Five-year experience with implantation and follow-up of transvenous implantable cardioverter defibrillators: placing postimplant defibrillation threshold testing in perspective.

BACKGROUND: The rapid technological advancement in transvenous implantable cardioverter defibrillators (ICDs) has resulted in heterogeneous and often controversial approaches to follow-up procedures. The efficacy of postimplantation defibrillation threshold (DFT) testing with new-generation biphasic ICDs is unknown. OBJECTIVE: In this retrospective study, predischarge and postdischarge DFT protocols were compared to evaluate their safety and effect on adverse clinical events. METHODS: The study population consisted of 89 patients with 92 ICDs and 103 endovascular lead systems. Forty-four patients had DFT tests during implant and the predischarge period. Thirty patients had DFT tests during implant and the postdischarge period. Sixteen patients had only implant DFT data available. The follow-up period ranged from 3 days to 5.6 years. RESULTS: Ninety-nine percent of patients had successful implants. Postimplant DFT tests detected potential problems in only 1% of asymptomatic patients. Thirty-six percent of patients with normal predischarge DFT tests had adverse clinical events compared with 18% in the postdischarge group. Patients with postimplant DFTs > 25 joules (J) and safety margins > or = 10 J had a lower incidence of adverse clinical events (p = 0.03) compared with those with safety margins < 10 J. An 11% malfunction rate was observed in ICD leads during the follow-up period. CONCLUSIONS: DFT testing after implant is safe; however, routine postimplant DFT testing has limited value in assessing abnormalities in patients with the current generation of biphasic transvenous ICD devices. A 10-J safety margin was associated with a lower incidence of adverse clinical events in patients with DFTs > 25 J. Endovascular lead failure remains a significant problem with ICD systems requiring vigilant follow-up.

Perioperative complications of cardioverter-defibrillator implantation: the Emory experience.

Over a 5-year period, 110 cardioverter-defibrillators (109 epicardial, 1 transvenous) were implanted consecutively in selected patients with ventricular tachyarrhythmias. The perioperative course of this patient population was examined to determine the associated morbidity and mortality of the procedure. Patients were predominantly male, with coronary artery disease and a decreased left ventricular ejection fraction. Most underwent median sternotomy for implantable cardioverter defibrillator implantation. The incidence of perioperative mortality was found to be 2.7%. New-onset atrial fibrillation or flutter occurred in 17.3% of the patients during the postoperative period and aggravation of ventricular tachyarrhythmias in 19.1%. The ICD system became infected in 2.7% of the patients and the mediastinal incision site infected in 2.4%. Pneumonia developed in 4.5%. Other complications included significant blood loss, ICD pocket hematomas, and lead dislodgement. There is an appreciable incidence of morbidity and mortality associated with ICD implantation.

Cytomegalovirus as nosocomial infection.

Nosocomial infections with cytomegalovirus are an area of great concern and controversy within the medical community. With the advent of organ transplantation there have been an increased number of susceptible individuals. In the past most cases were confined to newborn nurseries and the neonatal intensive care unit. It is of great interest that recent evidence suggests that health care providers are at no greater risk of acquiring CMV infection inside the hospital setting when compared to a representative control group within the same community. This paper will review some of the literature that deals with the nosocomial transmission of CMV. We will try to emphasize transmission, diagnosis, prevention, and treatment of CMV infection.