Search

Background: Cardiac resynchronization therapy-defibrillators (CRT-D) are devices established as treatment for symptomatic heart failure patients at risk of sudden cardiac death. Battery depletion poses a significant clinical and economic burden; extended service life may reduce costs because of generator changes and associated complications. Objective: This study estimated cost-savings associated with extended battery longevity in Medicare patients receiving CRT-D implantation. Methods: A decision tree was used to explore 3 battery capacities: 1.0 ampere-hours (Ah), 1.6Ah, and 2.1Ah. Yearly risk of all-cause mortality, device-related complications, and end of battery life were estimated. Over 6 years, estimated costs included device implantation, replacement, follow-up appointments, and complications. Results: The average total costs to Medicare over 6 years were $41,527, $48,515, and $56,647 per person (USD 2023) for the 2.1 Ah, 1.6 Ah, and 1.0 Ah, respectively. The total per-person replacement cost for the 1.0-Ah devices was more than 4 times that of the 2.1-Ah devices ($20,126 vs $5,006). When extrapolated to the total number of CRT-D implants over a 6-year period, the difference in costs between 2.1-Ah and 1.0-Ah battery capacity exceeded $500 million. Conclusion: Extended longevity CRT-D batteries demonstrate significant cost savings to Medicare over 6 years. These data indicate long-term economic considerations should be included in device selection.

Introduction: Vasodilator stress cardiovascular magnetic resonance (CMR) is a powerful diagnostic modality, but data toward its use in patients with permanent pacemakers (PPMs) or implantable cardioverter‐defibrillators (ICDs) is limited. Methods and Results: Patients with ICDs (>1% pacing) or PPMs who underwent regadenoson single photon emission computed tomography (SPECT) and all patients with ICDs or PPMs who underwent stress CMR were retrospectively identified. SPECT tests were analyzed for hemodynamic responses and new pacing requirements; CMR studies were examined for safety, device characteristics and programming, hemodynamic responses, and image quality. Changes from baseline were evaluated with the Related‐Samples Wilcoxon Signed Rank Test. Of 67 patients (median age 65 [IQR 58–72] years, 31 [46%] female, 31 [46%] Black), 47 underwent SPECT and 20 CMR. With regadenoson SPECT, 89% of patients experienced tachycardic responses above resting heart rates (+19 [13–32] beats per minute, p <.01). During stress CMR, 10 (50%) devices were asynchronously paced approximately 10 beats per minute above resting rates, and the remaining were temporarily deactivated. Those with asynchronous pacing had no changes in heart rates, whereas patients with deactivated devices had near uniform heart rate accelerations. Image quality was diagnostic in the majority of stress CMR sequences, with nonconditional ICDs contributing 40 of 57 (70%) of nondiagnostic segments. Conclusion: This data supports the safety of vasodilator stress CMR with promising diagnostic quality images in patients with CMR conditional ICDs and PPMs. Despite a near uniform tachycardic response to regadenoson in the SPECT environment, high rates of asynchronous pacing during vasodilator stress CMR did not result in competitive pacing or adverse arrhythmic events. Further studies are needed to validate these findings and confirm the diagnostic and prognostic performance of stress CMR in these individuals. [ABSTRACT FROM AUTHOR]

Abstract Aims This study aims to investigate the current status of biventricular pacemaker and defibrillator implantation in chronic heart failure (CHF) patients with indications for primary prevention of sudden cardiac death (SCD) in China and the effects of cardiac resynchronization therapy (CRT)‐pacemaker (P) and CRT‐defibrillator (D) implantation on the clinical prognosis of CHF among patients undergoing CRT. Methods and results Overall, 798 consecutive patients who had devices implanted (implantable cardioverter defibrillator: 199, CRT‐D: 362, and CRT‐P: 237) from May 2012 to July 2013 in POSCD‐China, a multicentric prospective cohort study, were enrolled. The primary endpoint was all‐cause death, and the secondary endpoint was SCD. In total, 71.3% of patients had non‐ischaemic CHF. The mean follow‐up time was 27.7 ± 12.0 months, and death occurred in 158 cases, with 35 cases of SCD. CHF was the main cause of death (68.4%), followed by sudden death (22.2%). In the CRT‐P group, the SCD rate was 8.0%, which was much higher than that in the CRT‐D (3.3%) and implantable cardioverter defibrillator (2.0%) groups. No significant differences were identified in the all‐cause death rate between the CRT‐D and CRT‐P groups (CRT‐D vs. CRT‐P, 20.4% vs. 19.4%, P = 0.840). Conclusions In China, among CHF patients with indications for primary prevention of SCD who received device implantation, non‐ischaemic CHF was the main aetiology, and the most important cause of death was heart failure. No differences in all‐cause death were observed between the CRT‐D and CRT‐P groups, but the CRT‐D group had a lower SCD rate than the CRT‐P group.

Background: Cardiac resynchronization therapy-defibrillators (CRT-D) are devices established as treatment for symptomatic heart failure patients at risk of sudden cardiac death. Battery depletion poses a significant clinical and economic burden; extended service life may reduce costs because of generator changes and associated complications., Objective: This study estimated cost-savings associated with extended battery longevity in Medicare patients receiving CRT-D implantation., Methods: A decision tree was used to explore 3 battery capacities: 1.0 ampere-hours (Ah), 1.6Ah, and 2.1Ah. Yearly risk of all-cause mortality, device-related complications, and end of battery life were estimated. Over 6 years, estimated costs included device implantation, replacement, follow-up appointments, and complications., Results: The average total costs to Medicare over 6 years were $41,527, $48,515, and $56,647 per person (USD 2023) for the 2.1 Ah, 1.6 Ah, and 1.0 Ah, respectively. The total per-person replacement cost for the 1.0-Ah devices was more than 4 times that of the 2.1-Ah devices ($20,126 vs $5,006). When extrapolated to the total number of CRT-D implants over a 6-year period, the difference in costs between 2.1-Ah and 1.0-Ah battery capacity exceeded $500 million., Conclusion: Extended longevity CRT-D batteries demonstrate significant cost savings to Medicare over 6 years. These data indicate long-term economic considerations should be included in device selection., Competing Interests: Ryoko Sato and Caroline M. Jacobsen are full-time employees of Boston Scientific. Jeffrey L. Williams is a Clinical Cardiac Electrophysiologist at the James A. Haley Veterans Affairs Medical Center in Tampa, FL. Jeffrey L. Williams was not compensated for his participation in this study.

Cardiac pacemakers are one of the most frequently encountered cardiac devices seen on chest imaging. They may include single or dual chamber pacemakers, automated implantable cardioverter defibrillators (AICD), biventricular pacemakers used for cardiac resynchronisation therapy (CRT), wireless CRT, leadless pacemakers, and subcutaneous implantable cardioverter defibrillators (SICD). This review aims to provide an up‐to‐date review on current implantable pacemaker and defibrillator devices. [ABSTRACT FROM AUTHOR]

There is a presentation of the results of a two-year follow-up after surgical treatment of a patient with chronic heart failure and a permanent form of atrial fibrillation, in which isolated apex hypoplasia and non-compaction of left ventricular myocardium were revealed.

The Task Force for the diagnosis and management of syncope of the European Society of Cardiology (ESC)Developed with the special contribution of the European Heart Rhythm Association (EHRA)Endorsed by: European Academy of Neurology (EAN), European Federation of Autonomic Societies (EFAS), European Federation of Internal Medicine (EFIM), European Union Geriatric Medicine Society (EUGMS), European Society of Emergency Medicine (EuSEM)(text is available in electronic version doi:10.15829/1560-4071-2019-7-130-194)

Aim. To study the possibility of using of heart rate turbulence (HRT) and deceleration capacity (DC) in the risk stratification of fatal events in patients with coronary artery disease (CAD) and implanted cardioverter defibrillator (ICD).Material and methods. The study included 45 patients with sinus rhythm and verified CAD, who had indications for ICD. A 24-hour ECG monitoring was performed with the evaluation of non-invasive predictors of sudden cardiac death. The minimum observation period was 30 months (the average observation period was 48 (42;51) months). Two endpoints were assessed: the onset of deaths and the justified ICD actuations.Results. During the observation period, 10 patients died (5 from progression of heart failure, 2 from recurrent myocardial infarction, 2 from non-cardiac pathology, and 1 died suddenly before implantation of a defibrillator). Arrhythmic events occurred in 13 people. Compared to the surviving patients, deceased patients’ mean DC value was significantly lower (1,25 (0,48;2,23) ms vs 3,3 (1,85;5,40) ms, p=0,016). There were significantly more frequent DC in the high-risk zone (80% vs 34%, p=0,024) and type 2 HRT disorders (80% vs 29%, p=0,009). When comparing patients with arrhythmic events and without them, no significant differences in DC and HRT were detected. According to univariate regression analysis, HRT and DC were risk factors for death (p=0,004 and p=0,006, respectively).Conclusion. Electrophysiological markers reflecting vegetative imbalance (HRT and DC) in patients with CAD and ICD can identify patients with high risk of overall mortality, but it is not associated with the risk of ventricular tachyarrhythmias development.

Background. Implementation of mechanical circulatory support and heart transplantation technologies in paediatric clinical practice is changing approaches of diagnostics and treatment of heart failure (HF) in children. The experience of carrying out such operations in Russian Federation is extremely limited until recently due to absence of legal mechanisms of people declaration of intention recording about postmortal use of organs for transplantation.Clinical Case Description. The rare clinical case of drug-refractory (cardiotonic agents and cardioverter defibrillator implantation) chronic cardiac failure caused by post-myocarditis dilated cardiomyopathy (DCM) which demanded heart transplantation. Postoperative course, specific and non-specific complications, diagnostics and correction approaches are described.Conclusion. In the absence of proper analysis of non-specific slight symptoms myocarditis can progress to DCM and be complicated by development of refractory HF. The only method of sustaining child’s life in such case is heart transplantation which is connected with high risk of numerous and life-threatening complications.

The objective of the present work is to conduct a Health Technology Assessment (HTA) on the use of the Wearable Cardioverter Defibrillator (WCD) in patients at risk of Sudden Cardiac Arrest (SCA) following Myocardial Infarction (MI) or with an explanted Implantable Cardioverter Defibrillator (ICD).

Aim: Cardiac death due to ventricular arrhyhtmias can occur in patients with ICD (implantable cardioverter defibrillator) for secondary prevention. The aim of this study is to assess the prognostic value of electrocardiographic ventricular repolarization parameters in patients with secondary prevention. Materials and Methods: Sixty five patients with ICD for secondary prevention after sustained ventricular tachycardia, ventricular fibrillation or sudden cardiac death were enrolled to the study retrospectively. Patients were divided into groups according to mortality during a follow up period of 4,5 years (48 patients alive and 17 dead). Heart rate, QT, QTc and T peak T end (Tp-e) duration were measured from 12 derivations ECG electronically. Results: Mean age of the study population was 70.6±11.9 years. Ventricular repolarization parameters such as QT, QTc, Tp-e duration and Tp-e index values were found to be similar between deaths and live patient groups. Patients who died during the follow-up had advanced age (68.7±12.5 vs 76.8±10.3 years, p=0.009), lower left ventricular ejection fraction percentage (LVEF %) (37.6±13.3 vs 26.9±9.2, p=0.003) and lower estimated glomerular filtration rate (81.2±22.5 vs 61±34.3 ml/min/m2, p=0.03). Arrhythmic death patients only had lower LVEF % than non-arrhythmic death patient’s group. Conclusions: In patients with ICD for secondary prevention QT, QTc, Tp-e duration and Tp-e index were not related to mortality. [ABSTRACT FROM AUTHOR]

It is unnecessary for wearable cardioverter defibrillator (WCD) to be implanted, and the device can be worn and took off at any time, very applicable for emergency defibrillation in the population with high risk of sudden death. The currently listed WCD devices are only LifeVest series produced by American ZOLL Medical Corporation, and the users include over 100 000 cases of patients in Europe and America. Remote ECG monitoring is regarded as a double insurance of WCD. Manipulation by using WCD's automatic programs, coupled with manual intervention of remote ECG, can further improve its efficacy and safety, reduce misoperation, improve accuracy of cardiac defibrillation, and save more lives. This paper briefly illustrates the status of WCD clinical application at home and abroad, introduces its composition and structure, the scopes of clinical application, and proposes its dis- advantages and promotion limitations. China is suggested combining the advantages of WCD and remote ECG analy- sis center, and developing WCD service system with Chinese characteristics. [ABSTRACT FROM AUTHOR]

Aims: This study aims to investigate the current status of biventricular pacemaker and defibrillator implantation in chronic heart failure (CHF) patients with indications for primary prevention of sudden cardiac death (SCD) in China and the effects of cardiac resynchronization therapy (CRT)‐pacemaker (P) and CRT‐defibrillator (D) implantation on the clinical prognosis of CHF among patients undergoing CRT. Methods and results: Overall, 798 consecutive patients who had devices implanted (implantable cardioverter defibrillator: 199, CRT‐D: 362, and CRT‐P: 237) from May 2012 to July 2013 in POSCD‐China, a multicentric prospective cohort study, were enrolled. The primary endpoint was all‐cause death, and the secondary endpoint was SCD. In total, 71.3% of patients had non‐ischaemic CHF. The mean follow‐up time was 27.7 ± 12.0 months, and death occurred in 158 cases, with 35 cases of SCD. CHF was the main cause of death (68.4%), followed by sudden death (22.2%). In the CRT‐P group, the SCD rate was 8.0%, which was much higher than that in the CRT‐D (3.3%) and implantable cardioverter defibrillator (2.0%) groups. No significant differences were identified in the all‐cause death rate between the CRT‐D and CRT‐P groups (CRT‐D vs. CRT‐P, 20.4% vs. 19.4%, P = 0.840). Conclusions: In China, among CHF patients with indications for primary prevention of SCD who received device implantation, non‐ischaemic CHF was the main aetiology, and the most important cause of death was heart failure. No differences in all‐cause death were observed between the CRT‐D and CRT‐P groups, but the CRT‐D group had a lower SCD rate than the CRT‐P group. [ABSTRACT FROM AUTHOR]

Johannes Sperzel,1 Ingo Staudacher,2 Olaf Goeing,3 Martin Stockburger,4 Thorsten Meyer,5 Ana Sofia Oliveira Gonçalves,6 Hanna Sydow,6 Tonio Schoenfelder,6 Volker Eric Amelung6 1Department of Cardiology, Hospital Kerckhoff Klinik GmbH, Bad Nauheim, Germany; 2Department of Cardiology, Medical University Hospital Heidelberg, Heidelberg, Germany; 3Department of Cardiology, Sana-Hospital Lichtenberg, Berlin, Germany; 4Medical Department I, Havelland Kliniken GmbH, Nauen, Germany; 5Department of Public Health, Universität Bielefeld, Bielefeld, Germany; 6Institute for Applied Health Services Research, inav – privates Institut für angewandte Versorgungsforschung GmbH, Berlin, GermanyWe read with great interest the article “Wearable cardioverter defibrillators for the prevention of sudden cardiac arrest: a health technology assessment and patient focus group study” by Ettinger et al. The authors conclude that wearable cardioverter defibrillators (WCDs) seem to be fairly safe in the short-to-medium term, but the quality of the available evidence is low. They also state that – according to their study inclusion criteria – they were not able to identify studies to assess the clinical effectiveness of the WCD. Given the importance of WCD for its target population and considering our clinical expertise, we see a particular need to clarify some points of this article.Author's ReplySabine Ettinger,1 Michal Stanak,1 Piotr Szymański,2 Claudia Wild,1 Romana Tandara Haček,3 Darija Erčević,3 Renata Grenković,3 Mirjana Huić31Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria; 2Institute of Cardiology, Warsaw, Poland; 3Department for Development, Research and Health Technology Assessment, Agency for Quality and Accreditation in Health Care and Social Welfare, Zagreb, CroatiaWe read the letter to the editor with regard to our published paper on “Wearable cardioverter defibrillators for the prevention of sudden cardiac arrest: a health technology assessment and patient focus group study” and gladly take the opportunity to appropriately address and clarify the issues that were raised. View the original paper by Ettinger and colleagues.

Introduction: Patients with implantable cardioverter defibrillator require physical therapy due to their decreased physical fitness. This is why standardized training has been designed for groups of subjects of varying endurance. Material and methods: Patients with heart failure and implantable cardioverter defibrillator who wished to do interval training program. The program included 55 patients. We divided them into two study groups. The first group had lower exercise tolerance level (3.94 ± 0.72 MET), and the other had higher exercise tolerance level (7.97 ± 1.80 MET). The training group had an 8-week long training program. The patients received treatment at an outpatient clinic three times a week. Patients had cardiac stress tests with modified Bruce protocol before receiving physical therapy and after they have finished the training program. We assessed the metabolic equivalent of task (METS), the duration of exercise, blood pressure, heart rate and BMI. Results: We observed longer duration of cardiac stress test performance and improvement of exercise tolerance. In patients from the group with lower exercise tolerance, the level of exercise tolerance was 3.94 ± 0.72 MET before therapy and rose to 5.93 ± 1.12 MET (p < 0.001) after therapy. In the group of higher exercise tolerance, the level was 7.97 ± 1.80 MET before therapy and rose to 9.32 ± 2.01 MET (p < 0.001) after the training cycle. Conclusions: Participation in 8-week interval training cycle resulted in greater increase of exercise tolerance and exercise time, as well as hemodynamic parameters in patients with lower exercise tolerance. [ABSTRACT FROM AUTHOR]

Introduction: The implantation of a heart pacemaker or cardioverter-defibrillator brings with it several advantages, positive sides, but it also carries certain limitations, negative sides. It should be emphasized that the choice of device depends on the medical diagnosis, the specific needs of the patient and the clinical decision of the physician. Each patient is unique, so therapy and device selection are individually tailored to achieve the best possible care. The positive aspects of implantation these devices are the preservation of a stable heart rhythm, prolongation of life, prevention of syncope, gives the patient individual therapy and the possibility of combining different therapeutic options. However, it is important to recognize the negative side of device implantation, such as the need for a surgical procedure during implantation, potential complications during the implantation procedure, regular check-ups of device, the possibility of improper stimulation, dependence on constant stimulation and device battery replacement. Case report: We present the case of a young patient who started treatment in another hospital, but due to complications that occurred during the therapy, the treatment continues at University Hospital Centre Rijeka. In the patient’s case, a cardioverter-defibrillator was implanted to identify and prevent lifethreatening arrhythmias. Although initially, after installation, the device recognized life-threatening arrhythmias and prevented sudden cardiac death, there were complications that highlighted the negative sides of the pacemaker and consequently negatively affected his quality of life. [ABSTRACT FROM AUTHOR]

Persistence of the left superior vena cava (PLSVC) is a congenital anomaly reported in 0.3–0.5% of patients. Due to the multiple and complex anatomical variations, transvenous lead placement can become challenging. We report the case of a 47-year-old patient diagnosed with non-ischemic dilated cardiomyopathy with reduced left ventricular ejection fraction (LVEF—27%), who was referred to our clinic for implantation of a dual-chamber cardioverter defibrillator for primary prevention of sudden cardiac death. During the procedure we encountered an abnormal guidewire trajectory and after venographic examination we established the diagnosis of persistent left superior vena cava. After difficult implantation of a 7F defibrillation lead through the coronary sinus, we managed to place the atrial lead through a narrow brachiocephalic vein into the right atrial appendage. In this paper, we aim to illustrate the medical and technical implications of implanting a cardioverter defibrillator in patients with PLSVC, highlighting the benefit of identifying and utilizing both the innominate vein, and the left superior vena cava and coronary sinus for placement of multiple leads, which would otherwise have been impossible.

Anaphylactic shock is a life-threatening condition which needs detailed and mediculous clinical assessment and thoughtful treatment. Several causes can join forces in order to degranulate mast cells. Amiodarone which is an iodine-containing highly lipophilic benzofuran can induce allergic reactions and anaphylactic shock in sensitized patients. Epinephrine is a life saving drug, but in sulfite allergic patients it should be given with caution due its metabisulfite preservative. Metals covering cardiac defibrillators and pacemakers can act as antigens attached to serum proteins and induce allergic reactions. In anaphylactic shock, myocardial involvement due to vasospasm-induced coronary blood flow reduction manifesting as Kounis syndrome should be always considered. Clinically, combined treatment targeting the primary cause of anaphylaxis together with protection of cardiac tissue seems to be of paramount importance.

Background: Left cardiac sympathetic denervation (LCSD) is a surgical procedure that has been shown to have an antiarrhythmic and antifibrillatory effect. Evidence indicating its antiarrhythmic effect has been available for over 100 years. It involves the removal of the lower half of the stellate ganglion and T2-T4 of the sympathetic ganglia and is carried out as either a unilateral or bilateral procedure. With advancements in thoracic surgery, it can be safely performed via a minimally invasive Video-Assisted Thoracoscopic Surgery (VATS) approach resulting in significantly less morbidity and a shortened inpatient stay. LCSD provides a valuable treatment option for patients with life-threatening channelopathies and cardiomyopathies. Aims and Methods: This case series reports the preliminary paediatric and adult experience in the Republic of Ireland with LCSD and describes five cases recently treated in addition to an outline of the operative procedure employed. Of the five cases included, two were paediatric cases and three were adult cases. Results: One of the paediatric patients had a diagnosis of the rare catecholaminergic polymorphic ventricular tachycardia (CPVT) and the other a diagnosis of long-QT syndrome. Both paediatric patients experienced excellent outcomes. Of the three adult patients, two benefitted greatly and remain well at follow-up (one inappropriate sinus tachycardia and one CPVT). One patient with idiopathic ventricular fibrillation unfortunately passed away from intractable VF despite all attempts at resuscitation. Conclusion: In this case series, we highlight that LCSD provides a critical adjunct to existing medical therapies and should be considered for all patients with life-threatening refractory arrhythmias especially those patients on maximal medical therapy. [ABSTRACT FROM AUTHOR]

The case report documents young man with myocarditis as a etiology of irreversible left ventricular dysfunction. Myocarditis is the pathological result of myocardial infection and autoimmunity that causes active inflammatory destruction of myocytes. In our case fibrotic scar tissue was documented with magnetic resonance imaging in the left ventricle and interventricular septal tissue. Malignant arrhythmia was the etiology of aborted sudden cardiac death in the acute phase and few months later. Case describes the process of differential diagnosis of acute phase after ventricular tachycardia at the emergency department. Prognosis of patients after myocarditis is not easy to estimate. In this case the patient's prognosis is relatively better due to implantation of the cardioverter defibrillator device and exclusion of the fulminant progression of the heart failure. [ABSTRACT FROM AUTHOR]

One of the clinical scenarios of hypertrophic cardiomyopathy (HCMP) is sudden cardiac death (SCD). The stratification of SCD risk is the key component of defining the therapeutic strategy in HCMP patients. Timely preventive treatment is the only life-saving intervention in patients with high SCD risk. The available clinical evidence suggests that SCD risk stratification is an effective algorithm for determining the need for preventive treatment. The latter should be individualised, based on the risk levels in each patient.

Myoclonus is a sudden and brief involuntary muscle contraction presenting with jerk-like movements that can occasionally involve the trunk muscles or the diaphragm as in the case of spinal myoclonus1. We here present an unusual case with unilateral diaphragmatic myoclonus owing to electrode dislocation of an implantable cardioverter defibrillator. [ABSTRACT FROM AUTHOR]

Background: Brugada syndrome is an arrhythmogenic disease characterized by an ECG pattern of ST-segment elevation in the right precordial leads and an increase risk of sudden cardiac death. Risk stratification for the life-threatening arrhythmic events in Brugada syndrome is not yet established. In the present study, we report our experience in patients with Brugada syndrome, following an ICD implantation.Methods and Results: A total of 12 patients (11 men, 1 woman) with a mean age of 46.5±11.8 were studied. At diagnosis, 7 patients had syncope of unknown origin, 2 patients were asymptomatic, 2 patients were survivors of cardiac arrest, and 1 had documented clinical VT requiring direct cardioversion for termination. Age was similar between the symptomatic and asymptomatic patients (46.6±13 vs. 46±2.8, respectively). Two patients reported a family history of sudden cardiac death. In 3 patients, spontaneous coved-type ECG was found at baseline. In 9 patients, a class I antiarrhythmic drug administration unmasked the characteristic type I ECG. In 4 patients (2 symptomatic with syncope at presentation and 2 asymptomatic), who underwent PES, sustained polymorphic VT or VF was induced. VF was induced by single extrastimuli in 2 symptomatic patients (1 from RV apex and 1 from RVOT). In 2 asymptomatic patients, VF was induced by two and triple ventricular extrastimli (1 from RV apex and 1 from RVOT). None of them experienced an event during follow-up. No significant difference was found between symptomatic and asymptomatic patients (p=NS). The mean follow-up period for the entire study population was 27.83±11.25 months. During follow-up, 2 patients (one with prior cardiac arrest and another with syncope) had VF. Both of them had a type I ECG after provocation with a class I antiarrhythmic drug. None of them had undergone programmed ventricular stimulation. Five patients (41.7 %) had inappropriate ICD interventions during follow-up. The cause of inappropriate therapy was sinus tachycardia in 2 patients, AF in 2 patients and T wave oversensing in 1 patient. Conclusions: Knowledge about Brugada syndrome is steadily progressing but there are still unanswered issues dealing with the risk stratification and the management of patients.

Background Primary prevention implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients with severe systolic dysfunction. Current guidelines suggest a 3- to 6-month waiting period before implantation. Methods We retrospectively studied 29 consecutive patients with newly diagnosed nonischemic cardiomyopathy (NICM) who underwent primary prevention ICD implantation within 6 months of diagnosis between January 2008 and April 2014. Cardiac MRI (CMR) evaluated left ventricular ejection fraction (LVEF) and regional fibrosis preimplant. The primary end point was 'failure to qualify for an ICD at 12 months postimplant,' either due to LVEF ≥ 35% or deterioration necessitating mechanical support or transplantation, without appropriate ICD therapy. Secondary end points were appropriate and inappropriate ICD therapy. Results Baseline mean age was 44.2 ± 14.8 years and median LVEF 16.4%. Median time from diagnosis to implant was 32 days. At 12 months, 17 patients (58.6%) no longer qualified for an ICD, mainly due to LVEF improvement. At follow-up (mean 32.0 ± 20.6 months), three patients received appropriate therapy (one for ventricular fibrillation). All three had CMR late gadolinium enhancement (LGE) and nonsustained ventricular tachycardia (NSVT) preimplant. Cardiac resynchronization at implant predicted LVEF improvement. Conclusion Early appropriate therapy, particularly for ventricular fibrillation, is infrequent for patients with very severe NICM who have ICDs implanted within 6 months of diagnosis. The majority of these patients would not qualify for an ICD at 12 months postinsertion. In the absence of a multimodality risk score, early ICD insertion should only be considered in selected cases (presence of LGE and NSVT). Wearable cardioverter defibrillators may have a role as a bridge to ICD decision. [ABSTRACT FROM AUTHOR]

Background: Post-infarct ventricular tachycardia is associated with channels of surviving myocardium within scar characterized by fractionated and low-amplitude signals usually occurring late during sinus rhythm. Conventional automated algorithms for 3-dimensional electro-anatomic mapping cannot differentiate the delayed local signal of conduction within the scar from the initial far-field signal generated by surrounding healthy tissue. Ripple mapping displays every deflection of an electrogram, thereby providing fully informative activation sequences. We prospectively used CARTO-based ripple maps to identify conducting channels as a target for ablation.Methods and Results: High-density bipolar left ventricular endocardial electrograms were collected using CARTO3v4 in sinus rhythm or ventricular pacing and reviewed for ripple mapping conducting channel identification. Fifteen consecutive patients (median age 68 years, left ventricular ejection fraction 30%) were studied (6 month preprocedural implantable cardioverter defibrillator therapies: median 19 ATP events [Q1-Q3=4-93] and 1 shock [Q1-Q3=0-3]). Scar (<1.5 mV) occupied a median 29% of the total surface area (median 540 points collected within scar). A median of 2 ripple mapping conducting channels were seen within each scar (length 60 mm; initial component 0.44 mV; delayed component 0.20 mV; conduction 55 cm/s). Ablation was performed along all identified ripple mapping conducting channels (median 18 lesions) and any presumed interconnected late-activating sites (median 6 lesions; Q1-Q3=2-12). The diastolic isthmus in ventricular tachycardia was mapped in 3 patients and colocated within the ripple mapping conducting channels identified. Ventricular tachycardia was noninducible in 85% of patients post ablation, and 71% remain free of ventricular tachycardia recurrence at 6-month median follow-up.Conclusions: Ripple mapping can be used to identify conduction channels within scar to guide functional substrate ablation. [ABSTRACT FROM AUTHOR]

Background We hypothesized that patients with de novo cardiac resynchronization therapy (CRT) implantation had a more intense frailty syndrome when compared to the patients who qualified for a system upgrade. Methods One hundred and six patients aged ≥65 years were included. They were divided into two groups: de novo CRT implantation-74 patients and upgrade from standard right heart pacing-32 patients. A CRT was finally implanted in all of the patients. Frailty was evaluated using the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS). Results The average results in CSHA-CFS were statistically higher (5.3 ± 0.8) in the de novo patients when compared to the patients who qualified for a system upgrade (4.9 ± 0.8); P = 0.027. Frailty syndrome was recognized in 81.1% of the patients in the de novo group and in 68.7% of the patients in the upgrade group; P = 0.164. Only one patient of the 106 had no attributes of frailty (or exposed ones) syndrome. Conclusions Frailty syndrome is a common phenomenon in patients with heart failure and over 65 years of age. The syndrome is most often recognized in patients who are de novo qualified for cardiac resynchronization. [ABSTRACT FROM AUTHOR]

Aims The choice of resynchronization therapy between with (CRT-D) and without (CRT-P) a defibrillator remains a contentious issue. Cause-of-death analysis among CRT-P, compared with CRT-D, patients could help evaluate the extent to which CRT-P patients would have additionally benefited from a defibrillator in a daily clinical practice. Methods and results A total of 1705 consecutive patients implanted with a CRT (CRT-P: 535 and CRT-D: 1170) between 2008 and 2010 were enrolled in CeRtiTuDe, a multicentric prospective follow-up cohort study, with specific adjudication for causes of death at 2 years. Patients with CRT-P compared with CRT-D were older (P < 0.0001), less often male (P < 0.0001), more symptomatic (P = 0.0005), with less coronary artery disease (P = 0.003), wider QRS (P = 0.002), more atrial fibrillation (P < 0.0001), and more co-morbidities (P = 0.04). At 2-year follow-up, the annual overall mortality rate was 83.80 [95% confidence interval (CI) 73.41-94.19] per 1000 person-years. The crude mortality rate among CRT-P patients was double compared with CRT-D (relative risk 2.01, 95% CI 1.56-2.58). In a Cox proportional hazards regression analysis, CRT-P remained associated with increased mortality (hazard ratio 1.54, 95% CI 1.07-2.21, P = 0.0209), although other potential confounders may persist. By cause-of-death analysis, 95% of the excess mortality among CRT-P subjects was related to an increase in non-sudden death. Conclusion When compared with CRT-D patients, excess mortality in CRT-P recipients was mainly due to non-sudden death. Our findings suggest that CRT-P patients, as currently selected in routine clinical practice, would not potentially benefit with the addition of a defibrillator. [ABSTRACT FROM AUTHOR]

Automated Implantable Cardioverter Defibrillators (AICD), simply known as an Implantable Cardioverter Defibrillator (ICD), has been used in patients for more than 30 years. An Implantable Cardioverter Defibrillator (ICD) is a small battery-powered electrical impulse generator that is implanted in patients who are at a risk of sudden cardiac death due to ventricular fibrillation, ventricular tachycardia or any such related event. Typically, patients with these types of occurrences are on anticoagulant therapy. The desired International Normalized Ratio (INR) for these patients is in the range of 2–3 to prevent any subsequent cardiac event. These patients possess a challenge to the dentist in many ways, especially during oral surgical procedures, and these challenges include risk of sudden death, control of post-operative bleeding and pain. This article presents the dental management of a 60 year-old person with an ICD and concomitant anticoagulant therapy. The patient was on multiple medications and was treated for a grossly neglected mouth with multiple carious root stumps. This case report outlines the important issues in managing patients fitted with an ICD device and at a risk of sudden cardiac death. [ABSTRACT FROM AUTHOR]

Anaphylactic shock is a life-threatening condition which needs detailed and mediculous clinical assessment and thoughtful treatment. Several causes can join forces in order to degranulate mast cells. Amiodarone which is an iodine-containing highly lipophilic benzofuran can induce allergic reactions and anaphylactic shock in sensitized patients. Epinephrine is a life saving drug, but in sulfite allergic patients it should be given with caution due its metabisulfite preservative. Metals covering cardiac defibrillators and pacemakers can act as antigens attached to serum proteins and induce allergic reactions. In anaphylactic shock, myocardial involvement due to vasospasm-induced coronary blood flow reduction manifesting as Kounis syndrome should be always considered. Clinically, combined treatment targeting the primary cause of anaphylaxis together with protection of cardiac tissue seems to be of paramount importance. [ABSTRACT FROM AUTHOR]

Purpose: Implantable cardioverter defibrillators (ICDs) prevent sudden cardiac death, but patients need to be counseled about potential harms. We summarized the evidence on adverse events from ICDs with a focus on ICD use for primary prevention of sudden cardiac death. Methods: We searched MEDLINE and Cochrane Central Register of Controlled Trials from 2002 through 2012 for reports of adverse events from ICDs implanted for primary prevention or mixed indications (primary and secondary prevention). Studies had to have ≥500 patients and specify patient numerators and denominators. Results: Data from 35 independent cohorts reported in 53 articles were included. Reports from one registry provided high quality evidence on adverse events during hospitalization for ICD implantation. Adverse events ranged from 2.8 to 3.6 %. Serious adverse events ranged from 1.2 to 1.4 %. The most frequent serious adverse events were pneumothorax (0.4-0.5 %) and cardiac arrest (0.3 %). The quality of the evidence for long-term adverse events was low. Frequency of adverse events post-hospitalization was variable, as was follow-up: device-related complications <0.1-6.4 % (2-49 months), lead-related complications <0.1-3.9 % (1.5-40 months), infection 0.2-3.7 % (1.5-49 months), and thrombosis 0.2-2.9 % (1.5-49 months). Evidence for inappropriate shock was of moderate quality with 3-21 % of patients experiencing at least one inappropriate shock during 1 to 5 years of follow-up. Limitations: The limitation of the evidence reviewed in this study is low quality evidence for adverse events post-hospitalization. Evidence is predominantly from mixed primary and secondary prevention populations. Conclusions: In-hospital adverse events after ICD implantation are infrequent. The estimates for long-term adverse events are uncertain. Up to one-fifth of patients receive inappropriate shocks. [ABSTRACT FROM AUTHOR]

Aims To evaluate the long-term efficacy and safety of an electrophysiologically guided therapy, based on a strategy of treatment using hydroquinidine (HQ) among asymptomatic Brugada patients with inducible ventricular fibrillation (VF). Methods and results In two French reference centres, consecutive asymptomatic type 1 Brugada patients with inducible VF were treated with HQ (600 mg/day, targeting a therapeutic range between 3 and 6 µmol/L) and enroled in a specific follow-up (mean 6.6 ± 3 years), including a second programmed ventricular stimulation (PVS) under HQ. An implantable cardioverter defibrillator (ICD) was eventually implanted in patients inducible under HQ, or during follow-up in case of HQ intolerance, as well as occurrence of arrhythmic events. From a total of 397 Brugada patients, 44 were enroled (47 ± 10 years, 95% male). Of these, 34 (77%) were no more inducible (Group PVS−), and were maintained under HQ alone during a mean follow-up of 6.2 ± 3 years. In this group, an ICD was eventually implanted in four patients (12%), with occurrence of appropriate ICD therapies in one. Among the 10 other patients (22%), who remained inducible and received ICD (Group PVS+), none of them received appropriate therapy during a mean follow-up of 7.7 ± 2 years. The overall annual rate of arrhythmic events was 1.04% (95% confidence interval 0.00–2.21), without any significant difference according to the result of PVS under HQ. One-third of patients experienced device-related complications. Conclusion Our long-term follow-up results emphasize that the rate of arrhythmic events among asymptomatic Brugada patients with inducible VF remains low over time. Our results also suggest that residual inducibility under HQ is of limited value to predict events during follow-up. [ABSTRACT FROM PUBLISHER]

Left ventricular ejection fraction (LVEF) ≤35% is a major determinant for implantable cardioverter-defibrillator (ICD) therapy for primary prevention of sudden death (SD) in patients with non-ischaemic dilated cardiomyopathy (DCM). However, as a risk marker for SD, low LVEF has limited sensibility and specificity. Selecting patients according to the current guidelines shows that most DCM patients do not actually benefit from ICD implantation and may suffer collateral effects and that many patients who are at risk of SD are not identified because a large proportion of SD patients exhibit only mildly depressed LVEF. Identifying patients who are at risk of SD on the sole basis of LVEF appears to be an over-simplification which does not maximize the benefit of ICD therapy. Owing to the complexity of the substrates underlying SD, multiple risk factors used in combination could probably predict the risk of SD better than any individual risk marker. Among non-invasive tests, microvolt T-wave alternans and cardiac magnetic resonance with late gadolinium enhancement may contribute to a better SD risk stratification by their high negative predictive value. Genetics may further contribute because approximately one-third of DCM patients have evidence of familial disease, and mutations in some known disease genes, including LMNA, have been associated with a high risk of SD. In this review, we critically analyse the current indications for ICD implantation and we explore existing knowledge about potentially predicting markers for selecting DCM patients who are at high and low risk of SD. [ABSTRACT FROM PUBLISHER]

The article reports on the case of a 56 year old man with a long history of coronary artery disease associated with moderately depressed systolic left ventricular ejection fraction who underwent placement of an implantable cardioverter defibrillator. A discussion of a ventricular tachycardia which was observed in the patient, and of the possible mechanisms which could have led to the tachycrdia, is presented.

Background: A multicenter European Registry, SEARCH-MI, was instituted in the year 2002 in order to assess patients’ outcomes and ICD interventions in patients with a previous MI and depressed LV function, treated with an ICD according to MADIT II results. In this analysis, we evaluate the influence of the time elapsed between last myocardial infarction (MI) and prophylactic cardioverter defibrillator (ICD) implant on device activations. Methods: 643 patients with left ventricular dysfunction (mean LVEF 26 ± 5%) and NYHA class I-III were prospectively followed for 1.8 ± 1.2 years in a multicenter registry. The population was divided into 3 groups according to the time between last MI and ICD implant: [1] from 40 days to less than 1.5 years; [2] from 1.5 to less than 7 years and [3] at least 7 years.Results: The cumulative incidence of ventricular tachyarrhymias and appropriate device therapy (ATP or shock) were higher in patients implanted longer time from last MI (Gray’s Test p = 0.002 and p = 0.013 respectively). No significant differences were seen in all cause mortality (Gray’s Test p = 0.618) or sudden cardiac death across the MI stratification groups (Gray’s Test p = 0.663).Conclusions: Patients implanted with an ICD longer after the MI have a higher chance of presenting ventricular tachyarrhythmias and appropriate ICD therapy, while no differences were seen in overall mortality. These observations may be important for improving patient targeting in sudden death prevention. [ABSTRACT FROM AUTHOR]

The interesting data reported by Bernhardt et al. strengthen the diagnostic benefit of CMR in patients with ischemic cardiomyopathy. Consequently, the presence, location and size of the CMR-determined scar tissue may be used for better risk stratification in patients with ischemic cardiomyopathy eligible for ICD therapy. [ABSTRACT FROM AUTHOR]

The search for effective treatment for preventing sudden cardiac death (SCD) initially started with anti-arrhythmic agents in high-risk patients, but the use of randomized controlled trials clearly led to the conclusion that an approach based on anti-arrhythmic agents is not useful, and sometimes potentially harmful (the risk of arrhythmic death was increased up to 159% in CAST study). Today the approach to SCD prevention includes considering both the setting of patients who have already presented a cardiac arrest or a malignant ventricular tachyarrhythmias (secondary preventions of SCD) and the much broader setting of primary prevention in patients at variable degrees of identifiable risk. For secondary prevention of SCD, implantable cardioverter defibrillation is now the standard of care (the risk of overall mortality may be reduced by 20-31%), and anti-arrhythmic agents, specifically amiodarone, have only a complementary role (for reducing device activations or for preventing atrial fibrillation). For primary prevention of SCD in high-risk patients, cardioverter defibrillators have nowadays specific indications in patients with left ventricular dysfunction (often in combination with cardiac resynchronization therapy), where the risk of overall mortality may be reduced by 23-54%. For the large number of subjects who have some risk of SCD, but are not identified as at high risk of SCD, a series of drugs could exert a favorable effect (beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blocker agents, statins, omega-3 fatty acids and aldosterone antagonists), and for some of them evidence is emerging, from subgroup analysis, of possible SCD prevention capabilities. [ABSTRACT FROM AUTHOR]

Background: Little is known about gender differences in the response to implantable cardioverter defibrillator (ICD) therapy. We compared female and male ICD patients on anxiety, depression, health-related quality of life (HRQL), ICD concerns, and ICD acceptance. Methods: A cohort of consecutive, surviving patients (n = 535; mean age = 61.5 ± 14.4, 81.9% male) implanted with an ICD between 1989 and 2006 completed the Hospital Anxiety and Depression Scale, the Short-Form Health Survey (SF-36), the ICD concerns questionnaire, and the Florida Patient Acceptance Survey. Results: High levels of anxiety (52% vs 34%, P < 0.001) and ICD concerns (34% vs 16%, P = 0.001) were more prevalent in women than men, whereas no significant differences were found on depression and device acceptance (Ps > 0.05). Women were more anxious (odds ratio [OR]: 2.60 [95% confidence interval (CI): 1.46–4.64], P < 0.01) and had more ICD concerns (OR: 1.81 [95% CI: 1.09–3.00], P < 0.05) than men, adjusting for demographic and clinical characteristics. Those ICD patients experiencing shocks were also more anxious (OR: 2.02 [95% CI: 1.20–3.42], P < 0.01) and had higher levels of ICD concerns (OR: 2.70 [95% CI: 1.76–4.16], P < 0.01). In multivariable analysis of variance, significant gender differences were found for only three of the eight subscales of the SF-36 (the physical social functioning and the mental health subscale), with women reporting poorer HRQL on all three subscales. Conclusions: Women were more prone to experience anxiety and ICD concerns compared to men regardless of whether they had experienced shocks. In clinical practice, female ICD patients should be closely monitored, and if warranted offered psychosocial intervention, as increased anxiety has been shown to precipitate arrhythmic events in defibrillator patients. [ABSTRACT FROM AUTHOR]

Objective: To compare the rates of all-cause mortality in recipients of cardiac resynchronization therapy devices without (CRT-PM) versus with defibrillator (CRT-D). Methods: Between February 1999 and July 2004, 233 patients (mean age = 69 ± 8 years, 180 men) underwent implantation of CRT-PM or CRT-D devices. New York Heart Association (NYHA) heart failure functional class II was present in 11%, class III in 69%, and class IV in 20% of patients; mean left ventricle ejection fraction (LVEF) was 26.5 ± 6.5 %, 48% presented with idiopathic dilated cardiomyopathy and 49% with ischemic heart disease. Cox multiple variable regression analysis was performed in search of predictors of death. Results: The clinical characteristics of the 117 CRT-PM and 116 CRT-D recipients were similar, except for LVEF (28.2 ± 6.2% vs 25.0 ± 6.5%, respectively; P < 0.001), and ischemic versus nonischemic etiology of heart failure (41% vs 56%, respectively P = 0.02). Over a mean follow-up of 58 ± 15 months, no significance difference in overall mortality rate was observed between the two study groups. Male sex, NYHA functional class IV, and atrial fibrillation at implant were significant predictors of death. Conclusions: There was no difference in long-term survival rate among patients with CRT-D versus CRT-PM, although CRT-D more effectively lowered the sudden death rate. Male sex, NYHA functional class IV, and atrial fibrillation predicted the worst prognosis. [ABSTRACT FROM AUTHOR]

Abstract: Implantable cardioverter defibrillators (ICDs) are routinely placed in the cardiac electrophysiology laboratory. Previously, these procedures were performed in the operating room during general anesthesia. In recent years, electrophysiologists have been performing these procedures using local anesthetics in conjunction with intravenous sedation. We report a case in which thoracic paravertebral blocks with mild sedation were successful for infected ICD and laser lead extraction. Randomized, controlled trials are required to determine whether thoracic paravertebral block with sedation is more effective than local anesthesia with sedation in providing adequate anesthesia for ICD placement and extraction. [Copyright &y& Elsevier]

Aims: Although all races are concerned with the Brugada syndrome, no case has ever been reported among black Africans. We describe five different cases in this specific group of populations. Methods and Results: In all patients, Brugada syndrome was identified after detailed noninvasive and invasive evaluations. Sex ratio was four males for one female. Convulsive syncope was noticed in 1 patient with a family history of sudden death. Diagnostic coved-type pattern was observed spontaneously in the normal position of right precordial leads in 3 patients and in a higher position of leads in 3 patients. Sixty percent had first-degree atrioventricular block. An ajmaline test was performed in 4 patients and was positive either in normal position of leads or in superior position in all of them. Sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) was inducible during programmed ventricular stimulation in 3 patients. Right ventricular cineangiography found localized apical hypokinesia with preserved systolic function in 1 patient. Automatic cardioverter defibrillator was implanted in 2 patients. SCN5A was not found in any of the patients. Conclusion: These observations demonstrate that Brugada syndrome is also present in black African populations, and increasingly reported cases of apparent sudden death in the sub-Saharan part of the world need to rule out cardiac electrical disturbance such as Brugada syndrome. [ABSTRACT FROM AUTHOR]

Information on the incidence of decompensation of chronic heart failure (CHF) in heart transplantation (HT) candidates eligible for prophylactic implantable cardioverter defibrillators (ICD) could provide insights into the influence of ICD on the timing for HT. Methods: We investigated the prevalence of candidates satisfying SCD-HeFT and MADIT-II criteria for prophylactic ICD among patients (n = 317) with CHF referred to our tertiary center for HT. In addition to standard clinical and laboratory assessments, baseline evaluation included two-dimensional standard transthoracic echocardiogram and 12-lead electrocardiogram. Results: At baseline, 19% of patients (n = 60) satisfied MADIT II criteria, and 58% (n = 185) fulfilled SCD-HeFT criteria. A total of 60% patients (n = 190) were eligible for prophylactic ICD implantation according to at least one set of criteria. Five-yr CHF decompensation-free survival was 68 ± 4% in patients eligible for prophylactic ICD (p = 0.003), (RR 2.5, 95% CI 1.35–4.63). Conclusions: SCD-HeFT could imply a threefold rise in ICD eligibility in tertiary settings. As ICD-eligible patients would likely remain at high risk of progressive ventricular dysfunction, strict follow-up should be considered extremely important to allow a timely referral for HT. [ABSTRACT FROM AUTHOR]

A paediatric patient with hypertrophic cardiomyopathy (HCM) presented cardiac arrest due to ventricular fibrillation. Ventricular arrhythmias were not induced in an electrophysiological study, but an implantable cardioverter defibrillator (ICD) was implanted. Nine months later, the child experienced a recurrence of cardiac arrest during exercise, which was successfully treated with a defibrillator shock from the device. Analysis of the stored electrograms demonstrated ventricular fibrillation of abrupt onset following sinus tachycardia. The risk factors and the potential mechanism leading to recurrent cardiac arrest in this case are discussed. This report supports implantation of an ICD as a life-saving therapeutic approach not only for adults but also for children with HCM at high risk. [ABSTRACT FROM PUBLISHER]