Pacemaker implantation in patients with major depression, should it be of concern? A case report and literature review.

BACKGROUND: Psychological adaptation after cardiac pacemaker implantation is a challenge for patients with mental illness. CASE PRESENTATION: Here we report a self-harming patient with a psychiatric disorder. A 73-year-old female patient with 16-year coronary heart disease and a 4-year depression was admitted to our hospital for a coma. Two months earlier, the local hospital confirmed that the patient had a second-degree sinoatrial (SA) block (type 2) as well as basal septal hypertrophy with the left ventricular outflow obstruction. Therefore, metoprolol sustained-release tablets 95 mg QD and diltiazem sustained-release tablets 90 mg QD was given as treatment after a pacemaker was implanted. However, the patient had continued complaining about discomfort due to the pacemaker implanted after being discharged from the hospital. Two months later, she attempted to commit suicide by removing her pacemaker and taking 80 sleeping pills. After a series of treatments, the patient improved and was discharged without a pacemaker re-implantation. With continued anti-depression treatment and strengthen family supervision, the patient's condition is stable now. CONCLUSIONS: A suicide attempt by intentionally removing the permanent pacemaker system was rarely reported. In bradycardia patients with a history of psychological or psychiatric disease, careful evaluation should be done before and after implantation of the pacemaker.

Cognitive behavioral intervention improves quality of life and perceived illness acceptance in patients after cardiac electrotherapy devices implantation. / Interwencja poznawczo-behawioralna poprawia jakosc zycia oraz akceptacje choroby wsród pacjentów po implantacji urzadzen do elektroterapii serca.

OBJECTIVES: This study is an attempt to provide an analysis of the influence of implementation of cognitive behavioral intervention (CBI) in patients after cardiovascular implantable electronic device (CIED) implantation on the quality of life following the procedure as well as the level of illness acceptance. METHODS: The study group consisted of patients who underwent standard medical care related to CIED implantation and who additionally received CBI. Patients who received only standard medical care related to CIED implantation constituted a control group. CBI consisted of four sessions conducted over 30 (±3) days after the implantation. Demographic, clinicaland psychological factors were assessed.The Acceptance of Illness Scale (AIS) and EuroQol-5D (EQ-5D) were applied. RESULTS: In total, 128 patients (women: 36.7%, mean age 64.5 ± 8.9) were included in the study. The proposed cycle of four structured CBI meetings was well accepted by the patients, which is confirmed by their high turnout for these meetings. After six months, quality of life indices were significantly improved in cardiac electrotherapy recipients assigned to CBI, including: Visual Analogue Scale EQ-5D (80.2 ± 11.8 vs. 64.9 ± 14.3; p < 0.0001) and better acceptance of illness (AIS: 35.6 ± 4.3 vs. 28.7 ± 6.1; p < 0.0001). CONCLUSIONS: Implementation of CBI in patients after CIED implantation significantly improved indices of quality of life as well as illness acceptance, when compared to the control group of patients in standard care following electrotherapy. CBI showed multiple benefits in this population, as well as ensures the fulfilment of its expected therapeutic effect, while short duration of the intervention did not prolong the hospitalization itself.

Examination of the differential impacts of antitachycardia pacing vs. shock on patient activity in the EMPIRIC study.

AIMS: Implantable cardioverter defibrillators (ICDs) have demonstrated mortality advantages over antiarrhythmic drug therapy, but ICD shock has known detrimental effects on quality of life and psychologic functioning. However, it remains unknown how patient activity level is affected by shock, or by antitachycardia pacing (ATP), which was developed to reduce the treatment burden of shocks. Examine the differential impact of ICD shock and ATP on patient activity level as a novel way to capture the relative behavioural repercussions of these ICD therapies. METHODS AND RESULTS: Accelerometer-derived activity data were analysed for a subset of patients (males = 83%; mean age = 62 years) enrolled in the EMPIRIC trial who received shock (n = 71) or ATP (n = 103). Differences in activity between a week pre-therapy and a week post-therapy were examined to assess the behavioural repercussions of shock vs. ATP when one, few (2-4), or many (5+) therapies were delivered. For patients receiving shock, a significant reduction in activity was observed for few (-26%) and many shocks (-34%) in the first week post-therapy (P < 0.05). In weeks 2-4, activity levels recovered towards baseline levels. In contrast, no level of ATP-only therapy significantly reduced patients' activity levels at any time following therapy. CONCLUSION: This study is the first to evaluate objective, behavioural effects of shock, and whether these effects are comparable with ATP therapy alone. In tandem with existing literature, current results highlight that ICD shocks and ATP have divergent effects on behavioural outcomes, with ATP's effect profile in these domains appearing somewhat favourable.

Evaluation of patients' quality of life aspects after cardiac pacemaker implantation.

OBJECTIVE: To evaluate patients' quality of life aspects after pacemaker implantation, relating it to gender, age, and implantation timespan. METHODS: A total of 107 clinically stable patients of both genders (49.5% women and 50.5% men) over 18 years old (average 69.3±12.6 years) and presenting an implantation timespan of three to 12 months (average 6.36±2.99 months) were evaluated. The evaluation included personal, clinical, and implant data as well as quality of life questionnaires (AQUAREL and SF-36). Statistical analysis was conducted using the t test and Pearson correlation, with a 5% significance level. RESULTS: The lowest SF-36 score referred to physical aspects, and the highest score referred to social aspects. In AQUAREL, the lowest score referred to dyspnea, and the highest referred to discomfort. There was a significant association between gender and quality of life in SF-36 (physical functioning and emotional aspects) and in AQUAREL (dyspnea). A negative correlation was observed between age and quality of life (functional capacity in SF-36, and discomfort in AQUAREL) in relation to implantation timespan, a correlation with vitality from SF-36. CONCLUSION: Lower quality of life scores were found in physical aspects and dyspnea; and higher scores in social aspects and discomfort. Men presented higher quality of life scores related to physical functioning, emotional aspects and dyspnea. As age increases, quality of life worsens regarding functional capacity and discomfort; and the longer the pacemaker implantation timespan, the worse quality of life when it comes to vitality. Gender, age, and implantation timespan influence quality of life; thus, these variables must be considered in strategies for improving quality of life of patients with pacemakers.

Avaliação de aspectos da qualidade de vida em pacientes pós-implante de marca-passo cardíaco / Evaluation of patients' quality of life aspects after cardiac pacemaker implantation

Objetivo: Avaliar aspectos da qualidade de vida em pacientes pós-implante de marca-passo e relacionar com gênero, idade e tempo de implante. Métodos: Foram estudados 107 indivíduos de ambos os gêneros (49,5% do sexo feminino e 50,5% do sexo masculino), tempo de implante três a 12 meses (média de 6,36±2,99 meses), estáveis clinicamente com idade acima de 18 anos (média de 69,3±12,6 anos). A avaliação constou de: dados pessoais, clínicos, do implante e questionários de qualidade de vida (AQUAREL e SF-36). Análise estatística empregou teste t e correlação de Pearson, com significância de 5%. Resultados: No SF-36, o menor escore ocorreu no domínio aspectos físicos e o maior, em aspectos sociais. No AQUAREL, o menor escore foi em dispneia e o maior em desconforto. Verificou-se associação significante entre gênero e qualidade de vida no SF-36 (capacidade funcional e aspectos emocionais) e no AQUAREL (dispneia). Observaram-se correlações negativas entre idade e qualidade de vida (capacidade funcional do SF-36 e em desconforto do AQUAREL) em relação ao tempo de implante, correlação com vitalidade do SF-36. Conclusão: Menores escores de qualidade de vida foram encontrados em aspectos físicos e dispneia; maiores em aspectos sociais e desconforto. Homens apresentaram maiores escores de qualidade de vida em capacidade funcional, aspectos emocionais e dispneia. Conforme aumenta a idade, pior é a qualidade de vida em capacidade funcional e desconforto, e, quanto maior o tempo de implante de marca-passo, pior a qualidade de vida em vitalidade. Gênero, idade e tempo de implante influenciam na qualidade de vida, dessa forma, essas variáveis devem ser consideradas nas estratégias para melhora da qualidade de vida em portadores de marca-passo. .

Objective: To evaluate patients' quality of life aspects after pacemaker implantation, relating it to gender, age, and implantation timespan. Methods: A total of 107 clinically stable patients of both genders (49.5% women and 50.5% men) over 18 years old (average 69.3±12.6 years) and presenting an implantation timespan of three to 12 months (average 6.36±2.99 months) were evaluated. The evaluation included personal, clinical, and implant data as well as quality of life questionnaires (AQUAREL and SF-36). Statistical analysis was conducted using the t test and Pearson correlation, with a 5% significance level. Results: The lowest SF-36 score referred to physical aspects, and the highest score referred to social aspects. In AQUAREL, the lowest score referred to dyspnea, and the highest referred to discomfort. There was a significant association between gender and quality of life in SF-36 (physical functioning and emotional aspects) and in AQUAREL (dyspnea). A negative correlation was observed between age and quality of life (functional capacity in SF-36, and discomfort in AQUAREL) in relation to implantation timespan, a correlation with vitality from SF-36. Conclusion: Lower quality of life scores were found in physical aspects and dyspnea; and higher scores in social aspects and discomfort. Men presented higher quality of life scores related to physical functioning, emotional aspects and dyspnea. As age increases, quality of life worsens regarding functional capacity and discomfort; and the longer the pacemaker implantation timespan, the worse quality of life when it comes to vitality. Gender, age, and implantation timespan influence quality of life; thus, these variables must be considered in strategies for improving quality of life of patients with pacemakers. .

Quality of life and functional capacity after long-term right ventricular pacing in pediatrics and young adults with congenital atrioventricular block.

BACKGROUND: Although several studies have demonstrated deleterious consequences of chronic right ventricular (RV) pacing on ventricular function and synchronicity, its effects on health-related quality of life (HRQoL) and functional exercise capacity remain uncertain. We aimed to evaluate the effect of RV pacing on HRQoL and functional capacity of children and young adults with congenital complete atrioventricular block (CCAVB). METHODS: We included 66 consecutive subjects with RV cardiac pacemaker due to CCAVB and under clinical follow-up for more than 1 year. Multidimensional HRQoL scores were evaluated by Short Form-36 Health Survey (SF-36) and Child Health Questionnaire-Parent Form 50 (CHQ-PF50). Functional capacity was tested by a 6-minute walk distance test (6MWDT). Association analysis was performed to examine if any demographic and clinical characteristics were associated with lower HRQoL scores and shorter distances at the 6MWDT. RESULTS: Domains presenting lower HRQoL scores were vitality (64.0 ± 17.3), mental health (67.3 ± 8.0), role emotional (69.7 ± 35.8) in the SF-36 questionnaire; general health perceptions (61.3 ± 8.3), general behavior (61.9 ± 15.6), parental impact-emotional (67.7 ± 28.7) in the CHQ-PF50. Female gender (P = 0.009), left ventricular ejection fraction lower than 55% (P = 0.013), cardiovascular drugs (P = 0.003) were significantly associated with lower HRQoL scores. Average distance traveled during the 6MWDT was 539.8 ± 82.9 m. The 6MWDT showed significant association with age (P = 0.006) and cardiovascular drugs (P = 0.024). CONCLUSIONS: Chronic RV pacing did not affect the HRQoL and physical capacity of pediatrics and young subjects. Female gender, ventricular function, and cardiovascular drugs were associated with lower HRQoL scores. Older subjects walked shorter distances in the 6MWDT, as well as subjects who were taking cardiovascular drugs.

[Change of quality of life and NYHA class in patients with advanced heart failure and permanent atrial fibrillation after 12-months period from upgrade of pacing system]. / Zmiana jakosci zycia oraz klasyfikacji NYHA u chorych z zaawansowana niewydolnoscia serca i utrwalonym migotaniem przedsionków po 12 miesiacach od rozbudowy systemu stymulacji.

UNLABELLED: There is no research on the change of quality of life and NYHA classification after pacing system upgrade performed as a treatment of advanced heart failure during a long observation period in a particular population of patients with long-term apical right ventricular pacing, permanent atrial fibrillation and complete atrio-ventricular block. The aim of the study was evaluation of changes in quality of life and NYHA class in group of patients in which upgrade from right ventricular apical pacing to biventricular or bifocal right ventricular pacing was done. MATERIAL AND METHODS: Evaluation of quality of life was performed in a chosen group of 27 patients (20 males, mean age 71.2) who completed the 12-month observation period. Quality of life was assessed by the Short Form-36 (SF-36) questionnaire. The first examination was carried out before the planned pacing system upgrade, that is, when advanced heart failure appeared in the course of permanent atrial fibrillation and right ventricular apical pacing present for a long time (on average 7.7 years). The change of quality of life after 12-month period of upgrade pacing system was analyzed. A comparison of patient's self assessment (as far as physical aspect of quality of life is concerned - Physical Component Summary - PCS) with doctor's interview concerning NYHA classification was performed. Additionally quality of life pointed out by a patient was analyzed in relation to the diseases most common in this population: hypertension, diabetes mellitus and renal failure. Because the questionnaires were completed by the patients personally without the third party, the assessment referred to mistakes in filling in the questionnaires (quantity of missed questions and incorrect marking the answers by adding individual comments) in relation to patients' age. RESULTS: In 12-month follow-up after pacing system upgrade, improvement of quality of life was found in 48.1% of patients. Assessment of physical aspect of quality of life was possible due to SF-36. Improvement occurred in 55.5% of patients, however in relation with NYHA classification improvement appeared in 51.8% of patients. Improvement in NYHA was in significant correlation with improvement in physical aspect of life (p = 0.025), especially in the subgroup treated by pacing system upgrade to bifocal right ventricular pacing (p = 0.0066). In the subgroup with improvement, hypertension and diabetes were less frequent, however frequency of renal failure was greater, than in the subgroup without quality of live improvement. Both before and after pacing system upgrade, there was no significant connection (only a trend) between the number of mistakes done during self-completion of the questionnaires and patients' age. CONCLUSIONS: In 12-month follow-up after pacing system upgrade, improvement of quality of life was found in 48.1% of patients. There exists a significant correlation between the improvement of physical efficiency in NYHA class and the improvement in physical aspect of quality of life in patients' self assessment (p = 0.025). In the subgroup treated by pacing system upgrade to bifocal right ventricular pacing this correlation is especially strong (p = 0.0066).

[Comorbid anxiety disorders and quality of life in patients with an artificial cardiac pacemaker].

AIM: To investigate correlations between anxiety disorders, quality of life (QoL) and patient's age, mode, duration and course of cardiac pacing (CP). MATERIAL AND METHODS: Examination covered 134 patients (75 females and 59 males) with artificial pacemaker (APM). It included psychological testing with Hospital Anxiety and Depression Scale (HADS), QoL study with questionnaire MOS-SF-36. RESULTS: APM implantation caused anxiety disorders in 80.6% patients, 51.5% had clinical symptoms of anxiety. An physiological and frequency-adaptive modes of PC, at the age under 50, in the absence of ECS complications frequency and severity of anxiety disorders are the lowest. Staged changes in the course of anxiety disorders were seen after primary APM implantation and in uncomplicated PC. APM implantation, irrespective of PC mode, significantly increased physical and mental parameters of QoL in patients under 50 years of age as well as mental health parameters in patients over 70. CONCLUSION: It is necessary to conduct psychological testing in APM patients and their psychic rehabilitation for improvement of QoL.

Health-related quality of life in patients with congenitally corrected transposition of the great arteries.

OBJECTIVE: The study's objectives were to survey the quality of life in patients with congenitally corrected transposition of the great arteries and to compare the responses of those who have undergone anatomic repair with those who have a systemic right ventricle. METHODS: Thirty-eight patients who underwent anatomic repair and 13 patients after either conventional repair or no surgical procedure were enrolled. Subjects completed the PedsQL 4.0 Generic and 3.0 Cardiac Modules. Scores were also compared with those of patients from the literature with at least moderately severe cardiovascular disease. Mean differences between groups were compared, and the association between clinical variables and score in the anatomic repair subgroup was measured. RESULTS: Caregivers of patients in the anatomic repair group reported similar scores compared with the non-anatomic repair group in all functional domains The anatomic repair group self-reported lower school function (63 vs 81, P = .02). On the Cardiac Module, patients in the anatomic repair group self-reported fewer problems related to residual heart disease (75 vs 63), appearance (81 vs 68), and treatment anxiety (74 vs 59), although the differences were not significant. Compared with patients with other heart disease, the anatomic repair group scored lower, with the largest differences in cognition and communication. Prolonged hospital stay and need for a pacemaker were associated with lower quality of life after anatomic repair. CONCLUSIONS: Patients in the anatomic repair group had similar quality of life compared with patients in the non-anatomic group, except in the domain of school functioning. Prolonged hospital stay and need for a pacemaker after anatomic repair may be risk factors for lower quality of life.

Changes in the mental and physical components of the quality of life for patients six months after pacemaker implantation.

BACKGROUND: The additional purpose for pacemaker implantation, beyond treating arrhythmias and conduction disturbances, is to improve the quality of life (QoL) of the patient. Most previous research has shown this purpose to have been achieved. However, the question as to whether all mental and physical components improve QoL to the same degree is still valid. The purpose of this study is to evaluate changes in the primary mental and physical areas of QoL in patients six months after they have had a pacemaker implanted. METHODS: Ninety eight patients with atrioventricular blocks (AVB) and 100 patients with sinus node dysfunction (SND) who were qualified for pacemaker implantation were included in this study. Every patient had a DDD(R)-type pacemaker with bipolar screw-in leads implanted. The ventricular lead was positioned in the right ventricular outflow tract. QoL was evaluated twice: three to five days before implantation and six months afterwards - the MLWHF questionnaire was used. RESULTS: A very high statistical improvement in QoL (p approximately 0,0000) - reduced number of points was found in all five areas of QoL in patients with SND and in four areas in patients with AVB. In the 'anxiety/depression area' in patients with AVB, the average number of points was higher (p = 0.3871), so QoL was worse. CONCLUSIONS: Implanting a pacemaker improves QoL in patients with AVB and SND. In patients with AVB, anxiety/depression is made more intense.

Quality of life and psychological well-being in patients with various pacing modes.

AIM: of the study was to assess the influence of different pacing modes on the quality of life (QOL), anxiety and depression. METHODS: QOL was assessed in 101 patients (58 men, mean age 69.39 +/- 14.64 years) with implanted pacemaker (35 patients received VVI pacemaker, 17 patients VVIR, 21 patients DDD, 28 patients DDDR). QOL was measured by the SF-36 and Aquarel questionnaires, anxiety by Beck scale and depression by Zung scale. RESULTS: No differences in QOL were observed between patients with single chamber and dual chamber pacing. Patients with rate-adaptive pacing had higher scores in SF 36 scales (physical component summary, mental component summary, vitality and bodily pain), Aquarel (chest pain and dyspnea) and they exhibited lower degree of anxiety and depression compared to non-rate-adaptive pacing. Differences were shown only in a group of dual chamber pacemakers, not in the group of single chamber pacemakers. There was a strong correlation between the degree of anxiety and depression and the QOL in pacemaker patients. CONCLUSION: Dual chamber rate-adaptive pacing offered better QOL and psychological profile compared to dual chamber non-rate-adaptive pacing. No differences were observed between single chamber and dual chamber pacing (Tab. 3, Fig. 3, Ref. 24).

Health status in patients treated with cardiac resynchronization therapy: modulating effects of personality.

BACKGROUND: Cardiac resynchronization therapy (CRT) is a promising treatment in chronic heart failure (CHF). However, a subgroup of patients still report impaired health status, cardiac symptoms, and feelings of disability following CRT. The aims of this study were to examine (1) whether CHF patients treated with CRT improved in patient-centered outcomes and functional capacity, and (2) whether personality traits exert a stable effect on these outcomes over two months. METHODS: Analyses are based on 31 patients (65% male; mean age 70 +/- 8) with CHF treated with CRT. Two weeks before and two months after CRT, patients completed the Type-D Scale (negative affectivity, i.e., tendency to experience negative emotions, and social inhibition, i.e., tendency to inhibit self-expression), the Minnesota Living with Heart Failure Questionnaire (disease-specific health status), and the Health Complaints Scale (cardiac symptoms and perceived disability), and performed the six-minute walking test (functional capacity). RESULTS: There was an improvement in disease-specific health status (P< 0.001), cardiac symptoms (P = 0.001), perceived disability (P< 0.001), and functional capacity (P = 0.007) in all patients over two months. However, high negative affectivity patients reported significantly lower disease-specific health status (P = 0.046), and more cardiac symptoms (P = 0.035), and perceived disability (P = 0.015) as compared to low negative affectivity patients. There was no significant main effect for negative affectivity on functional capacity. High negative affectivity patients still reported lower disease-specific health status (P = 0.06) and significantly more perceived disability (P = 0.04) when adjusting for left ventricular ejection fraction, gender, and age. The effects of negative affectivity on patient-centered outcomes, as measured by Cohen's effect size index, were moderate to large. CONCLUSIONS: Patient-centered outcomes improved over a two-month period in patients treated with CRT, but negative affectivity exerted a stable, negative effect on health status, cardiac symptoms, and perceived disability. Personality traits should be taken into account when evaluating effects of CRT.

Representações, mitos e comportamentos do paciente submetido ao implante de marcapasso na doença de Chagas / Representations, myths, and behaviors among Chagas disease patients with pacemakers

Estudo antropológico sobre o modo de incorporação e as repercussões do implante do marcapasso na vida do indivíduo portador da doença de Chagas. Foi realizada uma pesquisa etnográfica baseada no instrumento de entrevista aberta, buscando identificar a percepção do estado de saúde de um grupo de 15 pacientes portadores de cardiopatia Chagásica crônica que necessitaram de implante de marcapasso, atendidos no Ambulatório de Marcapasso do Hospital das Clínicas da Universidade Federal de Minas Gerais, em Belo Horizonte, Minas Gerais, Brasil. Utilizou-se o referencial da qualidade de vida para observar os recursos culturais, físicos e psicológicos que os pacientes utilizam para enfrentar, explicar e aceitar o processo de adoecimento, incluindo as representações mentais que constroem o sentido cultural da doença e definem as relações sociais. O estudo pretende contribuir para que os profissionais de saúde atendam seus pacientes em sua integralidade. A orientação decodificada e integrada no âmbito cultural assume um papel importante para evitar que a desinformação perpetue a difusão de mitos populares, que, por vezes, se tornam preconceitos e elementos sociais ativos de estigma do indivíduo portador de cardiopatia.

This anthropological study aimed to evaluate the incorporation of pacemakers into the lives of individuals with Chagas disease. An ethnographic methodology was used, based on an open interview focusing on the personal perceptions of 15 patients with chronic Chagas cardiopathy who had required pacemaker implants at the Federal University Hospital in Belo Horizonte, Minas Gerais State, Brazil. As part of a broader quality of life analysis, the study investigated the cultural, physical, and psychological resources used by patients to confront, explain, and accept the disease process, including mental representations on the cultural perception of the illness and definition of social relations. The study was intended to contribute to comprehensive patient care by health professionals, including psychosocial aspects. Decoded and integrated orientation in the cultural sphere assumes an important role in order to prevent disinformation from perpetuating the dissemination of popular myths as active elements in patient stigmatization.

[Representations, myths, and behaviors among Chagas disease patients with pacemakers]. / Representações, mitos e comportamentos do paciente submetido ao implante de marcapasso na doença de Chagas.

This anthropological study aimed to evaluate the incorporation of pacemakers into the lives of individuals with Chagas disease. An ethnographic methodology was used, based on an open interview focusing on the personal perceptions of 15 patients with chronic Chagas cardiopathy who had required pacemaker implants at the Federal University Hospital in Belo Horizonte, Minas Gerais State, Brazil. As part of a broader quality of life analysis, the study investigated the cultural, physical, and psychological resources used by patients to confront, explain, and accept the disease process, including mental representations on the cultural perception of the illness and definition of social relations. The study was intended to contribute to comprehensive patient care by health professionals, including psychosocial aspects. Decoded and integrated orientation in the cultural sphere assumes an important role in order to prevent disinformation from perpetuating the dissemination of popular myths as active elements in patient stigmatization.

Ventricular epicardial lead placement for resynchronization by determination of paced depolarization intervals: technique and rationale.

BACKGROUND: Cardiac resynchronization therapy has been shown to be an effective treatment to improve functional status and prolong survival among patients with advanced congestive heart failure. However, as many as 30% of patients do not respond. Nonresponse may be due to suboptimal left ventricular lead placement. Studies have indicated that leads placed in the midlateral left ventricle (LV) wall usually result in improved dP/dT and increased pulse pressure, compared with other locations. When the surgeon is placing the leads thoracoscopically, however, in a chest with multiple adhesions, anatomic landmarks can be obscured. It is desirable to have an objective physiologic method to determine optimal lead placement. The optimal LV pacing site may be best determined by locating the site with the latest depolarization. METHODS: A pacing lead attached to a pulse analyzer was introduced through a thoracoscopic port and used as a mapping electrode to electrically map exposed areas of the left ventricle. The right ventricular pacing lead was also attached to the pulse analyzer and the interval between the right ventricular pulse and the LV depolarization (paced depolarization interval) was measured in 19 patients undergoing thoracoscopic LV lead placement. A site with a paced depolarization interval less than 110 ms was not accepted. RESULTS: Electrical mapping was possible in 19 of 29 consecutive patients in whom it was attempted. The most frequent reason for not mapping was the presence of extensive scarring. In 7 of 19 patients (36.8%) mapped, the site that would have been chosen by anatomic landmarks was not the site with the longest paced depolarization interval, and thus the lead placement was altered. CONCLUSIONS: The site with the longest paced depolarization interval is only selected 63.2% of the time when utilizing anatomic landmarks for placement. Nonresponse may be due to suboptimal LV lead placement. Measurement of paced depolarization intervals provides a physiologic method of determining optimal LV lead placement.

Cardiac resynchronisation therapy for patients with heart failure.

Cardiac resynchronisation therapy (CRT) is a non-pharmacological treatment for heart failure. The method 'resynchronises' the contraction of the right and left ventricles, resulting in better cardiac output, thus improving symptoms. This article discusses symptoms, morbidity and mortality of heart failure; potential benefits of CRT to patients' quality of life; and the implications of CRT for nursing practice.

Pacing extremely old patients: who decides--the doctor, the patient, or the relatives?

Decision making competence is not necessarily present or absent. In many cases it is partial or compromised. This applies especially to those over 80 years old, in whom the prevalence of dementia is high. Three patients who presented with indications for permanent pacemaker insertion are considered. One was apparently competent, one had partial competence, and one was clearly incompetent. In all three cases the closest relatives were opposed to decisions made by either the patient or the doctors. The three cases reflect the tension between doctors, patients, and relatives in situations where medical interests, individual interests, and familial interests conflict. The cases illustrate the type of problems encountered in clinical practice. The current legal position is reviewed.