P<0.001) was a significant predictor of ICD therapy. Selvester score cutoff points of 5 for were calculated to estimate ICD therapy, with a sensitivity of 100% and specifity of 81%. Conclusion: In our study, it was found that a high Selvester score may be a predictor for ICD therapies in patients with DCM. As an inexpensive and non-invasive method, Selvester score can help in the decision-making in these patients.

Perfil dos usuários de dispositivos cardíacos eletrônicos implantavéis em um hospital universitário / Perfil de usuario de dispositivos cardíacos electrónicos implantables en un hospital universitario / User profile of implantable electronic cardiac devices in a university hospital

Objetivo:Identificar o perfil dos pacientes submetidos à inserção de dispositivos cardíacos eletrônicos implantáveis em um hospital de referência do Rio Grande do Norte.Método:Trata-se de um estudo descritivo, exploratório, retrospectivo dos últimos 03 anoscom abordagem quantitativa. Amostragem foiselecionada por conveniência. A coleta de dados ocorreu entre outubrode 2017 a março de 2018.Resultados: A amostra foi composta por 215prontuários,destes 182 foram analisados.Implantarammarca-passos63,7% e 28% cardiodesfibriladores, corresponderam ao sexo masculino69,3%,com média de idade 65 e 49.Entre as comorbidades,a Hipertensão Arterial Sistêmicaabrangeu 87,4%.Evidenciaram-se os bloqueios atrioventriculares como principal causa para implantes (35%), seguidos das miocardiopatias (12%).Conclusão:Percebeu-se que, os indivíduos que implantaram marcapassos eram acometidos por bradiarritmias,enquanto cardiodesfibriladores por taquiarritmias. As complicações pós-operatórias e intercorrências durante o procedimento foram de baixo risco. Salienta-se, que no manejo desses usuários é fundamental a elaboração de um protocolo, visando aperfeiçoar o cuidado.(AU)

Objective: Toidentifytheprofileofpatientsundergoinginsertionof implantable electroniccardiacdevices in a reference hospital in Rio Grande do Norte. Method: Thisis a descriptive, exploratory,retrospective studyofthelastthreeyearswith a quantitativeapproach. Samplingwasselectedby convenience. Data collectionoccurredbetweenOctober 2017 to March 2018. Results: Samplecomposedof 215 medical records, ofthese 182 wereanalyzed. Implantedpacemakers 63.7% and 28% cardiodesfibrillators, corresponded tothe male gender 69.3%, withaverageage 65 and 49. Amongthecomorbidities, Systemic Arterial Hypertensioncovered 87.4%. Theatrioventricular blocks wereevidenced as themain cause forimplantation (35%), followedbymyocardiopathies (12%). Conclusion: Itwasnoticedthatindividualswhoimplantedpacemakerswereaffectedbybradyarrhythmias, whilecardioverter-defibrillatorswereaffe ctedbytachyarrhythmias. Thepostoperativecomplications and complicationsduringtheprocedurewerelowrisk. Itisemphasizedthat in themanagementoftheseusersitisessentialtodevelop a protocol, aimingtoimprove care.(AU)

Objetivo: identificar el perfil de los pacientes sometidos a la inserción de dispositivos cardíacos electrónicos implantables en el hospital de referencia de Rio Grande do Norte. Método: se trata de un estudio descriptivo, exploratorio, retrospectivo de los últimos 3 años con enfoque cuantitativo. El muestreo fue seleccionado por conveniencia. La recolección de datos se llevó a cabo entre octubre de 2017 y marzo de 2018. Resultados: muestra compuesta por 215 historias clínicas, de las cuales se analizaron 182. Marcapasos implantados 63,7% y desfibriladores cardioversores 28%, correspondieron al sexo masculino 69,3%, con una edad media de 65 y 49 años. Entre las comorbilidades, la Hipertensión Arterial Sistémica cubrió el 87,4%. Los bloqueos auriculoventriculares se evidenciaron como la principal causa de implantes (35%), seguida de las miocardiopatías (12%). Conclusión: se notó que, los portadores de marcapasos se vieron afectados por bradiarritmias, mientras que los desfibriladores cardioversores por taquiarritmias. Las complicaciones postoperatorias y las complicaciones durante el procedimiento fueron de bajo riesgo. Cabe señalar que en el manejo de estos usuarios es fundamental la elaboración de un protocolo, con el fin de mejorar la atención.(AU)

Comparison of Anxiety and Depression Symptoms in Individuals According to their Sex, Type of Cardiac Device, and Diagnosis of Chagas Disease

ABSTRACT Introduction: Implantable cardiac pacemakers or cardioverter defibrillators are alternatives for the treatment of arrhythmias, however, their use has caused changes in the emotional state of patients. The objective of this study was to compare the measures of anxiety and depression symptoms in individuals according to their sex, type of cardiac device, and diagnosis of Chagas disease. Methods: This is an observational and cross-sectional study conducted with adults with implantable cardiac pacemakers or cardioverter defibrillators. Data was collected using a sociodemographic and clinical questionnaire and the Hospital Anxiety and Depression Scale. We used the Student's t-test for independent samples and the Chi-squared test, with a significance level of 0.05. Results: Two hundred forty-four patients participated in the study, 168 with cardiac pacemakers and 76 with implantable cardioverter defibrillators; 104 had Chagas cardiomyopathy (85 with cardiac pacemakers and 19 with implantable cardioverter defibrillators). No statistically significant differences were found in measures of anxiety and depression symptoms according to device type (P=0.594 and P=0.071, respectively) and the presence of Chagas etiology (P=0.649 and P=0.354, respectively). Women had higher mean scores for anxiety (P=0.002) and depression symptoms (P<0.001). Conclusion: In the comparison between the groups, according to the type of implanted device and the diagnosis of Chagas disease, no significant differences were found in the measures of anxiety and depression symptoms. Women showed higher means when compared to men, indicating the need to test and implement interventions to minimize these symptoms in this population.

Diagnostic Lacunae and Implications of an Automated Implantable Cardioverter Defibrillator Implantation in a Child with Type 3 Long QT (LQT3) Syndrome

A diagnosis of congenital long QT interval syndrome based on history and electrocardiogram was made in a child in the absence of readily available genetic testing. A genotype 3 (LQT3) was suspected after exclusion of other variants as the child was non?responsive to beta?blocker and sodium channel blocker medication. As the child continues to show episodic bradycardia, polymorphic ventricular ectopy, and T?wave alternans, a single?chamber automated implantable cardioverter?defibrillator implantation was done successfully. This report highlights how the diagnosis of LQT3 was arrived at as well as the anesthetic challenges in the management of patients with LQTS.

Qualidade de vida relacionada à saúde de pacientes antes e após o implante de cardioversor desfibrilador implantável / Health-related quality of life of patients before and after implantable cardioverter-defibrillator implantation

Introdução: Há diversos procedimentos que auxiliam no tratamento das doenças cardíacas, um deles é o implante do cardioversor desfibrilador implantável (CDI). Apesar dos inúmeros benefícios clínicos, existem evidências de que o CDI pode alterar a qualidade de vida dos pacientes. Objetivo: Avaliar a qualidade de vida relacionada à saúde (QVRS) e os sintomas de ansiedade, depressão e ansiedade cardíaca (AC) de pacientes no pré-operatório, três e nove meses após implante do CDI, bem como investigar a relação da QVRS com sintomas de ansiedade, depressão, AC e características sociodemográficas e clínicas. Método: Estudo observacional analítico, realizado em um hospital universitário do interior paulista. Uma amostra consecutiva e não probabilística foi constituída por pacientes de ambos os sexos, maiores de 18 anos, com indicação de implante do CDI. A coleta de dados foi realizada por entrevistas individuais e consulta aos prontuários, no dia da cirurgia (pré-operatório), três e nove meses após o implante do CDI. Para a avaliação da QVRS foi utilizado o instrumento "Medical Outcomes Study 36 - Item Short-Form Health Survey", com maiores valores indicando melhor avaliação, para a avaliação dos sintomas de ansiedade e depressão e ansiedade cardíaca, foram utilizados o "Hospital Anxiety and Depression Scale" e o "Questionário de Ansiedade Cardíaca", respectivamente, com maiores valores indicando maior sintomatologia. Utilizado o teste de Friedman para comparar a QVRS e os sintomas nos três tempos. Utilizados o Teste de Correlação de Spearman e o teste de Mann-Whitney para investigar as correlações/associações da QVRS com os sintomas de ansiedade, depressão, AC e características sociodemográficas e clínicas. Nível de significância de 5%. Resultados: Participaram 18 pacientes, maioria do sexo masculino (72,2%), inativa profissionalmente (88,9%), com baixa escolaridade e renda mensal. A média de idade foi de 57,7 (DP=13,2). Com relação a avaliação da QVRS nos três tempos, as medianas obtidas no domínio "Dor" apresentaram diferença estatisticamente significante, quando comparadas no pré-operatório (mediana = 35,0) e três meses após o implante (mediana = 15,0). Quanto à avaliação longitudinal dos sintomas, as medianas obtidas para ansiedade apresentaram diferença estatisticamente significante, quando comparadas três meses (mediana = 8,0) e nove meses após o implante (mediana = 6,0). Não encontramos associação da QVRS dos participantes com o sexo, a idade e o uso de psicofármacos. Encontramos correlações negativas, de forte magnitude e significativas entre o Componente Emocional da QVRS e os sintomas de ansiedade e depressão, nos três tempos, bem como correlações negativas, de forte magnitude e significativas desse componente com os sintomas de AC no pré-operatório e nove meses após o implante. Conclusão: os pacientes apresentaram piores avaliações no domínio "Dor" da QVRS no retorno de três meses quando comparados com o pré-operatório, bem como apresentaram mais sintomas de ansiedade três meses após o implante quando comparados com nove meses após o implante. Quanto à relação da QVRS com os sintomas de ansiedade e depressão, observou-se que nos três tempos investigados, quanto pior a avaliação do Componente Emocional da QVRS, maior a sintomatologia. O mesmo foi observado com os sintomas de AC e o Componente Emocional da QVRS no pré-operatório e nove meses após o implante.

Introduction: There are several procedures that help in the treatment of heart diseases, one of which is the implantation of an implantable cardioverter defibrillator (ICD). Despite the numerous clinical benefits, there is evidence that the ICD can change patients' quality of life. Objective: To assess health-related quality of life (HRQoL) and symptoms of anxiety, depression and cardiac anxiety (CA) in patients preoperatively, three and nine months after ICD implantation, as well as to investigate the relationship between HRQOL and symptoms of anxiety, depression, AC and sociodemographic and clinical characteristics. Method: Analytical observational study, carried out in a university hospital in the interior of São Paulo. A consecutive and non-probabilistic sample consisted of patients of both sexes, older than 18 years, with an indication for ICD implantation. Data collection was performed through individual interviews and consultation of medical records, on the day of surgery (preoperative), three and nine months after ICD implantation. For the assessment of HRQoL, the instrument "Medical Outcomes Study 36 - Item Short-Form Health Survey" was used, with higher values indicating better assessment, for the assessment of symptoms of anxiety and depression and cardiac anxiety, the "Hospital Anxiety and Depression Scale" and "Cardiac Anxiety Questionnaire", respectively, with higher values indicating greater symptoms. Friedman's test was used to compare HRQoL and symptoms at the three times. The Spearman Correlation Test and the Mann-Whitney Test were used to investigate the correlations/associations of HRQoL with symptoms of anxiety, depression, CA and sociodemographic and clinical characteristics. 5% significance level. Results: Eighteen patients participated, most of them male (72.2%), professionally inactive (88.9%), with low education and monthly income. The mean age was 57.7 (SD=13.2). Regarding the assessment of HRQoL at the three times, the medians obtained in the "Pain" domain showed a statistically significant difference when compared preoperatively (median = 35.0) and three months after implantation (median = 15.0). As for the longitudinal assessment of symptoms, the medians obtained for anxiety showed a statistically significant difference, when compared three months (median = 8.0) and nine months after implantation (median = 6.0). We found no association of participants' HRQoL with sex, age and use of psychotropic drugs. We found negative, strong and significant correlations between the Emotional Component of HRQoL and symptoms of anxiety and depression, at the three times, as well as negative, strong and significant correlations of this component with the symptoms of CA in the preoperative period and nine months after implant. Conclusion: the patients presented worse evaluations in the "Pain" domain of the HRQoL at the three-month follow-up period when compared to the preoperative period, as well as presented more anxiety symptoms three months after the implantation when compared to nine months after the implantation. As for the relationship between HRQOL and symptoms of anxiety and depression, it was observed that in the three times investigated, the worse the assessment of the Emotional Component of the HRQoL, the greater the symptomatology. The same was observed with the symptoms of CA and the Emotional Component of HRQoL preoperatively and nine months after implantation.

Cardiodesfibrilador implantable: estado del arte / Cardiac defibrillators: state of the art

Resumen La muerte súbita cardiaca es una consecuencia devastadora de las enfermedades estructurales del corazón y un problema de salud pública en todo el mundo; es responsable de alrededor del 50% de las muertes por causa cardiovascular. Su incidencia es mayor en personas por encima de los de 40 años, siendo en esta población la cardiopatía isquémica instaurada o durante la fase aguda del infarto al miocardio los factores de riesgo más importantes; sin embargo, hay otros factores no relacionados con isquemia, como la cardiomiopatía dilatada, hipertrófica o valvular. La fibrilación y la taquicardia ventricular son la causa más frecuente de muerte súbita cardiaca en adultos. Los cardiodesfibriladores implantables son ampliamente utilizados y recomendados por las sociedades de cardiología para la prevención primaria y secundaria de la muerte súbita cardiaca.

Abstract Sudden cardiac death is a devastating consequence of structural heart disease and a global public health problem, accounting for close to 50% of cardiovascular deaths. Its incidence is greater in people over the age of 40, with the most important risk factors being: established ischemic heart disease or ischemia during the acute phase of a myocardial infarction. However, there are other factors, unrelated to ischemia, such as dilated, hypertrophic, or valvular cardiomyopathy. Ventricular fibrillation and tachycardia are the most frequent causes of sudden cardiac death in adults. Implantable cardioverter-defibrillators are widely used and recommended by cardiology societies for primary and secondary prevention of sudden cardiac death.

Patient with an implantable cardiac electrical stimulation device. What should the anesthesiologist know? / Paciente con dispositivo de estimulación eléctrica cardiaca implantable. ¿Qué debe saber el anestesiólogo?

Abstract Patients with implantable electric stimulation devices are challenging to the anesthesiologist since these cases demand a comprehensive knowledge about how the device operates, the indications for the implant and the implications that must be addressed during the perioperative period. This article is intended to provide the reader with clear and structured information so that the anesthesiologist will be able to safely deal with the situation of a patient with an implantable cardiac stimulation device, who has been programmed for emergent surgery. A search for the scientific evidence available was conducted in Pubmed / Medline, ScienceDirect, OVID, SciELO), for a non-systematic review. The incidence of the use of cardiac electric stimulation devices has been growing. Their operation is increasingly complex, and demands being constantly updated on the knowledge in the area.

Resumen El paciente portador de un dispositivo de estimulación eléctrica cardiaca implantable se convierte en un reto para el anestesiólogo debido a que implica un conocimiento integral que abarca su funcionamiento, las indicaciones que llevaron a su implante y las implicaciones que se deben abordar en el perioperatorio. Este artículo busca proporcionar al lector información clara y estructurada que le permita al anestesiólogo enfrentarse de forma segura al escenario de un paciente con un dispositivo de estimulación eléctrica cardiaca implantable programado para cirugía emergente. Se realizó una búsqueda de la evidencia científica disponible en bases de datos (Pubmed / Medline, ScienceDirect, OVID, SciELO), para una revisión no sistemática. La incidencia en el uso de dispositivos de estimulación eléctrica cardiaca viene en aumento. Su funcionamiento es cada vez más complejo lo cual implica una actualización permanente del conocimiento en esta área.