Pacemaker lead endocarditis: A rare cause of relapsing brucellosis.

Implantable cardioverter-defibrillator endocarditis is a rare and potentially life threatening complication of brucellosis of difficult management for clinicians. We report an unusual case of pacemaker-related endocarditis due to Brucella melitensis in a patient with previous history of neurobrucellosis. Our patient was admitted to a hospital with severe swelling of his pacemaker pocket implanted 8 years earlier for sick sinus syndrome. Although pocket site cultures were positive for Brucella but blood cultures were not and serologic titer by the Rose Bengal test was positive. Transesophageal echocardiography showed two vegetations on the pacemaker leads. The patient was treated with doxycycline, rifampin and gentamicin with full recovery and the entire pacemaker apparatus was surgically explanted. Interestingly, two year prior this admission, the patient presented with meningoencephalitis diagnosed with neurobrucellosis proven by positive growth of Brucella mellitensis from the CSF. The patient was treated with doxycycline, rifampin and gentamicin with full recovery and the pacemaker had been removed. Reports of Brucella infection of prosthetic implants and devices have increased over the past decade. Consequently, potential relapsing of the disease and occupational exposure to Brucella should be considered in the differential diagnosis and management of cardiac device infection.

Safety, efficacy, and clinical applicability of pulmonary vein isolation with circular multi-electrode ablation systems: PVAC® vs. nMARQ™ for atrial fibrillation ablation.

AIMS: We compare our experience with available circular multi-electrode catheters for atrial fibrillation (AF) ablation: PVAC(®), a phased radiofrequency system, and nMARQ™, an irrigated tip-CARTO-based technology. METHODS AND RESULTS: Prospective observational study of 175 consecutive patients with follow-up duration of at least 5 months who underwent pulmonary vein isolation (PVI) for symptomatic AF using PVAC(®) (n = 93, age 61.4 ± 9.8 years; 60% male, 13% persistent AF) vs. nMARQ™ (n = 82, age 63.2 ± 10.6 years; 67% male, 24% persistent AF). Procedure and radiation times were 94 ± 27 and 33 ± 13 min for PVAC(®) and 81 ± 18 and 30 ± 8.5 for nMARQ™ (P = 0.0008 and P = 0.18), respectively. The number of applications and the total burning time (min) were 20 ± 7 and 19 ± 6.7 for PVAC(®) and 16 ± 5.6 and 11 ± 4 for nMARQ™ (P < 0.0001 for both), respectively. In two nMARQ™ patients with small atria and pulmonary veins (PVs) and in two PVAC(®) patients with large PVs, the procedure failed; switching to the alternative technology was successful. Acute success rate was 97% for PVAC(®) and 95% for nMARQ™. There was one tamponade in nMARQ™ group and non-significant different minor complications for both techniques. One-year freedom from AF was 79 and 80.7% with PVAC(®) vs. nMARQ™, after one PVI, and 88 vs. 87.7% after two PVIs. CONCLUSION: Both technologies have short procedure and fluoroscopy times, comparable complication rates, and comparable acute and 1-year success rates. The number of applications and total procedure and burning times were shorter with nMARQ™. nMARQ™ was more suitable for larger atria and PVs. Thus, a patient-based pre-ablation anatomy definition is probably warranted for appropriate selection of technology type.

Safety and Feasibility of Contrast Injection During Pulmonary Vein Isolation with the nMARQ™ Multi-Electrode Catheter.

INTRODUCTION: Pulmonary vein isolation (PVI) using the irrigated multi-electrode ablation system (nMARQ™) remains challenging in complex atrial anatomy cases and when CARTOMERGE™ technology is not available, due to absence of a leading guide-wire. OBJECTIVES: Our objective was to assess feasibility and safety of PVI using nMARQ™ catheter with intra-procedural contrast injections through the deflectable sheath compared to nMARQ™ alone. METHODS: This is a prospective non-randomized observational study of 78 consecutive patients who underwent PVI only with nMARQ™. The first group (n=37, 64±10.5 years, 62% male, 13.5% persistent AF) underwent the procedure with the guidance of signal mapping, fluoroscopy, and electro-anatomical mapping (EAM) alone. Since 12/2013 an automatic closed-loop contrast media injector was added to improve catheter location (n=41, 62.5±11 years, 71% male, 34% persistent AF). RESULTS: Total procedure time was 78±19 and 85.5±18.5 minutes, and mean fluoroscopy time was 30±9 and 29.5±8.7 minutes for the first and second groups, respectively (NS); acute success rate was 97% and 97.5%, with a mean of 14.7±5 and 17.6±5.4 RF applications, respectively (p=0.02); and mean total burning time of 10.3±3.6 and 12±4 minutes, respectively (p=0.08). Mean contrast used was 60±18 mL versus 203±65 mL, with no effect on renal function or major complications. One year freedom from AF was 77% and 83%, respectively (p=0.5). CONCLUSIONS: Addition of contrast injections to standard nMARQ™ procedure is feasible and safe. It has no benefit in routine use but further studies may confirm its potential added value to EAM in catheter localization by newly trained operators and in selective cases of large/common PV anatomy.

Snapshot of adult invasive cardiac electrophysiology in Canada: results of the web-based registry.

PURPOSE: Interventional cardiac electrophysiology (EP) has experienced a significant growth in Canada. Our aim is to establish a periodic registry as a nationwide initiative. METHODS: The registry is designed to collect information regarding EP laboratory infrastructure, human resources, and the spectrum and volumes of EP procedures. Respective administrative staff were contacted electronically. RESULTS: Out of 25 identified Canadian EP centers, 19 centers (76%) have participated in the registry. Responding centers have access on average to 5.3 lab days per week to perform EP studies/ablations; average lab time per full- and part-time (prorated to 0.5) EP physician is 0.8 day per week. Diagnostic EP studies and radio-frequency ablations are performed in all (19) centers; cryoablation is available in 83% of centers. Two centers have remote magnetic navigation systems. EnSite NavX is the most widely available 3D mapping system utilized in 15 (83%) centers, followed by CARTO and intracardiac echo which are each available in 14 (78%) centers; LocaLisa is actively used in one center. The number of full-time physicians ranges between 0 and 7, with a mean of 3.5 full-time physicians per center. The ratio of staff to trainees is 1.6:1. A total of 8,041 EP procedures are performed in the 19 centers per annum. On an annual average, 104 procedures per one operator and 159 procedures per trainee are performed. CONCLUSIONS: This registry provides contemporary information on invasive EP lab resources and procedures in Canada. It also demonstrates that Canadian EP procedural intensities of practice and training are comparable to international standards.