Endurance and performance of two different concepts for left ventricular stimulation with bipolar epicardial leads in long-term follow-up.

BACKGROUND: Epicardial left ventricular (LV) leads represent an alternative for CRT therapy if transvenous lead implantation fails. Data on endurance, performance, the impact of the surgical approach (lateral minithoracotomy vs. median sternotomy simultaneously with other cardiac surgery), and the optimal technical concept (screw-in vs. suture-on) is limited. METHODS: Over a period of 48 months we evaluated 130 consecutive patients with comparable characteristics. A total of 54 screw-in (MyoDex™ 1084T, SJM) and 76 suture-on (Capture Epi 4968, Medtronic) bipolar epicardial steroid-eluting LV leads were implanted either via a left lateral or a median thoracotomy. Sensing, pacing threshold, impedance and NYHA class were recorded at defined time points. RESULTS: No surgery-related death or major complication was observed. At the time of implantation, the pacing threshold, sensing and NYHA class did not differ significantly between the two groups. The impedances of screw-in leads were significantly lower compared to those of suture-on leads. Suture-on leads showed a moderate initial drop in their pacing threshold but afterwards remained stable. Screw-in leads were characterized by a moderate but significant increase in the pacing threshold in the first year followed by a continuous decrease thereafter. Twenty-four months post-implantation no differences between both lead types could be detected. Sensing and NYHA class improved in both groups. The surgical approach had no significant impact on lead functionality. CONCLUSION: Our study showed that the implantation of epicardial leads was safe with very low complication rates. There was no superior technical epicardial lead concept (screw-in vs. suture-on leads) and all epicardial leads demonstrated an excellent long-term performance and durability. Therefore, it seems that epicardial leads represent a good alternative to transvenous leads and surgeons should be encouraged to implant epicardial leads during concomitant cardiac surgery when the indications for CRT are present.

Intraluminal chondrosarcoma leading to occlusion of the brachiocephalic trunk.

A 62-year-old female patient was admitted with temporary neurological symptoms. CT scan revealed occlusion of the brachiocephalic trunk by an intraluminal mass suspicious for a thrombus and extending into the ascending aorta. The patient underwent aortic arch replacement with reinsertion of the supraaortic vessels. A 5 × 3 × 4 cm large mass was found in the aorta which had obviously caused occlusion of the brachiocephalic trunk. The patient had an uneventful postoperative recovery and follow-up imaging showed no pathological findings. Histopathological examination revealed inhomogeneous chondroid tissue such as that found in a G2 grade bone chondrosarcoma.

Recurrent Bacteremia After Heart Transplantation Due to Abandoned Lead Fragment in an Anonymous Vein-A Case Report.

Heart transplantation (HTx) represents the "gold standard" in end-stage heart failure therapy. Due to their severe heart failure and for prevention of sudden cardiac death, the majority of patients presenting for HTx will have a history of an implanted cardioverter-defibrillator (ICD). Usually, within the scope of HTx, all cardiac-implanted electronic device components are removed. In rare cases these efforts fail and some material remains. The abandoned lead fragments can cause serious complications. The case presented herein involves a patient with recurrent bacteremia after successful HTx originating from an abandoned and infected lead fragment. In 2016, a 64-year-old man received a donor heart transplant due to end-stage heart failure. Unfortunately, during the procedure, not all components of an ICD implanted in 2007 could be removed. An initially event-free period was followed by recurrent fever attacks and staphylococcal bacteremia was diagnosed. After an extensive search, the source of the bacteremia was identified by positron emission tomography-computed tomography (PET-CT), and percutaneous extraction of the abandoned and infected ICD lead fragment was scheduled. The fragment was extracted using a minimally invasive approach via percutaneous femoral vein access. The patient was discharged 3 days later, with no further complications. This case highlights the need for conscientious and complete removal of foreign material in the HTx setting. Difficult-to-diagnose sources of infection could be reliably identified by PET-CT. When required, extraction of the foreign body should be done using a minimally invasive approach.

The dynamic air bubble trap reduces cerebral microembolism during cardiopulmonary bypass.

OBJECTIVE: Neuropsychologic disorders are common after coronary artery bypass operations. Air microbubbles are identified as a contributing factor. A dynamic bubble trap might reduce the number of gaseous microemboli. METHODS: A total of 50 patients undergoing coronary artery bypass operation were recruited for this study. In 26 patients a dynamic bubble trap was placed between the arterial filter and the aortic cannula (group 1), and in 24 patients a placebo dynamic bubble trap was used (group 2). The number of high-intensity transient signals within the proximal middle cerebral artery was continuously measured on both sides during bypass, which was separated into 4 periods: phase 1, start of bypass until aortic clamping; phase 2, aortic clamping until rewarming; phase 3, rewarming until clamp removal; and phase 4, clamp removal until end of bypass. S100 beta values were measured before, immediately after, and 6 and 48 hours after the operation and before hospital discharge. RESULTS: The bubble elimination rate during bypass was 77% in group 1 and 28% in group 2 (P <.0001). The number of high-intensity signals was lower in group 1 during phase 1 (5.8 +/- 7.3 vs 16 +/- 15.4, P <.05 vs group 2) and phase 2 (6.9 +/- 7.3 vs 24.2 +/- 27.3, P <.05 vs group 2) but not during phases 3 and 4. Serum S100 beta values were equally increased in both groups immediately after the operation. Group 2 patients had higher S100 beta values 6 hours after the operation and significantly higher S100 beta values 48 hours after the operation (0.06 +/- 0.14 vs 0.18 +/- 0.24, P =.0133 vs group 2). Age and S100 beta values were correlated in group 2 but not in group 1. CONCLUSION: Gaseous microemboli can be removed with a dynamic bubble trap. Subclinical cerebral injury detectable by increases of S100 beta disappears earlier after surgical intervention.