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The number of procedures for upgrading implantable devices for cardiac resynchronization therapy has increased considerably during the last decade. A major challenge that operators face in these circumstances is occlusion of the access vein. We have modified a pull-through method to overcome this obstacle. Six consecutive patients with occluded access veins and well-developed collateral networks underwent a procedure in which the occluded vein was recanalized by snaring the existing atrial lead via transfemoral access. Upgrading the device was successful in all patients; none had intraprocedural complications. Our experience shows that our modified pull-through technique may be a feasible alternative for upgrading cardiac resynchronization therapy in patients with venous occlusion., (© 2020 by the Texas Heart® Institute, Houston.)

Background: Aldosterone antagonists have been proven to be beneficial in severe heart failure (HF) as a result of systolic dysfunction. We sought to determine if there is a disparity in their utilization compared with ACE inhibitors and beta-adrenoceptor antagonists (beta-blockers)., Methods: In the first part of the study, we asked physicians to answer a questionnaire presenting a hypothetical HF patient. In the second part, we reviewed hospital charts of patients with HF exacerbation., Results: Spironolactone was used less frequently than other drugs. At home, 75.0% of patients were receiving ACE inhibitors, 66.7% received beta-blockers, and 38.2% received spironolactone (p < 0.001). During the admission, 93.1% of patients received ACE inhibitors and 58.3% received spironolactone (p < 0.001)., Conclusions: Despite good evidence, underutilization of aldosterone antagonists in patients matching the population of the RALES (Randomized Aldactone Evaluation Study) trial persists in both outpatient and inpatient settings. The difference between the usage of ACE inhibitors and spironolactone is significant in patients with systolic dysfunction equally qualifying for both medications.