Clinical predictors of antitachycardia pacing response in implantable cardioverter defibrillator patients.

BACKGROUND: Antitachycardia pacing (ATP) provides safe and painless termination of reentrant ventricular arrhythmias in patients with implantable cardioverter defibrillator (ICDs), improving their quality of life. Established predictors of ATP responsiveness are not well known; only longer ventricular tachycardia (VT) cycle length and higher ejection fraction have been found to predict ATP success. OBJECTIVE: To investigate clinical and ECG predictors of ATP response in ICD patients with monomorphic VT. METHODS: The ICD clinic database was searched for monomorphic VT events requiring ICD therapy in patients with ischemic or non-ischemic cardiomyopathy. Each patient's first ICD encounter for VT was assessed. Patient demographics, clinical characteristics, VT rate, and ATP responsiveness (always, sometimes, and never successful) were recorded. An ECG was analyzed for QRS morphology and duration. Data was assessed for predictors of ATP responsiveness. RESULTS: In 527 patients, characteristics associated with always successful ATP included ACE-I/ARB therapy and slower VT rate (never successful ATP 197 ± 28 bpm, sometimes successful ATP 190 ± 27 bpm, always successful ATP 183 ± 22 bpm, P < .0001). Secondary prevention indication, amiodarone therapy, and longer QRS duration were associated with ATP failure. After multivariate analysis, only faster VT rate and amiodarone therapy were predictive of ATP failure. CONCLUSIONS: Neither QRS morphology nor duration was predictive of ATP success. Slower VT rate was predictive of repeated ATP responsiveness. Amiodarone therapy, which is known to increase VT cycle length, interestingly was associated with ATP failure for unclear reasons. More individualized and possibly more aggressive ATP programming may be warranted in patients on amiodarone.

Renal Cell Carcinoma Presenting with Paraneoplastic Hallucinations and Cognitive Decline from Limbic Encephalitis.

We present a 66-year-old woman with 2 months of visual hallucinations, unintentional weight loss, and short-term memory decline, whose clinical presentation and EEG supported a diagnosis of limbic encephalitis. Subsequent evaluation for a paraneoplastic etiology revealed a renal mass, which was resected and identified as clear cell renal carcinoma. The patient's clinical condition improved after resection of the mass. When patients present with incongruous subacute neuropsychiatric symptoms, clinicians should be mindful of paraneoplastic neurological disorders, as early diagnosis and treatment of malignancy may lead to symptomatic improvement.

Restoring Emphasis on Ambulatory Internal Medicine Training-The 3∶1 Model.

BACKGROUND: Resident dissatisfaction in ambulatory care training has prompted the need for new scheduling models that support a positive learning climate. INTERVENTION: We instituted a 3∶1 scheduling model for postgraduate year (PGY)-2 and PGY-3 residents. We hypothesized this model would provide a more structured ambulatory educational atmosphere, better continuity of care, and more exposure to subspecialty outpatient medicine. This model would also eliminate conflict with inpatient duties and contribute to enhance residents' satisfaction with ambulatory medicine and their ambulatory education experience. The model used weeklong ambulatory blocks every fourth week, consisting of morning continuity clinic and afternoon subspecialty clinics. The PGY-1 residents maintained a traditional schedule. RESULTS: Residents were surveyed regarding their ambulatory experience, with an overall response rate of 73 of 80 (91%). The PGY-2 and PGY-3 responses were analyzed descriptively and compared with PGY-1 responses. Residents reported that the 3∶1 model positively affected their satisfaction with residency training in general, their satisfaction with outpatient/primary care training, and their outpatient/clinic educational experience. Residents in the 3∶1 model perceived improvements in continuity of care and in the quality of care they provided for patients. The experience in ambulatory subspecialty training was positive. CONCLUSIONS: A 3∶1 scheduling model appears to mitigate some of the conflict between inpatient and outpatient duties. Residents agreed the new model promoted an improved ambulatory experience.

Novel treatment of an 11-cm saphenous vein graft aneurysm.

Saphenous vein graft pseudoaneurysms are rare and potentially fatal complications after coronary artery bypass graft surgery. Here we present an 11-cm saphenous vein graft pseudoaneurysm from a 20-year-old vein graft to the obtuse marginal artery. The pseudoaneurysm was directly located beneath the sternum and adjacent to two patent grafts. Therefore, we used a novel approach to access the aorta through a right thoracotomy, and using a pericardial patch, we closed the ostia to the pseudoaneurysm. Postoperatively there was no longer flow into the aneurysm, and at 1-year follow-up the patient is doing well.