Cardiac resynchronization therapy delivered with bipolar versus quadripolar leads: clinical outcomes and safety in a long-term follow up comparison

BACKGROUND: La terapia di resincronizzazione cardiaca (CRT) mediante elettrocatetere quadripolare in ventricolo sinistro (VS) permette un maggior numero di configurazioni rispetto ai cateteri bipolari, garantendo maggiore stabilità, minore stimolazione del nervo frenico (PNS) e migliori parametri elettrici. METODI: 106 pazienti con indicazioni CRT-D sono stati consecutivamente impiantati con catetere LV bipolare (66) o quadripolare (40). Sono stati analizzati tre endpoint primari: 1-reverse remodeling (RR) ecocardiografico; 2- libertà da “failure” del catetere VS (dislocazione/disattivazione CRT); 3- libertà da ogni evento avverso (OEA) comprendente mortalità totale, ospedalizzazione per scompenso cardiaco/revisione catetere VS, dislocazione catetere VS, disattivazione CRT, PNS, soglia di stimolazione VS>2 V o margine di sicurezza<2 V. Come endpoint secondari sono stati analizzati: 1-outcome clinico composito (mortalità cardiovascolare, ospedalizzazione per scompenso cardiaco o revisione elettrocatetere), 2-PNS clinicamente rilevante, 3-performance elettriche (soglia di stimolazione VS, margine di sicurezza). RISULTATI: Le caratteristiche basali dei 2 gruppi erano sovrapponibili. Tra bipolari e quadripolari non sussistevano differenze nel RR (rispettivamente 55,7 vs 64,1%) e nel failure-LV (12,1 vs 5%). Dopo un FU di 28,6 mesi, l’incidenza di OEA nel gruppo quadripolare era quasi dimezzata rispetto ai bipolari (35 vs 62,1%, p=0,04), con Number-Needed-to-Treat (NNT) di 5 per evitare OEA. Nei 2 gruppi (rispettivamente bipolari vs quadripolari) non sono state rilevate differenze nell’outcome clinico composito (33,3 vs 27,5%) e nel PNS (15,2 vs 10%). Gli elettrocateteri quadripolari hanno mostrato performance elettriche migliori, presentando minore soglia all'impianto (1,3 vs 1,1 V, p=0,03) e nel FU (1,6 vs 1,2 V, p=0,002) e mostrando maggiore margine di sicurezza all'impianto (3,3 vs 4,6 V, p=0,0007) e nel FU (3 vs 4,4 V, p=0,0001). CONCLUSIONI: I cateteri quadripolari hanno riportato outcome clinici simili ai bipolari, mostrando sovrapponibile failure del catetere e analogo reverse remodeling. D’altra parte il gruppo quadripolare ha riportato un’incidenza di OEA quasi dimezzata con performance elettriche significativamente miglioriBACKGROUND: Cardiac resynchronization therapy (CRT) using quadripolar left ventricular (LV) leads provides more pacing vectors compared to bipolar leads, with more stable lead positioning, better management of phrenic nerve stimulation (PNS) and improved pacing parameters METHODS: 106 consecutive patients with CRT-D indications were implanted with bipolar (66) or quadripolar (40) LV leads. Three primary endpoints were analyzed: 1-echocardiographic reverse remodeling (ERR), 2-freedom from LV lead failure (displacement/CRT termination), 3-freedom from composite adverse events (CAE) resulting in overall mortality, hospitalization due to heart failure or LV-lead revision/displacement, CRT termination, clinically relevant PNS, LV pacing threshold>2 V or safety margin<2 V. We evaluated 3 secondary endpoints: 1-composite clinical outcome (cardiovascular mortality, hospitalization due to heart failure/LV-lead revision), 2-clinically relevant PNS, 3-LV lead performance (LV pacing threshold and safety margin at implantation and FU) RESULTS: Baseline characteristics of both groups were similar. No differences were found in ERR between bipolar and quadripolar leads (respectively 55,7 vs 64,1%) and in LV lead failure (12,1 vs 5%). Over a FU of 28,6 CAE in quadripolar group were almost halved in comparison to CAE occurred in bipolar group (35 vs 62,1% p=0,04). The NNT to avoid any CAE was 5. There was no difference in composite clinical outcome (33,3 vs 27,5%) and in clinically relevant PNS (15,2 vs 10 %) between bipolar and quadripolar leads. Conversely, quadripolar leads showed significantly better performances in LV threshold both at implantation (1,3 vs 1,1 V p=0,03) and in FU (1,6 vs 1,2 V p=0,002) compared to bipolar leads, with higher safety margin both at implantation (3,3 vs 4,6 V, p=0,0007) and in FU (3 vs 4,4 V p=0,0001) CONCLUSION: Quadripolar leads achieved similar CRT clinical outcome, similar LV-lead failure and similar ERR as bipolar LV leads, but quadripolar leads group showed almost halved CAE and significantly better electrical performanc

Cardiac resynchronization therapy in persistent left superior vena cava: Can you do it two-leads-only?

Cardiac resynchronization therapy in persistent left superior vena cava: Can you do it two-leads-only

Rasmussen's Aneurysm in Childhood: A Case Report

In medical literature, few cases of Rasmussen's aneurysm have been reported until now, and to the best of our knowledge, there has been no description of a case of Rasmussen's aneurysm in childhood. The child described in the case report had a restrictive cardiomyopathy, complicated by pulmonary hypertension, in association with miliary tuberculosi

Inappropriate shock for myopotential over-sensing in a patient with subcutaneous ICD

Inappropriate ICD shocks are common adverse events; they are mainly due to supraventricular arrhythmias and secondly are related to noise, undersensing, oversensing, device malfunctions. We present a case of inappropriate device therapy due to myopotential oversensing in a patient with a subcutaneous ICD (s-ICD). A 58 years old male with an s-ICD during the device interrogation showed a previous episode of suspected sustained ventricular tachycardia at 210 bpm, which was effectively treated with ICD shock. The patient experienced the electrical shock while holding a big gas-cylinder in his arms. The EGM analysis revealed many irregular ventricular signals of low amplitude lasting for 24 s and interrupted by the shock. The device showed no malfunctions. This is the first case report of inappropriate S-ICD shock related to myopotential over-sensing. By recording intracardiac EGM, we demonstrated that the noise was created by the activity of the pectorals muscles

Holter ECG for pacemaker/defibrillator carriers: What is its role in the era of remote monitoring?

Nowadays several diagnostic tools are available to investigate cardiovascular symptoms like palpitations, dizziness and syncope: ECG Holter (or ambulatory ECG, AECG), external and implantable event/loop recorders. Despite this technological burden, many diagnoses are still missed. In the meantime, we are facing an increasing use of implantable devices for cardiac pacing/defibrillation (CIED), which have rapidly evolved from simple pacing/shock boxes to devices including several diagnostic features. However, these functions are not adequately exploited in current clinical practice and several redundant diagnostic tests, like AECG, are still prescribed to CIED carriers, leading to an increase of costs and a delay in final diagnosis. This review is aimed at identifying the current role of AECG in CIED carriers in view of this technological improvement. First, we will briefly present the indications for AECG according to current guidelines. We will then provide a direct comparison of the different diagnostic features provided by AECG (and event/loop recorders) versus automatic diagnostic CIED to highlight the respective pros and cons. This will serve to carefully discuss these indications in view of the results of recent studies on CIED carriers, highlighting the need for proper implantation and follow-up. Eventually, we will provide useful hints to properly analyse AECG in CIED carriers, considering the different behaviours according to the implemented algorithms. We will conclude by suggesting updated indications for AECG

Electrocardiographic Eligibility for Subcutaneous Implantable Cardioverter Defibrillator: Evaluation during Bicycle Exercise

Background: The subcutaneous implantable cardioverter-defibrillator (S-ICD) is used in patients at risk of sudden death. Our aim was to assess clinical predictors of electrocardiographic ineligibility for S-ICD, and the impact of exercise on S-ICD eligibility in an unselected series of patients requiring ICD therapy. Methods: 102 patients at risk of sudden death were evaluated at rest and during exercise. Electrocardiograph screening using limb lead electrodes (to simulate the S-ICD sensing vectors) was performed at rest and during bicycle ergometer exercise. Results: R wave amplitude in lead D3 during exercise &gt;16 mV, baseline QTc and the sum of amplitudes of the R waves at supine &gt;30 mV were predictors of ineligibility for S-ICD. Eligibility increased from 90% to 100% of patients when evaluated with an "any of the three leads" criterion compared to current recommendations. A more restrictive criterion based on two of three ECG leads caused an eligibility drop at 66%, that further decreased to 56% during exercise; these figures improved to 79% and 81%, respectively, when an "any 2 of 3 leads" criterion was used. Conclusions: Huge ECG amplitude and QTc duration are associated with ineligibility in the current S-ICD release. By performing exercise testing, lead suitability changes in one patient out of 14 (7% of tested patients) and eligibility is decreased by use of a more stringent criterion for eligibility (ECG criteria satisfied in two of three leads). A dynamic selection of sensing vectors aiming at situation-specific suitability (any of three leads) would increase S-ICD eligibility to 100% of patients

Clinical management of electromagnetic interferences in patients with pacemakers and implantable cardioverter-defibrillators: Review of the literature and focus on magnetic resonance conditional devices

The number of cardiac implantable electronic devices (CIEDs) has greatly increased in the last 10 years. Many electronic devices used in daily activities generate electromagnetic interferences (EMIs) that can interact with CIEDs. In clinical practice, it is very important to know the potential sources of EMIs and their effect on CIEDs in order to understand how to manage or mitigate them. A very important source of EMI is magnetic resonance (MR), which is considered nowadays the diagnostic gold standard for different anatomical districts. In this review, we focused on the effects of EMI on CIEDs and on the clinical management. Moreover, we made a clarification about MR and CIEDs. In patients with CIEDs, EMIs may cause potentially serious and even life-Threatening complications (inappropriate shocks, device malfunctions, inhibition of pacing in pacemaker-dependent patients) and may rarely dictate device replacement. The association of inappropriate shocks with increased mortality highlights the importance of minimizing the occurrence of EMI. Adequate advice andrecommendations about the correct management of EMIs in patients with CIEDs are required to avoid all complications during hospitalization and in daily life. Furthermore, the article focused on actual management about MR and CIEDs

Recent temporal trends for first-time hospitalization for acute myocardial infarction. Treatment patterns and clinical outcome in a large cohort study

Abstract BACKGROUND: The objective was to report recent trends in the incidence, adoption of evidence-based treatment, and clinical outcomes for first-time hospitalization for acute myocardial infarction. METHODS: This is a large retrospective population-based cohort study using medical administrative data (International Classification of Diseases, Ninth Revision, Clinical Modification, codes) performed in the Emilia-Romagna Region of Italy (approximately 4.5 million inhabitants). We identified 60,673 patients with a first hospitalization for acute myocardial infarction from 2002 through 2009. RESULTS: The standardized incidence rate per 100,000 person-years of acute myocardial infarction increased from 173 cases in 2002 to a peak of 197 cases in 2004 and then decreased each year thereafter to 167 cases in 2009. The proportion of patients who underwent coronary angiography and angioplasty in the acute phase increased over time, respectively, from 45.4% and 27.1% to 72.3% and 57.2% (P &lt; .001). Medication use within 12 months of discharge increased for aspirin, β-blockers, and statins. A reduction in crude and adjusted in-hospital all-cause (16.1% in 2002 vs 12.8% in 2009, P &lt; .001) and cardiovascular mortality (13.6% in 2002 vs 9.5% in 2009, P &lt; .001) was observed over time. At 1 year after hospital discharge, no significant variations occurred in adjusted risk for all-cause mortality or cardiovascular mortality. Notably, crude and adjusted risk for in-hospital and postdischarge bleeding showed a significant increment. CONCLUSIONS: The utilization of evidence-based treatments in patients with myocardial infarction increased between 2002 and 2009. These changes in practice over time favored a reduction in early case fatality at the cost of a significant increase in bleeding

Valvuloplastica percutanea della stenosi aortica congenita oltre il primo mese di vita: una valida alternativa alla chirurgia [Percutaneous aortic valvuloplasty in congenital aortic valve stenosis performed in patients older than one month: a good alternative to surgery]

Razionale. La valvuloplastica aortica percutanea è una procedura efficace nel trattamento delle stenosi valvolari aortiche congenite. Il nostro studio si è proposto di valutare sia i risultati immediati della procedura sia l’evoluzione nel medio-lungo termine per stabilire l’efficacia del trattamento nell’evitare o nel posticipare una nuova valvuloplastica aortica o la chirurgia valvolare aortica. Materiali e metodi. Lo studio retrospettivo ha valutato 37 pazienti di età >1 mese (età media 6.3 anni) che sono stati sottoposti a valvuloplastica aortica per stenosi aortica severa. Nel 16% dei casi erano presenti difetti cardiaci congeniti associati. Il follow-up medio è stato di 5.07 anni. È stata posta particolare attenzione all’incidenza e alla progressione dell’insufficienza aortica. Risultati. Il gradiente emodinamico dopo valvuloplastica aortica percutanea è sceso da 58.5 a 22.5 mmHg, con decremento percentuale del 61.5%. Ecograficamente il gradiente massimo è passato da 93.0 a 40.5 mmHg, con riduzione percentuale del 56.5%; il gradiente medio è sceso da 52.0 a 20.5 mmHg, con diminuzione percentuale del 60.6%. All’ultimo follow-up il gradiente massimo e quello medio erano rispettivamente 50.0 e 27.0 mmHg. È stato necessario eseguire reintervento nel 21.6% dei casi: 8.1% sono stati sottoposti a seconda valvuloplastica aortica e 13.5% a chirurgia aortica. A 14 anni dalla valvuloplastica aortica la sopravvivenza è stata del 97.2%, la libertà da chirurgia è stata dell’85.5%, quella da valvuloplastica dell’89.5% e la libertà da qualsiasi tipo di procedura è stata del 76.1%. Conclusioni. La valvuloplastica aortica percutanea è un trattamento sicuro ed efficace nelle stenosi aortiche congenite in pazienti >1 mese di vita. L’insufficienza aortica è la principale complicanza nel follow-up. Nonostante ciò, il 75% dei pazienti è libero da qualsiasi tipo di reintervento valvolare aortico a 14 anni dalla valvuloplastica aortica percutanea