The different forms of the left brachiocephalic vein visualised during cardiovascular implantable electronic device implantation procedures.

BACKGROUND: Among the factors ensuring successful completion of such minimally invasive procedures as cardiac implantable electronic device (CIED) implantation and central venous catheter (CVC) placement are the morphometry and topography of the vessels used for cardiac lead or catheter advancement. Venous access through the left clavipectoral triangle makes use of the left brachiocephalic vein (BCV). The purpose of this study was to present the radiology images of various individual forms of this vessel observed during CIED implantation procedures. MATERIALS AND METHODS: Our analysis included 100 venography recordings illustrating the left BCV, obtained during de novo CIED implantation procedures. We assessed the mediastinal course of the left BCV, with its natural angles, including angle α (in the middle section of the vessel) and the two angles created by the left BCV and the left subclavian vein (angle ß) and the left BCV and the superior vena cava (angle γ). RESULTS: The mean values of angle α tended to be higher (approximately 141°) than those of the two remaining angles (γ and ß), which were comparable at 123° and 127°, respectively. An increase in mean angle α values were accompanied by increased mean angle γ and ß values (p = 0.05), with only 5% of ß and γ angles, in total, having values close to those of a right angle (90 ± 10º). CONCLUSIONS: Individual variability of left BCV topography and morphology comes from developmental formation of the physiological angle in the middle section of this mediastinal vessel's course. The presence of near-right angles along the course of left BCV may potentially result in injuries to the vessel during intravascular procedures.

Double superior vena cava and left brachiocephalic vein agenesis: a rare systemic vein anomaly and potential source of cardiac implantable electronic device and central venous catheter placement complications.

Abnormal systemic vein development produces anomalous veins, which - in the case of persistent left superior vena cava and/or left brachiocephalic vein - exhibit considerable topographic and morphometric differences in comparison with their usual anatomy. The nature and extent of those developmental anomalies - detected during intravenous procedures, such as cardiac implantable electronic device (CIED) lead insertion or central venous catheter placement - may hinder the procedure itself and/or adversely affect its outcome, both at the stage of cardiac lead advancement through an abnormally shaped vessel and lead positioning within the heart. This may lead to problems in achieving optimal sensing and pacing parameters and in ensuring that the patient cannot feel the pacing impulses. These events accompanied a de novo CIED implantation procedure in the patient with a double superior vena cava and left brachiocephalic vein agenesis, who ultimately required reoperation.

Types of left brachiocephalic vein aberrations detected during cardiac implantable electronic device implantation procedures.

BACKGROUND: Cardiac implantable electronic device (CIED) implantation procedures with transvenous lead placement afford an opportunity to observe vascular anatomic variations. The course of CIED implantation depends largely on morphometric and topographic characteristics of the relevant brachiocephalic vein (BCV), which is the left BCV in the case of lead insertion via the left clavipectoral triangle. This study aims to present left BCV anomalies arising from abnormal systemic vein embryogenesis and encountered during CIED implantation. MATERIALS AND METHODS: Venograms obtained during CIED implantation procedures and illustrating left BCV topography/morphometry were analysed retrospectively for two types of anomalies: anomalies of the left BCV itself (data from the period 2014-2018) and a combination of left BCV variations with a persistent left superior vena cava (PLSVC); since the latter instances are rare, the analysed period was longer (2003-2018). RESULTS: Analysis of data from the first, 5-year-long, period included data from a group of 1812 patients and revealed 5 (0.3%) cases of developmental left-BCV anomalies (3 double left BCV and 2 cases of a single subaortic left BCV). The 16-year-long analysed period included 6110 CIED implantation procedures, which showed 12 (0.2%) cases of PLSVC including 4 (33%) cases of left BCV agenesis. CONCLUSIONS: The analysed venograms rarely showed isolated left-BCV aberrations (0.3%), with the combination of left-BCV agenesis and PLSVC being much more common (33%). The morphometry and/or topography of aberrant left-BCV may result in difficulties during cardiac lead insertion.

Vasoconstrictive responses of the cephalic vein during first-time cardiac implantable electronic device placement.

BACKGROUND: During cardiac implantable electronic device (CIED) implantation procedures cardiac leads have been mostly introduced transvenously. The associated injury to the selected vessel and adjacent tissues may induce reflex vasoconstriction. The aim of the study was to assess the incidence of cephalic vein (CV) vasoconstriction during first-time CIED implantation. MATERIALS AND METHODS: Of the 146 evaluated first-time CIED implantation procedures conducted in our centre in 2016, we selected those during which CV vasoconstriction was recorded. We focused on the stage of the procedure involving CV cutdown and/or axillary vein (AV)/subclavian vein (SV) puncture for lead insertion. Only cases documented via venography were considered. RESULTS: Vasoconstriction was observed in 11 patients (5 females and 6 males, mean age 59.0 ± 21.2 years). The presence of this phenomenon affected the stage of CIED implantation involving cardiac lead insertion to the venous system, in severe cases, requiring a change of approach from CV cutdown to AV/SV puncture. The extent of vasoconstriction front propagation was limited to the nearest valves. Histological examinations of collected CV samples revealed an altered spatial arrangement of myocytes in the tunica media at the level of leaflet attachment. CONCLUSIONS: Cephalic vein vasoconstriction is a rare phenomenon associated with accessing the venous system during first-time CIED implantation. The propagation of CV constriction was limited by the location of the nearest valves.

A rare vascular anomaly in the form of double left brachiocephalic vein detected incidentally during cardiac implantable electronic device (CIED) placement.

The growing number of transvenous cardiac implantable electronic device (CIED) implantation procedures helps detect rare vascular anomalies. Genetic disturbances in vascular development can produce systemic vein anomalies, including the left brachiocephalic vein (BCV). BCV anomalies commonly coexist with a persistent left superior vena cava (PLSVC), detected in 0.3-0.5% of the general population. The three known anatomical variations of PLSVC are two variations involving a BCV bridge and the third with BCV agenesis. BCV anomalies occur in 1% of patients with congenital heart defects, whereas the estimated proportion of BCV anomalies in the population with no cardiovascular symptoms is below 0.4%. A rarely observed, and thus rarely reported, BCV variation is a double left BCV, with the additional vessel typically found inferior and posterior to the ascending aorta prior to draining into the superior vena cava. This case report presents a previously unreported variation of double left BCV, with both vessels coursing parallel to each other, superior to the aortic arch. (Folia Morphol 2018; 77, 1: 161-165).

Altered topography of systemic veins following lung tissue resection: the effect on de novo cardiac implantable electronic device implantation.

Venous anomalies discovered on cardiac implantable electronic device (CIED) implantation may hinder both the insertion of cardiac leads and the selection of their optimal intraventricular placement. Such venous anomalies may be a result of congenital vascular defects, e.g. anomalies of the foetal venous system, or be a consequence of earlier cardio- or thoracosurgical procedures. In the case of the latter, the extent of morphometric changes to mediastinal structures may depend on the extent of prior lung tissue resection. This paper presents 3 cases of CIED implantation procedures performed in patients with systemic veins topographically and morphometrically altered post lung surgery.

Imaging topography and morphometry of persistent left superior caval vein and its variations, detected on cardiac implantable electronic device implantation.

BACKGROUND: Persistent left superior caval vein (PLSCV) is a rare, anatomically diverse developmental anomaly of systemic veins. Clinically asymptomatic PLSCVs are detected incidentally during medical procedures that utilise systemic veins, such as cardiac implantable electronic device (CIED) placement, and whose successful completion depends on favourable morphometric parameters of these vessels. The aim of this paper was to present topography and morphometry of PLSCV variations encountered during CIED implantation procedures. MATERIALS AND METHODS: We analysed a group of 5,010 patients for detection of PLSCV during de-novo CIED implantation procedures with transvenous lead placement in the years 2003-2015. PLSCVs were detected intraprocedurally based on venographic images illustrating the venous anomaly and its morphometric parameters, and were subsequently confirmed via postoperative diagnostics. RESULTS: PLSCVs were detected in 10 patients (mean age 66.0 ± 14.0 years; 5 females and 5 males), who constituted 0.2% of the analysed group. There were 6 cases of double superior vena cava (DSVC), 3 of which had a brachiocephalic vein (BCV) connection and did not have BCV bridging. Four patients with a PLSCV had right superior vena cava agenesis; this very rare variation is known as 'single PLSCV'. All of the detected PLSCV variations drained into the right atrium via the coronary sinus. CONCLUSIONS: Our data from a period of 13 years illustrate how rare the PLSCV-type venous anomaly is. The three distinct anatomical PLSCV types showed inter-individual morphometric variations. Due to asymptomatic nature of this anomaly, all cases were detected incidentally, during CIED implantation procedures.

Axillary vein spasm during cardiac implantable electronic device implantation.

BACKGROUND: The technique of axillary vein (AV) or subclavian vein (SV) puncture has become an important alternative to cephalic vein (CV) cutdown as an approach allowing cardiac lead introduction into the venous system during cardiac implantable electronic device (CIED) implantation procedures. Irrespective of the technique used, the injury associated with lead insertion may induce a reflex venous spasm that can even cause total venous obstruction. In order to assess the incidence of AV spasm during AV puncture, we analysed a total of 735 (382 in females and 353 in males; mean age 75 ± 11 years) de novo CIED implantation procedures involving transvenous lead insertion conducted between January 2014 and December 2015. MATERIALS AND METHODS: In 337 patients the leads were introduced via AV puncture only, in 66 patients AV puncture was used in combination with CV cutdown, together yielding a total of 403 procedures (55% of all de novo CIED implantation procedures; mean patient age 72 ± 14 years), out of which we observed 12 cases (mean patient age 57 ± 25 years) of AV spasm (3%). RESULTS: We evaluated only the procedures with unambiguous fluoroscopy images recorded during AV puncture: complete blockage of contrast medium flow through the AV, with preserved flow through the CV or collateral vessels, followed by eventually resumed flow of contrast via the AV. The contrast-enhanced movements of AV walls showed the spasm propagating both proximally and distally along the vessel, while the subsequent vessel wall relaxation occurred along the entire spasm-affected venous segment simultaneously. CONCLUSIONS: An AV spasm induced by AV puncture during CIED implantation is a rare phenomenon; however, if severe, it may significantly affect the course of the procedure.

Selected clinical challenges of a supraclavicular cephalic vein in cardiac implantable electronic device implantation.

BACKGROUND: Supraclavicular variations of the cephalic vein (CV) are detected sporadically. A somewhat more common finding is a CV variation with the typical course of the main vessel but with an additional supraclavicular branch, called the jugulocephalic vein (JCV). The aim of the study was to detect supraclavicular CVs or JCVs via intra-operative venography as well as assess their effects on primary and later revision cardiac implantable electronic device (CIED) procedures in our patients. MATERIALS AND METHODS: We analysed venographic images obtained during CIED procedures at our centre between 2011 and 2015. Out of the 324 venographies conducted during first-time CIED implantation, we identified 14 showing either a supraclavicular course of the CV itself or a persistent JCV. Among revision procedure venographies, we identified 1 case of pertinent CV variations. These vessels had been morphometrically altered by previous medical interventions. RESULTS: Based on topography and morphometric parameters, we identified three anatomical variations of supraclavicular vessels: 2 cases of a supraclavicular CV and 12 cases of an infraclavicular CV accompanied by a persistent supraclavicular JCV (with the diameter larger than that of the main CV in 5 cases and smaller in 7 cases). In 2 cases the enlarged diameter of the JCV was probably due to increased collateral venous flow resulting from thrombotic lesions in the subclavian vein. CONCLUSIONS: Supraclavicular CV variations are rare. Nonetheless, they may significantly affect both first-time and later revision CIED procedures. The presence of a supraclavicular vein is an indication for diagnostic venography in the area of the clavipectoral triangle before the CIED procedure.

Clinical implications of cephalic vein morphometry in routine cardiac implantable electronic device insertion.

BACKGROUND: Morphometric parameters of the venous vasculature constitute an important aspect in successful cardiac implantable electronic device (CIED) insertion. The purpose of this study was to present morpho-anatomical variations of the cephalic vein (CV) and their effect on the course of CIED implantation procedures, based on the patients from our centre. MATERIALS AND METHODS: We analysed contrast venography results obtained during first-time lead placement. Venography was indicated in the cases of problematic lead introduction with either the CV cutdown or axillary/subclavian vein puncture techniques. The 214 cases of venography (15%) performed out of 1425 first-time lead placement in the period 2011-2013 were divided into 9 subgroups according to the most commonly observed CV variations of similar morpho-anatomical features that limited the use of the CV cutdown technique for lead insertion. RESULTS: The following CV morphometric parameters were found to be unfavo-urable in terms of lead placement: CV diameter of ≤ 1 mm (18%), sharp curva-ture of the terminal CV segment as it joined the axillary vein (14%), terminal CV bifurcation (9%), additional CV branches (7%) or tributaries (7%), stenoses (5%), sharply winding course (5%), single CV with a supraclavicular course (4%). CONCLUSIONS: The radiographic records obtained during the procedures allowed us to assess the prevalence of those atypical CV variations in our study group, with graphic presentation of characteristic types and sporadically reported CV variations.

Paroxysmal atrial fibrillation in a young female patient following marijuana intoxication--a case report of possible association.

Marijuana is one of the most popular drugs legally admitted for general sale in many countries. To consider it safe and unlikely to develop drug dependence is abusive. The use of marijuana as a herbal medication is being widely discussed in literature. The most promising effect of delta-9-etrahydrocannabinol seems to be observed in the case of nausea, following cancer chemotherapy. Despite its positive action on the human organism, marijuana smoking has been shown to exert adverse effects on the cardiovascular system causing well-tolerated tachycardia and/or hypotension. We also observed that marijuana abuse was associated with an increased risk of paroxysmal atrial fibrillation. The report presents a case of young healthy white subject suffering from paroxysmal atrial fibrillation following marijuana intoxication. The abuse of this substance was the most possible and identifiable risk factor for observed paroxysmal atrial fibrillation.

[Should sinus rhythm be restored in patients with chronic atrial fibrillation? Preliminary results from the Polish "Hot Cafe" study]. / Czy przywracac rytm zatokowy u chorych z przewleklym migotaniem przedsionków? Wstepne wyniki polskiego badania "Hot Cafe".

Atrial fibrillation (AF) is the most common arrhythmia occurring in clinical practice. It is the most frequent cause of hospitalization in cardiac rhythm disturbance. Despite comprehensive progress in the research into electrophysiological mechanisms leading to this loss of normal rhythm and new procedures dealing with it, the main problem being the conversion to and maintaining the normal sinus rhythm (SR) has not been solved. The polish study "Hot Cafe" is trying to evaluate the advantages and risks of the two procedures widely used in clinical practice in patients (pts) with chronic AF, i.e. conversion and maintaining SR vs leaving pts with the arrhythmia. Pts with non-valvular chronic AF fulfilling the criteria for including them into the sample are randomly assigned to two procedures: conversion to SR by means of direct current cardioversion and maintaining it or leaving pts with AF. Pts left with AF are treated by rate control and antithrombotic treatment. The project is of prospective kind and it will be carried out by many medical institutions. It is planned to include 200 pts. The observation period will last at least 12 months. Preliminary results after inclusion of the first 121 pts are shown.

[Coronary disease and hormonal treatment during the perimenopausal period]. / Choroba wiencowa a leczenie hormonalne w okresie okolomenopauzalnym.

Hormone replacement therapy (HRT) is widely recognized as probably most advisable treatment of perimenopausal women with cardiovascular disorders. Whenever HRT is administered for gynecological reasons, special attention should be paid to the presence of cardiological risk factors as these may be potentiated by high doses of gestogens. The authors undertake this problem inspired by a cases of a 53-years old patient (given oral lynestrol fair persisting uterine bleedings) who suffered from several complications, including venous thrombosis and myocardial infarction.

Elevated plasma atrial natriuretic peptide concentrations in hypertensive patients with acute myocardial infarction.

BACKGROUND: Atrial natriuretic peptide (ANP) has been extensively studied in cardiovascular disorders in recent years. Particular attention has been paid to the role of ANP in the pathogenesis of hypertension and congestive heart failure and in the neurohormonal response to myocardial infarction. However, no published data are available on the significance of ANP in hypertensive patients with acute myocardial infarction. METHODS: We studied the relationship between plasma ANP concentration and systolic blood pressure, diastolic blood pressure, left atrial dimension, left ventricular diastolic dimension and left ventricular mass index in patients with essential hypertension in the acute phase of myocardial infarction. Plasma ANP concentrations were determined at 0, 4, 8, 16, 24, 48 and 72 h after admission in 40 patients with a first myocardial infarction (18 hypertensive patients, group 1; 22 normotensive patients, group 2). Left atrial dimension and left ventricular diastolic dimension were assessed echocardiographically within the first 48 h of acute myocardial infarction. RESULTS: Maximum and mean plasma ANP values at 0, 4, 8, 16, 24, 48, and 72 h as well as mean ANP concentrations within the 72 h period were higher in group 1 than in group 2 (P < 0.001). Plasma ANP concentration, left atrial dimension (r = 0.59) and left ventricular diastolic dimension (r = 0.56) were positively correlated in both groups. CONCLUSION: Acute myocardial infarction is characterized by a more pronounced rise in plasma ANP concentration in hypertensive patients than in those without a history of hypertension. Plasma ANP concentration correlates with left heart chamber sizes.

[Effect of coronary artery patency after myocardial infarction on ventricular late potentials]. / Wplyw droznosci tetnicy wiencowej, w której dorzeczu doszlo do zawalu serca na wystepowanie póznych potencjalów komorowych.

This study evaluated the relation between patency of the infarct related artery and the presence of ventricular late potentials (VLP) on the signal-averaged electrocardiogram (ECG). 44 patients (pts) after myocardial infarction (MI) (35 men, 9 women; mean age 50 years) were studied by coronary angiography. measurement of ejection fraction and signal-averaged ECG. The infarct-related artery was closed in 15 pts and open in 29 pts. There was no difference in age, previous MI and location of infarct between the two study groups. Thrombolytic therapy in acute stage of MI was significantly often (p less than 0.05) in pts with open (59%) than closed (13%). The incidence of VLP was significantly higher (p less than 0.05) in group of pts with closed (40%) than open artery (7%). These data indicate that patency of the infarct-related artery has a beneficial effect on the electrophysiologic substrate for serious ventricular arrhythmias.