Chronic lymphocytic leukemia skin infiltration mimicking an ICD pocket infection: a case report.

BACKGROUND: We are presenting a case report on an unreported and unusual cutaneous manifestation of chronic lymphocytic leukemia in a patient with an implantable cardioverter-defibrillator (ICD). CASE PRESENTATION: A 65-year-old man with a history of chronic lymphocytic leukemia (CLL), previously treated with chlorambucil, was referred in October 2013 for extraction of a single chamber ICD due to a suspected device-related infection in the pulse generator area (left-hand side of Fig. 1). The ICD system (Current VR, St. Jude Medical, USA) had been implanted in November 2009. The patient complained of painless erythema with pruritus in the pocket area. Inflammatory blood parameters were C-reactive protein 17.3 mg/L and leucocytes 29.0 × 109/L. Due to the atypical appearance of the pocket area we did not extract the device. Instead, we created an exploratory excision in the skin induration, which had been present for approximately 6 weeks, and conducted a microbiological and histological examination. All cultivation examinations were negative. However, we did histologically show skin infiltration by CD-5 positive low-grade B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma (B-CLL/SLL). Re-initiation of chemotherapy was not necessary and the skin induration completely disappeared within 2 months (right-hand side of Fig. 1). CONCLUSIONS: Complete removal of an ICD system carries considerable risk. In patients with a history of hematological disease, it is crucial to exclude cutaneous manifestations of the disease prior to device removal.

New implantable cardiac monitor with three-lead ECG and active noise detection.

BACKGROUND: A new implantable cardiac monitor (BioMonitor, Biotronik) with a continuous remote monitoring option was prospectively implanted in patients with suspected arrhythmias or for therapy control after atrial fibrillation (AF) ablation. A three-lead ECG detection was intended to make the implantation more independent of the implantation site and the electrical heart axis. Because noise is a frequent problem in implantable cardiac monitors, an active noise detection algorithm was implemented. The aim of the trial was to evaluate the clinical performance of the device. METHODS: The device performance was evaluated in a prospective nonrandomized multicenter study with a follow-up of 12 months. Study endpoints were device-related serious adverse events at 3 months, appropriate QRS detection in direct comparison with synchronized Holter ECG recordings, sensitivity and positive predictive value of arrhythmia detection in comparison with Holter ECG and independent of it, and noise burden during the entire follow-up period. RESULTS: The implantation was successful in all 152 patients. Two device-related serious adverse events (pocket infections) occurred by 3 months. The mean QRS amplitude of 0.3 ± 0.2 mV at implantation remained stable over 12 months. QRS sensing performance indicated little over- and undersensing in most patients. More than 80 % of the patients had more than 22 h of noise-free monitoring per day. CONCLUSION: BioMonitor effectively detects patients with bradycardia, tachycardia, AF, or asystole. Active noise detection seems to reduce the transmission of meaningless data without diminishing the positive predictive value of the device.

[The benefits of a remote monitoring system in longterm follow up of patients with implantable cardioverter  defibrillators]. / Prínos systému vzdáleného sledování v dlouhodobé péci o pacienty s implantabilními kardiovertery defibrilátory.

INTRODUCTION: An increasing number of patients with implantable devices in cardiology raises the need for better and more efficient outpatient followup. Telemonitoring (remote monitoring) can be widely used as an important part of care for the patient and the device itself due to the technological progress in communication and transmission systems and implantable devices themselves. OBJECTIVES: To evaluate the benefits of continuous remote monitoring system using Home Monitoring (HM)TM (BIOTRONIK) compared with standard outpatient controls. PATIENTS AND METHODS: 198 patients (67 ± 12 years, 80.8 % men) who have been implanted a single chamber or dual- chamber implantable cardioverter defibrillator (ICD) (163/ 35) in 2008- 2009 in the primary or secondary prevention (75/ 123) of sudden cardiac death were followed prospectively. Planned and emergency visits, hospitalization for events related to ICD, delivered shock therapies and their adequacy were evaluated in a group of patients followed in a standard way of outpatient visits (HM- ) and a group telemonitored by HM system (HM+). RESULTS: A significant reduction was achieved in the number of planned (48 %) and total controls (45 %) during a three years follow up. There was a comparable number of patients who experienced one or more shock therapy (only with a trend to a lower number of patients who obtained a shock in HM+ group, p = 0.25), and there was equivalent mortality of both groups and the number of patients hospitalized in relation to ICD. However there was a success in significant reduction in the number and proportion of inadequate shocks delivered in HM+ patient group by 80 % in ambulatory follow up and by 90 % including multiple shocks, which required a hospitalization. CONCLUSION: The HM system demonstrates an effective and safe way of ICD patients followup which helps to reduce the number of outpatient visits and inadequate shock therapies in longterm monitoring.

[Long term results of cardiac resynchronisation therapy for patients with severe heart failure]. / Dlouhodobé výsledky srdecní resynchronizacní lécby u pacientu s tezkým srdecním selhaním.

INTRODUCTION: Cardiac resynchronisation therapy (CRT) has been shown to be a highly effective treatment strategy for patients with severe chronic heart failure (ChHF). OBJECTIVE OF STUDY: To determine the clinical response of patients to CRT, to measure morbidity and mortality for this population of patients, to determine causes and predictors of death. To test whether the parameters of tissue Doppler echocardiography are able to predict response to CRT. PATIENTS AND METHODS: Before and after implantation of the CRT and 12 months later, echocardiograph tests were carried out and relevant clinical data was recorded during the monitoring of patients. RESULTS: 102 patients (71 men, 31 women) with an average age of 71 +/- 9 years took part in the study. 68% patients had cardiac ischemia, 29% had idiopathic dilated cardiomyopathy. 75% patients were in functional class NYHA III, 25% NYHA IV. After a monitoring period of 711 +/- 329 days, 26 patients had died and 35 patients had been hospitalised. 34% of all hospitalisations were for acute exacerbation of ChHF. Patients with initial functional classification NYHA IV had a higher mortality rate in years one and two than patients in class NYHA III. The proportion of clinical responders was 64% after 12 months of CRT. In 58% of patients, a year of CRT produced a relative increase in the ejection fraction of the left ventricle (EF LV) of > or = 30%. 1/3 of patients had EF LV ? 45% with minimal symptoms of ChHF. The following were found to predict reverse remodelling of the left ventricle: less advanced state of the basic illness (EFLV > 23%, left ventricular end-diastolic diameter < 65 mm, left ventricular end-diastolic volume < 160 ml and left ventricular end-systolic volume < 120 ml) and interventricular mechanical delay > 45 ms. CONCLUSION: CRT is a safe method with a high success rate. There continues to be a problem with identifying responders. Symptoms of less advanced heart disease and interventricular delay were identified as sensitive predictors of the response to treatment.

[Chronic benign exsudative pericarditis--a case of familiar incidence]. / Chronická exsudativní benigní perikarditida--popis familiárního výskytu.

Pericarditis is a common disease caused by a number of factors. Chronic pericarditis is defined as the presence of pericardial effusion for more than 3 or 6 months. The case study reports a case of familiar incidence of chronic exsudative pericarditis in a young woman, her sister and her mother, with an analysis of diagnostic and therapeutic options. According to available literature, this is the second case described of such form of familiar incidence.

[Fire-eater's pneumonia--a difficult differential diagnosis]. / Pneumonie u polykace ohne--obtízná diferenciální diagnostika.

Acute aspiration of petroleum or other hydrocarbon products can cause a distinct type of chemical pneumonitis known as fire-eater's pneumonia. Initial findings on chest X-rays are ambiguous and not uniform in nature. Among the most common belong mottled or patchy, local or diffuse perihilar and basal uni- or bilateral infiltrates, areas of atelectasis, tumor-like lesions and rarely pleural effusions. CT finding often shows formation of smaller or larger pneumatoceles. Those cavities tend to regress spontaneously over weeks or months. Clinical diagnosis is sometimes very difficult, especially in cases, when past history of "fire-eating" is not known to the physician. The authors present clinical manifestation, sequential X-ray and CT findings in one patient with fire-eater's pneumonia. To diagnose the disease, not only paraclinical exploration is needed, but also the patient's past history plays an important role. Without it this puzzling clinical unit can remain undiagnosed.

[Electrocardiographic changes in patients with acute pancreatitis. Case report and review of the literature]. / Elektrokardiografické zmeny u pacientu s akutní pankreatitidou. Kazuistika a prehled literatury.

Transient electrocardiographic changes in patients with acute pancreatitis are well known in the literature. Mostly these changes are in the form of T-wave inversion, ST-segment depression, and rarely ST-segment elevation without the presence of coronary artery disease. We report a patient, in whom electrocardiographic changes mimicked acute inferior myocardial infarction with subsequent evolution of Q-waves in the inferior leads and ischaemia in the anterior wall. To the authors' knowledge, this is the first report documenting the evolution of Q-waves on surface ECG in the absence of myocardial necrosis verified by postmortem examination in the patient, who died of cardiorespiratory failure and massive haemoperitoneum as a complication of ongoing acute necrotizing haemorrhagic pancreatitis. The authors also discuss diagnostic and therapeutic options in patients with acute pancreatitis and ECG pattern of acute myocardial infarction. Acute pancreatitis may mimic acute myocardial ischaemia (or infarction) or these two diseases may be present at the same time. In differential diagnosis, selective coronarography might be helpful and it allows also immediate revascularisation. Administration of thrombolytic therapy in such patients is not safe and might end up with fatal consequences.

[Ventricular tachyarrhythmias in patients without structural heart disease. Clinical and electrophysiologic characteristics of the tachyarrhythmias and long-term results of catheter ablation]. / Komorové tachyarytmie u pacientu bez strukturálního postizení srdce. Klinické a elektrofyziologické vlastnosti tachyarytmií a dlouhodobé výsledky katétrové ablace.

PURPOSE OF THE STUDY: Ventricular tachyarrhythmias without structural heart disease (SHD) form a heterogeneous group of unknown mechanism and different clinical and electrophysiological behavior. Purpose of the study was to analyze clinical and electrophysiological characteristics of the arrhythmias, and immediate and long-term results of catheter ablation. PATIENTS: Nineteen consecutive patients without SHD (7 F) aged 44.5 +/- 14.1 (18-66) years had 23 ablation procedures. Documented arrhythmias varied from incessant ventricular premature beats (1 patient) through paroxysmal nonsustained ventricular tachycardia (5 patients), incessant "repetitive" (non)sustained ventricular tachycardia (4 patients) to paroxysmal sustained ventricular tachycardia (9 patients). METHOD: Patients underwent standard electrophysiological examination. Mapping of focal arrhythmias was guided by earliest endocardial and epicardial activation, pace-mapping or both. In 1 patient with reentry tachycardia, mapping was guided by late potential during sinus rhythm and low-voltage fractionated diastolic potential during the tachycardia. RESULTS: Catheter ablation was performed in 19 patients and 23 ablation procedures. Mean fluoroscopy time per procedure was 25.4 +/- 16.0 (7-65) minutes. The arrhythmia was targeted in the right ventricle in 13 patients, and in the left ventricle in 6 patients. All clinically significant ectopic activity was eliminated in 14 patients and significantly reduced in other 2 patients. Ablation procedure failed in 2 patients. In 1 patient sustained monomorphic ventricular tachycardia originating in the epicardial aspect of outflow tract close to the left anterior descending artery was not ablated. During the long-term follow-up 19.2 +/- 10.9 (2-42) months 14 (73.7%) patients are free of targeted ectopic activity, symptoms, and antiarrhythmic drugs. Other 2 patients experienced significant reduction of ectopic activity and previously ineffective antiarrhythmic therapy could be reduced. Thus, the clinical benefit was enhanced to 16 (84.2%) patients. CONCLUSION: Ventricular tachyarrhythmias in patients without SHD form a heterogeneous group of different clinical and electrophysiological behavior and different pathophysiological mechanisms. Majority of the arrhythmias can be eliminated by focal catheter ablation with high efficacy and safety. Deep intramural and epicardial origin of the arrhythmic substrate is common reason for catheter ablation failure.

[Treatment of atrioventricular accessory pathways using catheter ablation: analysis of immediate and long-term results at the end of the learning curve period]. / Lécba sínokomorových prídatných drah katétrovou ablací: analýza bezprostredních a dlouhodobých výsledku v období po ukoncení ucební fáze.

UNLABELLED: Immediate and long-term results of catheter ablation of atrioventricular accessory pathways (AP) are presented. METHOD: One hundred and seventy-one patients aged 41.8 +/- 14.4 years underwent catheter ablation of 179 AP. Right and left AP occurred simultaneously in 3 patients; thus 65 ablation procedures for 57 rights AP in 57 patients were compared with 125 ablation procedures for 122 left AP in 117 patients. RESULTS: Including repeated procedures ablation was successful in 116 (99%) patients with left AP and in 57 (100%) patients with right AP. First catheter ablation failed in 4 (7%) patients with right AP and in 4 (3.4%) patients with left AP (p = NS). Two of these patients with left AP and all 4 pts with right AP had successful reablation. AP conduction recurred after successful ablation in 7 (12.3%) patients with right AP and in u 5 (4.1%) patients with left AP (p = 0.1). Three patients with right AP did not undergo another ablation, other 9 patients with AP recurrence had successful reablation. Procedure time during left AP ablation was shorter (159.6 +/- 70.7 vs. 183.4 +/- 75.6 min.; p = 0.02) and number of RF current deliveries was lower during left AP ablation (9.3 +/- 8.5 vs. 13.3 +/- 11.8; p = 0.008) compared to right AP ablation. Fluoroscopy time during left AP ablation (22.4 +/- 19.1 min.) did not significantly differ from that during right AP ablation (20.9 +/- 17.1 min.). Concealed AP was present in 13 (22.8%) patients with right AP and in 59 (48.4%) patients with left AP (p = 0.002). Anatomico-functional variant of AP occurred in 5 (8.8%) patients with right AP and in 4 (3.3%) patients with left AP (p = NS). Atrial fibrillation complicated ablation procedure in 9 (15.8%) patients with right AP and in 7 (5.7%) patients with left AP (p = NS). During 30.3 +/- 17 (2-60) months follow-up period tachyarrhythmia associated with the presence of an AP occurred in 3 patients with right AP and in 1 patient with unsuccessful ablation of left AP. None of these patients underwent repeated ablation. CONCLUSION: Successful ablation of AP can be achieved successfully in 100%. Catheter ablation of right AP is generally more difficult and primary ablation failure and AP conduction recurrence is nonsignificantly more often. Irregularity of the tricuspid annulus, instability of the ablation catheter, presence of the conduction system, higher occurrence of anatomico-functional AP variants and sustained atrial fibrillation during the ablation procedure represent the main causes of this finding.

[Acute myocardial infarct as a result of external compression caused by an expanding pulmonary adenocarcinoma]. / Akutní infarkt myokardu jako dusledek zevní komprese prorustajícího adenokarcinomu plic.

The case report describes a rare cause of acute myocardial infarction. 68-years old man with the cancer triplicity (follicular and papillar carcinoma of the thyroid gland, Grawitz tumor, bronchogenic carcinoma with generalization) was admitted to the intensive care unit for the sudden onset of chest pain, positivity of cardioselective enzymes and signs of cardiogenic shock. Echocardiographic examination proved diaphragmatic akinesis with low left ventricular ejection fraction about 30%. The acute coronary angiogram revealed unimportant atherosclerotic narrowing of the left coronary artery and a long significant stenosis in the proximal portion of the right coronary artery untypical for atherosclerotic lesion suspicious of extramural compression. A pathological vascularization to the extramyocardial region was documented during right coronary angiogram. The patient was treated conservatively and finally transferred to the pulmonary disease department, where he died of progression of the cancer disease two months later. Postmortem examination found spreading of the bronchogenic adenocarcinoma to the pericardium along the course of the right coronary artery, but neither direct infiltration of the vessel wall by the tumor nor atherosclerotic disease of the proximal portion of the right coronary artery were proved. These findings together with the coronary angiogram demonstrate a rare cause of the myocardial infarction due to the extramural compression by the malignant tumor.

[Endothelial injury and activation of the coagulation cascade during radiofrequency catheter ablation]. / Endoteliální poskození a aktivace koagulacní kaskády behem radiofrekvencní katétrové ablace.

GOAL OF STUDY: To identify the extent of systemic activation of the coagulation cascade and to evaluate thrombogenic effect of the radiofrequency catheter ablation. METHODS AND RESULTS: Markers of activation of the coagulation cascade (D-dimers [DD]), markers of activation of the fibrinolytic system (tissue plasminogen activator [t-PA] and its inhibitor [PAI-1]), and markers of endothelial damage (von Willebrand factor [vWf]) were monitored in 50 patients undergoing catheter ablation. Levels of these substances were identified in time T0--at the beginning of the examination, T1--after finishing diagnostic part of the electrophysiological study, T2--after finishing all applications of radiofrequency energy, and T3--24 hours after T2. Levels of vWf were significantly elevated in time T1 compared to values in T0 (p < 0.001) and were further elevating after finishing the procedure in time T2 (p < 0.05). Levels of t-PA were also elevated in time T1, however after application of the radiofrequency energy, further increase in T2 was nonsignificant. Concentrations of PAI-1 were in time T2 significantly lower compared to T1 values (p < 0.001). Levels of DD were significantly elevated during entire procedure and elevated levels persisted even 24 hours later (p < 0.001). Levels of vWf a t-PA in time T2 correlated with total time of application of radiofrequency energy. Significantly higher activation of the coagulation cascade was identified, in patients undergoing isolation of pulmonary veins compared to patients undergoing catheter ablation of other arrhythmias. In the subgroup of patients treated with anticoagulation before the intervention elevation of DD levels in times T1 and T2 was lower compared to patients who did not undergo any treatment (p < 0.05). CONCLUSION: The radiofrequency catheter ablations activate the coagulation cascade. Moreover, application of the radio frequency energy increases systemic thrombogenic state and this effect "depends on the dose". A risk group make patients undergoing catheter isolation of pulmonary veins.