Improved 'cut-down' technique for transvenous pacemaker lead implantation.

AIMS: We improved the cut-down approach aiming at minimizing the subclavian/axillary vein puncture during implantation of permanent pacemaker leads. METHODS AND RESULTS: We incorporated previously reported refinements of the cut-down approach, i.e. the use of a hydrophilic guidewire when direct lead insertion failed and cannulation of retro-pectoral veins in cases of insufficient calliper of the cephalic vein. In addition, we introduced two further techniques, namely the simultaneous use of two guidewires and the use of stiff angiography guidewires. The efficacy of this integrated 'no-puncture' strategy was assessed in the first consecutive 200 patients and was compared with the 'standard' approach in an equal number of consecutive preceding implantations. Puncture was required more often (P < 0.0001) in the 'standard'-approach group (40/200; 20.0%). The 'no-puncture' policy was successful in 192/200 (96%) of implantations over a course of 40 months with absence of major complications. This was due to more frequent (P < 0.0001) use of hydrophilic guidewires (49.0% vs. 9.5% of cases), as well as due to cannulation of retro-pectoral veins (3.5%), use of a second guidewire (16.0%) and use of stiff guidewires (7.0%). CONCLUSION: The improved cut-down approach obviates subclavian/axillary puncture in the vast majority of cases and improves the safety of pacemaker implantation.

Outcome of patients with haemodynamically stable ventricular tachycardia treated with an implantable cardioverter-defibrillator.

INTRODUCTION: The benefit of implantable cardioverter defibrillator (ICD) therapy in patients with haemodynamically stable ventricular tachycardia (VT) is not well documented. METHODS: In this single-centre observational study, we examined the medical records of 53 patients (48 men, mean age 66 +/- 1 years) treated with an ICD. The patients were classified into four groups with comparable clinical and electrophysiological characteristics, as follows: patients presenting with (a) stable VT, (b) unstable VT, (c) cardiac arrest, and (d) non-sustained VT and induced sustained VT or ventricular fibrillation (VF) on electrophysiological study. Kaplan-Meier event-free survival curves were constructed and the incidence of appropriate device therapy was compared among the four groups. RESULTS: All patients had structural heart disease with a mean ejection fraction of 32.5 +/- 1.3%. During a mean follow-up period of 35.5 +/- 2.7 months, event-free survival was similar in the four groups. However, appropriate device therapy occurred in 9 (81.8%) patients with stable VT, in 6 (44.4%) patients with unstable VT, in 2 (33.3%) patients with cardiac arrest and in 6 (33.3%) patients with non-sustained VT and induced sustained VT/VF. Compared to the total patient cohort, appropriate therapy was significantly (p = 0.024) more common in patients presenting with stable monomorphic VT. In 2 (22.2%) of these patients, the tachycardia rate was faster than the presenting VT. CONCLUSIONS: High recurrence rates are observed in patients with structural heart disease and stable VT, with a considerable proportion being faster than the presenting VT. ICD therapy is beneficial and should be offered in these patients.

A prospective randomized trial comparing the safety and efficacy of three commercially available closure devices (Angioseal, Vasoseal and Duett).

PURPOSE: We compared the safety and efficacy of three closure devices (Angioseal, Vasoseal and Duett) used to close arterial puncture sites in patients who underwent coronary percutaneous procedures. METHODS: A prospective randomized, single-center trial was carried out of consecutive patients who underwent coronary angiography [705 patients: Angioseal (243),Vasoseal (228) and Duett (234)] or angioplasty [146 patients:Angioseal (47), Vasoseal (52) and Duett (47)]. RESULTS: In the angiography patients the device deployment rates were similar, with the Angioseal been significantly slower in achieving hemostasis (p = 0.0001) but resulting in earlier ambulation (p = 0.0001). In the coronary angioplasty patients the deployment rates were similar to those for angiography: time to hemostasis was longer for the Angioseal (p = 0.003), while ambulation times were not different, although prolonged compared with angiography (p = 0.0001). The three devices had similar major complication rates. The Vasoseal had a higher major complication rate after angioplasty than after angiography (p = 0.004). The incidence rate of peripheral embolization was lower when the Angioseal was utilized. Severe complications were mainly seen in patients who received abciximab. CONCLUSIONS: The three closure devices had high rates of successful deployment and were relatively safe. The Angioseal resulted in earlier ambulation after angiography. Utilization of closure devices after abciximab administration possibly increased the complications.