Financial impact of adopting implantable loop recorder diagnostic for unexplained syncope compared with conventional diagnostic pathway in Portugal.

BACKGROUND: To estimate the short- and long-term financial impact of early referral for implantable loop recorder diagnostic (ILR) versus conventional diagnostic pathway (CDP) in the management of unexplained syncope (US) in the Portuguese National Health Service (PNHS). METHODS: A Markov model was developed to estimate the expected number of hospital admissions due to US and its respective financial impact in patients implanted with ILR versus CDP. The average cost of a syncope episode admission was estimated based on Portuguese cost data and landmark papers. The financial impact of ILR adoption was estimated for a total of 197 patients with US, based on the number of syncope admissions per year in the PNHS. Sensitivity analysis was performed to take into account the effect of uncertainty in the input parameters (hazard ratio of death; number of syncope events per year; probabilities and unit costs of each diagnostic test; probability of trauma and yield of diagnosis) over three-year and lifetime horizons. RESULTS: The average cost of a syncope event was estimated to be between 1,760€ and 2,800€. Over a lifetime horizon, the total discounted costs of hospital admissions and syncope diagnosis for the entire cohort were 23% lower amongst patients in the ILR group compared with the CDP group (1,204,621€ for ILR, versus 1,571,332€ for CDP). CONCLUSION: The utilization of ILR leads to an earlier diagnosis and lower number of syncope hospital admissions and investigations, thus allowing significant cost offsets in the Portuguese setting. The result is robust to changes in the input parameter values, and cost savings become more pronounced over time.

Late right ventricular perforation: a rare complication of a pacemaker implantation.

Right ventricular perforation by a pacemaker lead is a rare complication of pacemaker implantation, with an incidence inferior to 1%. It usually occurs at the time of lead insertion or during the first 24 hours after the procedure (acute perforation).Late right ventricular perforation, defined as occurring at least 1 month after lead implantation, is even rarer. The clinical presentation varies widely and is mainly related to the stimulation of extracardiac structures and/or lead dysfunction.Its diagnosis may be difficult and must be complemented by appropriate imaging methods. The optimal management strategy remains controversial, varying from surgery to more conservative treatments. The authors present a case of late right ventricular myocardium lead perforation occurring in a 56-year-old-male patient, approached with open surgery.

Ventricular lead dysfunction and subclavian vein stenosis: when problems come in pairs.

The widespread and increasing use of cardiac devices implantation naturally augments the number of device related complications. Lead failure is a known complication associated with increased morbidity, mortality and need for reintervention.Chronic stenosis or occlusions of coronary, cephalic or subclavian veins, especially at the site of previous device implantation,can limit lead passage through the target vein, imposing great technical difficulties, especially in patients needing follow-up procedures such as lead revisions and/or system upgrades. Venous balloon angioplasty can be a valuable and safe tool for successful implantation, helping to avoid more complex and hazardous procedures. The authors report the case of a 65 years old male presenting with a "Sprint Fidelis" defibrillator lead malfunction and severe asymptomatic left subclavian vein stenosis after cardiac resynchronization defibrillator therapy. The patient was submitted to a successful percutaneous balloon venoplasty in order to regain adequate venous access and enable reimplantation of the right ventricular lead.

[Ventricular cardiac resynchronization--initial surgical experience]. / Ressincronização cardíaca ventricular--experiência cirúrgica inicial.

Cardiac resynchronization therapy (CRT) is a recent method for patients with myocardial failure resulting from systolic malfunction. CTR is achieved by simultaneous stimulation of both ventricles which resynchronizes the time of depolarization of the left ventricle and improves myocardial contractility, diminishing mitral regurgitation. Usually the TCR is applied percutaneously/transvenously but in some cases it is impossible to use such techniques due to several reasons. The authors of this article suggest the minithoracotomy as an alternative approach of the left ventricle for implantation of the epicardic electrode. This technique has proven to be simple and safe, allowing short implantation times in comparison with the traditional technique, as well as a better choice of the site of electrode implantation.