Alternative techniques for left ventricular pacing in cardiac resynchronization therapy.

Cardiac resynchronization therapy (CRT) is an important treatment modality for a well-defined subgroup of heart failure patients. Coronary sinus (CS) lead placement is the first-line clinical approach but the insertion is unsuccessful in about 5-10% of the patients. In recent years, the number of CRT recipients and the considerable need for left ventricular (LV) lead revisions increased enormously. Numerous techniques and technologies have been specifically developed to provide alternatives for the CS LV pacing. Currently, the surgical access is most frequently used as a second choice by either minithoracotomy or especially the video-assisted thoracoscopy. The transseptal or transapical endocardial LV lead implantations are being developed but there are no longer follow-up data in larger patient cohorts. These new techniques should be reserved for patients failing conventional or surgical CRT implants. In the future, randomized studies are needed to asses the potential benefits of some alternative LV pacing techniques and other new technologies for LV lead placement are expected.

Bilateral remote ischemic conditioning in children: A two-center, double-blind, randomized controlled trial in young children undergoing cardiac surgery.

Objective: The study objective was to determine whether adequately delivered bilateral remote ischemic preconditioning is cardioprotective in young children undergoing surgery for 2 common congenital heart defects with or without cyanosis. Methods: We performed a prospective, double-blind, randomized controlled trial at 2 centers in the United Kingdom. Children aged 3 to 36 months undergoing tetralogy of Fallot repair or ventricular septal defect closure were randomized 1:1 to receive bilateral preconditioning or sham intervention. Participants were followed up until hospital discharge or 30 days. The primary outcome was area under the curve for high-sensitivity troponin-T in the first 24 hours after surgery, analyzed by intention-to-treat. Right atrial biopsies were obtained in selected participants. Results: Between October 2016 and December 2020, 120 eligible children were randomized to receive bilateral preconditioning (n = 60) or sham intervention (n = 60). The primary outcome, area under the curve for high-sensitivity troponin-T, was higher in the preconditioning group (mean: 70.0 ± 50.9 µg/L/h, n = 56) than in controls (mean: 55.6 ± 30.1 µg/L/h, n = 58) (mean difference, 13.2 µg/L/h; 95% CI, 0.5-25.8; P = .04). Subgroup analyses did not show a differential treatment effect by oxygen saturations (pinteraction = .25), but there was evidence of a differential effect by underlying defect (pinteraction = .04). Secondary outcomes and myocardial metabolism, quantified in atrial biopsies, were not different between randomized groups. Conclusions: Bilateral remote ischemic preconditioning does not attenuate myocardial injury in children undergoing surgical repair for congenital heart defects, and there was evidence of potential harm in unstented tetralogy of Fallot. The routine use of remote ischemic preconditioning cannot be recommended for myocardial protection during pediatric cardiac surgery.

Comparison of the efficacy of two surgical alternatives for cardiac resynchronization therapy: trans-apical versus epicardial left ventricular pacing.

BACKGROUND: Epicardial pacing lead implantation is the currently preferred surgical alternative for left ventricular (LV) lead placement. For endocardial LV pacing, we developed a fundamentally new surgical method. The trans-apical lead implantation is a minimally invasive technique that provides access to any LV segments. The aim of this prospective randomized study was to compare the outcome of patients undergoing either trans-apical endocardial or epicardial LV pacing. METHODS: In group I, 11 end-stage heart failure (HF) patients (mean age 59.7 ± 7.9 years) underwent trans-apical LV lead implantation. Epicardial LV leads were implanted in 12 end-stage HF patients (group II; mean age 62.8 ± 7.3 years). Medical therapy was optimized in all patients. The following parameters were compared during an 18-month follow-up period: LV ejection fraction (LVEF), LV end-diastolic diameter (LVEDD), LV end-systolic diameter, and New York Heart Association (NYHA) functional class. RESULTS: Nine out of 11 patients responded favorably to the treatment in group I (LVEF 39.7 ± 12.5 vs 26.0 ± 7.8%, P < 0.01; LVEDD 70.4 ± 13.6 mm vs 73.7 ± 10.5 mm, P = 0.002; NYHA class 2.2 ± 0.4 vs 3.5 ± 0.4, P < 0.01) and eight out of 12 in group II (LVEF 31.5 ± 11.5 vs 26.4 ± 8.9%, P = < 0.001; NYHA class 2.7 ± 0.4 vs 3.6 ± 0.4, P < 0.05). During the follow-up period, one patient died in group I and three in group II. There was one intraoperative LV lead dislocation in group I and one early postoperative dislocation in each group. None of the patients developed thromboembolic complications. CONCLUSIONS: Our data suggest that trans-apical endocardial LV lead implantation is an alternative to epicardial LV pacing.

Feasibility of percutaneous implantation of transapical endocardial left ventricular pacing electrode for cardiac resynchronization therapy.

Failure of coronary sinus lead implantation for resynchronization therapy requires alternative approaches. For such events we have developed a transapical implantation technique as a feasible alternative. We report the outcome of this technique and its evolution from a minithoracotomy to a percutaneous approach. Twenty patients underwent alternative resynchronization therapy with transapical endocardial left ventricular (LV) pacing lead implantation in a multicentre, international study between October 2007 and March 2010. Eighteen patients underwent minithoracotomy and transapical puncture under direct observation. Two recent patients had transthoracic echocardiography-guided percutaneous apical puncture to enter the LV cavity. A 19 or 21 ga needle and two-stage Seldinger dilatation with 4 and 7 Fr sheaths were then used to introduce the lead. In the two patients with closed-chest insertion of the electrode there was no puncture related bleeding or lung damage. Lead dislocation occurred in two minithoracotomy patients. Repositioning was performed without re-opening the pleural cavity. One patient developed right-sided implanted cardiac defibrillator lead endocarditis requiring complete system removal. Twelve patients have >1 year follow-up; all have sustained and significant improvement in LV dimensions (diastolic Δ4.2 ± 2.9, systolic Δ7.2 ± 5.8 mm), ejection fraction (Δ9.5 ± 9.6%), and functional status (Δ1.1 ± 0.3). Transapical placement of LV endocardial pacing lead is an effective alternative strategy for cardiac resynchronization. A closed-chest, percutaneous approach is feasible and should offer even less invasive intervention.

[Heart transplantation after corrective surgery of a congenital heart disease. Surgical technical problems]. / Sikeres szívátültetés veleszületett szívhiba korrekciós szívmutéte után. Sebésztechnikai problémák.

Heart transplantation was performed in a 17-year old boy with severe left ventricular failure. Previously a congenital heart disease, tetralogy of Fallot was reconstructed in one and half years old of age. Authors present the different surgical problems complicated this procedure. In Hungary this is the first heart transplantation after a corrective surgical procedure of a complex congenital heart disease.

[Redo procedures for correction of aortic valve diseases in infants and children. The Bentall-Konno procedure]. / Csecsemô- és gyermekkori REDO mûtéteket igénylô aortabillentyû-betegség. Az elsô magyarországi Bentall-Konno-mûtét gyermekkorban.

On an infant with critical valvular aortic stenosis balloon-valvoplasty, and 3 years later because of the aortic valve regurgitation Ross operation was performed. In the early postoperative period an aortic-root abscess occurred due to an infective endocarditis; the aortic root was corrected by homograft implantation. Due to a relatively small, calcified aortic valve, with aortic valve regurgitation grade III at the age of 12 years, a Bentall-Konno procedure was performed successfully. This is the first case when this complex surgical procedure was performed successfully on a child in Hungary.

A novel approach for endocardial resynchronization therapy: initial experience with transapical implantation of the left ventricular lead.

BACKGROUND: Coronary sinus lead placement for transvenous left ventricular (LV) pacing in cardiac resynchronization therapy (CRT) has a significant failure rate at implant and a considerable dislocation rate during follow-up. For these patients epicardial pacing lead implantation is the most frequently used alternative. Recent data support endocardial lead implantation through the atrial septum and the mitral valve, because this method provides further hemodynamic advantages. On the other hand transseptal CRT carries a significant risk for device related infective endocarditis of the mitral valve. The aim of this prospective, nonrandomized study was to demonstrate the feasibility of a fundamentally new approach for endocardial LV lead implantation. METHODS: We performed 12 transapical LV lead implantations in 10 end-stage heart failure patients. In each operation an active fixation lead was placed into the LV cavity using standard Seldinger technique through the LV apex. By use of a J-shaped guide wire, the tip of the lead was positioned and fixed into the basal-lateral segment of the LV under fluoroscopy guidance. Pacing parameters were assessed and found to be optimal in all patients. The lead was conducted through the chest wall near the apex into a subcutaneous tunnel up to the pocket of the previously implanted device. After surgery the patients are anticoagulated with target anticoagulation level identical to mechanical valve prostheses. RESULTS: In 8 patients there were no major or minor complications related to this new technique. During the follow-up period (mean 7.2 +/- 4.1 months) all patients responded favorably to the treatment. One lead dislocation and 1 pocket infection were detected; the lead repositioning and replacing could be performed without reopening of the pleural cavity. CONCLUSIONS: The potential advantages of this new technique are that it is minimally invasive, endocardial, and does not involve the mitral valve. LV lead repositioning can also be performed minimally invasively.

[Surgical management of congenital heart defects in adolescent and adult patients, between years 2001-2008]. / Tapasztalataink a fiatal- és felnottkori veleszületett szívhibák sebészi kezelésében 2001-2008.

UNLABELLED: The leading interventions due to congenital heart defects performed in adults are: (I) reconstructive operations, including: (a) newly diagnosed malformations, (b) previously adjudged to be inoperable defects, (c) so called "tardive" interventions due to pulmonary hypertension or right ventricle insufficiency. There is a growing number of (II) REDO operations, including: (a) correction of residual defects, (b) replacement of damaged or outgrown homografts, (c) recoarctation (aneurysm, dissection) of the aorta after surgical or catheter interventions, (d) Ross procedure, valve replacements due to previously performed aortic valvulotomy/valvuloplasty or corrections of different malformations (e.g. TGA). PATIENTS AND RESULTS: 166 of all 4496 operations were performed in adolescents and adults (age: 16-52 years, mean: 28 years) between years 2001-2008. The distribution of these interventions: Ia: 77, Ib: 15, Ic: 4, IIa: 11, IIb: 22, IIc: 9, IId: 28. Mortality rates were the following: 0 intraoperative, 4 early postoperative, 1 pulmonary hypertensive crisis, 1 malignant rhythm disturbances, 2 multi-organ failure. CONCLUSIONS: The main risk factors are pulmonary hypertension and right ventricle failure. Complex surgical solutions do not mean extreme problems for a congenital cardiac surgeon, but earlier diagnosis and the use of ECMO during therapy may improve the results.

New method for cardiac resynchronization therapy: transapical endocardial lead implantation for left ventricular free wall pacing.

Coronary sinus lead placement for transvenous left ventricular (LV) pacing in cardiac resynchronization therapy (CRT) has a significant failure rate at implant and a significant dislocation rate during follow-up. For these patients, epicardial pacing lead implantation is the most frequently used alternative. The aim of this case report is to describe a fundamentally new approach for the endocardial LV lead implantation. An epicardial lead implantation was planned, but after thoracotomy, extensive pericardial adhesions were found. An active fixation lead was placed into the LV cavity using the standard Seldinger technique through the LV apex. After an uneventful post-operative period at the 3- and 6-month follow-up visits, the patient had effective CRT with unchanged pacing parameters. In conclusion, this is the very first report showing feasibility of transapical LV lead implantation.

[Alternative method for cardiac resynchronization: transapical lead implantation]. / Alternatív módszer a szívelégtelenség reszinkronizációs kezelésére: az elektróda transapicalis beültetése.

Coronary sinus lead placement for transvenous left ventricular pacing in cardiac resynchronization has significant failure rate at implant and significant dislocation rate during follow-up. Alternative methods are necessary for these patients. We aim to describe a fundamentally new approach using transapical implantation of an active fixation endocardial pacing lead. This technique is based on direct puncture of the left ventricular apex using standard Seldinger technique. The tip of the lead is positioned with intracavitary navigation under fluoroscopy. This method offers various advantages, because it is minimally invasive, provides endocardial pacing and does not involve the mitral valve.

[Successful cardiac surgical removal of migrated Kirschner wires used for fixation of the surgical neck of the humerus]. / Collum chirurgicum törését rögzíto, elvándorolt Kirschner-tuzodrótok sikeres szívsebészeti eltávolítása.

Dislocation and migration of two Kirschner wires were found 13 days after fixation of the surgical neck of the humerus. One of the wires was located between the lateral thoracic muscles, while the other one has perforated the apex of the heart, showing a synchronous motion with heart contractions. An anterolateral thoracotomy was performed and the wires were removed successfully.

Transapical approach to optimize left ventricular resynchronization in patients with dilated cardiomyopathy.

An alternative to coronary sinus implantation for a left ventricular pacing lead is frequently needed for cardiac resynchronization therapy. We have developed a transapical approach to implant an endocardial pacing lead that will reach the most delayed segment of the left ventricle. This method is easily combined with other transapical heart surgeries. After some technological improvement, our technique should offer easier access and better results than other currently available implantation methods.

Transapical approach to optimize left ventricular resynchronization in patients with dilated cardiomyopathy.

An alternative to coronary sinus implantation for a left ventricular pacing lead is frequently needed for cardiac resynchronization therapy. We have developed a transapical approach to implant an endocardial pacing lead that will reach the most delayed segment of the left ventricle. This method is easily combined with other transapical heart surgeries. After some technological improvement our technique should offer easier access and better results than other currently available implantation methods.

Long-term cerebral thromboembolic complications of transapical endocardial resynchronization therapy.

PURPOSE: Cardiac resynchronization therapy (CRT) is an established therapeutic option in selected heart failure patients (pts). However, the transvenous left ventricular (LV) lead implantation remains ineffectual in a considerable number of pts. Transapical LV (TALV) lead implantation is an alternative minimally invasive, surgical, endocardial implantation technique. The aim of the present prospective study is to determine the long-term outcome, including the cerebral thromboembolic complications, of pts who underwent TALV lead placement. METHODS: Twenty-six CRT candidates (19 men (78 %); mean age 61 ± 10 years) with a previously failed transvenous approach underwent TALV lead placement as a last resort therapy. The following data was collected: mortality rate, reoperation rate, and cerebrovascular event rate. Patients underwent a cerebral CT scan to determine any possible cerebrovascular event related to the presence of the TALV lead. RESULTS: Eleven out of 26 (47 %) patients survived after a median follow-up of 40 ± 24.5 months. Major acute ischemic stroke occurred in two cases, while in one case transient ischemic stroke was observed. Cerebral CT scan examination performed in asymptomatic patients revealed chronic ischemic lesions with minimal extension in two patients. Reoperation occurred in one case due to TALV lead fracture. CONCLUSIONS: This is the first study reporting the long-term outcome, mortality, and thromboembolic event rate exclusively after TALV lead implantation. Patients who underwent TALV lead implantation have a comparable long-term mortality rate to conventional CRT, although a major ischemic cerebrovascular event after TALV lead implantation is worrisome and has an impact on the outcome.

Chlamydia pneumoniae in coronary bypass grafts of redo patients. The concept of the 'adventitial baseline infection'.

The pathogenic role of Chlamydia pneumoniae in late coronary bypass graft failure has not yet been extensively investigated. We examined failed and new arterial/venous bypass grafts using immunohistochemistry, polymerase chain reaction (PCR), and serology. Thirty-four long-term failed grafts and 28 new grafts were examined in 21 patients undergoing redo coronary artery bypass grafting (CABG). Immunohistochemically, 28 (82%) failed grafts were positive in the intimal-medial compartment, and 33 grafts (97%) were positive for C. pneumoniae in the adventitia. Thirteen (46%) and 27 (96%) new grafts showed infection in the intima-media and in the adventitia, respectively (p < 0.05). Immunohistochemically, the overall presence of C. pneumoniae in all vessels examined was 66% in the intima-media and 97% in the adventitia (p < 0.05). C. pneumoniae was detected by PCR in 19 (31%) of all the vessels examined. C. pneumoniae seems to be frequently present in grafts of patients considered for redo CABG in Hungary. The adventitia of both failed, and new grafts particularly often contained C. pneumoniae. The results suggest that there exists an adventitial baseline infection from which infection of the inner wall layers develops, depending on local microenvironmental conditions. This is the first study to evaluate chlamydial infection in arterial/venous coronary grafts by immunohistochemistry, PCR, and serology.

Alternative method for cardiac resynchronization: transapical lead implantation.

Alternative methods are necessary for cardiac resynchronization therapy when coronary sinus lead implantation fails. We aim to describe a fundamentally new approach using transapical implantation of an active fixation endocardial pacing lead. This technique is based on direct puncture of the left ventricular apex using the standard Seldinger technique. The tip of the lead is positioned with intracavital navigation under fluoroscopy. This method offers advantages for cardiac resynchronization because it is minimally invasive, provides endocardial pacing, and does not involve the mitral valve.