[Predictive parameters of occurrence of adequate interventions in patients with implanted cardioverter-defibrillators with or without resynchronisation therapy in primary prevention of sudden cardiac death in dilated cardiomyopathy]. / Parametry predykcyjne wystepowania adekwatnych interwencji u pacjentów z implantowanymi kardiowerterterami-defibrylatorami z lub bez funkcji resynchronizacji w prewencji pierwotnej naglego zgonu sercowego w kardiomiopatii rozstrzeniowej.

The task of the ICD is to detect ventricular arrhythmias and treatment of its adequate intervention. The task of the CRTD in addition to the above tasks is the treatment of heart failure. AIM: The aim of the study was to assess the predictive parameters of adequate interventions in patients with an ICD and CRTD. MATERIALS AND METHODS: The study consisted of 273 patients (230 M, mean age 65±11 years) with ICD and/or CRTD. The inclusion criteria were: left ventricle ejection fraction (LVEF) ≤ 35%, NYHA class ≥ II, implantation in primary SCD prevention and in case of CRTD additionally LBBB with wide QRS ≥ 120ms. The following data were assessed: age, gender, presence of dilated cardiomyopathy, diabetes, chronic kidney failure, atrial fibrillation (AF), LVEF, NYHA class, device interventions, number of arrhythmias, changes in pharmacotherapy, device parameters and mortality. RESULTS: During observation, which lasted the mean of 770±490 days, 102 patients had adequate device interventions. In the ICD group, adequate interventions appear mainly in the initial observation period (HR 2,01), in patients with left ventricular hypertrophy (HR 2,98) and ventricular arrhythmias (HR 6,78) and not treated with amiodarone (HR 4,31). In the CRTD group, adequate interventions appear mainly in younger patients (HR 1,06), in diabetes (HR 1,68), in NYHA class II, in paroxysmal atrial fibrillation (HR 1,09) and ventricular arrhythmias (HR 2,54) and not treated with amiodarone (HR 1,09). CONCLUSIONS: In the ICD group, left ventricular hypertrophy, ventricular arrhythmias is not treated with amiodarone in a significant influence on the risk of adequate intervention. In the Group of CRTD younger age, diabetes, NYHA class II, paroxysmal atrial fibrillation, ventricular arrhythmias is not treated with amiodarone in a significant influence on the risk of adequate intervention. In the ICD group, adequate interventions particularly often in the first year of follow-up. Patients with CRTD require special medical care.

[The evaluation of the ventricular arrhythmias and interventions of cardiac implantable electronic devices in patients with dilated cardiomyopathy for primary prevention of sudden cardiac death in ambulatory and telemetric follow-up]. / Ocena wystapienia arytmii komorowych i interwencji wszczepialnych urzadzen do elektroterapii serca u chorych na kardiomiopatie rozstrzeniowa w zapobieganiu pierwotnej naglego zgonu sercowego w obserwacji ambulatoryjnej i w kontroli metoda telemonitoringu.

Telemetric follow-up (RM) after cardiac devices implantation is not inferior to classic follow-up and enables earlier clinical complications detection. AIM: The aim of the study was to evaluation of the ventricular arrhythmias and interventions of ICD/CRTD in ambulatory and telemetric follow-up in patients with dilated cardiomyopathy. MATERIALS AND METHODS: Group A (CRT-D+ICD) - retrospective, patients followed-up in outpatient clinic - was consisted with 273 patients (mean age 65±11 years, 230M). In group A 128 patients after CRT-D implantation and 145 patients with ICD were selected. Group B (RM group) - prospective, RM Medtronic Carelink followup - was consisted with 177 patients (mean age 61±13 years, 141M). 35 patients had CRT-D and 142 had ICD implanted. Follow-up of patients from group A was performed in outpatient clinic. Follow-up of patients from group B was monitored daily follow-up using RM system (Medtronic Carelink). Frequency/type of ventricular arrhythmias, device interventions, patient's clinical status, medications, were assessed in both groups. To assess presence of ventricular arrhythmias, device interventions, ICD and CRT-D programming changes, pharmacotherapy changes, patients were randomly chosen from group A, according to age, gender, LVEF value, NYHA class, comorbidities, time of follow-up as a control group to group B (RM group). RESULTS: In multivariate analysis, it was found that a low ejection fraction <25% (HR 0,929; p<0,001), and diabetes mellitus (HR 7,038; p<0,009) predispose to ventricular arrhythmias. In the RM group, compared to control group, there were significantly less programming changes (5,9 vs 47,1%, p<0,001), time to first events (ventricular arrhythmias - 258 vs 487 d, p<0,001; interventions - 295 vs 775 d, p<0,01) was shorter, while time to first necessary programming (364 vs 304 d, p<0,001) or pharmacotherapy (330 vs 244 days, p<0,001) change was longer. General mortality did not differ significantly between the groups (p=0,130). CONCLUSIONS: Low ejection fraction <25%, and diabetes mellitus predispose to ventricular arrhythmias. Telemetric follow-up of cardiac implantable devices enables quick information transmission in cases of clinical complications (arrhythmias, interventions) and reduces number of ambulatory visits to only necessary ones. Telemetric followup of cardiac implantable devices is a safe. Key words: ventricular arrhythmias, interventions.

[The assessment of factors influencing occurrence of adequate interventions of cardiac resynchronization therapy with cardioverter-defibrillator implanted in primary prevention of sudden cardiac death in dilative cardiomyopathy and percentage of biventricular pacing].

The assessment of factors influencing occurrence of adequate interventions of cardiac resynchronization therapy with cardioverter-defibrillator implanted in primary prevention of sudden cardiac death in dilative cardiomyopathy and percentage of biventricular pacing. Introduction: The function of cardiac resynchronization therapy with cardioverter-defibrillator (CRT-D) is to treat heart failure (HF) and to treat ventricular arrhythmia, if it occurs, with adequate intervention. Aim: The aim of the study was to find predictors of adequate interventions and in how many patients biventricular pacing percentage decreases during the follow-up. Material and methods: The study comprised of 228 patients (178 M, mean age 66±10, 31-89 years) with implanted CRTD. The following data were analyzed: age, sex, presence of dilative cardiomyopathy, diabetes mellitus, lowered creatinine clearance, atrial fibrillation (AF), LVEF, NYHA class, adequate interventions, number of arrhythmias, pharmacotherapy modifications, device parameters and mortality. Results: Mean ejection fraction of the left ventricle was 20.9±6.4, (10.0- 35%). During the mean follow up of 770±490 days in 84 (37%) patients adequate interventions of the device occurred. The adequate interventions concerned mainly patients with diabetes mellitus (HR 2.95), in NYHA class II, with paroxysmal atrial fibrillation (HR 2.15). In 39 patients (17%) the mean percentage of biventricular pacing was below 90%, and in 18 (8%) below 85%. Conclusions: Diabetes mellitus, NYHA class II, paroxysmal atrial fibrillation have significantly increased the risk of adequate intervention. The most common causes of loss of biventricular pacing were: inappropriate AV delay, supraventricular arrhythmias and premature ventricular complexes. A significant correlation between low biventricular pacing percentage and the occurrence of supraventricular arrhythmias and adequate interventions was observed.

[Arrhythmia, device interventions and mortality analysis in patients with implanted cardioverter-defibrillator with/without resynchronisation therapy in dilative cardiomyopathy in primary prevention of sudden cardiac death]. / Analiza arytmii, interwencji urzadzenia oraz umieralnosci w populacji chorych z implantowanym kardiowerterem-defibrylatorem i/lub z funkcja resynchronizacji z powodu kardiomiopatii rozstrzeniowej w prewencji pierwotnej naglego zgonu sercowego.

UNLABELLED: Ambulatory follow-up of patients with implanted cardioverter-defibrillator (ICD) with/without resynchronisation therapy (CRTD) requires regular visits to assess arrhythmias, device interventions and mortality. AIM: The aim of the study was to examine arrhythmia prevalence, device interventions and mortality in patients with dilative cardiomyopathy with ICD/CRTD implanted in primary sudden cardiac death (SCD) prevention. MATERIALS AND METHODS: The study consisted of patients with ICD and/or CRTD implanted between 2010-2011. The inclusion criteria were: left ventricle ejection fraction (LVEF) ≤ 35%, NYHA class ≥ II, implantation in primary SCD prevention and in case of CRTD additionally LBBB with wide QRS ≥ 120ms. All of patients' visits in outpatient clinic were analysed. The following data were assessed: age, gender, presence of coronary artery disease (CAD), diabetes, thyroid gland diseases, chronic kidney failure, atrial fibrillation (AF), LVEF, NYHA class, device interventions, number of arrhythmias, changes in pharmacotherapy, device parameters and mortality. RESULTS: The study analysed 360 patients (302 M, mean age 64±12 years) with cardiac implantable devices (127 with CRTD, 233 with ICD). During observation, which lasted the mean of 768±491 days, 258 patients had ventricular arrhythmias and 118 patients had adequate device interventions. 10 patients died because of the progression of heart failure. Ventricular arrhythmia was more frequent in patients with CRTD, who died, with low cholesterol level, high NYHA class, low LVEF, diabetes and kidney failure. Device interventions occurred in the above described groups and additionally in patients with AF. After step exclusion of characteristics with highest p value in Wald test, it was confirmed that the factors influencing ventricular arrhythmia and death were low LVEF (HR=0,944, p<0,002 and HR=0,813, p<0,013) and diabetes (HR=7,043, p<0,009 and HR=29,931, p<0,002). CONCLUSIONS: Ventricular arrhythmia is more often in patients with CRTD, who died, with low cholesterol level, high NYHA class, low LVEF, diabetes and kidney failure. Adequate interventions are more often in patients who died, with low cholesterol level, high NYHA class, low LVEF, diabetes, kidney failure and AF. Patients who died, compared to those who survived, had significantly more often lipid level anomalies, high NYHA class, low LVEF, advanced age, diabetes, kidney failure, atrial fibrillation, arterial hypertension, device interventions and pharmacotherapy changes. Diabetes and low LVEF are predictors of ventricular arrhythmias and death.

[Safety and efficacy of classic ambulatory implantable cardioverter-defibrillator and resynchronisation systems follow-up compared to telemetric follow-up]. / Porównanie bezpieczenstwa i skutecznosci tradycyjnej kontroli ambulatoryjnej z kontrola metoda telemonitoringu wszczepialnych kardiowerterów-defibrylatorów oraz urzadzen resynchronizujacych serca.

UNLABELLED: Telemetric follow-up (RM) after cardiac devices implantation is not only not inferior to classic follow-up, but also enables earlier clinical complications detection and stricter patient monitoring. THE AIM: of the study was to confirm safety and efficacy of RM in patients with implantable cardioverter-defibrillator (ICD) or cardioverterdefibrillator with resynchronisation therapy (CRT-D), compared to traditional follow-up in outpatient clinic. MATERIALS AND METHODS: Group A (CRT-D+ICD) (retrospective, patients followed-up in outpatient clinic) was consisted with 273 patients (mean age 65±11 years, 230M). Group A included 128 patients after CRT-D implantation and 145 patients with ICD. Group B (RM group) (prospective, RM Medtronic CareLink follow-up) involved 89 patients (mean age 61±14 years, 73M). 11 patients had CRT-D and 78 had ICD implanted. Only patients with Medtronic equipment were included to group B. Follow-up of patients from group A - ambulatory visit in outpatient clinic: 1-3 months after implantation, then every 6 months. Follow-up of patients from group B - daily follow-up using RM system (Medtronic CareLink). Patient's clinical status, medications, frequency/ type of arrhythmias, device interventions were assessed in both groups. RESULTS: To assess presence of ventricular arrhythmia, device interventions, ICD and CRT-D programming changes, pharmacotherapy changes, a number of patients were randomly chosen from group A. They were similar in age, gender, LVEF value, NYHA class, comorbidities, time of follow-up (control group) to Group B (RM group). In the RM group, compared to control group, there were significantly less programming changes (3,4 vs 28,6%, p<0,001), time to first event was shorter (ventricular arrhythmia - 39 days, p<0,001; intervention - 102 days, p<0,001), time to first necessary programming change was longer (201 days, p<0,001). RM system proved to be save, more accurate (22% visits were performed personally by the physician operating Medtronic CareLink system, 71,4% consultations were performed via internet, phone), and general mortality did not differ significantly between the groups (p=0,147). CONCLUSIONS: Telemetric follow-up of cardiac implantable devices is a safe and more accurate method in comparison to classic ambulatory follow-up. Telemetric follow-up of cardiac implantable devices enables quick information transmission in case of clinical complications (arrhythmia, intervention). Telemetric follow-up allows to reduce number of ambulatory visits to only necessary ones.

[Ventricular arrhythmia and device intervention analysis in patients with implanted cardioverter-defibrillator with/without resynchronisation therapy in dilative cardiomyopathy in primary prevention of sudden cardiac death in telemetric follow-up].

Introduction: Remote monitoring of ICD/CRTD is safe, during which evaluates the type of arrhythmia, intervention. Aim: The aim of the study was the assessment of ventricular arrhythmia and ICD/CRTD intervention. Material and methods: The study included 177 patients (mean age 61,1±13; 23-88 y; Men 141) with an ICD/CRTD implanted. Patients were controlled telemonitoring system, Medtronic Carelink. The following variables were analyzed: age, gender, comorbidities, LVEF value, NYHA class, type of ventricular arrhythmias, device interventions, reprogramming and pharmacotherapy changes. Results: In multivariate analysis, it was found that, diabetes mellitus (HR 3,49), a low ejection fraction <25% (HR 2,51) predispose to ventricular arrhythmias; and a low ejection fraction <25% (HR 1,88), ischemic DCM (HR 1,92), II NYHA class, the lack of Amiodarone (HR 5,01) predispose to device intervention. Conclusions: 1. A low ejection fraction, ischemic dilative cardiomyopathy, II NYHA class, the lack treatment of Amiodarone predispose to ventricular arrhythmias. 2. A low ejection fraction, diabetes mellitus predispose to device intervention. 3. A significant correlation between interventions and ventricular arrhythmias, renal failure, diabetes mellitus, abnormal lipidogram were observed. 4. Telemetric follow-up of cardiac implantable devices is a safe and enables quick information transmission in cases of clinical complications (arrhythmias, interventions).

[Antitachyarrhythmic interventions of implantable cardioverter-defibrillator in primary and secondary sudden cardiac death prevention patients]. / Interwencje antyarytmiczne u chorych po wszczepieniu kardiowertera-defibrylatora w prewencji pierwotnej i wtórnej naglego zgonu sercowego.

UNLABELLED: Antitachycardia pacing (ATP) and high voltage interventions (CV) are methods of interrupting dangerous ventricular arrhythmias. The aim of the study was to determine the frequency of ventricular tachyarrhythmias and form of ICD interventions in patients in the primary and secondary sudden cardiac death (SCD) prevention groups. MATERIAL AND METHODS: The study involved 399 patients (334 male, 65 female), mean age was 65.2 +/- 12.1 years (21-89 years), who had an ICD implanted in years 2008-2010. The analysis comprised age, gender, indications for ICD implantation, intracardiac electrograms derived from ICD during the follow-up. RESULTS: The patients were divided in 2 groups depending on the SCD prevention type: group A - primary prevention, group B - secondary prevention. In the A group, the peak death rate was in the 7th decade of life, while in the B group it was 10 years later. In the A group the main condition was coronary arteries disease (CAD) (76%) and dilating non-ischemic cardiomiopathy (18%), whilst in the B group, only CAD (100%). In the A group different forms of ventricular tachyarrhythmias were registered more often in the dead (57%), than living patients (38%). The difference was statistically significant (p < 0.025) and considered mainly ventricular fibrillation observed in 21% of dead patients and only in 4,2% living. Despite the fact, that in the B group the percentage of dangerous ventricular tachyarrhythmias (VT and especially VF) was higher, there were fewer deaths than in A group (7.8 vs 12.8%). In living patients in the B group, there were registered twice as many ICD interventions as in the A group. In the A group, in patients over 70 years old, in contrary to the younger, more frequently ventricular tachyarrhythmias and antiarrhythmic interventions (ATP, CV) were observed. In the B group, the relation was reversed. Inadequate and ineffective interventions occurred mainly in the A group. CONCLUSIONS: There were twice as many ICD interventions in patients implanted in secondary SCD prevention than in patients implanted in primary prevention. In secondary prevention, in contrary to the primary, the frequency of ventricular tachyarrhythmias and ICD interventions in patients younger than 70 years old is higher than in older patients. The most frequent reason for inadequate ICD interventions are sinus tachycardia and atrial fibrillation.

[Venous thrombosis as a complication of pacemaker implantation--own observations]. / Zakrzepica zylna jako powiklanie po wszczepieniu rozrusznika serca--wlasne obserwacje.

UNLABELLED: Thrombosis is a fairly rare, yet dangerous complication of pacemaker implantation. It may occur in various time intervals after the actual implantation procedure. The risk factors are as follows: inflammation or injury, vein anomalies, arrhythmia, venous stenosis. The aim of the study was to assess the risk factors for venous thrombosis, determine the interrelationship between venous thrombosis and the level of select inflammatory and pro-thrombotic factors, as well as to evaluate the actual impact of pacemaker implantation procedure within a group of patients with permanent heart stimulation system. MATERIAL AND METHODS: The study involved 48 patients with permanent heart stimulation system, divided into 2 groups. Group A (18 F, 20 M; mean age 71.7 +/- 13.6 years) consisted of patients who had up to 3 thrombotic risk factors, whereas group B (2 F, 8 M; mean age 71.6 +/- 7.5 years) comprised the patients with more than 5 thrombotic risk factors. All patients were subsequently followed up for 18 months. Prior to pacemaker implantation the following factors were assessed in each patient: specific indications for pacemaker implantation, overall clinical condition, coexisting diseases, history of tobacco smoking, medications used prior to the procedure (anti-platelet, anti-coagulation), history of thrombotic or infectious complications, previous temporary heart stimulation. A transthoracic echocardiogram (TTE) and an ultrasound examination of the veins in both upper extremities were carried out. The levels of: D-dimers, fibrinogen, interleukin-6 (IL-6), hsCRP, TF and PAI-1 were determined in the venous blood. During the pacemaker implantation procedure the actual access to the veins and possible venous anomalies were assessed. After the pacemaker implantation, the TTE and venous ultrasound examination were carried out after 6 and 12 months, blood analyses for up to 7 days after the implantation, and subsequently after 6 and 12 months. RESULTS: Patients in group B had significantly lower left ventricle ejection fraction and larger left ventricle end diastolic diameter than group A patients. In 3 patients in group B (which made up 6.25% of the study population), symptomatic venous thrombosis occurred after a 12-month observation period (mean 13.06 months). Initially, the levels of IL-6, hsCRP, TF, PAI-1, fibrinogen and D-dimers were considerably higher in group B, in comparison to group A. In all patients the levels of the above referenced factors kept on increasing for up to 7 days after the procedure. In group A they subsequently decreased, whereas in group B they kept on growing. In group B a significant negative correlation was observed between the left ventricle ejection fraction and the inflammatory and thrombotic factors under study. The lower the ejection fraction, the higher actually were their values. CONCLUSIONS: In patients with more than 5 thrombosis risk factors, the increased levels of IL-6, hsCRP, fibrinogen, D-dimers, TF and PAI-1 were observed. A pacemaker implantation procedure is believed to increase both thrombotic and inflammatory state in a patient for up to 7 days after the procedure. In patients prone to thrombosis, a negative correlation between the ejection fraction and the levels of hsCRP, D-dimers, TF and PAI-1 were observed.

Heart perforation in patients with permanent cardiac pacing - pilot personal observations.

INTRODUCTION: Heart perforation is a rare complication of pacemaker (PM)/implantable cardioverter-defibrillator (ICD) implantation. MATERIAL AND METHODS: In our clinic in 2005-2010, 6 patients with heart perforation were hospitalized (3 women, 3 men), mean age 58.6 ±20.8 years (17 to 73 years). The indication to PM/ICD implantation was tachy-brady syndrome in 3 cases, second-degree atrioventricular block, advanced with losses of consciousness, vaso-vagal syndrome type II B with asystole lasting 12 s and recurrent non-sustained ventricular tachycardia in 1 patient. We analyzed patient's medical records, X-rays, echocardiography, computed tomography (CT) and procedure protocols. RESULTS: The incidence of heart perforation was 0.09%. Symptoms developed 4 to 990 days (mean 186.3 ±394.3) after PM/ICD implantation. The perforation site was found in the right atrial wall in 1 cases and the right ventricular wall in 6 cases. The TTE revealed an accumulation of fluid in the pericardium over 10 mm behind the posterior wall of the left ventricle in all patients. The CT scan confirmed perforation of the heart chambers (atrium and in 6 cases ventricle). In 5 cases the whole device was removed by direct traction or percutaneous lead extraction with pericardiocentesis when necessary (pericardium drainage in 3 cases) while in 1 case cardiac surgery was needed. CONCLUSIONS: The perforating lead may be removed by direct traction in the operating room with cardiosurgical, anesthesiological and echocardiographical backup. In case of the lead perforation outside the pericardial sac or its atypical location, cardiac surgery is a safer method. The most important diagnostic method remains computed tomography.

Factors predisposing to ventricular tachyarrhythmia leading to appropriate ICD intervention in patients with coronary artery disease or non-ischaemic dilated cardiomyopathy.

BACKGROUND: In order to achieve optimal outcomes when treating ventricular tachyarrhythmias with implantable devices, it is extremely important to identify parameters predisposing to arrhythmia. In view of current restrictions in healthcare funding, there is a growing demand for additional predictors of arrhythmia that would allow better patient selection for implantable cardioverter-defibrillator (ICD) use for primary prevention of sudden cardiac death (SCD). AIM: To identify parameters predisposing to ventricular tachyarrhythmia/appropriate ICD intervention in ICD recipients. METHODS: We analysed 376 patients (56 women, 320 men, mean age 66.1 ± 11.2 [range 22-89] years) who underwent ICD implantation between January 2008 and December 2010. Of these, 275 patients underwent ICD implantation for primary prevention of SCD and 101 for secondary prevention. Operative protocols and in-hospital and outpatient records were analysed retrospectively. Mean QRS width and heart rate (HR) were calculated in resting surface electrocardiograms (25 mm/s, 10 mm/1 mV). Intracardiac electrograms stored in ICD memory were used to evaluate appropriateness of anti-arrhythmic interventions and analyse the number of ventricular tachyarrhythmia events, ICD interventions and their type. We analysed the following clinical and procedural variables: age, gender, left ventricular ejection fraction (LVEF), type of SCD prevention (primary or secondary), ICD type (single chamber--VR, dual chamber--DR), performing defibrillation threshold testing to establish defibrillation safety margin at ICD implantation, ventricular lead location (right ventricular outflow tract region, right ventricular apex), mean HR, QRS width, New York Heart Association (NYHA) functional class, occurrence of ventricular tachyarrhythmia/appropriate ICD intervention after implantation, ICD interventions, history of cardiovascular disease and arrhythmia (myocardial infarction, ischaemic and non-ischaemic dilated cardiomyopathy, arterial hypertension, ventricular fibrillation, ventricular tachycardia, permanent atrial fibrillation, percutaneous coronary intervention, and/or coronary artery bypass grafting), and medications (amiodarone, sotalol, beta-blockers, angiotensin-converting enzyme inhibitors [ACEI]/angiotensin receptor blockers [ARB], statins, loop diuretics, aldosterone antagonists). RESULTS: During the mean follow-up period of 387 ± 300 (range 5-1400) days, appropriate ICD intervention due to ventricular tachyarrhythmia occurred in 68 of 376 ICD patients (61 men, 7 women, mean age 64.7 ± 12.3 [range 22-89] years). Mean time interval from ICD implantation to the occurrence of arrhythmia was 281 ± 229 (range 5-972) days (p 〈 0.001). To optimize sensitivity and specificity when analysing ventricular tachyarrhythmia/appropriate ICD intervention vs. no ventricular tachyarrhythmia/appropriate ICD intervention, cutoff values were established using ROC curves (cutoff for LVEF = 31%, HR = 79 bpm). Using these cutoff values, patients with ventricular tachyarrhythmia/appropriate ICD intervention were compared to those without ventricular tachyarrhythmia/appropriate ICD intervention. Significant differences were observed in LVEF (p< 0.001), HR (p< 0.022), ACEI/ARB use (p< 0.034), and NYHA class (p< 0.001). By Kaplan-Meier univariate analysis, patients with LVEF> 31% (log-rank test p< 0.001), HR ≤ 79 bpm (log-rank test p< 0.022), QRS width ≤ 114 ms (log-rank test p < 0.045), and NYHA class II (log-rank test p< 0.001) were more likely to be free from ventricular tachyarrhythmia/appropriate ICD intervention. Cox multivariate analysis showed that reduced LVEF (≤ 31%) was the only independent predictor of arrhythmia/intervention. LVEF values below 31% are associated with a significant 20-fold increase (p< 0.02) in the risk of arrhythmia during the first 3 years after ICD implantation. Among 68 patients with ventricular tachyarrhythmia/appropriate ICD intervention, mean 4.1 interventions per person occurred during the follow-up period. In the overall study population, the number of interventions was 0.28 per person per year. Overall, 92 inappropriate ICD interventions were observed, all resulting from atrial fibrillation with rapid ventricular rate. Interventions had no effect on total mortality. Higher numbers of appropriate interventions were observed in patients who died due to heart failure. CONCLUSIONS: Factors associated with a significantly increased risk of ventricular tachyarrhythmia/appropriate ICD intervention included reduced LVEF, increased resting HR, NYHA class II or higher heart failure, and wide QRS. Patients with low LVEF (< 31%) are at particular risk of SCD due to ventricular arrhythmia and this parameter alone can influence the decision regarding ICD implantation. No effect of ICD interventions on total mortality was observed, although more ICD interventions were observed in patients who died due to heart failure.

Determinants of patient survival rate after implantation of a cardioverter-defibrillator without resynchronisation capability.

BACKGROUND: Proper selection of patients at high risk for sudden cardiac death (SCD) and increasing use of implantable cardioverter-defibrillators (ICD) may contribute to improved survival among patients at the highest SCD risk. AIM: To assess patient survival rate after implantation of an ICD without resynchronisation capability in our own patient population. Using uni- and multivariate analysis, we attempted to identify factors associated with significant worsening of patient survival rate. METHODS: From the population of patients who underwent ICD implantation for primary or secondary prevention of SCD in 2008-2010, we selected 376 patients with coronary artery disease or dilated cardiomyopathy (56 females, 320 males). Mean age was 66.1 ± 11.2 (range 22-89) years. ICD implantation protocols and in-hospital and outpatient records were reviewed retrospectively. We analysed the following clinical and procedural variables: age, gender, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class, mean heart rate (HR), QRS width, number of antiarrhythmic ICD interventions, type of SCD prevention, ICD type, performing defibrillation threshold testing (DFT) to establish defibrillation safety margin at ICD implantation, ventricular lead location, history of cardiovascular disease and arrhythmia, medications used (amiodarone, sotalol, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins, loop diuretics, aldosterone antagonists). Date and cause of death were established by contacting patient family and/or the hospital to which the patient was admitted shortly before death or the general practitioner caring for the patient (verification of death certificates). RESULTS: During the mean follow-up period of 447 ± 313 days, 46 patients died of known causes. Causes of death included sudden death in 16 patients, heart failure in 20 patients, and other causes in 10 patients (respiratory failure - 1, bleeding diathesis - 2, lung cancer - 3, colorectal cancer - 1, traffic accident - 1, and stroke - 2 patients). A comparison between primary and secondary prevention patients was performed. Mean QRS width <118 ms, resting HR < 78 bpm and LVEF >30% were significant cutoff values for improved survival as determined using the ROC curves. HR >78 bpm was observed in all SCD patients. In Kaplan-Meier univariate analysis including 27 parameters potentially influencing survival, 10 significant parameters were identified (type of prevention, presence of cardiomyopathy, ventricular tachycardia, HR, QRS width, LVEF, NYHA class, performing DFT, and statin and diuretic treatment). In Cox multivariate analysis, risk of death was increased with mean LVEV <30% (3-fold increase in risk), no DFT (2-fold increase in risk), NYHA class III or IV (3-fold increase in risk), and no statin use (2-fold increase in risk). Mean HR <78 bpm and QRS width <118 ms were independently related to an increased survival. CONCLUSIONS: Death rate was higher in patients with LVEF <30%, NYHA class III or IV, no DFT performed and no statin treatment. In these patients, indications for cardiac resynchronisation therapy should be considered. HR <78 bpm and QRS width <118 ms are independent protective factors. HR >78 bpm was observed in all SCD patients. Sicker ICD patients live for a shorter time. The presence of atrial fibrillation, number of antiarrhythmic ICD interventions, ICD type and revascularisation approach did not affect survival/mortality.

Association between selected risk factors and the incidence of venous obstruction after pacemaker implantation: demographic and clinical factors.

BACKGROUND: Venous obstruction and subsequent pulmonary embolism belong to the most common and dangerous complications of pacemaker implantation. Thus, identification of patients at risk of venous obstruction seems to be of critical importance. AIM: To determine risk factors of venous obstruction following pacemaker implantation. METHODS: Eighty one patients with permanent cardiac pacing (31 F, 50 M; mean age 71.1 ± 7.6 years) were included. Prior to pacemaker implantation, the following factors were evaluated in each patient: indications for pacemaker implantation, heart failure severity assessed using the NYHA classification, coexisting diseases, a history of tobacco smoking, medications used before the procedure (antiplatelet drugs, anticoagulants, antibiotics), a history of thrombotic or infectious complications, and previous temporary cardiac pacing. Type of venous access and procedure time were also assessed. Venous ultrasound examination to evaluate veins in both upper extremities, shoulder areas and the neck was performed before pacemaker implantation and 6 and 12 months following the procedure. Computed tomography and conventional digital subtraction angiography were performed to confirm the diagnosis of venous obstruction. RESULTS: The patients were divided into two groups based on the occurrence of venous obstruction after pacemaker implantation. Group I (n = 71, 29 F, 42 M; mean age 71.0 ± 7.7 years) included patients without venous obstruction, and group II (n = 10, 2 F, 8 M; mean age 71.6 ± 7.0 years) included patients diagnosed with venous obstruction. Each patient was followed for 19 months. In group II (12.3% of the study population), venous obstruction developed mean 13 months after pacemaker implantation. In this group, symptomatic venous obstruction was observed in 3 patients (3.7% of the study population), mean 15 months after pacemaker implantation. Risk factors for venous obstruction included a history of myocardial infarction, temporary cardiac pacing, arrhythmia, venous anomalies, NYHA class III and IV heart failure, a history of infection, and tobacco smoking. Depending on the number of risk factors, the probability of development of venous obstruction was described by the following equation: e(-14.6 + 3.19x)/1 + e(-14.6 + 3.19x), where x is the number of risk factors. In patients who had more than 6 risk factors, almost a 100% probability of the occurrence of venous obstruction was observed. CONCLUSIONS: 1. Risk factors for venous obstruction include a history of myocardial infarction, temporary cardiac pacing, arrhythmia, venous anomalies, infections, NYHA class III and IV heart failure, and tobacco smoking. 2. In patients who had more than 6 risk factors, almost a 100% risk of venous obstruction was observed.