Strategies for the Long-Term Preservation of Site for Future Implantation of Cardiac Implantable Electronic Devices (CIEDs): Two Decades of Experience.

Introduction Implantation of cardiac implantable electronic devices (CIEDs) is an art of science. As the volume of implantation has increased worldwide, so has the rate of complications. Infection, fibrosis, lead and device erosion, lead displacement, right ventricle perforation, lead fracture, and insulation break are the common complications in the implantation process. This exposes the patient for reopening and threatens the implantation for further complication due to infection, fibrosis of veins, failure to retrieve the implanted wire, and failure to re-implant the device on the same site. We slightly changed our implantation technique to preserve the implantation site for future implantation and reduce the rate of complication in the index implantation. Methods This randomized control trial was conducted from January 2016 to September 2019 at Hayatabad Medical Complex Peshawar, Pakistan. A consecutive sampling technique was used to obtain a sample size of 602 patients keeping a 95% confidence interval and a 5% margin error. We adopted a strategy to take prick, for implantation of devices, inside the pocket, which reduces the number of sutures, hastens the procedure, prevents erosion, and minimizes the chance of subclavian crush syndrome and insulation break. We also selected the minimum possible length of leads. This will possibly decrease the chances of cumbersome fibrosis around the lead and device and will make future implantation convenient. Results There was a total of 602 procedures in the study period. About 253 (42%) procedures were done in the newly adopted strategy and 349 (58%) were performed in the conventional way. Our complication rate grossly reduces in the novel way of implantation in which we took our prick inside the pocket. Conclusion A slight modification in the implantation of CIEDs not only prevents the rate of complication in the index implantation but will also possibly preserve the site for future implantation.

Implantation Of The Permanent Pacemaker; From Superior Vena Cava In A Patient With Fibrosis Of Both Subclavian Veins.

Overall life span has increased with improved management of cardiac diseases all over the world which has opened the door of degenerative cardiac diseases. On the other hand, stat of the art corrective congenital cardiac disease also increased the volume of adult living with treated congenital heart diseases. Both these factors lead to a new epidemic in cardiology of complete heart block (CHB). Permanent pacemakers (PPM) implantation is a life-saving procedure for CHB. Permanent pacemakers are usually implanted from upper limb veins. But at time upper limb veins are not suitable for implantation due to various anatomical and pathological reasons, so alternative methods are used for implantation of devices. We are reporting a case of PPM implantation from Superior Vena Cava (SVC).

Innovation in Permanent Pacemaker's Implantation Technique: Trans-Axillary Approach.

INTRODUCTION: Permanent pacemakers' (PPM) implantation is an integral part of electrophysiology and general cardiology. The implantation technique has evolved a lot since the first implantation. Several innovations have been undertaken to improve the effectiveness, life of the transplant, and patient outcomes. In this study, we introduced a new implantation technique to improve the procedure and possibly reduce the rate of complication. METHODS: This study was conducted from January 2016 to February 2017 in Hayatabad Medical Complex, Peshawar. Patients destined for implantation of PPM based on a clinical treatment plan, after proper explanation of the procedure, were brought to the catheterization laboratory. Venogram of the upper limb performed. Patients were scrubbed and draped. The axillary vein was approached via the Seldinger technique. About 2 to 3 cm superolateral to the puncture site, a skin incision was made and subcutaneous pocket constructed, and a guidewire external end was pulled in from inside the pocket keeping the venous end at the place. Subsequently, in a routine way, lead was placed, secured and the wound was closed in layers. RESULTS: A total of 690 PPM were implanted under the study. About 290 devices were implanted in the conventional way and 380 devices via the trans-axillary approach. The mean implantation time was less than 30 minutes via the trans-axillary approach. Immediate and delayed complications of the procedure were minimal. CONCLUSION: Trans-axillary approach holds some significant advantages over the conventional technique. The subcutaneous pocket and venous puncture successfully reduce the burden of foreign material, minimize the tension on the wound, shorten implantation time and reduce the chances of erosion of the device.

Infection Of Permanent Pacemaker's Pocket, What Do We Do?

BACKGROUND: With increased rate of permanent pacemaker's (PPM) implantation, the rate of complication also increased many folds. Infection in pacemakers is one of the dreaded complications which need a multidisciplinary approach in its management. METHODS: All patients with permanent pacemakers, who presented with infection of device, were admitted in our unit. The infected device was explanted and wound left open. The same device was used as a temporary pacemaker with a new PPM screwing lead from internal jugular approach. Once the infection was under control, a new device was implanted on the other side and temporary wire (PPM screwing lead) pulled out. Wound on both side closed and patient kept on antibiotics for a week. RESULTS: Total 10 cases of infected device received. Single chambers devices with infection were six and dual chamber pacemakers were four. One case with infection had tine lead and nine patients presented with screwing leads. Male and female ratio was 2.3:1. All leads were explanted in our department with conventional gadgets using rotation and traction maneuvers. Culture sensitivity in all cases remained negative. Patients were kept on broad spectrum antibiotics till the wound was clear. One patient had small pericardial effusion soon after explantation of tine lead, which was treated conservatively. No other major or minor complication documented.. CONCLUSIONS: Scrupulous planning and preparation before system extraction and later on new Cardiac implantable electronic device re-implantation is essential for better patient outcome.

Electrophysiological changes in the conducting properties of fast pathway following modification of the slow pathway of the atrio ventricular node for atrio ventricular nodal re-entrant tachycardia.

OBJECTIVES: To determine the possible changes in the conducting properties of the fast pathway after modification of the atrioventricular slow pathway for AVNRT which leads to the failure of the induction of tachycardia. METHODS: This study was conducted in the Cardiac electrophysiology Laboratory of Hayatabad Medical Complex, Peshawar, Pakistan from March 2017 to March 2018. All the patients underwent radiofrequency modification of the slow pathway for AVNRT. Patients in whom typical AVNRT was inducible with demonstration of dual AV nodal physiology were included in the study. RESULTS: A total of 171 cases were included in the study, 42 (25%) were males, mean age recorded was 47 ± 15 years. There were no significant changes pre and post ablation in the base line parameters like VV interval, atrioventricular nodal (AV nodal) Wenckebach cycle length, slow pathway effective refractory period (SPERP) or fast and slow pathways maximal Atrio His interval. However significant change was observed in the effective refractory period of the fast pathway 350±49 Vs 290±32 (p value 0.0001). The difference between slow and Fast pathway ERP was also decreased significantly 82±36 Vs 56± 24 (p value 0.004). CONCLUSION: Our study showed that ablation of AV nodal slow pathway for atrioventricular nodal reentrant tachycardia leads to changes in the effective refractory period of the fast pathway.

Clinical and Echocardiographic Follow-up after Successful Percutaneous Transvenous Mitral Commissurotomy.

Background The objective of the study was to determine the long-term outcomes, including mitral restenosis and regurgitation, after successful percutaneous transvenous mitral commissurotomy (PTMC). Methods This cross-sectional prospective study was conducted at the cardiology department of Lady Reading Hospital, Peshawar, Pakistan, from January 2007 to December 2009. A total of 84 patients were followed up for a period of 96 months. Pre and post percutaneous transvenous mitral commissurotomy echocardiography was done on the mitral valve area (MVA) using two-dimensional (2D) and color doppler echocardiography. Patients who had successful PTMC were followed up for MVA loss, mitral regurgitation (MR), and cardiac death. SPSS Software (IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY: IBM Corp.; 2013) was used for data analysis. Results Of the 84 patients, 21 were male, and 63 were females. The mean age was 35 ± 11 years. After PTMC, the mean valve two-dimensional area increased from 0.84 ± 0.13 to 1.83 ± 0.49 cm2 (p value <0.001). MR was mild in 49 patients (62.8%), moderate in 27 patients (34.6%), and severe in two patients (2.6%). Good results were achieved in 60 (71.4%). Patients with good results were younger (24 ± 4), and had a relatively lower Wilkin's score, with a mean value of (8.4 ± 2.8). Follow-up events were death in six patients, mitral valve replacement (MVR) in 10 patients, and restenosis in seven patients. The Kaplan-Meier curve was used for the follow-up end points. Patient who required PTMC for mitral restenosis survived for a longer time than those requiring MVR, and those who had cardiac death due to severe pulmonary hypertension or heart failure. Conclusion Patients who had favorable Wilkin's score and underwent PTMC for severe symptomatic mitral stenosis had better event-free survival in the long term follow-up.

Cross Over: A Reliable Maneuver In The Confirmation Of Atrioventricular Nodal Reentrant Tachycardia Ablation.

BACKGROUND: Atrioventricular nodal re-entrant tachycardia (AVNRT) is still the most common presentation to our electrophysiology laboratory for ablation. The aim of this study is to document the confirmative value of cross over manoeuvre in successful AVNRT ablation. METHODS: This study was conducted in Hayat Abad Medical complex Peshawar June 2006 to October 2015. In all patient with AVNRT, Dual-nodal pathway physiology confirmed by programmed atrial pacing of eight Tran with an extra beat by 10 millisecond (ms) decrement and at least Atrial HIS (A-H) interval prolongation of 50 ms. The dual pathway was further confirmed by cross over manoeuvre. Slow pathway potential identified and radiofrequency ablation (RFA) energy applied at 60 temperatures and 30 powers in Left Anterior Oblique (LAO) projection. Post ablation absence of cross over documented with and without isoproterenol and patient followed for any complication or recurrence. RESULTS: Total 567 patients studied with mean age 36.56±12.16 and male to female ratio 1:1.4 with presentation of supraventricular tachycardia (SVT). Slow pathway was successfully modified and statistically no significant complication or recurrence documented. CONCLUSIONS: Failure to cross over reliably excludes any conduction over the slow pathway and so recurrence of AVNRT.

Permanent Pace Maker Implantation Through Axillary Vein Approach.

BACKGROUND: Device implantation is an integral part of interventional cardiology particularly electrophysiology. In this study, we are going to shear our experience of device implantation technique at electrophysiology department Hayatabad Medical Complex, Peshawar. METHODS: The study was conducted from June 2011 to December 2015. Axillary vein was used to implant the devices but in some cases when this rout was not convenient due to any reason then subclavian vein was entered through the Seldinger technique. Fluoroscopy time was less than 10 minutes and total procedure time was not more than 45 minutes. Electric cautery was used only in two cases. Pressure dressing was used in a few cases. RESULTS: Total numbers of permanent pacemakers (PPM) remain 800 during the study period. There were 450 single chamber pacemakers and 350 dual chambers pacemakers. No case of any major bleeding was documented and in very few cases there was mild ooze from the procedure site after the operation which was tackled with pressure dressing. Four cases of pneumothorax were noted during the study period and in three cases chest intubation were done and one patient was kept on conservative management. Patient were followed after one moth of discharge from the hospital and then yearly. Eight cases of lead dislodgment were documented during the study period. CONCLUSIONS: Axillary vein approach for implantation of permanent pacemakers is a safe and less time-consuming technique.

Localization Of Accessory Pathway In Patients With Wolff-Parkinson-White Syndrome From Surface Ecg Using Arruda Algorithm.

BACKGROUND: To ablate accessory pathway successfully and conveniently, accurate localization of the pathway is needed. Electrophysiologists use different algorithms before taking the patients to the electrophysiology (EP) laboratory to plan the intervention accordingly. In this study, we used Arruda algorithm to locate the accessory pathway. The objective of the study was to determine the accuracy of the Arruda algorithm for locating the pathway on surface ECG. METHODS: It was a cross-sectional observational study conducted from January 2014 to January 2016 in the electrophysiology department of Hayat Abad Medical Complex Peshawar Pakistan. A total of fifty nine (n=59) consecutive patients of both genders between age 14-60 years presented with WPW syndrome (Symptomatic tachycardia with delta wave on surface ECG) were included in the study. Patient's electrocardiogram (ECG) before taking patients to laboratory was analysed on Arruda algorithm. Standard four wires protocol was used for EP study before ablation. Once the findings were confirmed the pathway was ablated as per standard guidelines. RESULTS: A total of fifty nine (n=59) patients between the age 14-60 years were included in the study. Cumulative mean age was 31.5 years±12.5 SD. There were 56.4% (n=31) males with mean age 28.2 years±10.2 SD and 43.6% (n=24) were females with mean age 35.9 years±14.0 SD. Arruda algorithm was found to be accurate in predicting the exact accessory pathway (AP) in 83.6% (n=46) cases. Among all inaccurate predictions (n=9), Arruda inaccurately predicted two third (n=6; 66.7%) pathways towards right side (right posteroseptal, right posterolateral and right antrolateral). CONCLUSIONS: Arruda algorithm was found highly accurate in predicting accessory pathway before ablation.

TEMPORARY PACE MAKERS IMPLANTATION: DO WE NEED FLUOROSCOPY?

BACKGROUND: Temporary pace maker (TPM implantation is done mostly in emergency with assistance of fluoroscopy. Fluoroscopy has various constrains which may delay the procedure at different occasion. We are going to share our experience in TPM implantation without fluoroscopy from internal jugular vein. METHODS: The case series study was conducted in Hayatabad Medical complex Peshawar from January 2011 to November 2011. Internal jugular vein was cannulated with 6 French sheaths in the supra-clavicular region with modified Seldinger technique. TPM wire connected to the TPM device and advanced in the sheath to the right ventricle. Position was confirmed from captured beat on monitor. There was no need of repositioning and lead remains stable. RESULTS: Total 122 TPM leads were implanted in the study period. All patients were implanted from internal jugular vein. There were 71 male and 51 female patients. Among these patients 55 were in hemodynamically unstable state. The average time of implantation was less than 10 minutes. There was failure in one case. So the overall success rate was 99.180%. CONCLUSION: TPM implantation from the internal jugular vein even without fluoroscopy is safe, less time consuming and convenient.

Lead erosion in permanent pacemaker: a cumbersome complication.

BACKGROUND: Lead erosion is one of the troublesome complications which are very difficult to treat and most of the time leads to device explanation and replacement prematurely. METHODS: From 2005 to 2011, total 415 pacemakers were implanted in our cardiology department at Hayatabad Medical Complex Peshawar. The patients were followed regularly at six month interval or more frequently in case there were complications. At every visit we inspected the wound site, electrocardiography was done and device was analyzed with compatible programmer for the device. If there was soreness at the site of implantation, patient was seen more frequently and if there was erosion of skin, wound was reopened margin refreshed and wound closed. Initially we closed the wound in two layers after reopening but we got repeated erosion with this method and so we buried the leads sub-muscularly as change strategy which again proved unsuccessful. Results: During the six years study about 415 permanent pacemakers were implanted. During this time period, we received: three lead erosion, which were repositioned. There were recurrence in two cases and they were again subjected to procedure with a change strategy; by burying the leads in muscles, which proved unsuccessful. CONCLUSION: Leads erosion can be prevented by carefully burying leads in three layers first in muscle followed by subcutaneous tissue and then closing the wound by suturing the skin during initial implantation.

Electrical storms and their prognostic implications.

BACKGROUND: Prevention of sudden cardiac death has always been a challenge for electrophysiologists and to date, automatic implantable cardiovertor defibrillator (AICD) is found to be the only remedy. This device delivers an intracardiac shock whenever it senses a fatal ventricular arrhythmia in order to achieve sinus rhythm. If the delivery of these intracardiac shocks becomes frequent, the situation is declared as an electrical storm. This article deals with the frequency, precipitating factors and prevention of electrical storms. METHODS: One hundred and ten episodes of electrical storms (a total of 668 shocks) were retrospectively analysed in 25 recipients of automatic implantable cardioverter defibrillators. ECG, echocardiography, serum electrolytes, urea and creatinine were done for all the patients, and they were hospitalized for a minimum of 24 hours. RESULTS: During the 3 year study period, all the 25 patients with an implantable cardiovertor defibrillator, on an average, received one shock per two years. However, 12 out of these 25 patients (50%) had more than two shocks within 24 hours. Most of these patients with electrical storms were having active ischemia, electrolytes imbalances or renal failure. CONCLUSION: Electrical storms are common in patients with coronary artery disease with impaired left ventricular functions. Ischemia, electrolytes imbalances and renal failure predispose to the electrical storms. Electrical Storms are predictors of poor prognosis.

Radiofrequency catheter ablation for supraventricular tachycardias: experience at Peshawar.

BACKGROUND: Drug therapy is mostly employed in the management of supraventricular tachycardias (SVTs). However, radiofrequency catheter ablation has been found to be highly effective and safe in the treatment of SVTs. The current study is aimed at sharing our experience of 320 patients who presented with SVTs, and were treated with radiofrequency catheter ablation. METHODS: This descriptive study was carried out in the Cardiac Electrophysiology Laboratory of Lady Reading Hospital, Peshawar from October 2006 to December 2009. Standard 4-wire electrophysiological study was carried out to identify the mechanism of SVT in 320 consecutive patients. Radiofrequency catheter ablation was used to interrupt the tachycardia circuit. RESULTS: Out of a total 320 patients who underwent electrophysiologic study, 168 were found to have atrioventricular nodal re-entry as underlying mechanism; 121 patients were having accessory pathway responsible for re-entry (of these 95 presented with orthodromic reciprocating tachycardia and 26 as antidromic reciprocating tachycardia); 19 patients were having focal atrial tachycardia, 4 atrial fibrillation and 8 atrial flutter as the underlying cause for SVT. Radiofrequency catheter ablation was used with an overall success of 94% and a complication risk of complete AV block in 0.3% and recurrence rate of 3%. CONCLUSION: Radiofrequency catheter ablation is safe and highly effective mode of treatment of SVTs.