Amiodarone or implantable cardioverter-defibrillator in chagas cardiomyopathy: the CHAGASICS randomized clinical trial

IMPORTANCE: Over 10 000 people with Chagas disease experience sudden cardiac death (SCD) annually, mostly caused by ventricular fibrillation. Amiodarone hydrochloride and the implantable cardioverter-defibrillator (ICD) have been empirically used to prevent SCD in patients with chronic Chagas cardiomyopathy. OBJECTIVE: To test the hypothesis that ICD is more effective than amiodarone therapy for primary prevention of all-cause mortality in patients with chronic Chagas cardiomyopathy and moderate to high mortality risk, assessed by the Rassi score. DESIGN, SETTING, AND PARTICIPANTS: CHAGASICS is an open-label, randomized clinical trial. The study enrolled patients from 13 centers in Brazil from May 30, 2014, to August 13, 2021, with the last follow-up November 8, 2021. Patients with serological findings positive for Chagas disease, a Rassi risk score of at least 10 points (intermediate to high risk), and at least 1 episode of nonsustained ventricular tachycardia were eligible to participate. Data were analyzed from May 3, 2022, to June 16, 2023. INTERVENTIONS: Patients were randomized 1:1 to receive ICD or amiodarone (with a loading dose of 600 mg after randomization). MAIN OUTCOMES AND MEASURES: The primary outcome was all-cause mortality, and secondary outcomes included SCD, hospitalization for heart failure, and necessity of a pacemaker during the entire follow-up. RESULTS: The study was stopped prematurely for administrative reasons, with 323 patients randomized (166 in the amiodarone group and 157 in the ICD group), rather than the intended 1100 patients. Analysis was by intention to treat at a median follow-up of 3.6 (IQR, 1.8-4.4) years. Mean (SD) age was 57.4 (9.8) years, 185 patients (57.3%) were male, and the mean (SD) left ventricular ejection fraction was 37.0% (11.6%). There were 60 deaths (38.2%) in the ICD arm and 64 (38.6%) in the amiodarone group (hazard ratio [HR], 0.86 [95% CI, 0.60-1.22]; P = .40). The rates of SCD (6 [3.8%] vs 23 [13.9%]; HR, 0.25 [95% CI, 0.10-0.61]; P = .001), bradycardia requiring pacing (3 [1.9%] vs 27 [16.3%]; HR, 0.10 [95% CI, 0.03-0.34]; P < .001), and heart failure hospitalization (14 [8.9%] vs 28 [16.9%]; HR, 0.46 [95% CI, 0.24-0.87]; P = .01) were lower in the ICD group compared with the amiodarone arm. CONCLUSIONS AND RELEVANCE: In patients with chronic Chagas cardiomyopathy at moderate to high risk of mortality, ICD did not reduce the risk of all-cause mortality. However, ICD significantly reduced the risk of SCD, pacing need, and heart failure hospitalization compared with amiodarone therapy. Further studies are warranted to confirm the evidence generated by this trial.

"Ring-like" à ressonância cardíaca: intervenção precoce com cardiodesfibrilador implantável / "Ring-like" cardiac resonance: early intervention with implantable cardioverter defibrillator

INTRODUÇÃO: O padrão de realce tardio miocárdico (RT) do ventrículo esquerdo, denominado "ring-like", localiza-se no meso-epicárdio e abrange pelo menos três segmentos contíguos no mesmo corte de eixo curto, na ressonância cardíaca (RMC). Este padrão tem sido associado a uma maior incidência de eventos arrítmicos potencialmente fatais. Descreve-se um caso de intervenção precoce com a indicação de implantação de cardiodesfibrilador implantável (CDI), considerando o achado de "Ring like" com uma possível associação com laminopatia. RELATO DE CASO: Homem de 51 anos iniciou quadro de dispneia paroxística noturna, ortopneia e dispneia aos mínimos esforços em 2022. O ecocardiograma evidenciou disfunção ventricular com Fração de Ejeção (FE) de 32% às custas de hipocinesia difusa. Angiotomografia de coronárias sem lesões. A RMC demonstrou dilatação de todas câmaras (Ventrículo Esquerdo 78 mm x 75 mm), disfunção sistólica biventricular (FE de ventrículo esquerdo 12% e FE de ventrículo direito 17%), com RT de padrão não coronariano mesocárdico em todo o septo e nos segmentos anterior e inferior mediobasal. Os achados de RMC são compatíveis com cardiomiopatia dilatada com fibrose padrão ring-like (Figuras 1 e 2). Iniciado terapia médica com terapia quádrupla, com evolução satisfatória. Ao Holter de 24h, alta densidade de ectopias ventriculares, com episódios de Taquicardia Ventricular Polimórfica Não Sustentada. Apesar do teste genético não confirmatório, os achados de imagem com extensa quantidade de fibrose sugeriram uma cardiomiopatia dilatada por provável laminopatia. Considerando a FEVE < %, o sexo masculino e as arritmias ventriculares no Holter, caso foi discutido em reunião e indicado CDI como profilaxia primária. Evoluiu assintomático, sem novas intercorrências. CONCLUSÕES: Este relato de caso destaca a importância da RMC na avaliação e manejo da cardiomiopatia dilatada com padrão "ring-like", com papel fundamental na caracterização da extensão da fibrose mesocárdica, fornecendo informações adicionais que corroboram na indicação de CDI por profilaxia primária. O sexo masculino, as arritmias ventriculares não sustentadas no Holter e a fração de ejeção inferior a 45% foram identificados como fatores de risco para morte súbita nas séries de casos descritas de laminopatias até o momento.

Predictors of Quality of Life, Anxiety and Acceptance in Patients with Implantable Cardioverter-Defibrillator. / Preditores de Qualidade de Vida, Ansiedade e Aceitação em Pacientes com Cardioversor-Desfibrilador Implantável.

BACKGROUND: An implantable cardioverter-defibrillator (ICD) can cause high levels of anxiety and depression, resulting in negative effects on quality of life. OBJECTIVES: To evaluate the quality of life, anxiety, and acceptance of the ICD using standardized measurement instruments and identify predictors of better responses for each of the outcomes studied. METHOD: This is a prospective cohort study with patients undergoing initial ICD implantation or reoperation to maintain the device. The study outcomes included quality of life, anxiety, and acceptance of the ICD. The change in scores (30 and 180 days) was assessed using the minimal important difference (MID). Univariate analysis and the multivariate logistic regression model were used to identify predictors of better responses, adopting a significance level of 5%. RESULTS: A total of 147 patients were included between January/2020 to June/2021, with a mean age of 55.3 ± 13.4 years and a predominance of males (72.1%). The MID for quality of life, anxiety, and ICD acceptance were observed in 33 (22.4%), 36 (24.5%) and 43 (29.3%) patients, respectively. Age equal to or greater than 60 years (OR=2.5; 95%CI=1.14-5.53; p=0.022), absence of atrial fibrillation (OR=3.8; 95%CI=1.26-11.63; p=0.017) and female gender (OR=2.2; 95%CI=1.02-4.97; p=0.045) were independent predictors of better responses to quality of life, anxiety and acceptance of the ICD, respectively. CONCLUSION: The identification of predictors for better quality of life scores, anxiety, and acceptance of the device can support the implementation of specific care for patients with a greater chance of presenting unfavorable results.

FUNDAMENTO: O cardioversor-desfibrilador implantável (CDI) pode causar níveis elevados de ansiedade e depressão, resultando em efeitos negativos na qualidade de vida. OBJETIVOS: Avaliar a qualidade de vida, a ansiedade e a aceitação do CDI por meio de instrumentos de medida padronizados e identificar preditores de melhores respostas para cada um dos desfechos estudados. MÉTODO: Coorte prospectiva com pacientes submetidos a implante inicial de CDI ou reoperação para a manutenção do dispositivo. Os desfechos do estudo incluíram: qualidade de vida, ansiedade e aceitação do CDI. A mudança nos escores (30 e 180 dias) foi avaliada por meio da diferença mínima importante (DMI). Foi utilizada a análise univariada e o modelo de regressão logística multivariada para a identificação de preditores de melhores respostas, adotando-se o nível de significância de 5%. RESULTADOS: De janeiro/2020 a junho/2021 foram incluídos 147 pacientes, com idade média de 55,3 ± 13,4 anos e predomínio do sexo masculino (72,1%). A DMI para qualidade de vida, a ansiedade e a aceitação do CDI foram observadas em 33 (22,4%), 36 (24,5%) e 43 (29,3%) pacientes, respectivamente. Idade igual ou maior que 60 anos (OR=2,5; IC 95%=1,14-5,53; p=0,022), ausência de fibrilação atrial (OR=3,8; IC 95%=1,26-11,63; p=0,017) e sexo feminino (OR=2,2; IC 95%=1,02-4,97; p=0,045) foram preditores independentes de melhores respostas para qualidade de vida, ansiedade e aceitação do CDI, respectivamente. CONCLUSÃO: A identificação de preditores para melhores escores de qualidade de vida, ansiedade e aceitação do dispositivo pode subsidiar a implementação de cuidados específicos para os pacientes com maiores chances de apresentar resultados desfavoráveis.

Factors of mortality in patients with cardiac implantable electronic device: 5-year experience.

OBJECTIVE: The use of cardiac implantable electronic devices has increased in recent years. It has also brought some issues. Among these, the complications of cardiac implantable electronic devices infection and pocket hematoma are difficult to manage. It can be fatal with the contribution of patient-related risk factors. In this study, we aimed to find mortality rates in patients who developed cardiac implantable electronic devices infection and pocket hematoma over 5 years. We also investigated the risk factors affecting mortality in patients with cardiac implantable electronic devices. METHODS: A total of 288 cardiac implantable electronic devices patients were evaluated. Demographic details, history, and clinical data of all patients were recorded. Cardiac implantable electronic devices infection was defined according to the modified Duke criteria. The national registry was used to ascertain the mortality status of the patients. The patients were divided into two groups (exitus and survival groups). In addition, the pocket hematoma was defined as significant bleeding at the pocket site after cardiac implantable electronic devices placement. RESULTS: The cardiac implantable electronic devices infection was similar in both groups (p=0.919), and the pocket hematoma was higher in the exitus group (p=0.019). The exitus group had higher usage of P2Y12 inhibitors (p≤0.001) and novel oral anticoagulants (p=0.031). The Cox regression analysis, including mortality-related factors, revealed that renal failure is the most significant risk factor for mortality. Renal failure was linked to a 2.78-fold higher risk of death. CONCLUSION: No correlation was observed between cardiac implantable electronic devices infection and mortality, whereas pocket hematoma was associated with mortality. Furthermore, renal failure was the cause of the highest mortality rate in patients with cardiac implantable electronic devices.

Seguimento dos pacientes com síndrome arritmogênica do prolapso valvar mitral após implante de cardioversor desfibrilador implantável / Follow-up of patients with arrhythmogenic mitral valve prolapse syndrome after implantable cardioverter defibrillator implantation

INTRODUÇÃO: A síndrome arritmogênica do prolapso valvar mitral (PVM) é uma entidade pouco estudada, associada a eventos arrítmicos ventriculares graves, podendo chegar a 12% de associação com morte súbita cardíaca (MSC). O acompanhamento por telemetria do cardioversor desfibrilador implantável (CDI) pode aprimorar a compreensão dessa síndrome. Este estudo descreve o acompanhamento de pacientes com síndrome arritmogênica do PVM e CDI. MÉTODOS: Estudo retrospectivo, observacional, descritivo que incluiu pacientes com diagnóstico de síndrome arritmogênica do PVM e implante de CDI acompanhados entre 2021 e 2024 em hospital terciário de São Paulo. Seguimento realizado por avaliação eletrônica do dispositivo, eletrocardiograma (ECG), ecocardiograma e Holter de 24h. RESULTADOS: A amostra inclui 4 mulheres com CDI, entre 31 a 54 anos, e disjunção do anel mitral (DAM) de 8 a 16mm. Metade da amostra implantou o dispositivo para prevenção primária de MSC, enquanto as outras para prevenção secundária com tempo médio de seguimento após implante de 3,3 anos. Contudo, uma das pacientes havia sido operada há 10 anos, as demais, nos últimos 2 anos. A amiodarona foi utilizada em uma paciente e as demais estavam em uso de beta-bloqueador. Todos os ECG de repouso mostraram extrassístoles ventriculares isoladas com morfologia sugestiva de origem no músculo papilar posteromedial. Os achados do ecocardiograma da amostra estão representados na tabela 1. Apenas uma paciente apresentou fibrose miocárdica na ressonância magnética com padrão ínfero-septal basal e no músculo papilar posteromedial. PVM e DAM foram observados em toda a amostra, com média do comprimento de 12,25mm. Na avaliação semestral por telemetria, nenhuma paciente apresentou terapia antitaquicardia no período e não houve relato de síncope. Taquicardia ventricular não sustentada foi registrada (Holter e CDI) em duas pacientes, e foram encaminhadas a ablação, tendo sucesso em um dos procedimentos. Uma paciente realizou reabilitação cardíaca no último ano, não teve piora na densidade de arritmias ou terapias inapropriadas durante exercícios. CONCLUSÃO: O comportamento das arritmias avaliado neste estudo revelou incidência reduzida de eventos arrítmicos graves, mesmo entre portadores de CDI para profilaxia secundária. Notadamente, há uma lacuna significativa na literatura em relação à indicação e ao manejo da profilaxia primária na síndrome arritmogênica do PVM, bem como ao impacto dos exercícios físicos nesse grupo específico de pacientes, indicando a necessidade premente de pesquisas adicionais sobre o tema.

Evaluation of patients with implantable cardioverter-defibrillator in a Latin American tertiary center.

INTRODUCTION: Despite advancements in implantable cardioverter-defibrillator (ICD) technology, sudden cardiac death (SCD) remains a persistent public health concern. Chagas disease (ChD), prevalent in Brazil, is associated with increased ventricular tachycardia (VT) and ventricular fibrillation (VF) events and SCD compared to other cardiomyopathies. METHODS: This retrospective observational study included patients who received ICDs between October 2007 and December 2018. The study aims to assess whether mortality and VT/VF events decreased in patients who received ICDs during different time periods (2007-2010, 2011-2014, and 2015-2018). Additionally, it seeks to compare the prognosis of ChD patients with non-ChD patients. Time periods were chosen based on the establishment of the Arrhythmia Service in 2011. The primary outcome was overall mortality, assessed across the entire sample and the three periods. Secondary outcomes included VT/VF events and the combined outcome of death or VT/VF. RESULTS: Of the 885 patients included, 31% had ChD. Among them, 28% died, 14% had VT/VF events, and 37% experienced death and/or VT/VF. Analysis revealed that period 3 (2015-2018) was associated with better death-free survival (p = .007). ChD was the only variable associated with a higher rate of VT/VF events (p < .001) and the combined outcome (p = .009). CONCLUSION: Mortality and combined outcome rates decreased gradually for ICD patients during the periods 2011-2014 and 2015-2018 compared to the initial period (2007-2010). ChD was associated with higher VT/VF events in ICD patients, only in the first two periods.

Risk stratifier for sudden cardiac death beyond the left ventricular ejection fraction in Chagas cardiomyopathy.

BACKGROUND: Sudden cardiac death (SCD) risk markers are needed in Chagas cardiomyopathy (CC). Action potential duration restitution (APDR) dynamics is capable of extracting information on cardiac regional heterogeneity. This study intends to develop a patient-specific variables-based algorithm to predict SCD in the low-intermediate subgroups of the Rassi risk score. METHODS: Cross-sectional study of patients who underwent 24-h Holter for research purposes between January 1992 and February 2017. From 4-h ECG segment, RR series were generated and APDR dynamics metrics were calculated. Classification tree and sensitivity analysis were applied. As outcomes, SCD, SCD-free and non-cardiovascular death and 34 variables were included. RESULTS: Two hundred twenty-one (129 in the group SCD-free, 80 in the SCD group and 12 non-cardiovascular death group) were analyzed. In the groups with and without SCD (209 patients), the median age was 66 years, 52% were female, the cardiac involvement was mild to moderate in 72% with a Rassi point median of 8 (IQ: 3 to 11). The SCD group had more ventricular remodeling and more ventricular electrical instability. The occurrence of a %beats QTend/TendQ ratio > 1 (AUC, 0.96 (95% CI 0.89-0.98) present in more than 56.7% of the 4-h ECG segments was sufficient to identify patients of the SCD subgroup. Variables representing different stages of CC were also relevant in the model. CONCLUSION: It is possible to use APDR dynamics as an adjuvant in the SCD risk assessment in a subgroup of patients with a high risk of SCD and a very low risk of non-CV death with high power of discrimination.

Follow-up de dispositivos cardíacos implantáveis suscetíveis a recall através de monitoramento remoto: resultados de um serviço de referência

INTRODUÇÃO: Em março de 2021 a Biotronik emitiu um comunicado sobre uma possível depleção prematura da bateria de cardiodesfibriladores implantáveis (CDI) e ressincronizadores cardíacos com desfibrilador (TRC-D). A empresa não orientou troca imediata das baterias e sugeriu o acompanhamento através de monitoramento remoto desses pacientes com dispositivos implantados em nosso serviço. Relatamos neste trabalho a taxa de recall. MÉTODOS: Estudo retrospectivo observacional com pacientes com CDI e TRC-D Biotronik suscetíveis a recall implantados no Instituto Dante Pazzanese de Cardiologia entre os anos de 2015 a 2021. Em consulta médica, os pacientes foram convidados a participar do monitoramento remoto com o uso do monitor CardioMessenger Smart, orientados quanto ao comunicado da empresa e sobre como manusear o aparelho. RESULTADOS: Foram identificados 76 pacientes com dispositivos passíveis de disfunção. Através de contato telefônico, observou-se que 34 pacientes já haviam falecido. Uma paciente foi submetida à troca do gerador previamente ao comunicado por desgaste da bateria. Dos 41 restantes, realizouse o monitoramento remoto de 73% (30), sendo 2 TRC-D e 28 CDI. Não ocorreu a monitorização de 10 pacientes devido à não disponibilização dos aparelhos pela empresa. Não foi possível contato com um paciente. Durante o follow-up de 2 anos, 6,6% dos casos (2) apresentaram depleção prematura da bateria, sendo submetidos à troca do gerador. CONCLUSÃO: A percentagem de recall encontrada neste estudo foi relevante e o monitoramento remoto foi fundamental para a detecção precoce e prevenção de uma situação potencialmente fatal.

Monocyte/High-Density Lipoprotein Ratio Is Associated with Atrial High-Rate Episodes within One Year Detected by Cardiac Implantable Electronic Devices.

OBJECTIVE: To investigate the risk factors for predicting atrial high-rate episodes (AHREs) detected by cardiac implantable electronic devices (CIEDs). METHODS: A total of 140 patients with CIED in our hospital from June 2013 to June 2018 were included and were followed up to observe whether they had AHREs. AHRE are defined as atrial rate ≥ 175 times/minute, lasting > 5 minutes, and reviewed by an experienced electrophysiologist with unclear clinical diagnosis. The patients fasted for 12 hours after implantation, and blood samples were collected for biochemical, lipid, and whole blood count detection. Follow-up was regular after discharge to record follow-up data of each patient and conduct statistical analysis. RESULTS: One hundred and forty patients were implanted with dual-chamber pacemakers, their median age was 70 years old, 44.29% were male, 27 patients had AHRE within one year, and AHRE incidence rate was 19.29%. The microcytic to hypochromic (M/H) ratio was calculated for all AHRE patients and compared with the patients without AHRE; the M/H value of AHRE patients was significantly higher. Throughout the entire follow-up period, a total of 44 patients developed AHRE; when adjusted by multivariate analysis, only M/H ratio ≥ 4.5 vs. < 4.5 had statistical significance, and the adjusted hazard ratio value was 4.313 (1.675-11.105). CONCLUSION: As an indicator, M/H ratio may play an important role in the occurrence and development of atrial fibrillation and can be used as a predictor of AHRE in patients with CIED.

Desfibriladores automáticos implantables y su desactivación, una conversación necesaria. Revisión de la literatura y propuesta multidisciplinaria / Implantable automatic defibrillators and their deactivation, a necessary conversation. Literature review

El uso de desfibriladores automáticos implantables (DAI) ha ido en aumento. Los pacientes usuarios de DAI inevitablemente transitan hacia el fin de la vida en algún momento, incluyendo la concurrencia de patologías terminales. En dicho contexto se hace relevante discutir y evaluar la desactivación de estos dispositivos en búsqueda del confort del paciente y evitar descargas en la fase de fin de vida. Hay múltiples barreras comunicacionales y operacionales a la hora de considerar la desactivación del DAI. En primer lugar, un gran porcentaje de pacientes no lo ha discutido con su tratante pese a las recomendaciones de guías internacionales de realizarlo previo a la instalación del dispositivo. En segundo lugar, existe un importante desconocimiento de pacientes, familiares e incluso médicos sobre los beneficios de DAI así como del proceso de desactivación y la discusión ética que incluso los lleva a pensar que ocurrirá una muerte inmediata, considerándolo como eutanasia o suicidio asistido. Finalmente, el manejo de pacientes en hospicios o el manejo de fin de vida en usuarios de DAI está escasamente protocolizado, con bajos porcentajes de desactivación, lo que se traduce en descargas en los últimos minutos de vida que producen angustia marcada a pacientes y familiares. Es necesario abordar estas barreras y discutir dichas temáticas con los pacientes para informarlos y educarlos en el funcionamiento de su dispositivo, con el objetivo final de permitir la toma de una decisión informada y compartida, en línea con el bienestar de los pacientes.

The use of implantable cardioverter-defibrillators (ICDs) has been on the rise. Patients using ICDs inevitably transit towards the end of life at some point, including some who develop terminal illnesses. In this context, it is relevant to discuss and evaluate the deactivation of these devices with the aim of addressing patients' comfort and avoiding shocks during the end-of-life phase. There are multiple communicational and operational barriers when considering ICDs deactivation. Firstly, many patients have not discussed this issue with their physicians despite international guidelines recommending such discussions before device installation. Secondly, there is a significant lack of knowledge among patients, family members, and even doctors about the benefits of ICDs, as well as the deactivation process and ethics considerations, which leads them to believe that immediate death will occur, considering it as euthanasia or assisted suicide. Finally, the management of hospice patients or end-of-life ICDs users is poorly standardized, with low rates of deactivation, resulting in shocks in the last minutes of life, which can cause marked distress to patients and families. It is necessary to address these barriers and discuss these issues with patients to inform and educate them about the functioning of their devices, with the ultimate goal of enabling informed and shared decision-making for patient well-being.

Use of subcutaneous cardioverter-defibrillator. First cases reported from National Institute of Cardiology Ignacio Chávez-Mexico.

INTRODUCTION: The transvenous implantable cardioverter defibrillator (ICD) is the treatment of choice for the prevention of sudden cardiac death (SCD). Its use could be restricted when device-related infections occurs or in the pediatric population. In the later, an ICD represents a challenge, due to the minimal dimensions of the venous system in children, the length of the electrodes, the size of the generator, as well as the anatomical complexity in cases with associated congenital heart disease. OBJECTIVE: This article presents the first Mexican patients with a subcutaneous ICD (SC-ICD) implant as a therapy for the prevention of SCD. METHODS: The first four cases were implanted at the Ignacio Chávez National Institute of Cardiology with a SC-ICD (Emblem, Boston Scientific, USA), three of them were pediatric patients, including the first implant of this type of device in a pediatric patient in Latin America. The 3-incision and 2-incision techniques were used under general anesthesia. RESULTS: A successful implantation was obtained with the 3-incision technique in the first 2 cases and the last 2 with the 2-incision technique. Proper functioning of the device was corroborated in the operating room with proof of appropriate therapy (65 J) for ventricular fibrillation induced with 50 Hz stimulation. No immediate complications were observed. One patient had appropriate shocks two months after the implant. During follow-up, one child developed skin erosion at the level of the curve of the electrode on the sternum, with no signs of infection. In the operating room, the damaged skin was resected, the barrel and the fixation silk were removed, surgical lavage was performed, and the skin was closed again, thus avoiding removal of the system. CONCLUSIONS: The SC-ICD is an alternative therapy to the transvenous ICD. It can be considered first choice in subjects who do not require ventricular pacing, including pediatric patients. Skin complications can occur but do not pose a threat as venous complications of conventional ICDs.

INTRODUCCIÓN: El desfibrilador automático implantable (DAI) transvenoso es el tratamiento de elección para la prevención de muerte súbita (MS) cardiaca por arritmias ventriculares malignas. Su uso se puede ver limitado cuando existe infección del sistema de estimulación o en población pediátrica donde representa un reto por diversas razones, incluyendo: las mínimas dimensiones del sistema venoso de los niños, la longitud de los electrodos, el tamaño del generador, así como por la complejidad anatómica en casos de cardiopatía congénita asociada. OBJETIVO: El presente artículo tiene por objetivo presentar la primera serie de casos de pacientes mexicanos a los cuales se les implantó un DAI subcutáneo (DAI-SC) como terapia para la prevención de MS. MÉTODOS: Se presentan los cuatro primeros casos que fueron implantados en el Instituto Nacional de Cardiología Ignacio Chávez con un DAI-SC (Emblem, Boston Scientific, EE.UU.), tres de ellos eran pacientes pediátricos, incluyendo el primer implante de este tipo de dispositivo en un paciente pediátrico en América Latina. Las técnicas de tres y dos incisiones fueron empleadas bajo anestesia general. RESULTADOS: Se realizó el implante exitoso con técnica de tres incisiones en los dos primeros casos y con técnica de dos incisiones en los dos últimos casos. Se corroboró el adecuado funcionamiento del dispositivo en sala, con la verificación de terapia apropiada (65 J) de la fibrilación ventricular inducida mediante estimulación a 50 Hz. No hubo complicaciones inmediatas. Un paciente presentó descargas apropiadas a los dos meses del implante. En el seguimiento, un niño desarrolló erosión de la piel a nivel de la curva del electrodo en el esternón, sin datos de infección. En quirófano se resecó la piel dañada, se retiró el barril y la seda de fijación, se realizó lavado quirúrgico y se volvió a cerrar la piel, logrando así evitar el retiro del sistema. CONCLUSIONES: El DAI-SC es una terapia alternativa al DAI endovenoso y puede ser considerado de primera elección en aquellos casos que no requieran de estimulación ventricular, incluyendo pacientes pediátricos. Pueden ocurrir complicaciones cutáneas, pero no representan una amenaza como las complicaciones venosas de los DAI convencionales.

Pacemaker Reuse in Portuguese Speaking Countries: A Clinical Reflection. / Reprocessamento de Marca-Passos em Países de Língua Portuguesa: Uma Reflexão Clínica.

There is a gap between high-income countries and others in terms of access to medical cardiac devices, such as pacemakers and implantable cardioverter defibrillators. Costs are one of the main barriers to the use of cardiac devices in these countries. There are international initiatives that aim to reduce the gap. The reuse of pacemakers has been discussed as a possible alternative to this problem. The concept of reusing pacemakers is not new; however, recent studies have proven to be safe, ethical, and effective for those who need cardiac implantable electronic devices and cannot afford them. Part of the Portuguese-speaking countries, especially in Africa, need an immediate response that benefits their countless patients who suffer from treatable arrhythmias.

Há uma enorme disparidade entre os países de alta renda e outros em termos de acesso a dispositivos médicos cardíacos, como marca-passos e desfibriladores implantáveis. Os custos são uma das principais barreiras ao uso de dispositivos cardíacos nesses países. Existem iniciativas internacionais que visam reduzir essa disparidade, e o reuso de marca-passos tem sido discutido como uma possível alternativa. O conceito de reutilização de marca-passos não é novo; entretanto, estudos recentes têm se mostrado seguros, éticos e eficazes para aqueles que precisam de dispositivos eletrônicos cardíacos implantáveis e não tem como adquiri-los. Parte dos países de língua portuguesa, especialmente na África, precisam de uma resposta imediata que beneficie seus inúmeros pacientes que sofrem de arritmias tratáveis.

Assisted reality device to guide cardiac implantable device programming in distant rural areas.

BACKGROUND: Patients with cardiac implantable electronic devices (CIEDs) living in rural areas have difficulty obtaining follow-up visits for device interrogation and programming in specialized healthcare facilities. OBJECTIVE: To describe the use of an assisted reality device designed to provide front-line workers with real-time online support from a remotely located specialist (Realwear HTM-1; Realwear) during CIED assistance in distant rural areas. METHODS: This is a prospective study of patients requiring CIED interrogation using the Realwear HMT-1 in a remote rural population in Colombia between April 2021 and June 2022. CIED interrogation and device programming were performed by a general practitioner and guided by a cardiac electrophysiologist. Non-CIED-related medical interventions were allowed and analyzed. The primary objective was to determine the incidence of clinically significant CIED alerts. Secondary objectives were the changes medical interventions used to treat the events found in the device interrogations regarding non-CIED related conditions. RESULTS: A total of 205 CIED interrogations were performed on 139 patients (age 69 ± 14 years; 54% female). Clinically significant CIED alerts were reported in 42% of CIED interrogations, consisting of the detection of significant arrhythmias (35%), lead malfunction (3%), and device in elective replacement interval (3.9%). Oral anticoagulation was initiated in 8% of patients and general medical/cardiac interventions unrelated to the CIED were performed in 52% of CIED encounters. CONCLUSION: Remote assistance using a commercially available assisted reality device has the potential to provide specialized healthcare to patients in difficult-to-reach areas, overcoming current difficulties associated with RM, including the inability to change device programming. Additionally, these interactions provided care beyond CIED-related interventions, thus delivering significant social and clinical impact to remote rural populations.

Inter-American Society of Cardiology (CIFACAH-ELECTROSIAC) and Latin-American Heart Rhythm Society (LAHRS): multidisciplinary review on the appropriate use of implantable cardiodefibrillator in heart failure with reduced ejection fraction.

BACKGROUND: Our main objective was to present a multidisciplinary review on the epidemiology of sudden cardiac death (SCD) and the tools that could be used to identify malignant ventricular arrhythmias (VAs) and to perform risk stratification. In addition, indications and contraindications for the use of implantable cardioverter defibrillator (ICD) in general and in special populations including the elderly and patients with chronic kidney disease (CKD) are also given. METHODS: An expert group from the Inter American Society of Cardiology (IASC), through their HF Council (CIFACAH) and Electrocardiology Council (ElectroSIAC), together with the Latin American Heart Rhythm Society (LAHRS), reviewed and discussed the literature regarding the appropriate use of an ICD in people with heart failure (HF) with reduced ejection fraction (HFpEF). Indications and contraindications for the use of ICD are presented in this multidisciplinary review. RESULTS: Numerous clinical studies have demonstrated the usefulness of ICD in both primary and secondary prevention of SCD in HFpEF. There are currently precise indications and contraindications for the use of these devices. CONCLUSIONS: In some Latin American countries, a low rate of implantation is correlated with low incomes, but this is not the case for all Latin America. Determinants of the low rates of ICD implantation in many Latin American countries are still a matter of research. VA remains one of the most common causes of cardiovascular death associated with HFrEF and different tools are available for stratifying the risk of SCD in this population.

The Emerging Role of FDG PET/CT in Diagnosing Endocarditis and Cardiac Device Infection.

Infective endocarditis and cardiac implantable electronic device infection (CIEDI) have witnessed an increasing incidence in clinical practice and associated with increasing health care expenditure. Expanding indications of CIED in various cardiovascular conditions have also contributed to the surge of these infections. Early diagnosis of these infections is associated with a favorable prognosis. Given the lack of a single definitive diagnostic method and the limitations of echocardiography, which is considered a central diagnostic imaging modality, additional imaging modalities are required. Recent studies have highlighted the diagnostic utility of FDG PET and CT. In this review article, we discuss the existing limitations of echocardiography, acquisition protocols of PET/CT, and indications of these advanced imaging modalities in infective endocarditis and CIEDI diagnosis.