Hybrid Approach for the Treatment of Superior Vena Cava Syndrome Induced by Pacemaker.

Pacemaker-induced superior vena cava syndrome (SVCS) is a rare but incapacitating adverse event that can occur years after implantation. Inasmuch as it is a rare disease, there is no consensus about its treatment. The most widely used option is balloon angioplasty and venous stent implantation, with preservation of the lead or previous extraction and subsequent reimplantation after the procedure, which is associated with new episodes of thrombosis. The epicardial implantation reduces the risk of thrombosis. We report a case of pacemaker-induced SVCS for which we used a hybrid approach for epicardial lead implantation and electrode extraction, balloon angioplasty, and stent implantation.

Which type of valve should we use in tricuspid position? Long-term comparison between mechanical and biological valves.

BACKGROUND: Nowadays, tricuspid valve replacement (TVR) is much less common than aortic or mitral valve replacement, since repair is almost always preferable. Prosthetic tricuspid valves are associated with high mortality and morbidity, mostly due to thrombotic or hemorrhagic events. Nevertheless, there is lack of evidence of which is the optimal type of valve (biological versus mechanical) in tricuspid position. METHODS: We analyzed all the patients who underwent TVR in our Institution, from 2005 to 2015. Patient baseline characteristics were recorded (such as functional class, previous cardiac surgery, right ventricular dysfunction or pulmonary hypertension), and a clinical long-term follow-up was conducted. We compared the outcomes between mechanical and biological prostheses: in-hospital mortality, long-term mortality, need for reintervention and adverse events (such as stroke or valve thrombosis). RESULTS: During the study period 120 tricuspid prosthetic valves were implanted in 111 patients. 81 of them (67.5%) were bioprostheses, and 39 (32.5%) mechanical valves. 73 patients (60.8%) had undergone a previous cardiac surgery (28.4% had previous tricuspid surgery). Most of the patients (87.1%) were in high functional class (grade III-IV of the NYHA classification), and 85% had moderate to severe pulmonary hypertension. Mean logistic EuroSCORE I was 14.80%. Only 37 cases were isolated TVR (30.6%), as most of the cases were TVR concomitant to mitral valve replacement. In-hospital mortality was 21.7%, and during the follow-up (mean follow-up of 7 years) reached 37.5%. Three mechanical tricuspid valves (7.7%) had to be replaced due to thrombosis, while 7 biological valves (8.6%) had to be replaced due to valve deterioration. The incidence of stroke was 7.5%. CONCLUSIONS: Tricuspid valve replacement is an infrequent procedure with a high incidence of perioperative morbidity and mortality. Biological or mechanical valves have similar mortality, and a reasonably low incidence of need for reintervention due to thrombosis or valve deterioration.

Rotura iatrogénica de electrodos de marcapasos permanente en la realización de esternotomía media: presentación de un caso / Iatrogenic rupture of permanent pacemaker electrodes while performing a median sternotomy: a case report

RESUMEN La esternotomía media continúa siendo el gold-standart de abordaje quirúrgico en cirugía cardiaca. Aún realizada correctamente, la apertura media del esternón presenta complicaciones en el 1-5% de los casos que varían en su gravedad desde la infección de la herida quirúrgica a la lesión de estructuras intratorácicas. En el presente estudio se describe un caso de rotura de electrodos de marcapasos tras esternotomía media por retracción y fibrosis del tronco venoso braquiocefálico. Debido a la ausencia de artículos semejantes en la literatura y al extendido empleo de la esternotomía en pacientes portadores de marcapasos permanente, se pretende disminuir las lesiones asociadas mediante la publicación de un infrecuente caso de lesión iatrogénica durante la apertura esternal, con escasos precedentes en la literatura publicada hasta la fecha. MÉD.UIS. 2016;29(3):95-9.

ABSTRACT Median sternotomy is still the gold-standard surgical approach in cardiac surgery. Even correctly performed, the sternum median opening presents complications in an incidence of 1-5% of cases comprising in severity from infection of the surgical wound to the injury of intrathoracic structures. We describe a case in which the pacemaker leads were broken after median sternotomy because of the brachiocephalic vein fibrosis. Due to the absence of similar items in the literature and the widespread use of sternotomy in patients with permanent pacemakers, we intended to reduce associated injuries by posting a rare case of iatrogenic injury during sternal opening with few precedents in the literature. MÉD.UIS. 2016;29(3):95-9.

Selección del mejor lugar de estimulación tras cirugía cardiaca evaluando la asincronía con strain tras diferentes estimulaciones / Selecting the best site for pacing leads after cardiac surgery by evaluating the asynchrony of myocardial deformation observed with different pacing sites

Introducción y objetivos. Implantar electrodos transitorios en ventrículo derecho (VD) tras cirugía cardiaca es habitual. El objetivo es estudiar en pacientes intervenidos el efecto de la estimulación en diferentes localizaciones ventriculares en la sincronía, analizando la deformación miocárdica (strain), y en la eficacia cardiaca. Métodos. En 19 pacientes se midió la asincronía interventricular (diferencia en el tiempo al comienzo del strain entre VD y ventrículo izquierdo [VI]: TE DI) y la intraventricular (desviación estándar [TE DE] y máxima diferencia en el tiempo de comienzo del strain en las seis caras del VI [TE MD]). Estas estimaciones y el gasto cardiaco (GC) mediante Doppler se determinaron tras la estimulación en VD en tres diferentes segmentos del VI. Resultados. La estimulación en VD fue la que más aumentó los parámetros de asincronía respecto al estudio basal: TE DI, 59,8 ± 40,5 frente a 28,23 ± 56,9 ms (p = 0,002); TE DE, 53,2 ± 34,4 frente a 36,6 ± 34,9 ms (p = 0,007); TE MD, 135,3 ± 82,9 frente a 90,5 ± 87,4 ms (p = 0,007). La estimulación en VI produjo menos asincronía (estimulación en segmento anterior del VI: TE DI, 17,2 ± 53,8 ms; TE DE, 35,8 ± 17,9 ms; TE MD, 91,3 ± 45,2 ms (sin significación estadística respecto a basal). El GC tras la estimulación en VD fue menor que tras estimulación en la cara anterior del VI: 4,36 ± 1 frente a 4,7 ± 1 (p = 0,001). Conclusiones. La estimulación en VI produce menos asincronía que en VD. Asimismo, la estimulación en la cara anterior del VI consigue mayor GC que la estimulación en VD. Estos datos indican que se debería modificar la localización de los electrodos transitorios tras cirugía cardiaca (AU)

Introduction and objectives. After cardiac surgery, temporary pacing leads are routinely implanted in the right ventricle (RV). The objective was to investigate the effect of different ventricular pacing locations on cardiac synchrony (by evaluating myocardial deformation, or strain) and efficiency in patients undergoing cardiac surgery. Methods. Interventricular asynchrony (i.e. the difference in the time of onset of deformation between right and left ventricles; TE-R/L) and intraventricular asynchrony (i.e. the standard deviation and maximum difference in the time of onset of deformation in six segments of the left ventricle [LV]; TE-SD and TE-MD, respectively) were assessed in 19 patients. Doppler echocardiography was used to evaluate these parameters and cardiac output after pacing in the RV and in three different LV segments. Results. Pacing in the RV resulted in the greatest increases in asynchrony parameters from baseline: TE- R/L 59.8 ms (standard deviation [SD] 40.5 ms) vs. 28.23 ms (SD 56.9 ms), P=.002; TE-SD 53.2 ms (SD 34.4 ms) vs. 36.6 ms (SD 34.9 ms), P=.007; and TE-MD 135.3 ms (SD 82.9 ms) vs. 90.5 ms (SD 87.4 ms), P=.007. Pacing in the LV resulted in less asynchrony: for anterior LV pacing, TE-R/L was 17.2 ms (SD 53.8 ms), TE-SD was 35.8 ms (SD 17.9 ms), and TE-MD was 91.3 ms (SD 45.2). The change from baseline was not significant. Cardiac output was lower after RV pacing than after anterior LV pacing: 4.36 (SD 1) vs. 4.70 (SD 1); P=.001. Conclusions. Pacing in the LV produced less asynchrony than RV pacing. In addition, anterior LV pacing resulted in a higher cardiac output than RV pacing. These findings suggest that the location normally used for temporary leads after cardiac surgery should be changed (AU)

Selecting the best site for pacing leads after cardiac surgery by evaluating the asynchrony of myocardial deformation observed with different pacing sites.

INTRODUCTION AND OBJECTIVES: After cardiac surgery, temporary pacing leads are routinely implanted in the right ventricle (RV). The objective was to investigate the effect of different ventricular pacing locations on cardiac synchrony (by evaluating myocardial deformation, or strain) and efficiency in patients undergoing cardiac surgery. METHODS: Interventricular asynchrony (i.e. the difference in the time of onset of deformation between right and left ventricles; Tε-R/L) and intraventricular asynchrony (i.e. the standard deviation and maximum difference in the time of onset of deformation in six segments of the left ventricle [LV]; Tε-SD and Tε-MD, respectively) were assessed in 19 patients. Doppler echocardiography was used to evaluate these parameters and cardiac output after pacing in the RV and in three different LV segments. RESULTS: Pacing in the RV resulted in the greatest increases in asynchrony parameters from baseline: Tε-R/L 59.8 ms (standard deviation [SD] 40.5 ms) vs. 28.23 ms (SD 56.9 ms), P=.002; Tε-SD 53.2 ms (SD 34.4 ms) vs. 36.6 ms (SD 34.9 ms), P=.007; and Tε-MD 135.3 ms (SD 82.9 ms) vs. 90.5 ms (SD 87.4 ms), P=.007. Pacing in the LV resulted in less asynchrony: for anterior LV pacing, Tε-R/L was 17.2 ms (SD 53.8 ms), Tε-SD was 35.8 ms (SD 17.9 ms), and Tε-MD was 91.3 ms (SD 45.2). The change from baseline was not significant. Cardiac output was lower after RV pacing than after anterior LV pacing: 4.36 (SD 1) vs. 4.70 (SD 1); P=.001. CONCLUSIONS: Pacing in the LV produced less asynchrony than RV pacing. In addition, anterior LV pacing resulted in a higher cardiac output than RV pacing. These findings suggest that the location normally used for temporary leads after cardiac surgery should be changed.