Snare technique for coronary sinus cannulation in cardiac resynchronization therapy

PURPOSE Biventricular pacing is a mainstay of therapy for patients with heart failure. However, lead implantations may fail due to anatomical reasons including the impossibility of coronary sinus cannulation. METHODS AND RESULTS A dual approach from the subclavian vein using a snare through a sheath and from the femoral vein using a steerable electrophysiology catheter was performed. Once the snare hooked the catheter, the latter was advanced into the coronary sinus and finally, the sheath could also be advanced in an "over-the-wire" technique. CONCLUSION The snare technique for coronary sinus cannulation offers a "bail-out" strategy for left ventricular lead implantation

Guggulsterone, an anti-inflammatory phytosterol, inhibits tissue factor and arterial thrombosis

Background: The phytosterol guggulsterone is a potent anti-inflammatory mediator with less side effects than classic steroids. This study assesses the impact of guggulsterone on tissue factor (TF) expression and thrombus formation. Methods and results: Guggulsterone inhibited TNF-α-induced endothelial TF protein expression and surface activity in a concentration-dependent manner; in contrast, dexamethasone did not affect TNF-α-induced TF expression. Guggulsterone enhanced endothelial tissue factor pathway inhibitor and impaired plasminogen activator inhibitor-1 as well as vascular cell adhesion molecule-1 protein. Real-time polymerase chain reaction revealed that guggulsterone inhibited TNF-α-induced TF mRNA expression; moreover, it impaired activation of the MAP kinases JNK and p38, while that of ERK remained unaffected. In vivo, guggulsterone inhibited TF activity and photochemical injury induced thrombotic occlusion of mouse carotid artery. Guggulsterone also inhibited TF expression, proliferation, and migration of vascular smooth muscle cells in a concentration-dependent manner. Conclusions: Guggulsterone inhibits TF expression in vascular cells as well as thrombus formation in vivo; moreover, it impairs vascular smooth muscle cell activation. Hence, this phytosterol offers novel therapeutic options, in particular in inflammatory diseases associated with an increased risk of thrombosi

Amphetamines induce tissue factor and impair tissue factor pathway inhibitor: role of dopamine receptor type 4

Aims Amphetamine intake is associated with acute vascular syndromes. Since these events are caused by arterial thrombosis and this in turn is triggered by tissue factor (TF), this study examines whether amphetamines regulate TF in human endothelial cells. Methods and results Amphetamine (10−7-10−4 mol/L) enhanced thrombin- and tumour necrosis factor (TNF)-α-induced as well as basal TF expression (P = 0.029, 0.0003, and 0.003 at maximal concentration), and TNF-α-induced plasminogen activator inhibitor (PAI)-1 expression (P = 0.003), whereas tissue factor pathway inhibitor expression was impaired (P = 0.008). Similarly, 3,4-methylenedioxymethamphetamine (10−7-10−4 mol/L) enhanced TF expression (P = 0.046). These effects were paralleled by an increased TF activity (P = 0.002); moreover, clotting time of human plasma was accelerated by supernatant from amphetamine-treated cells (P = 0.03). Amphetamine enhanced TF mRNA expression via phosphorylation of the mitogen-activated protein kinases (MAPKs) extracellular signal-regulated kinase (ERK) and p38 (P = 0.03 and 0.033), but not c-Jun NH2-terminal kinase (JNK; P = 0.81). The effect of amphetamine on TF expression was abrogated by the dopamine D4 receptor antagonists L-745,870 and L-750,667, but not D2 or D3 receptor antagonists; furthermore, L-745,870 blunted the amphetamine-induced activation of ERK and p38, but not JNK. Conclusion Amphetamines induce endothelial TF expression via stimulation of dopamine D4 receptor and activation of the MAPKs p38 and ERK. These effects occur at clinically relevant amphetamine concentrations and may account for the increased incidence of acute vascular syndromes after amphetamine consumptio

Success and Complication Rates of Transvenous Lead Extraction in a Developing High-Volume Extraction Center: The Zurich Experience

INTRODUCTION: Transvenous lead extractions are increasingly performed for malfunction or infection of cardiac implantable electronic devices, but they harvest a potential for complications and suboptimal success. Apart from multicenter registries and reports from highly experienced single centers, the outcome in individual newly developing high-volume centers starting a lead extraction program is less well established. We aimed to evaluate the clinical and radiological success and complication rate at our center, having started a lead extraction program less than a decade ago. METHODS: We retrospectively analyzed patients who underwent transvenous lead extraction at the University Hospital Zurich from 2013 to 2021 regarding success as well as complications and compared our results to previously reported outcome rates. RESULTS: A total of 346 patients underwent 350 transvenous lead extractions from January 2013 to December 2021. Combined radiological success was achieved in 97.7% and clinical success in 96.0% of interventions. Procedure-related major complications occurred in 13 patients (3.7%). Death within 30 days after transvenous lead extractions occurred in 13 patients (3.7%), with a procedure-related mortality of 1.4% (five patients). SUMMARY: Transvenous lead extractions in newly developing high-volume centers can be performed with high clinical and radiological success rates, but procedure-related major complications may affect a relevant number of patients. Compared to large single or multicenter registries of experienced centers, the success rate may be lower and the complication rate higher in centers newly starting with lead extraction, which may have important implications for patient selection, procedural planning, proctoring, and safety measures

Transvenous ICD Implantation into a Coronary Sinus Branch: A Safe and Feasible Alternative to Deliver ICD after Tricuspid Valve Reconstruction

Significant lead-induced tricuspid regurgitation after cardiovascular implantable electronic devices is not uncommon. Absolute or relative contraindications to place the lead in the right ventricle after tricuspid valve (TV) surgery still remains a challenge. We report about successful lead extraction followed by transvenous implantable cardioverter defibrillator lead placement in the side branches of coronary sinus after TV reconstruction. Furthermore, we discuss therapeutic options to deliver concomitant anti-bradycardia therapy, technical pitfalls, and surgical approaches

Sense-B-noise: an enigmatic cause for inappropriate shocks in subcutaneous implantable cardioverter defibrillators.

AIMS Subcutaneous implantable cardioverter defibrillators (S-ICDs) are well established. However, inappropriate shocks (IAS) remain a source of concern since S-ICDs offer very limited troubleshooting options. In our multicentre case series, we describe several patients who experienced IAS due to a previously unknown S-ICD system issue. METHODS AND RESULTS We observed six patients suffering from this novel IAS entity. The IAS occurred exclusively in primary or alternate S-ICD sensing vector configuration (therefore called 'Sense-B-noise'). IAS were caused by non-physiologic oversensing episodes characterized by intermittent signal saturation, diminished QRS amplitudes, and disappearance of the artefacts after the IAS. Noise/oversensing could not be provoked by manipulation, X-ray did not show evidence for lead/header issues and impedance measurements were within normal limits. The pooled experience of our centres implies that up to ∼5% of S-ICDs may be affected. The underlying root cause was discussed extensively with the manufacturer but remains unknown and is under further investigation. CONCLUSION Sense-B-noise is a novel cause for IAS due to non-physiologic signal oversensing, arising from a previously unknown S-ICD system issue. Sense-B-noise may be suspected if episodes of signal saturation in primary or alternate vector configuration are present, oversensing cannot be provoked, and X-ray and electrical measurements appear normal. The issue can be resolved by reprogramming the device to secondary sensing vector

The effect of first step right atrial mapping (FRAM) on ablation duration and fluoroscopy exposure during cavotricuspid isthmus ablation of atrial flutter

AIM To investigate the clinical significance of right atrial mapping prior to cavotricuspid isthmus (CTI) ablation in patients with typical atrial flutter (AFL). METHODS Clinical and ablation parameters were retrospectively assessed and compared in patients undergoing CTI ablation with or without a first-step right atrial mapping (FRAM) by using the CARTO 3D mapping system. RESULTS CTI block by radiofrequency ablation (RFA) was achieved in all 143 patients. In the FRAM group there was a shorter ablation duration and fluoroscopy exposure compared with the non-FRAM group. CHA$_{2}$DS$_{2}$-VASc score was associated with higher ablation durations, more ablation applications and increased fluoroscopy exposure. Body mass index (BMI) was associated with longer ablation duration and more ablation applications. Furthermore, patients with reduced left ventricular ejection fraction (LVEF) had longer ablation durations and more fluoroscopy exposure. One patient in the non-FRAM group developed cardiac effusion after ablation. None of the patients had recurrence after 6 months of follow-up. CONCLUSIONS Patients with high BMI, high CHA$_{2}$DS$_{2}$-VASc score and reduced LVEF may benefit from the FRAM approach by reducing ablation duration, number of ablation applications and fluoroscopy exposure