Pacemaker Lead Placement via Transmural Approach in an Adult With Palliated Single Ventricle Heart Disease.

Given the lack of systemic venous return to the heart, palliated single ventricle patients frequently require epicardial pacemaker implantation for management of dysrhythmias including sinus node dysfunction, atrial arrhythmias, and heart block. Repeated device hardware replacement, frequently required due to high lead thresholds or other device failure, is a challenging and significant problem for this population. 3-dimensional imaging can assist in delineating the cardiac anatomy allowing for novel approaches to intervention. We review a patient with extracardiac Fontan circulation who underwent placement of an endocardial atrial pacemaker lead via a transmural approach with a 3D-printed model used for procedural guidance.

Torsades de Pointes During Myringotomy in a Child with Congenital Long QT Syndrome: A Case Report.

BACKGROUND Long QT syndrome (LQTS) is an arrhythmogenic heart condition that can be congenital or acquired. Prolonged ventricular repolarizations in individuals with the disorder can cause fatal arrhythmias. Abnormal functioning of cardiac ion channels leads to arrhythmias such as torsades de pointes (TdP) and may be triggered by stress or medications. Many medications used in the perioperative period are triggers for the arrythmia. CASE REPORT A 7-year-old patient with known congenital LQTS type 2 presented for bilateral myringotomy and tube placement. The patient was otherwise healthy and taking propranolol daily. Preoperative midazolam was administered for anxiolysis, and induction of anesthesia was uneventful. He sustained an episode of TdP immediately following general anesthetic induction after failure of an in situ automatic implantable cardioverter-defibrillator (AICD). External defibrillation succeeded, and the patient was stabilized in the Postanesthesia Recovery Unit before transfer to the Pediatric Intensive Care Unit. Interrogation of the AICD revealed several undelivered defibrillation attempts. A chest X-ray showed an area suggestive of an epicardial electrode fracture. The following day, the AICD was replaced with no arrythmias noted. The patient had an uneventful recovery. CONCLUSIONS In patients with a known history of LQTS, preparation and prevention are cornerstones of anesthesia care. Minimizing the use of triggering medications and emotional stress in the perioperative period, combined with ready equipment and medications to respond to arrythmias, are essential. In children, there is a greater chance of lead fracture and resulting device failure. Preoperative history of device function or interrogation of the AICD and possibly a chest X-ray are essential to ensure the integrity of the leads.

Angina pectoris with troponin increase in arrhythmogenic right ventricle dysplasia: case article and review of the literature.

A 16-year-old Hispanic girl with arrhythmogenic right-ventricle dysplasia (ARVD) presented with angina pectoris and troponin increase on three occasions. There was a family history of sudden cardiac death in a cousin. Her mother was diagnosed with ARVD. The patient herself had a history of nonsustained ventricular tachycardia but did not meet diagnostic criteria for ARVD. Cardiac workup, including serial transthoracic echocardiograms and a coronary angiogram, showed a structurally normal heart without coronary artery stenosis. Results of cardiac magnetic resonance imaging were questionable, but endomyocardial biopsy did not show evidence of viral myocarditis by polymerase chain reaction. Genetic testing confirmed ARVD.

Utilizing simulation technology for competency skills assessment and a comparison of traditional methods of training to simulation-based training.

BACKGROUND: The respiratory care department of one campus within our health system evaluated simulation-based medical education for training and competency evaluation of the mini bronchoalveolar lavage (mini-BAL) procedure, with an emphasis on patient safety and procedure performance standards. METHODS: Training and competency evaluation occurred in 4 phases. In phase one, 24 staff respiratory therapists (RTs) were randomly chosen and individually underwent a simulation-based test of their mini-BAL performance, using a patient-simulator mannequin. Their performance on this test reflected the effectiveness of traditional training methods. In phase two, 83 staff RTs were given unlimited access to a Web-based curriculum on mini-BAL, including a video of a mini-BAL. They then took 2 tests: one online Web-based test, then a patient-simulator test. In phase three, the same 83 RTs attended a workshop that used the patient simulator for training and practice, then were re-evaluated with the patient-simulator test. Phase four was another simulator-based re-evaluation, 90 days after phase three, to study skills retention. RESULTS: The mean scores were: phase one 73 +/- 10%, phase two 77 +/- 11%, phase three 95 +/- 5% (p < 0.01), phase four 92 +/- 8%. CONCLUSION: Our results suggest that employing simulation technology within a comprehensive departmental program can enhance staff training.

Ablation of tachyarrhythmias in pediatric patients.

PURPOSE OF REVIEW: Radiofrequency (RF) ablation treatment for tachyarrhythmias has been available only for the past 15 years. The success rates have been excellent with a very low frequency of complications. Because of this efficacy, the use of RF ablation in children has become standard of care even though long-term data are unavailable. In this review, common tachyarrhythmias and their current treatments in children will be discussed. RECENT FINDINGS: Novel electrophysiology technologies such as electroanatomic mapping and sophisticated ablating catheters have improved success rates and decreased complications. The improvement is also due to better understanding of the mechanisms and etiologies of tachyarrhythmias. Both have positively impacted success rates and have made more complicated tachyarrhythmias treatable with ablation. SUMMARY: The technologic advances in ablation and improved understanding of tachyarrhythmias over the past 15 years have greatly improved outcomes in ablative treatment of tachyarrhythmias in children. In most cases this method of treatment is the preferred first-line approach to symptomatic tachyarrhythmias in children.