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Background Transvenous lead extraction (TLE) is rising in parallel to cardiac implantable electronic device implantations. Persistent left side superior vena cava (PLSVC) is a relatively common anatomical variant in the healthy population; TLE in patients with a PLSVC is rare. Method Data were collated from 6 European TLE institutes of 10 patients who had undergone lead extraction with a PLSVC. Patient demographics, procedural challenges and outcomes were reported. Results Ten patients aged 73.4 ± 7.8 years (60% male) underwent TLE of 20 leads (3 left ventricle, 10 right ventricle, 7 right atrium) with dwell time of 82.95 ± 39.1 months. Of the 10 cases, 4 had an infection indication and 5 were biventricular system extractions; 25% of the extracted leads were defibrillator leads. The majority of the procedures were completed in the cardiac catheterization suite (80%) under general anaesthesia (60%) by cardiologists (80%) using a rotational powered sheath (65%). The Tandem approach was used successfully in 3 cases. Complete procedural success was obtained in 100% of cases in the absence of complications within 127.4 ± 74.7 min. There was no 30-day mortality. Conclusion TLE in PLSVC is feasible albeit rare. Standard extraction techniques in experienced hands are associated with favorable outcomes; the Tandem procedure may be an additional technique to improve the safety and efficacy of TLE in PLSVC.

Background High adherence to remote monitoring (RM) in pacemaker (PM) patients improves outcomes; however, adherence remains suboptimal. Bluetooth low-energy (BLE) technology in newer-generation PMs enables communication directly with patient-owned smart devices using an app without a bedside console. Objective To evaluate the success rate of scheduled RM transmissions using the app compared to other RM methods. Methods The BlueSync Field Evaluation was a prospective, international cohort evaluation, measuring the success rate of scheduled RM transmissions using a BLE PM or cardiac resynchronization therapy PM coupled with the MyCareLink Heart app. App transmission success was compared to 3 historical “control” groups from the Medtronic de-identified CareLink database: (1) PM patients with manual communication using a wand with a bedside console (PM manual transmission), (2) PM patients with wireless automatic communication with the bedside console (PM wireless); (3) defibrillator patients with similar automatic communication (defibrillator wireless). Results Among 245 patients enrolled (age 64.8±15.6 years, 58.4% men), 953 transmissions were scheduled through 12 months, of which 902 (94.6%) were successfully completed. In comparison, transmission success rates were 56.3% for PM manual transmission patients, 77.0% for PM wireless patients, and 87.1% for defibrillator wireless patients. Transmission success with the app was superior across matched cohorts based on age, sex, and device type (single vs dual vs triple chamber). Conclusion The success rate of scheduled RM transmissions was higher among patients using the smart device app compared to patients using traditional RM using bedside consoles. This novel technology may improve patient engagement and adherence to RM., Graphical abstract

Aims Remote monitoring of patients with physiological data derived from cardiac implanted electronic devices (CIEDs) offers potential to reconfigure clinical services. The ‘Heart Failure Risk Score' (HFRS) uses input from integrated device physiological monitoring to risk‐stratify patients as low‐risk, medium‐risk, or high‐risk of a heart failure event in the next 30 days. This study aimed to evaluate a novel clinical pathway utilizing a combination of CIED risk‐stratification and telephone triage to identify patients with worsening heart failure (WHF). Methods and results A prospective, single‐centre, real‐world evaluation of the ‘Triage‐HF Plus' clinical pathway (HFRS in combination with telephone triage) over a 27 month period. One hundred and fifty‐seven high‐risk HFRS transmissions were referred for telephone triage assessment. Interventions were at the discretion of the clinical assessor acting in accordance with clinical guidelines. An additional 3month consecutive sample of low and medium HFRS transmissions (control group) were also contacted for telephone triage assessment (n = 98). Successful telephone contact was made in 127 (81%) of referred high‐risk HFRS cases: 71 (55.9%) were confirmed to have WHF requiring intervention; 19 (14.9%) had an alternative acute medical problem; one patient had been recently discharged from hospital with WHF; and 36 (28.0%) had no apparent cause for the high score. In the control group, only one patient had symptoms of WHF. The sensitivity and specificity of CIED‐based remote monitoring to identify WHF 98.6% (92.5–100.0%) and 63.4% (55.2–71.0%), respectively. Conclusions The Triage‐HF Plus clinical pathway is a potentially useful remote monitoring tool for patients with heart failure and in situ CIEDs.

Background Previous results from global Micra Transcatheter Pacemaker clinical trials have demonstrated leadless pacing as a safe and attractive option for patients with prior cardiac implantable electronic device (CIED) infection and extraction. Whether outcomes differ based upon the timing of prior device extraction has not been studied. Purpose To describe characteristics and outcomes of patients undergoing CIED extraction during or prior to Micra implantation. Methods Patients who underwent CIED explant and Micra implantation were identified from the Micra Post-Approval Registry and Micra Acute Performance studies. Baseline characteristics were summarized. A Fine-Gray competing risk model was used to compare risk for major complication through 24 months. Results Of the 2739 patients included in the studies, 99 (3.6%) patients had CIED extraction the day of Micra implantation (same day) and 127 (4.6%) patients had CIED extraction within 30 days prior to Micra implantation (prior). Although infection was the primary reason for CIED extraction in both groups, a larger proportion of prior patients underwent extraction for this reason (87.4% vs. 42.4%). In contrast, more same day patients underwent CIED extraction for physician/elective reasons (16.2% vs. 3.1%). Same day patients prior device history included pacemaker (42 dual chamber and 30 single chamber), ICD (1 single chamber and 4 dual chamber), CRT (7 CRT-ICD and 13 CRT-P) while prior patients device history included pacemaker (29 single chamber, 80 dual chamber), ICD (3 dual chamber), CRT (5 CRT-ICD and 7 CRT-P). Overall, patients with extraction were aged 72.8±14.3 years, predominantly male (65.9%), and medical history was similar between groups, with the exception to CHF, which was higher for the same day group (18.2% vs 6.3%, P=0.021). The implant success rate was 98.0% for same day patients and 100% for prior patients. Median procedure duration was not significantly different between the groups (26.0 minutes and 25.0 minutes for same day and prior, respectively). Average follow-up duration was 16.5±13.8 months (range 0–53.4) for same day patients and 18.2±15.2 months (range 0–58.3) for subsequent patients. The rate of acute major complications ( Conclusion The Micra leadless pacemaker was implanted with a high success rate following CIED extraction. Outcomes following CIED extraction appear similar, whether the extraction is performed during or prior to Micra implant. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic, Inc. Risk of major complications

Aims This study aims to establish the feasibility, safety, and efficacy of outpatient intravenous (IV) diuretic treatment for the management of decompensated heart failure (HF) for patients enrolled in the HeartFailure@Home service. Methods and results We retrospectively analysed the clinical episodes of decompensated HF for patients enrolled in the HeartFailure@Home service, managed by ambulatory IV diuretic treatment either at home or on a day‐case unit. A control group consisting of HF patients admitted to hospital for IV diuretics (standard‐of‐care) was also evaluated. In total, 203 episodes of decompensated HF (n = 154 patients) were evaluated. One hundred and fourteen episodes in 79 patients were managed exclusively by the ambulatory IV diuretic service—78 (68.4%) on a day‐case unit and 36 (31.6%) domiciliary; 84.1% of patient episodes under the HF@Home service were successfully managed entirely in an out‐patient setting without hospitalization. Eleven patients required admission in order to administer higher doses of IV diuretics than could be provided in the ambulatory setting. During follow‐up, there were 20 (17.5%) 30 day re‐admissions with HF or death in the ambulatory IV group and 29 (32.6%) in the standard‐of‐care arm (P = 0.02). There was no difference in 30 day HF readmissions between the two groups (14.9% ambulatory vs. 13.5% inpatients, P = 0.8), but 30 day mortality was significantly lower in the ambulatory group (3.5% vs. 21.3% inpatients, P

Background The use of transvenous pacing leads is associated with the risk of developing tricuspid valve (TV) dysfunction. This develops through several mechanisms including the failure of leaflet coaptation or direct damage to the TV or to its sub-valvular apparatus and can result in significant tricuspid regurgitation (TR). Multiple approaches to pacemaker implantation after transvenous lead extraction (TLE) or surgical TV repair have been described. Placement of pacing leads across the TV is generally avoided in such circumstances. Case summary A 66-year-old woman presented with a year-long history of exertional dyspnoea, peripheral oedema, and postural neck pulsations. Her medical history included a dual-chamber pacemaker implantation for sinus node dysfunction 14 years ago. Echocardiography revealed severe lead-related TR. Her case was discussed in our multi-disciplinary team meeting. A decision was made to perform a TLE and implant a leadless pacemaker in an attempt to avoid open-heart surgery if possible. This was reserved as an option in the event of persistent severe TR. Transvenous extraction of the right ventricular lead was performed. The atrial lead was preserved and connected to and AAI device. A Micra AV was implanted allowing for atrioventricular (AV) synchronous pacing. Discussion We present the first case of successful implementation of AV sequential pacing using a dual-pacemaker approach involving the use of an AAI pacemaker and a Micra AV device. This was performed after TLE for severe lead-related TR.

Background/introduction Previous studies examining the utility of cardiac implantable electronic devices (CIEDs) to remotely monitor heart failure patients for decompensation have not demonstrated an impact on hard end-points. However, a key limitation of these prior studies (REM-HF and MORE-CARE) has been the failure to stratify patients according to their risk of worsening heart failure (WHF) prior to randomization (usual care vs active monitoring). We examined a different approach, using a single manufacturer’s remote monitoring platform, whereby only patients with CIED-derived data indicating the highest risk of WHF are contacted for assessment. The validated ‘Triage Heart Failure Risk Score’ (Triage-HFRS) is a medical algorithm within Medtronic CIEDs that can risk-stratify patients as low-, medium- or high-risk of WHF in the next 30 days based on integrated monitoring of physiological parameters. Purpose This study is the largest prospective evaluation of the Triage-HFRS, and examines the additional role of contacting those patients with a ‘High-Risk’ Triage-HFRS alert by telephone (Triage-HF Plus pathway). Methods Prospective, real-world evaluation of the Triage-HF Plus pathway undertaken between June 2016 and September 2019. 326 high-risk Triage-HFRS transmissions were contacted for telephone triage assessment. Screening questions were designed to identify episodes of WHF and non-heart failure events. Interventions were at the discretion of the clinical practitioner and in line with guideline-directed practice. An additional 3-month consecutive sample of low and medium Triage-HFRS transmissions (control group) were also contacted for telephone triage assessment (n= 98). Results Successful telephone contact was made following 245 high-risk Triage-HFRS alerts. Following contact, 194 (79.1%) patients reported an acute medical issue: 137 (70.6%) reported symptoms consistent with worsening heart failure (WHF) requiring intervention; and 57 (29.4%) had an alternative acute medical problem. 51 (26.2%) had no apparent reason for the high score. The sensitivity and specificity of CIED-based remote monitoring to identify any HF and non-HF events requiring intervention was 99.5% (97.2-99.9%) and 65.5% (57.3-73.2%) respectively; positive predictive value was 79.2%. The negative predictive value of a non-high risk score to rule out an acute event was 98.9%. Overall accuracy of the pathway to identify an acute issue (HF or non-HF related) was 84.8%. Conclusion The Triage-HF Plus clinical pathway is a potentially useful remote monitoring tool for patients with heart failure. The pathway has high diagnostic accuracy to identify patients with WHF and a wide range of non-HF issues which are just as relevant in a population who often have multiple complex co-morbidities and are known for their high health care utilisation.

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Aim Surgical site infection (SSI) and wound dehiscence are dreaded complications following laparotomy in general surgical patients, and can potentially occur more often in various comorbid states. Negative-pressure wound therapy (NPWT) has a positive effect of on open and complicated wounds and so has been used for at-risk surgical incisions with the aim of redistributing lateral tension and holding incision edges together. The aim of the present study was to compare the rate of wound complications following laparotomy in high-risk general surgical patients with a clean incision treated with closed-incision negative-pressure therapy (ciNPT) with those receiving conventional care. Method A retrospective review was performed of the hospital medical records of patients who underwent laparotomy between 1 October 2010 and 31 March 2012. Records of 69 patients who received ciNPT and 112 who were managed by adherent gauze dressings were included in the final analysis. Results Two (2.9%) patients in the ciNPT group and 23 (20.5%) in the non-NPWT group developed a wound complication following laparotomy (P

Introduction: Leadless pacemakers may provide a safe and attractive pacing option to patients with cardiac implantable electronic device (CIED) infection. We describe the characteristics and outcomes of patients with a recent CIED infection undergoing Micra implant attempt. Methods and Results: Patients with prior CIED infection and device explant with Micra implant within 30 days, were identified from the Micra post approval registry. Procedure characteristics and outcomes were summarized. A total of 105 patients with prior CIED infection underwent Micra implant attempt ≤30 days from prior system explant (84 [80%] pacemakers and 13 [12%] ICD/CRT-D). All system components were explanted in 93% of patients and explant occurred a median of 6 days before Micra implant, with 37% occurring on the day of Micra implant. Micra was successfully implanted in 99% patients, mean follow-up duration was 8.5 ± 7.1 months (range 0-28.5). The majority of patients (91%) received IV antibiotics preimplant, while 42% of patients received IV antibiotics postprocedure. The median length of hospitalization following Micra implant was 2 days (IQR, 1-7). During follow-up, two patients died from sepsis and four patients required system upgrade, of which two patients received Micra to provide temporary pacing support. There were no Micra devices explanted due to infection. Conclusion: Implantation of the Micra transcatheter pacemaker is safe and feasible in patients with a recent CIED infection. No recurrent infections that required Micra device removal were seen. Leadless pacemakers appear to be a safe pacing alternative for patients with CIED infection who undergo extraction.

Background\ud There are limited reports outlining the financial cost of treating cardiac implantable electronic device (CIED) infection outside the United States. This study aimed to determine the average treatment cost of CIED infection in a large UK tertiary referral centre and compared costs of different treatment pathways that are recognised in the management of CIED infection (early versus delayed re-implantation).\ud \ud Methods\ud We retrospectively analysed cost and length of stay (LOS) data for consecutive patients undergoing infected CIED extraction with cardiac resynchronization therapy (CRT-D [with defibrillator], CRT-P [with pacemaker]), implantable cardioverter-defibrillators (ICDs) and permanent pacemakers (PPMs).\ud \ud Results\ud Between January 2013 and March 2015, complete data was available for 84 patients (18 [21.4%] CRT-D, 24 [28.6%] ICDs and 42 [50.0%] PPMs). When all cases were considered the cost of infection ranged from £5,139 (PPM) to £24,318 (CRT-D). Considering different treatment strategies; 41 (48.8%) underwent CIED extraction and re-implantation during the same admission (early re-implant strategy (ER). 43 (51.2%) underwent extraction, but were then discharged home to be re-admitted for day-case re-implantation (delayed re-implant strategy (DR)). Median LOS was significantly shorter in DR compared to ER (5.0 vs. 18.0 days, p

Background Advances in clinical management have improved life expectancy in the ACHD population; as a result, implantable cardiac devices remain in situ for longer periods than ever before. These patients pose unique challenges, including; young age at implant, multiple device procedures during their lifetime, complex venous and cardiac anatomy, and co-morbidities which may predispose to infection. In the non-ACHD population, there is useful long-term research which helps to guide clinical decision-making; however, small numbers and incomplete outcome data has lead to limited comparability against ACHD patients. Aims This study aimed to examine 20 years of pacing experience in a large ACHD centre, using novel data-mining techniques to generate comprehensive lead survival data. Methodology A retrospective analysis was performed of pacing and defibrillator leads implanted between June 1996 and December 2016 in a 173 patient ACHD cohort. Automated text searching algorithms with manual review of over 1 00 000 pieces of clinical correspondence was used to maximise identification of outcomes. Lead-specific complications, non-elective removal and overall lead survival were compared for surgical and transvenous leads in patients with complex and non-complex ACHD anatomy. Results 340 leads with complete implant and follow-up data were identified of which 53% were in patients with complex ACHD anatomy and 15% were in patients with tricuspid valve abnormalities. Median lead survival time was 13.6 years in transvenous leads and 15.9 years in surgical leads (p=n .s.) Transvenous leads were associated with a higher risk of major infection than were surgically-implanted leads (11.5% vs 0% p Conclusion In this large cohort of patients with ACHD, lead survival appears to be reasonable regardless of whether a transvenous or surgical approach is used. A higher incidence of infection in transvenous leads is offset by a higher electrical failure rate in surgical leads. Further work examining large cohorts is required to determine optimal pacing strategies tailored to patient-specific anatomical challenges.

Purpose The NHS Bowel cancer screening programme (NHSBCSP) aims to reduce colorectal cancer (CRC) cumulative mortality by up to 23 per cent; long-term outcomes at national level are not yet known. The purpose of this paper is to examine a local population of CRC patients of screening age for their characteristics and long-term survival in relation to their presentation, including through the NHSBCSP. Design/methodology/approach Retrospective analysis of a prospectively maintained CRC database for the years 2009-2014 in a single district hospital providing bowel cancer screening and tertiary rectal cancer services. Findings Of 528 CRC patients diagnosed in the screening age range, 144(27.3 per cent) presented through NHSBCSP, 308(58.3 per cent) electively with symptoms and 76(14.4 per cent) as emergency. NHSBCSP-diagnosed patients were younger (median 66 vs 68 and 69 years, respectively, p=0.001), had more often left-sided cancers (59(41.0 per cent) vs 82(26.6 per cent) and 24(31.6 per cent), respectively, p=0.001), more UICC-stage I (42(29.2 per cent) vs 49(15.9 per cent) and 2(2.6 per cent)), stage III (59(41.0 per cent) vs 106(34.4 per cent) and 20(26.3 per cent)) and less stage IV disease (8(5.6 per cent) vs 61(19.8 per cent) and 34 (44.7 per cent), respectively, pp Originality/value Patients diagnosed within the NHSBCSP have improved outcome compared to both symptomatic elective and emergency presentations. A reduction in overall cumulative mortality in order of 25 per cent may well be achieved, but continuing high levels of emergency presentations and undetected right-sided disease emphasise need for further improvement in public participation in the NHSBCSP and research into more sensitive and acceptable alternative screening methods.

Objectives Recently published clinical guidelines recommend cardiac resynchronisation therapy (CRT) for patients with heart failure (HF) with reduced LVEF and non-left bundle branch block (non-LBBB) QRS morphology. We sought to define the potential benefit of CRT in these patients through meta-analysis of randomised controlled trials (RCTs) that have reported outcomes in patients with non-LBBB QRS morphology. Methods We searched MEDLINE and EMBASE for RCTs of CRT that reported outcomes according to QRS morphology. We performed meta-analysis of these RCTs to assess the effect of CRT on the end points of death, HF hospitalisation, and the composite of death and HF hospitalisation. Results Five RCTs were analysed, including 6523 participants (1766 with non-LBBB QRS morphology). CRT was not associated with a reduction in death and/or HF hospitalisation in subjects with non-LBBB QRS morphology (HR 0.99 95% CI 0.82 to 1.20). Conclusions CRT is not associated with a reduction in death or HF hospitalisation in patients with non-LBBB QRS morphology. Wide QRS with non-LBBB morphology remains an area of uncertainty for CRT, which is included in the recent European Society of Cardiology guidelines with a weaker strength of recommendation, but is not supported by a dedicated RCT.

AIMS: To examine the utility of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) in the early diagnosis of cardiac implantable electronic device (CIED) generator pocket infection. METHODS AND RESULTS: A total of 86 patients with CIEDs were evaluated with (18)F-FDG PET/CT imaging: 46 with suspected generator pocket infection and 40 without any history of infection. (18)F-FDG activity in the region of the generator pocket was expressed as a semi-quantitative ratio (SQR)-defined as the maximum count rate around the CIED divided by the mean count rate between normal right and left lung parenchyma. All patients underwent standard clinical management, independent of the PET/CT result. Patients with suspected generator pocket infection that required CIED extraction (n = 32) had significantly higher (18)F-FDG activity compared with those that did not (n = 14), and compared with controls (n = 40) [SQR: 4.80 (3.18-7.05) vs. 1.40 (0.88-1.73) vs. 1.10 (0.98-1.40), respectively; P < 0.001]. On receiver operator characteristic analysis, SQR had a high diagnostic accuracy (area under curve = 0.98) for the early identification of patients with confirmed infection (i.e. those ultimately needing extraction)-with an optimal SQR cut-off value of >2.0 (sensitivity = 97%; specificity = 98%). CONCLUSION: This study highlights the potential benefits of evaluating patients with suspected CIED generator pocket infection using (18)F-FDG PET/CT. In this study, (18)F-FDG PET/CT had a high diagnostic accuracy in the early diagnosis of CIED generator pocket infection, even where initial clinical signs were underwhelming.

Purpose Higher caseloads are associated with better outcomes for many conditions treated in secondary and tertiary care settings, including colorectal cancer (CRC). There is little known whether such volume-outcome relationship exist in primary care settings. The purpose of this paper is to examine general practitioner (GP) CRC-specific caseload for possible associations with referral pathways, disease stage and CRC patients’ overall survival. Design/methodology/approach The paper retrospectively analyses a prospectively maintained CRC database for 2009-2014 in a single district hospital providing bowel cancer screening and tertiary rectal cancer services. Findings Of 1,145 CRC patients, 937 (81.8 per cent) were diagnosed as symptomatic cancers. In total, 210 GPs from 44 practices were stratified according to their CRC caseload over the study period into low volume (LV, 1-4); medium volume (MV, 5-7); and high volume (HV, 8-21 cases). Emergency presentation (LV: 49/287 (17.1 per cent); MV: 75/264 (28.4 per cent); HV: 105/386 (27.2 per cent); p=0.007) and advanced disease at presentation (LV: 84/287 (29.3 per cent); MV: 94/264 (35.6 per cent); HV: 144/386 (37.3 per cent); p=0.034) was more common amongst HV GPs. Three-year mortality risk was significantly higher for HV GPs (MV: (hazard ratio) HR 1.185 (confidence interval=0.897-1.566), p=0.231, and HV: HR 1.366 (CI=1.061-1.759), p=0.016), but adjustment for emergency presentation and advanced disease largely accounted for this difference. There was some evidence that HV GPs used elective cancer pathways less frequently (LV: 166/287 (57.8 per cent); MV: 130/264 (49.2 per cent); HV: 182/386 (47.2 per cent); p=0.007) and more selectively (CRC/referrals: LV: 166/2,743 (6.1 per cent); MV: 130/2,321 (5.6 per cent); HV: 182/2,508 (7.3 per cent); p=0.048). Originality/value Higher GP CRC caseload in primary care may be associated with advanced disease and poorer survival; more work is required to determine the reasons and to develop targeted intervention at local level to improve elective referral rates.

Background:\ud Subcutaneous implantable cardioverter defibrillators (S-ICD) are an alternative to conventional transvenous implantable cardioverter defibrillators (TV-ICD) in patients not requiring pacing. We sought to define the efficacy and safety of S-ICD through literature review.\ud \ud Methods:\ud We searched MEDLINE and EMBASE for studies evaluating efficacy and safety outcomes among patients undergoing S-ICD implantation. We performed narrative synthesis and pooled efficacy and safety outcomes across studies.\ud \ud Results:\ud 16 studies were included with 5,380 participants (mean age range 33–56 years). Short-term follow-up data were available for 1670 subjects. The commonest complication was pocket infection, affecting 2.7% (range 0–19%). Other complications included delayed wound healing (0.6%), wound discomfort (0.8%), haematoma (0.4%) and lead migration (0.3%). A total of 3.8% (range 0–12%) of S-ICDs were explanted. The commonest reason for explant was pocket infection. Mortality rates in hospital (0.4%) and during follow-up (3.4% from 12 studies reporting, 2.1% per person-years) were low. The number of patients experiencing ventricular arrhythmia varied across studies from 0 to 12%. Overall shock efficacy for treatment of ventricular arrhythmias exceeded 96%. Inappropriate shocks affected 4.3% (range 0–15%) of patients and was most commonly caused by T-wave oversensing.\ud \ud Conclusions:\ud Although long-term randomised data are lacking, observational data suggest shock efficacy, peri-procedural and short-term complication rates of the S-ICD are similar to TV-ICD, making the S-ICD a suitable alternative in patients without an indication for pacing.

BACKGROUNDPredicting which individuals will have a decline in left ventricular (LV) function after pacemaker implantation remains an important challenge. We investigated whether LV global longitudinal strain (GLS), measured by 2D speckle tracking strain echocardiography, can identify patients at risk of pacing-induced left ventricular dysfunction (PIVD) or pacing-induced cardiomyopathy (PICMP).METHODSFifty-five patients with atrioventricular block and preserved LV function underwent dual-chamber pacemaker implantation and were followed with serial transthoracic echocardiography for 12 months for the development of PIVD (defined as a reduction in LV ejection fraction (LVEF) ≥5 percentage points at 12 months) or PICMP (reduction in LVEF to RESULTSAt 12 months, 15 (27%) patients developed PIVD; of these, 4 patients developed PICMP. At one month, GLS was significantly lower in the 15 patients who subsequently developed PIVD, compared to those who did not (n = 40) (GLS -12.6 vs. -16.4 respectively; p = 0.022). When patients with PICMP were excluded, one month GLS was significantly reduced compared to baseline whereas LVEF was not. One-month GLS had high predictive accuracy for determining subsequent development of PIVD or PICMP (AUC = 0.80, optimal GLS threshold: CONCLUSIONSGLS is a novel predictor of decline in LV systolic function following pacemaker implantation, with the potential to identify patients at risk of PIVD before measurable changes in LVEF are apparent. GLS measured one month after implantation has high predictive accuracy for identifying patients who later develop PIVD or PICMP.

OBJECTIVE Implantation of biventricular devices (BiV) with a transvenous left ventricular lead is complex requiring a significant fluoroscopy time and radiation dose. In the United Kingdom, the Health Protection Agency (HPA) collects data regarding radiographic procedures and sets national diagnostic reference levels (DRL) at the 75th percentile of the distribution of doses for a wide range of procedures. Insufficient data were returned to the HPA to allow them to set DRL for BiV devices at the last publication in 2010. Due to the large variation in data available and small datasets for BiV procedures we aimed to collect a large dataset to guide standards for implantation. METHODS We collected retrospective data (fluoroscopy time and radiation dose [DAP]) for new BiV devices for the three years 2009-2011 from three high volume tertiary centres in the North West of England. Databases were scrutinised to ensure the quality of the data. RESULTS From a total of 1374 implants we identified data for 1319 patients for fluoroscopy time and 1316 for DAP. The mean fluoroscopy time for all three centres combined was 18.7±0.3 min. The 75th percentile fluoroscopy time for the combined data was 24.2 min. The mean DAP for the three centres combined was 25.1±1.3 Gy cm2. The 75th percentile DAP for the combined data was 27.7 Gy cm2. CONCLUSIONS We present a large dataset of new biventricular device implants, based on the 75th percentile data we suggest a DRL of 24.2 min and 27.7 Gy cm2.

A 58-year-old woman noticed right-hand jerky tremor exclusively while curling her hair. Her tremor-generating posture was reminiscent of the Asturian pourer of cider, or “escanciador,” who holds the bottle above the head when vertically pouring to aerate the liquid (figure). On examination, we asked her to hold a water bottle as if it were a hair curler. This elicited an action-induced, position-dependent, task-specific, weight-sensitive tremor, which attenuated when touching her affected hand with the unaffected one (closed-loop sensory feedback or sensory trick) (video 1). The rest of the examination was normal. These 5 clinical features distinguish dystonic tremor from all other tremor syndromes.1,2

Background: The use of pacemakers in the treatment of cardioinhibitory vasovagal syncope is controversial with a mixed message from the limited evidence base. Single chamber leadless pacemakers have been shown to be an effective alternative option to conventional pacemakers. Objective: This study examines the use of leadless pacemakers in a cardioinhibitory vasovagal population in the United Kingdom. Methods: Observational data on 32 patients implanted with the Micra Transcatheter Pacemaker System for vasovagal syncope are presented. Data was collected on implant indications, implant procedure and follow up data from 12 centres across the United Kingdom that had elected to use a Micra leadless pacemaker in this patient population. Results: 32 patients aged 37 ± 14 years (range 18 to 64 years) with 62% of the patients being female were recruited to the study. Vasovagal syncope was diagnosed clinically and with the support of Holter monitoring, tilt table testing and implantable loop recorders. The duration of symptoms was 8 ± 8 yrs. with an average frequency of syncope being 4 ± 6 times/year. The Micra pacemaker was successfully implanted in all patients with a major complication rate of 3.1%. Patients were followed up for 404 ± 237 days (range 63–928 days). At follow up 28 (87%) patients were free from symptoms. Conclusions: This observational study suggests that the use of a single chamber leadless pacemaker in the treatment of cardioinhibitory vasovagal syncope might be a reasonable clinical option. Keywords: Vasovagal, Cardioinhibitory, Syncope, Pacemaker, Leadless pacemaker, Micra

Due to expanding clinical indications and an aging society there has been an increase in the use of implantable pacemakers. At the same time, due to increased diagnostic yield over other imaging modalities and the absence of ionizing radiation, there has been a surge in demand for magnetic resonance imaging (MRI) assessment, of both cardiac and noncardiac conditions. Patients with an implantable device have a 50-75% chance of having a clinical indication for MRI during the lifetime of their device. The presence of an implantable cardiac device has been seen as a relative contraindication to MRI assessment, limiting the prognostic and diagnostic utility of MRI in many patients with these devices. The introduction of MRI conditional pacemakers will enable more patients to undergo routine MRI assessment without risk of morbidity or device malfunction. This review gives a general overview of the principles and current evidence for the use of MRI conditional implantable cardiac devices. Furthermore, we appraise the differences between those pacemakers currently released to market.

Pacing-induced ventricular dysfunction and pacing-induced cardiomyopathy (PiCMP) are recognized complications of chronic right ventricular pacing. Alterations in myocardial perfusion and sympathetic innervation contribute to the development of pacing-induced heart disease. However, it is unlikely that these are the only processes involved. Matrix metalloproteinases (MMPs) are proteolytic enzymes that degrade the collagenous extracellular matrix and play a central role in left ventricular remodelling during the development of heart failure. While the pathophysiological mechanisms and altered MMP expression that occur in chronic pressure overload, ischaemic and non-ischaemic dilated cardiomyopathy have been defined, those that occur in the clinical setting of pacing-induced ventricular dysfunction and PiCMP have not been reported. Here we review the clinical epidemiology of pacing-induced ventricular dysfunction and discuss how data derived from animal models provide insight into how changes in MMP expression and function contribute to the development of PiCMP. The review concludes by exploring pacing strategies that may be used to prevent pacing-induced ventricular dysfunction.

Primary headache disorders affect large number of people worldwide. Migraine and tension type headaches constitute 95% of all headaches. Both tension type headaches and migraine impose huge socioeconomic impact on society. The role of non-pharmacological interventions in management of primary headaches is not entirely clear. Acupuncture is one of the most historical non pharmacological ways of treating migraine and tension type headaches. The evidence in support of its effectiveness however is conflicting. This review evaluates the available evidence regarding effectiveness of acupuncture for migraine and tension type headaches.

Introduction:There are several options to achieve a sufficient safety margin in a patient with a high defibrillation threshold (DFT), with varying and typically modest success. Programming fixed (millisecond) durations of both phases of a biphasic waveform in an implantable cardioverter defibrillator (ICD) has demonstrated utility. Methods:We established an informal multisite registry of ICD implanting facilities. Each facility agreed to attempt the use of fixed duration waveforms whenever there was an inadequate safety margin with tilt-based waveforms. A 3.5-ms-based fixed duration shock was tried first. If that failed to achieve a 10-J safety margin then a 2-ms-based shock was used. We also tabulated an HEDFT (high estimate DFT) as precise DFTs were not determined. Results:Sixteen patients (15 M, 1 F) were entered into the registry (age 58.2 ± 17.9 years) with ejection fractions of .30 ±.11. Superior vena cava coils were used in 7 patients according to physician preference. The tilt-based HEDFTs were 35.4 ± 3.2 J delivered and 35.8 ± 3.3 J stored energy. The 3.5-ms based shocks were evaluated on 14 patients and the HEDFT fell to 23.4 ± 6.3 J delivered (P < 0.0001) and 26.2 ± 6.9 J stored energy (P < 0.0001). The 2-ms-based fixed duration shocks were then evaluated on 6 patients and the delivered energy HEDFT was 22.2 ± 5.8 J (P = 0.001 vs. tilt-based shocks) while the stored energy HEDFT was 27.9 ± 6.4 J (P = 0.01 vs. tilt-based shocks). Using the better of the two fixed duration waveforms, the mean safety margin was improved from −1.2 ± 1.9 J to 9.5 ± 5.9 J (P < 0.00001). Multivariate predictors of the safety margin improvement were the absence of the Superior Vena Cava (SVC) coil and absence of Ventricular fibrillation (VF) presentation. Four patients still required lead repositioning after the use of the fixed duration waveforms. No additional leads were implanted. Conclusion:The use of a selection of directly programmed fixed duration biphasic shocks had a striking impact on the HEDFT for these difficult patients. Adequate safety margins were obtained for 12 of 16 patients with no lead manipulation or other approaches.

Aims The incidence of cardiac device infection (CDI) more than 12 months following complex device implant (late infection) has not been extensively reported. Our objective was to compare both early (within 12 months) and late infection rates following complex device implantation. Methods and results Patients who received either a cardiac resynchronization therapy (CRT) device with or without a defibrillator (CRT-D or CRT-P), or a defibrillator alone [implantable cardioverter-defibrillator (ICD)], between March 2005 and December 2011 were studied retrospectively. The study endpoint was device removal due to CDI. A total of 496 patients underwent complex device implantation. There were 1883 patient years of follow-up. Mean age was 73 ± 8 years. Seventy per cent were male. Overall, 24 infections (4.8%) were identified; 6 infections were within 12 months (1.2%) and 18 (3.7%) infections at least 12 months following implant ( P < 0.025). The mean intervals between implant and infection were 6 months (±3.7) and 30 months (±14.4) in the early and late groups, respectively. Early infection rates (%) for ICD, CRT-P, and CRT-D devices were 1.5, 1.6, and 0.6, respectively. Corresponding late infection rates were 2.2, 2.1, and 6.4. The increased late infection rate was driven by increased CRT-D infection ( P < 0.01; compared with early CRT-D infection). Conclusion Early CDI rates are consistent with published data. Compared with early infection, late CDI rates are significantly increased and are due to CRT-D infection. These findings are consistent with emerging reports. Late CRT-D infection threatens to undermine the long-term costs and overall health gain from these devices.

Amir Zaidi speaks to Caroline Telfer, Assistant Commissioning Editor. Amir Zaidi qualified in 1989 from Manchester University (UK) and undertook postgraduate training in London and in the northwest of England. Dr Zaidi worked as a consultant cardiologist at Royal Bolton Hospital (Lancashire, UK) from 2002 until 2009 before moving to his current position of consultant at the Manchester Royal Infirmary (Manchester, UK). Dr Zaidi is currently the training program director for cardiology in North-Western Deanery and a member of the Cardiology Specialist Advisory Committee.

Danon disease is a rare X-linked lysosomal disease causing severe hypertrophic cardiomyopathy (LAMP2 cardiomyopathy) and an extremely poor prognosis in males, with several reported cases of sudden cardiac death despite the use of transvenous implantable cardioverter defibrillators (TV-ICD). We describe a case in which a TV-ICD was unable to defibrillate induced ventricular fibrillation (VF), but a wholly subcutaneous system (S-ICD) was successful in terminating induced VF and spontaneous ventricular tachycardia. These findings have relevance to the selection of device therapy in the management of these individuals and a wider group of young patients with severe hypertrophic cardiomyopathy.

KRAHN, A. D., et al.: Predicting the Outcome of Patients with Unexplained Syncope Undergoing Prolonged Monitoring. Patients with unexplained syncope are often considered candidates for prolonged monitoring or empiric pacing when noninvasive and invasive investigations fail to provide a diagnosis. Identifying the outcome of patients undergoing prolonged monitoring that would ultimately benefit from empiric pacing may permit a cost-effective approach to resolution of syncope. Two hundred and six patients (age 57 ± 18 years, 57% male) underwent prolonged monitoring with an implanted loop recorder for syncope of unknown origin. The median number of previous syncopal episodes was four (mean 29 ± 133). Prior tilt testing was performed in 63% of patients, and electrophysiological testing in 46%. Symptoms recurred during follow-up in 142 patients (69%). Recurrence was associated with bradycardia leading to pacemaker implantation in 35 patients (17.0%), tachycardia in 12 (5.8%), sinus rhythm in 63 (30.6%), neurally mediated syncope based on rhythm and clinical assessment in 22 (11%), and failed activation in 10 (5%). Logistic regression analysis of baseline variables found that age was the only independent variable that predicted the need for pacing, associated with a 3% increase in risk per advancing year of age (odds ratio 1.027, P = 0.026). Despite this finding, no age group could be identified in which the likelihood of requiring pacing exceeded 30%. Logistic regression also found that patients with structural heart disease were less likely to experience recurrent symptoms during monitoring (49% vs 78%, P = 0.001) and that advancing age was associated with earlier recurrence of symptoms (P = 0.01). The etiology of recurrent syncope is diverse and cannot be predicted by baseline clinical variables. Empiric pacing appears to have little role in the management of this patient population.

Ventricular oversensing in an implantable defibrillator may be associated with inappropriate shocks. We report a case of oversensing during implantable cardioverter-defibrillator (ICD) implantation, which occurred recurrently during manual lead impedance testing. The oversensing is determined to be normal device function, explained by the programmed parameters, and algorithms determining the related aspects of device function.

A 43-year-old man was admitted to the intensive treatment unit with refractory status epilepticus. He was treated with intravenous benzodiazepines, phenytoin and levetiracetam. His EEG was consistent with status epilepticus. MRI of the brain showed a high signal change in T2-weighted images (not suppressed on fluid-attenuated inversion recovery (FLAIR)) in the right frontal lobe with inferior extension to the cingulate gyrus. Similar changes were also noted in the superior aspect of the left cerebellar hemisphere (figure 1). Diffusion-weighted images (DWI) showed gyral restriction of diffusion in the right frontal lobe and …

Characteristic twiddling and lead macro-displacement are well-documented radiological hallmarks of Twiddler’s Syndrome. What is less well known is that the different variants of Twiddler’s Syndrome can be distinguished by assessing orientation of the pins on X-ray. Illustrations of a change in orientation of the header and pins are rarely reported in cases of pacemaker Twiddler’s Syndrome and the phenomenon has not been described in implantable cardioverter-defibrillator recipients. We highlight an important classic finding that is seldom depicted in the literature

Software-based metal artefact reduction (MAR) techniques are available to reduce artefacts from cardiac implantable electronic devices (CIED) in the CT data. The impact of disabling MAR techniques on quantification of 18F-FDG uptake around the CIED has not been examined. We consider the importance of enabling MAR in patients with suspected CIED infection to prevent inaccuracies in quantification of tissue tracer uptake on the attenuation-corrected PET images.

A 76 year old man with dilated ischaemic cardiomyopathy, severe left ventricular dysfunction, and left bundle branch block was admitted for implantation of a biventricular internal cardioverter-defibrillator. The procedure was performed via the left subclavian approach and pacing leads were implanted into the right atrium and right ventricle. Coronary sinus (CS) angiography …

s / International Journal of Surgery 12 (2014) S13eS117 S34 1056: EFFECT OF NEGATIVE PRESSURE INCISION CARE DRESSING ON WOUND INFECTION RATE IN COLORECTAL SURGERY: A PROSPECTIVE NON RANDOMIZED TRIAL Syed Muhammad Amir Zaidi, Wasif Majeed Chaudhry, Haseeb Anwar Khokhar, Hamid Majeed, Suhail Aslam Khan. Our Lady of Lourdes Hospital, Drogheda, Co Louth, Ireland. Introduction: Negative Pressure Incision care therapy (NPICT) has never been reported in colorectal surgery. The aim of this trial is to evaluate the effect of NPICT on wound infection rate. Methods: 317 consecutive patients underwent major colorectal procedures in a regional hospital over 3 years by a single team. 104 (32.1%) patients were excluded on the basis of other complications affecting LOS. Out of 213 patients included, 71 (33.3%) patients received NPICT, while 142 (66.6%) patients received regular dressings (Non-NPICT group). Study endpoints were rate of 30-day wound infection rate and LOS. Results: The mean age was 66.46 (NPICT) and 65.58 (Non-NPICT). Male to female ratio was 1:1.06(NPICT) and 1:1.04(Non-NPICT). Patients in NPICT group underwent at least 07 days of incision care therapy. 3 patients (4.2%) in NPICT group and 29 patients (20.4%) in Non-NPICT group developed wound complications [p 250pmol/L) leading to higher urinary losses of potassium (p1⁄40.03) and creatinine (p1⁄40.01). 19 patients 32%) demonstrated postprandial hypoglycaemia( 2 major system disorders in 21(16%) patients. Common referral sources to the MDT were surgical out-patients (42%), and endoscopy (13%). The average lead time from referral to index MDT discussion was 14-days. In phase II, ACE27 was administered in 50-patients, mean age-54-years (range 20-84). Male: female ratio 26: 24. Average time to administer ACE-27 was 4.8minutes (range 1-15). Conclusions: The phase I study confirmed the previously widely acknowledged view of poor co-morbidity data availability within a CRC

Introduction: Cardiac resynchronisation therapy (CRT) has been reported to significantly reduce one–year mortality from 12.6 percent to 9.7 percent when compared with optimal medical therpay for patients with heart failure. We aimed to establish whether improved one-year mortality rates continue to be observed in real world clinical practice. Methods: We performed post-hoc analysis of all patients implanted with new CRT devices at the Manchester Heart Centre between 04/01/2010 to 15/11/2011. Baseline characteristics were collected prospectively. Patient mortality at one-year was recorded using contemporaneous electronic records. Results: 228 patients received new CRT devices during the study period. Co-morbidities included diabetes mellitus (21%), ischaemic heart disease (65%) and chronic kidney disease (14%). 183 patients (86%) were in NYHA class III and 30 (13%) NYHA class IV. 42% of patients received a CRT-P device, the remainder (58%) received CRT-D. 29/228 patients (13%) died within 1-year of implantation (10% in CRT-P and 14% of CRT-D recipients). Age-adjusted Charlson score was significantly higher in patients who died within 1 year than those who survived (5.66 vs. 4.25; p

Introduction: Right ventricular (RV) pacing causes heart failure in up to 9% of patients. A priori identification of patients who will develop pacing induce heart failure (PIHF) represents an important challenge. We aimed to establish whether speckle tracking strain echocardiography (STE), performed soon after pacemaker implantation, can predict development of PIHF. Methods: Fifty-five patients with high-grade atrioventricular block underwent dual chamber pacemaker implantation. At baseline all patients had preserved LV ejection fraction (LVEF > 55%). Two-dimensional echocardiography and 12-lead electrocardiograms were performed before pacemaker implantation and repeated alongside pacemaker interrogation at one and six months. As a function of time, patients were grouped according to the cumulative percentage of ventricular pacing (Cum%VP), determined from pacemaker diagnostics at six months. Baseline, one and six month LVEF and STE findings for group 1 (Cum% VP > 40) were compared to cases where Cum%VP was

The patented Optim coating was designed to prevent insulation abrasions on the Durata lead (St Jude Medical, St Paul, Minnesota) and avoid the problems that had afflicted its predecessor, the Riata silicone lead (St Jude Medical). We report a case of external insulation failure 8 months after implantation of a dual-coil Durata lead and consider the potential causes of the failure.

R A L A B ST R A C T S used to guide the puncture in 23 pts. The site of the puncture was dilated with a 6mm (3 pts), later with an 8 mm balloon (28 pts). After the puncture of the left subclavian vein, an electrophysiological deflectable CS catheter was introduced into the CS sheath. The CS catheter was used to reach the left atrium and the left ventricle through the dilated transseptal puncture hole. At the latest LV activation site 65 cm active fixation bipolar lead was screwed into the LV wall. Results: The lead was fixed in the left ventricle in all cases with good pacing threshold values (0,85 0,4 V;0,4 ms). Puncture complication, pericardial effusion was not observed. Because of intraoperatively started anticoagulation therapy, pocket haematoma was observed postoperatively in three (10%) and needed evacuation in one case (3%). Follow-up is longer than one month in 30 patients (32 12 months). Significant improvement of the NYHA class was observed in all but one case (97%), on the first month control LV EF was 30 8% vs 37 7%. Early lead dislocation was noticed in two cases (6%), reposition was performed using the original puncture site in one, and transvenous implantation was succesfully carried out in the other case. Explantation of the system was necessary because of pocket infection in four cases (12%), in two of these cases TELVLI was carried out succesfully 3 months later. All patients were maintained on anticoagulation therapy either with warfarine or cumarine with INR between 2-3. No thromboembolic complication was noticed during the follow up. 2 patients were lost, one of them died five years after the implantation in renal failure, the other patient died in malignant tumor 4 years after the implantation. Conclusion: TELVLI approach might be a very promising alternative technique of the surgical epicardial procedure when transvenous implantation could not be applied, however more evidences and multicenter studies are needed to evaluate this method. Disclosure of Interest: L. Geller Consultancy for: Biotronik, Speakers bureau: Medtronic, Biotronik, St. Jude, Biosense, L. Molnar: None Declared, S. Szilagyi: None Declared, E. Zima: None Declared, G. Szeplaki: None Declared, I. Osztheimer: None Declared, T. Tahin: None Declared, E. Evren Ozcan: None Declared, B. Merkely: None Declared

Objectives We sought to investigate the value of cardiovascular tests to diagnose convulsive syncope in patients with apparent treatment-resistant epilepsy. Background As many as 20% to 30% of epileptics may have been misdiagnosed. Many of these patients may have cardiovascular syncope, with abnormal movements due to cerebral hypoxia, which may be difficult to differentiate from epilepsy on clinical grounds. Methods Seventy-four patients (33 men, mean age 38.9 +/- 18 years [range 16 to 77]) who were previously diagnosed with epilepsy were studied. Inclusion criteria included continued attacks despite adequate anticonvulsant drug treatment (n = 36) or uncertainty about the diagnosis of epilepsy, on the basis of the clinical description of the seizures (n = 38). Each patient underwent a head-up tilt test and carotid sinus massage during continuous electrocardiography, electroencephalography and blood pressure monitoring. Ten patients subsequently underwent long-term electrocardiographic (ECG) monitoring with an implantable loop recorder. Results In total, an alternative diagnosis was found in 31 patients (41.9%), including 13 (36.1%) of 36 patients taking an anticonvulsant medication. Nineteen patients (25.7%) developed profound hypotension or bradycardia during the head-up tilt test, confirming the diagnosis of vasovagal syncope. One other patient had a typical vasovagal reaction during intravenous cannulation. Two patients developed psychogenic symptoms during the head-up tilt test. Seven patients (9.5%) had significant ECG pauses during carotid sinus massage. In two patients, episodes of prolonged bradycardia correlated precisely with seizures according to the insertable ECG recorder. Conclusions A simple, noninvasive cardiovascular evaluation may identify an alternative diagnosis in many patients with apparent epilepsy and should be considered early in the management of patients with convulsive blackouts.

OBJECTIVE—To investigate the haemodynamic effects of varying the angle of head up tilt. METHODS—20 healthy subjects (12 female, eight male; mean (SD) age 33.6 (8.4) years) underwent head up tilt for five minutes to each of four angles of tilt in random order, with a five minute rest period at the horizontal between each angle. Forearm blood flow was measured using intermittent occlusion mercury strain gauge plethysmography at two and five minutes. Subjects underwent continuous monitoring of heart rate, systolic blood pressure (SBP), and diastolic blood pressure (DBP) by Finapres and cardiac output and stroke volume by impedance cardiography. Each variable was measured at two and five minutes, averaged over the period of blood flow measurement. RESULTS—Every haemodynamic variable at each angle was significantly different from supine values. Head up tilt produced progressive increases in heart rate (11-21%), SBP (12-21%), and DBP (20-33%) with increasing tilt angle. However, although 45° produced significantly less haemodynamic effect, there were no significant differences for angles between 60° and 90°. Cardiac output fell on head up tilt by 17-20% and stroke volume by 28-34%, but increasing tilt angle produced no significant additional reduction in cardiac output and stroke volume because of increases in heart rate and vasoconstriction. CONCLUSIONS—Angles

Convulsive syncope due to transient bradycardia is recognized as a cause of treatment-resistant seizures. However, the diagnosis may be difficult to make with conventional electrocardiographic devices if attacks are infrequent. We present a case of apparent epilepsy in which a new implantable electrocardiographic event recorder (the ‘Reveal’ insertable loop recorder) was used to show that attacks were caused by prolonged asystole of up to 36 s in duration. The insertable loop recorder may have an important role in the investigation of patients with treatment-resistant seizures, particularly where there is a strong suspicion of an underlying cardiac arrhythmia.

Diabetic amyotrophy is a distinctive form of diabetic neuropathy. It is characterised by a weakness and wasting of proximal muscles of the lower limbs with associated pain. We report a case of an elderly patient with unusual presentation of diabetic amyotrophy. He presented with myoclonic jerks and recurrent falls. Examination findings and electrophysiological studies were consistent with a diagnosis of diabetic amyotrophy. He responded well to steroids with marked improvement in strength of the lower limb muscles and complete resolution of myoclonic jerks. Diabetic amyotrophy presenting as myoclonic jerks has been rarely reported before.

Tilt-table testing for patients with unexplained syncope was first described in 1986 by Kenny et al. [(1)][1] and later by Almquist et al in the U.S. [(2)][2]. The tilt protocols proposed differed, with the Westminster Protocol favoring prolonged passive tilt alone [(1,3)][1] and the Minneapolis