Arrhythmology and cardiac pacing – an overview of the situation in Croatia.

Unazad nekoliko godina prisutan je značajan napredak u zbrinjavanju bolesnika s poremećajima srčanog ritma, kako u svijetu, tako i u Republici Hrvatskoj. Ovaj pregledni članak prikazuje postojeće stanje u području aritmologije i elektrostimulacije u Republici Hrvatskoj. Najveći napredak vidljiv je u području elektrofiziologije značajnim povećanjem broja učinjenih kateterskih ablacija aritmija, a osobito ablacije fibrilacije atrija. Prisutni su i znatni pomaci u novim spoznajama u području elektrostimulacije, daljnji porast u brojnu centara gdje se takvi postupci provode, kao i u broju učinjenih postupaka, pri čemu edukacija prati nove spoznaje i trendove, sve s ciljem kako bi našim bolesnicima omogućili dulje preživljenje i bolju kvalitetu života. Međutim, glavni izazovi koji ostaju pred nama nisu se bitno promijenili u odnosu na prijašnje godine, a osnovno je pronalazak dodatnih sredstava koji bi osigurali bolju prevenciju nagle srčane smrti neophodnim povećanjem broja ugradnje implantabilnih kardioverter defibrilatora i uređaja za resinkronizacijsku terapiju. Prostor za poboljšanje je znatan, pri čemu se ne može dovoljno naglasiti važnost ustrajne aktivnosti stručnog društva u ovom području.In the past few years there has been a significant progress in the management of patients with heart rhythm disorders both in the world and in Croatia. This review article summarizes the current situation in the area of arrhythmology and cardiac pacing in the Republic of Croatia. The greatest improvement is seen in the field of electrophysiology due to a significant increase in the number of performed electrophysiological procedures, particularly catheter ablation of atrial fibrillation. There are also significant advancements in new insights in the field of electrical stimulation, a further increase in a number of centers where such procedures are performed, as well as in the number of performed procedures where education follows new insights and trends, all with an aim to enable our patients to have prolonged survival and a better quality of life. However, some major challenges we are facing have not significantly changed compared to the previous year, and the basic one is finding additional resources to ensure better prevention of sudden cardiac death by necessary increasing the implantation rate of implantable cardioverter defibrillators and cardiac resynchronization therapy devices. The room for improvement is great, whereas we can not sufficiently emphasize the importance of persistent activities of the professional society in this area

Transvenous Pacemaker Lead Extraction: First Experiences in the University Hospital Centre Rijeka

Posljednih godina dolazi do znatnog porasta broja implantiranih elektrostimulatora srca. Posljedično tomu raste i broj mogućih komplikacija te potreba za njihovom ekstrakcijom. Najčešća indikacija za ekstrakciju elektrostimulatora jest lokalizirana ili sustavna infekcija. S obzirom na to da je riječ o najkompleksnijim i najrizičnijim zahvatima iz područja kardiologije, iz godine u godinu razvijaju se nove tehnike i alati koji znatno olakšavaju ekstrakciju i smanjuju rizik od nastanka mogućih, pokatkad i vrlo teških komplikacija. S obzirom na navedeno, potrebno je organizirati dovoljan broj adekvatnih centara u kojima bi djelovao specijalizirani multidisciplinarni tim educiran za provođenje navedenih zahvata. Od početka 2013. godine na Odjelu za aritmije i elektrostimulaciju Zavoda za kardiovaskularne bolesti Kliničkog bolničkog centra Rijeka započeo je program ekstrakcija elektroda. U razdoblju od dvije i pol godine učinjeno je ukupno 27 zahvata te je uklonjena ukupno 51 elektroda, od čega su dvije bile defibrilatorske. Glavni uzrok ekstrakcije elektroda bila je lokalizirana infekcija / dekubitus lože, dok je sustavna infekcija bila mnogo rjeđa. U postupku ekstrakcije prevladava tehnika trakcije i „locking” stileta. Najznačajnija je komplikacija razvoj simptomatskoga perikardijalnog izljeva. Smrtnih ishoda nije bilo.During recent years there has been a significant increase in pacemaker implantation. Consequently, the number of possible complications and the need for pacemaker lead extraction has grown as well. The most common indication for pacemaker lead extraction is localized or systemic infection. Since lead extraction is among the most complex and dangerous cardiologic procedures, new techniques and tools are being developed on a yearly basis that significantly facilitate extraction and reduce the risk of possible, often very severe, complications. Considering the above, it is necessary to organize enough appropriate centers with specialized multidisciplinary teams trained for the performance of these procedures. Since early 2013, a pacemaker lead extraction program was started at the Department for Arrhythmia and Electrical Stimulation at the University Hospital Centre Rijeka. Over a period of two and a half years, a total of 27 procedures have been performed and 51 pacemaker leads were extracted, of which two were defibrillator leads. The main cause of lead extraction was localized infection/pocket decubitus, while systemic infection was much rarer. Extraction techniques used were predominantly traction and locking stylet extractions. The most significant complication was the development of symptomatic pericardial effusion. There were no fatal outcomes

Preporuke za perioperacijski postupak kod bolesnika koji imaju ugrađene kardiovaskularne implantabilne elektroničke uređaje

Four thousand cardiac implantable electronic devices (CIED) are implanted yearly in Croatia with constant increase. General anesthesia and surgery carry some specific risk for the patients with implanted CIEDs. Since most of the surgical procedures are performed in institutions without reprogramming devices available, or in the periods when they are unavailable, these guidelines aim to standardize the protocol for perioperative management of these patients. With this protocol, most of the procedures can be performed easily and, more importantly, safely in the majority of surgical patients.U Republici Hrvatskoj na godinu se implantira oko 4000 kardiovaskularnih implantabilnih uređaja i taj broj je u stalnom porastu. Anestezija i kirurški zahvati kod bolesnika s ugrađenim implantabilnim uređajima nose određene rizike. Ove smjernice su nastale zato što se većina zahvata izvodi u ustanovama bez mogućnosti testiranja i reprogramiranja navedenih uređaja ili u vrijeme kada to nije dostupno. Cilj je standardizirati perioperacijsku skrb ovih bolesnika te učiniti kirurške zahvate dostupnima i sigurnima za veliku većinu ovih kirurških bolesnika u svim ustanovama u Hrvatskoj

Mysterious atrial mass mimicking severe mitral stenosis

Introduction: The differential diagnosis of an intracardiac mass include benign and malignant primary heart tumors, metastatic tumors and thrombi. Primary tumors of the heart consist mainly of myxomas, with an incidence of less than 0.5%. Clinical manifestations are consequence of embolic phenomena, intracardiac obstruction or constitutional symptoms. In rare instances, myxomas can cause a mass effect, resulting in mitral valve obstruction1. Case report: 68-year-old male with a history of ulcerative colitis complained to his gastroenterologist about having exercise intolerance. Undergoing regular colitis evaluation, CT thorax and abdomen scan was performed incidentally revealing a large intracardiac mass. Echocardiogram ordered by the consulting cardiologist demonstrated a large ellipsoid left atrial cyst (50×31 mm), occupying nearly the entire left atrium (Figure 1). The mass was protruding across the mitral valve orifice in diastole causing functional stenosis with an elevated mean diastolic gradient of 10,9 mmHg. Mitral valve area calculated by pressure half-time was 1.0 cm2. Doppler showed moderate tricuspid regurgitation with a systolic pulmonary artery pressure of 50 mmHg. The systolic function was preserved with an estimated left ventricular ejection fraction of 58%. Transesophageal echocardiography described a cavitating lesion (measuring 15,1 cm2, attached to interatrial septum with 24 mm base), having characteristics consistent with a hemorrhagic cyst (Figure 2). Preoperative coronary angiography displayed coronary artery disease and a rare condition of dual coronary artery supply with left circumflex artery (LCx) providing two (Figure 3) and right coronary artery (RCA) one tumor branch (Figure 4) producing a characteric "tumor blush". CT showed large intracardiac mass (Figure 5 and Figure 6). Patient underwent cardiothoracic surgery with successful excision of the tumor (4,5x3x2 cm), the pathohistology confirmed myxoma. Postoperative course was uneventful, exercise intolerance symptoms improved, and echocardiographic follow up showed no intracardiac mass. Conclusion: We described a rare case of cystic-appearance cardiac myxoma with dual coronary supply mimicking mitral valve stenosis. There are not many patients reported with left atrial myxoma being vascularized from both RCA and LCx as seen in our case2. Although more than half of atrial myxomas show obstructive symptoms, severe mitral valve obstruction is rare1. Early echocardiographic examination of patients presenting with exertional dyspnea is advised, as myxomas have an excellent prognosis following surgical excision, preventing complications and improving quality of life

Long QT syndrome — a cause of sudden death.

Sindrom dugog QT intervala (LQTS) je primarni aritmijski poremećaj koji može dovesti do pojave malignih ventrikularnih aritmija tipa torsades de pointe (TdP) i iznenadne srčane smrti. Obilježja u elektrokardiogramu (EKG) uključuju produljenje korigiranog QT intervala i abnormalnosti T-vala. Do danas identificirana genetska osnova za LQTS uključuje trinaest podložnih gena za LQTS: KCNQ1, KCNH2, SCN5A, ANK2, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP9, SNTA1, i KCNJ5. Najčešći genotip su mutacije KCNQ1 te gotovo polovica pacijenata ima tu vrstu mutacije. Navedeni geni kodiraju ionske kanale i regulatorne proteine koji su uključeni u modulaciju struja srčanog akcijskog potencijala. Stečeni oblici LQTS-a mogu također biti uzrokovani genetskim mutacijama, u tim slučajevima nositelji mutacija razvijaju aritmije isključivo u određenim uvjetima (npr. uporaba određenih lijekova). Trenutna terapija uključuje primjenu beta-blokatora, ugradnju implantabilnog kardioverter defibrilatora (ICD) te simpatičku denervaciju srca. LQTS mutacije povezane su s iznenadnom srčanom smrti kod mladih i veoma mladih; a post-mortem genetska testiranja LQTS gena mogu biti korisna kod procjene uzroka iznenadne neobjašnjive smrti (sudden unexplained death). Kaskadni probir koristan je za identificiranje asimptomatskih članova obitelji koji mogu biti pod povećanim rizikom od iznenadne smrti. U ovom preglednom članku prikazali smo gene povezane s LQTS-om zajedno s opisom povezanih patofizioloških mehanizama.Long QT syndrome (LQTS) is a primary arrhythmic disorder that may lead to the precipitation of torsades de pointe (TdP) and sudden death. Electrocardiogram (ECG) features include prolongation of the corrected QT interval and T-wave abnormalities. The genetic basis of LQTS identified to date includes thirteen susceptibility genes for LQTS: KCNQ1, KCNH2, SCN5A, ANK2, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP9, SNTA1, and KCNJ5. Mutations in KCNQ1 are by far the most frequent genotype with nearly half of the patients carrying KCNQ1 mutations. These genes code for ion channels and regulatory proteins that are involved in the modulation of the currents of the cardiac action potential (AP). Acquired forms of LQTS may also have underlying genetic mutations, in these cases mutation carriers develop arrhythmias only under certain conditions (e.g. use of certain medications). Current therapies include use of beta-blockers, implantable cardioverter defibrillators (ICD) and left cardiac sympathetic denervation. LQTS mutations have been associated with sudden death in the young and very young; and postmortem genetic testing in LQTS genes can be useful when assessing the cause of a sudden unexplained death. Cascade screening is also useful to identify asymptomatic family members that may be at risk of sudden death. Here we have reviewed the genes associated with LQTS along with the description of the related pathophysiological mechanisms

Preporuke za postupanje kod bolesnika sa srčanim implantabilnim elektroničkim uređajima koji su podvrgnuti magnetskoj rezonanci - Radna skupina za aritmije i elektrostimulaciju Hrvatskoga kardiološkog društva

For many years, magnetic resonance imaging (MRI) was contraindicated in patients with cardiac implantable electronic devices (CIED). Today, there is a growing amount of evidence that MRI can be performed safely in the majority of patients with CIEDs. Firstly, there are devices considered MRI conditional by manufacturers that are available on the market and secondly, there is clear evidence that even patients with MRI non-conditional devices can also undergo MRI safely. Protocols have been developed and recommendations from different cardiac and radiologic societies have been published in recent years. However, the majority of physicians are still reluctant to refer these patients to MRI. Therefore, this document is published as a joint statement of the Croatian Working Group on Arrhythmias and Cardiac Pacing and Department of Radiology, Sestre milosrdnice University Hospital Centre to guide and ease the management of patients with CIED undergoing MRI. Also, we propose a unified protocol and checklist that could be used in Croatian hospitals.Magnetska rezonanca (MR) dugo je bila kontraindicirana dijagnostička metoda kod bolesnika sa srčanim implantabilnim elektroničkim uređajima (CIED). Danas imamo dovoljno dokaza da se MR može sigurno učiniti kod većine bolesnika s CIED. Prvo, postoje uređaji koji mogu biti podvrgnuti MR prema preporukama proizvođača, a drugo, postoje jasni dokazi da većina uređaja koji nisu označeni kao sigurni za MR od proizvođača također mogu biti podvrgnuti MR. Tijekom godina razvijeni su brojni protokoli kardioloških i radioloških društava, međutim, dio liječnika i dalje oklijeva kod postavljanja indikacije za MR u ove skupine bolesnika. Stoga je Radna skupina za aritmije i elektrostimulaciju srca Hrvatskoga kardiološkog društva u suradnji s radiolozima KBC Sestre milosrdnice pripremila preporuke za postupanje s bolesnicima s CIED koji su podvrgnuti MR

Long QT syndrome — a cause of sudden death.

Sindrom dugog QT intervala (LQTS) je primarni aritmijski poremećaj koji može dovesti do pojave malignih ventrikularnih aritmija tipa torsades de pointe (TdP) i iznenadne srčane smrti. Obilježja u elektrokardiogramu (EKG) uključuju produljenje korigiranog QT intervala i abnormalnosti T-vala. Do danas identificirana genetska osnova za LQTS uključuje trinaest podložnih gena za LQTS: KCNQ1, KCNH2, SCN5A, ANK2, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP9, SNTA1, i KCNJ5. Najčešći genotip su mutacije KCNQ1 te gotovo polovica pacijenata ima tu vrstu mutacije. Navedeni geni kodiraju ionske kanale i regulatorne proteine koji su uključeni u modulaciju struja srčanog akcijskog potencijala. Stečeni oblici LQTS-a mogu također biti uzrokovani genetskim mutacijama, u tim slučajevima nositelji mutacija razvijaju aritmije isključivo u određenim uvjetima (npr. uporaba određenih lijekova). Trenutna terapija uključuje primjenu beta-blokatora, ugradnju implantabilnog kardioverter defibrilatora (ICD) te simpatičku denervaciju srca. LQTS mutacije povezane su s iznenadnom srčanom smrti kod mladih i veoma mladih; a post-mortem genetska testiranja LQTS gena mogu biti korisna kod procjene uzroka iznenadne neobjašnjive smrti (sudden unexplained death). Kaskadni probir koristan je za identificiranje asimptomatskih članova obitelji koji mogu biti pod povećanim rizikom od iznenadne smrti. U ovom preglednom članku prikazali smo gene povezane s LQTS-om zajedno s opisom povezanih patofizioloških mehanizama.Long QT syndrome (LQTS) is a primary arrhythmic disorder that may lead to the precipitation of torsades de pointe (TdP) and sudden death. Electrocardiogram (ECG) features include prolongation of the corrected QT interval and T-wave abnormalities. The genetic basis of LQTS identified to date includes thirteen susceptibility genes for LQTS: KCNQ1, KCNH2, SCN5A, ANK2, KCNE1, KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP9, SNTA1, and KCNJ5. Mutations in KCNQ1 are by far the most frequent genotype with nearly half of the patients carrying KCNQ1 mutations. These genes code for ion channels and regulatory proteins that are involved in the modulation of the currents of the cardiac action potential (AP). Acquired forms of LQTS may also have underlying genetic mutations, in these cases mutation carriers develop arrhythmias only under certain conditions (e.g. use of certain medications). Current therapies include use of beta-blockers, implantable cardioverter defibrillators (ICD) and left cardiac sympathetic denervation. LQTS mutations have been associated with sudden death in the young and very young; and postmortem genetic testing in LQTS genes can be useful when assessing the cause of a sudden unexplained death. Cascade screening is also useful to identify asymptomatic family members that may be at risk of sudden death. Here we have reviewed the genes associated with LQTS along with the description of the related pathophysiological mechanisms

Croatian National Data and Comparison with European Practice: Data from the Cardiac Resynchronization Therapy Survey II Multicenter Registry

. The Cardiac Resynchronization Therapy (CRT) Survey II was conducted between October 2015 and December 2016 and included data from 11088 CRT implantations from 42 countries. The survey’s aim was to report on current European CRT practice. The aim of this study was to compare the Croatian national CRT practice with the European data. . Five centres from Croatia recruited consecutive patients, in a 15-month period, who underwent CRT implantation, primary or an upgrade. Data were collected prospectively by using online database. . A total of 115 patients were included in Croatia, which is 33.2% of all CRT implants in Croatia during the study period (total ). Median age of the study population was 67 (61–73) years, and 21.2% were women. Primary heart failure (HF) aetiology was nonischemic in 61.1% of patients, and HF with wide QRS was the most common indication for the implantation (73.5%). 80% of patients had complete left bundle branch block, and over two-third had QRS ≥150 ms. Device-related adverse events were recorded in 4.3% of patients. When compared with European countries, Croatian patients were significantly younger (67 vs. 70 years, ), had similar rate of comorbidities with the exception of higher prevalence of hypertension. Croatian patients significantly more often received CRT-pacemaker when compared with European population (58.3 vs. 29.9%, OR 3.27, 95%CI 2.25–4.74, ). . Our data indicate strict selection of patients among HF population and adherence to guidelines with exception of higher proportion of CRT-pacemaker implantation. This is likely to be influenced by healthcare organization and reimbursement issues in Croatia

New hemodynamic pacing lead sensor based on high frequency parameters

CILJ ISTRAŽIVANJA. Ovim istraživanjem želi se dokazati mogućnost upotrebe srčane elektrode za elektrostimulaciju kao novog, jedinstvenog senzora za monitoriranje kontraktilnosti srca. Senzor se temelji na mjerenju koeficijenta refleksije visokofrekventnog (HF) električnog signala primijenjenog na srčanu elektrodu kojeg smo nazvali LBS (engl. Lead bending signal). ISPITANICI I METODE.Istraživanje je provedeno na skupini od deset odraslih ovaca križanih pasmina (42 ± 6 kg) u kojima su implantirane tri vrste elektroda. Izvršena je istovremena akvizicija LBS, EKG i tlaka u lijevoj klijetki (LVP), prilikom implantacije i nakon četiri mjeseca od implantacija elektroda, u bazalnim uvjetima i pri hemodinamskim intervencijama koje su se sastojale od infuzije dobutamina, esmolola te indukcije tahikardije brzom ventrikularnom stimulacijom frekvencije do 200/min. REZULTATI. Stabilni, reproducibilni i konzistentni signali dobiveni su u svih životinja, u oba dijela istraživanja, te u svim eksperimentalnim uvjetima i tijekom hemodinamskih intervencija. Dobutamin je uzrokovao signifikantni porast frekvencije srca, krvnoga tlaka, LV dP/dt i akceleracije savijanja elektrode (LBA). Korelacija između LBAmax i LVdp/dtmax pokazala se kao statistički značajna, s visokim Pearsonovim koeficijentom korelacije (r = 0.855, p << 0,001), što dokazuje mogućnost korištenja LBS signala kao hemodinamskog, kardiomehaničkog senzora. Prilikom brze ventrikularne stimulacije mogli smo zamijetiti hemodinamsku deterioraciju životinja koja je dovela do sniženja LVP, LV dP/dt, LBS i LBA, te oporavka hemodinamskih parametara nakon ponovne uspostave sinusnog ritma. ZAKLJUČAK. Ovo je prvo istraživanje koje je istražilo mogućnost upotrebe HF parametara srčanih elektroda za monitoriranje kontraktilnosti srca. Visoki koeficijent korelacije između akceleracije savijanja elektrode i kontraktilnosti miokarda dokazuje Vmogućnost njegove uporabe kao hemodinamskog, kardiomehaničkog senzora. U budućim istraživanjima bit će potrebno potvrditi mogućnost korištenja LBS senzora uporabom bilo koje standardne bipolarne elektrode.OBJECTIVES.In this study, we propose a new hemodynamic (cardiomechanic) sensor based upon high frequency (HF) parameters of bipolar cardiac pacing leads. By measuring the lead HF impedance variation, or any related parameter such as HF reflection coefficient, we can quantify the lead bending due to the myocardial contraction. Therefore, the signal obtained by measuring the HF reflection coefficient on an implanted cardiac lead is named the lead bending signal (LBS). The purpose of this pilot study was to investigate the possibility of detecting the ventricular contraction in sheep utilizing LBS measurements on endovenous pacemaker and defibrillator leads. We also compared the cardiomechanic parameter - maximum rate of rise of the lead bending signal (dLBS/dtmax), i.e. the maximum lead bending acceleration (LBAmax), with the hemodynamic parameter - positive peak LV dP/dt, universally accepted as a good and highly sensitive index for contractility assessment in an individual patient. MATERIAL AND METHODS.The study was a single-centre, experimental animal feasibility study. The study was designed to evaluate the following hypotheses: (1) measuring and recording LBS in implanted bipolar or multipolar cardiac leads at the time of implantation procedure and after four months is feasible, (2) there is a correlation between LBS, LBAmax and LV dp/dtmax acquired four months after the implantation procedure. We implanted three different pacing leads and tested the measurement system in ten sheep (42 ± 6 kg) at baseline and during acute hemodynamic intervention with dobutamine infusion, esmolol infusion and tachycardia induced by fast ventricular pacing at rate up to 200 bpm. VIIRESULTS.A stable, consistent, and reproducible LBS was obtained in all sheep during the implantation procedure and four months after the implant during different experimental conditions that included hemodynamic interventions. Dobutamine infusion significantly increases heart rate (HR), left ventricular pressure (LVP), maximum rate of rise of left ventricular pressure (LV dP/dtmax) and maximum rate of rise of the lead bending signal (dLBS/dtmax) being the maximum lead bending acceleration (LBAmax). The dependence between LBAmax and LV dP/dtmax was found to be statistically significant and with high Pearson’s correlation coefficient (r = 0.855, p < 10-9). We could observe the hemodynamic deterioration caused by RV pacing. Pacing at 200 ppm decreased the LVP, LV dp/dt, LBS and LBA compared with the sinus rhythm. The return to sinus rhythm was associated with restoration of normal hemodynamics. CONCLUSION. To my knowledge, the present study is the first to evaluate and confirm the feasibility and efficacy of the hemodynamic sensor based upon HF lead parameters. Moreover, it was demonstrated that the maximum lead bending acceleration is highly correlated to the ventricular contractility and, therefore, can be efficiently used as a hemodynamic and cardiomechanic sensor. Our ongoing studies should reveal that the high-frequency system functions with every standard cardiac lead having at least two conductors. To establish fully the advantages and limits of this new method, comparison with LV pressure-volume loops in humans and multicentre study data are neede