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A 75-year-old man attended a yearly pacemaker check. His VVIR device was inserted in 2008 for atrial fibrillation with a slow ventricular rate. He subsequently developed ischaemic cardiomyopathy, severely impaired left ventricular (LV) function and underwent tissue aortic valve replacement in 2010. During the pacemaker check he suffered a cardiac arrest consisting of Torsades-de-Pointes and ventricular fibrillation. Cardiopulmonary resuscitation and a single DC shock restored spontaneous circulation, subsequent examination and bloods were unremarkable. Scrutiny of the pacemaker tracings revealed the cause (figure 1). Figure 1 Ventrictular capture …

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

A 52-year-old woman presented for investigation of exertional chest pain. Her medical history included an atrial septal defect; this was extensively investigated with right and left heart catheterizations at 13 years. There were complications related to this investigation, and further details were unavailable. The atrial septal defect was surgically repaired at 15 years; she had a subarachnoid hemorrhage, resulting in clipping of a middle cerebral artery aneurysm in 1999. She had bilateral inguinal scarring with normal femoral pulsation and distal limb pulsation; physical examination was otherwise unremarkable. She was a current smoker, and her total cholesterol level was 5.6 mmol/L (low-density lipoprotein, 3.8 mmol/L). Resting ECG showed a sinus rhythm with partial right bundle branch block and T-wave flattening in leads V2 through V6. Transthoracic echocardiogram was normal. Exercise stress testing with a standard Bruce protocol resulted in 2 mm of inferolateral ST-segment depression in Stage 2 (7 METS). In light of these results, she came forward for elective coronary angiography. The procedure was undertaken by means of a right femoral artery approach. The vessel …

to the editor: The heart rate of the athlete can be

Femoral vein phlebotomy is a commonly used technique to obtain venous blood in situations where peripheral venous access is not possible. It is often performed by junior medical staff members and there is little formal teaching of the technique. There are no good research articles on safe postprocedural management or of complication rates. Furthermore, few medical textbooks deal with the procedure beyond demonstration of the femoral neurovascular anatomy. Information available recommends compression times of between 3–15 min following femoral arterial blood sampling in patients with normal coagulation parameters.1 2 There are no guidelines available in the literature for compression times following femoral venous puncture. The authors report a case of life threatening occult haemorrhage following apparently unsuccessful femoral venepuncture. This case demonstrates the importance of post procedural care in all cases of invasive central venous access.