Clinical profile and outcomes of semi-permanent pacing in a tertiary care institute in southern India.

BACKGROUND: Semi-permanent pacing (SPP) includes the placement of a permanent lead through the internal jugular vein and connection to a pulse generator on the skin outside the venous access site. AIM: To evaluate the clinical profile and outcomes of semi-permanent pacing in a tertiary care institute in Southern India. METHODS: This is a retrospective observational study. All patients admitted and requiring management with semi-permanent pacing from January 2017 to June 2020 were included. RESULTS: From January 2017 to June 2020, 20 patients underwent semi-permanent pacing (SPP) with a median age of 54 (21-74) years. Males comprised a majority of the patients (55%). Hypertension was noted in 50% of patients and 30% were diabetic. The right internal jugular vein was the most common access in 95% of patients. The most common indication for semi-permanent pacing was pocket site infection in 30% of patients. There were no procedural complications. The median duration on SPP was 7 (5-14) days and the median duration of hospital stay was 13 (8-21) days. Permanent pacemaker implantation was done in 55% of patients. Mortality in our study group was 15% with 10% dying due to cardiogenic shock (post resuscitated cardiac arrest) and 5% dying due to non-cardiac cause (Epidural hematoma). CONCLUSION: In our study, semi-permanent pacing was noted to be a safe procedure and was more commonly indicated in emergent conditions with complete heart block secondary to underlying reversible causes and in the management of pocket site infection.

Study of atrial arrhythmias after surgical or device closure of atrial septal defect.

Background Device closure of atrial septal defect (ASD) has emerged as a treatment modality for the past 3 decades and has changed the natural history of ASD compared to that of surgical closure. Early intervention in ASD retards the geometrical and electrical remodelling of the atrium that contributes to the development of atrial tachyarrhythmias. We studied the incidence of atrial arrhythmias in patients undergoing surgical and device closure of ASD. Methods We did this retrospective observational study at a tertiary referral centre, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala. Patients of all age groups undergoing surgical and device closure of ASD between 1 January 2003 and 31 December 2008 were included to compare the incidence and nature of atrial arrhythmias and also analyse the difference in new-onset atrial arrhythmias between the two arms. Results Of 277 patients, 144 with surgical closure and 133 with device closure were followed up for 10-15 years. A larger number of men underwent surgical closure (41.7%) compared to device closure (25.6%). The mean (SD) follow-up was 12.6 (3.7) years in the surgical closure group and 10.9 (2.6) years in the device closure arm. There were a larger number of patients with atrial tachyarrhythmias in the surgical closure group (6.3%) compared to the device closure group (0.8%) at baseline (p=0.02). A significantly larger number of patients had atrial fibrillation in the surgical closure group (5.6%) compared to the device closure group (0.7%) at baseline (p=0.003). Pulmonary hypertension at baseline was present in 38.9% of patients in the surgical closure group and in 23.3% of patients in the device closure group (p=0.006). New-onset atrial arrhythmias occurred in patients ≥30 years of age (p=0.006) and exclusively in patients with pulmonary hypertension in the surgical group (3.7%) and in the device closure group (6.6%). This was statistically significant in the device closure group (p=0.05) but not in the surgical closure group (p=0.13). The incidence of new-onset arrhythmias was not statistically significant in both groups. Conclusions Atrial arrhythmias were significantly more common in patients who underwent surgical or device closure at ≥ 30 years of age and in patients with pulmonary hypertension. There was no difference in new-onset atrial arrhythmias between the surgical and device closure groups. Our study results suggest that surgical or device closure before 30 years of age and before the development of atrial arrhythmias may be beneficial with respect to the development of atrial arrhythmias.

Management of a complicated 'pacemaker pocket' site infection.

Pocket site infection after implantation of a pacemaker is a dreaded complication which requires removing the device and reimplanting it at a contralateral site. Difficulties arise when the patient is dependent on pacing and when there are issues with venous access at the contralateral site. We report a patient with pacemaker pocket site infection with congenital complete heart block managed with explantation of the device, semi-permanent pacing during antibiotic treatment, reimplantation of the device at the contralateral site and management of subtotal subclavian vein stenosis noted during reimplantation.

Tachycardiomyopathy managed by successful ablation of right ventricular outflow tract premature ventricular complexes.

Tachycardiomyopathy is a common reversible cause of left ventricular dysfunction. Prompt diagnosis and treatment of this condition is essential to ensure a good prognosis for the patient. We report a case of tachycardiomyopathy due to frequent premature ventricular complexes arising from the right ventricular outflow tract midseptum managed with successful ablation.

Left ventricular apical aneurysm in Takayasu arteritis and chronic active Epstein-Barr virus infection.

BACKGROUND: Takayasu arteritis (TA) is a chronic inflammatory disease of unknown etiology characterized by a large vessel vasculitis involving the aorta and its branches. Myocardial involvement is extremely unusual in TA and is mostly in the form of myocarditis, ventricular hypertrophy, and ventricular dysfunction secondary to coronary ischemia. Submitral aneurysms have been reported in TA and has been attributed to the chronic inflammatory process in TA. CASE PRESENTATION: We report a novel instance of left ventricular apical aneurysm in a 37-year-old lady with TA and normal epicardial coronaries. She was diagnosed with a left ventricular apical aneurysm, moderate aortic regurgitation, and moderate pericardial effusion. The coronary arteries were normal. The patient had concomitant chronic active Epstein-Barr virus infection complicating patient outcome. CONCLUSIONS: Left ventricular apical aneurysm with normal epicardial coronaries is a rare cause of heart failure in Takayasu arteritis. Concomitant chronic active Epstein-Barr virus infection can potentially accentuate the inflammatory process in Takayasu arteritis and complicate management and patient outcomes.

Endovascular thrombectomy in the setting of occult cerebral artery aneurysm: Reducing the risk of iatrogenic rupture.

Cerebral artery aneurysms are present in up to 10% of ischemic stroke patients, often within or adjacent to the occluded vessel. In some cases, the approach to intervention may need to be modified based on the size and location of the aneurysm. We describe a 99-year-old female with a known history of cerebral aneurysm who underwent successfully mechanical thrombectomy of a right middle cerebral artery thrombus; an 8-mm aneurysm involving the right M1 bifurcation was identified only on post-procedural digital subtraction angiography. In addition, we discuss strategies to reduce the risk of iatrogenic aneurysm rupture in the setting of endovascular thrombectomy.

Factors Associated With Normal Flow (TIMI 3) After Thrombolysis With Streptokinase in ST-Elevation Myocardial Infarction: A Prospective Observational Study.

Background Thrombolysis with streptokinase (STK) is the most widely used reperfusion strategy for ST elevation myocardial infarction (STEMI) in India. Achieving full reperfusion as evidenced by thrombolysis in myocardial infarction (TIMI) flow grade 3 in coronary angiography (CAG) is associated with better outcomes. Recent studies show that hematological indices like neutrophil-lymphocyte ratio (NLR) and mean platelet volume (MPV) estimated before thrombolysis could predict TIMI 3 flow. We studied clinical, electrocardiographic and hematological parameters associated with TIMI 3 flow after thrombolysis with STK. Methods We prospectively studied 201 adult patients with STEMI presenting within 12 hours of onset of chest pain. Before thrombolysis, blood sample was collected for estimating NLR and MPV. Timing of CAG after thrombolysis was decided by consultant cardiologists. Patients were followed up for one month after discharge. Results Of 201 patients, 162 (81%) had relief of chest pain and 131 (65%) had ST segment recovery of ≥50% at 90 minutes after thrombolysis. CAG was performed within median (IQR) of four (3-5) days after thrombolysis. TIMI 3 flow was observed in 112 (56%) patients. NLR and MPV had no significant association with TIMI 3 flow. In multivariable analysis, ST-segment recovery of ≥50% at 90 minutes was associated with TIMI 3 flow (adjusted OR 3.47, 95% CI: 1.84-6.53, P= <0.001). Of 198 patients followed up for one month after discharge, 13 (6.5%) died. Conclusions In patients with STEMI, ST-segment recovery of ≥50% at 90 minutes after thrombolysis with STK predicted TIMI 3 flow independently. NLR and MPV values were not predictive of TIMI 3 flow.

A rare case of a cervical dural arteriovenous fistula presenting in a younger patient with vertex subarachnoid hemorrhage: Case report and literature review.

Spinal dural arteriovenous fistulas (SDAVF) are rare entities, which mainly occur in the thoracic and lumbar regions of older adults with a significant male predominance. The clinical manifestations are nonspecific such as myelopathy and this can make it challenging to diagnose. Rarely these have been described in the cervical region with even rare manifestations including subarachnoid hemorrhage. In the few reports of hemorrhage, it is usually infratentorial. We present a case of 40-year-old female (uncommon gender and younger age) who presented with headaches and was found to have supra tentorial subarachnoid hemorrhage and a suspicious lesion in the spinal canal. This proved to be a type 1 AVM of the spinal canal (per the American British and French classification). This was successfully treated endovascularly. With the discussion of the relevant literature we hope that this case can add to our medical knowledge as another presentation of this uncommon condition and ultimately help in diagnosing this illusive and rare entity.