Biventricular implantable cardioverter-defibrillator device placement in patients with hostile tricuspid valve anatomy: two case reports and review of the literature

AIMS: Right ventricular (RV) lead placement can be contraindicated in patients after tricuspid valve (TV) surgery. Placement of the implantable cardiac-defibrillator (ICD) lead in the middle cardiac vein (MCV) can be a viable option in these patients who have an indication for biventricular (BiV) ICD. We aim to describe the case of two patients with MCV lead placement and provide a comprehensive review of patients with complex TV pathology and indications for RV lead placement. METHODS AND RESULTS: We describe the cases of two patients with TV pathology unsuitable for the standard transvenous or surgical RV lead placement and undergoing BiV ICD implantation. Their characteristics, procedure, and outcomes are summarized. The BiV ICD was successfully placed with the RV lead positioned in the MCV in both patients. The procedures had no complications and were well-tolerated. On follow-up, both patients had appropriate tachytherapy with no readmissions for heart failure or worsening of cardiac function. CONCLUSION: Right ventricular lead placement of BiV ICD in the MCV can be an excellent alternative in patients with significant TV pathology and poor surgical candidacy

TRICUSPID VALVE DISEASE AND RIGHT VENTRICULAR DYSFUNCTION AFTER RIGHT VENTRICULAR TRANSVENOUS LEAD PLACEMENT IN PATIENTS WITH TRICUSPID VALVE PROSTHESIS

Background: First time transvenous right ventricular (RV) lead implant after tricuspid valve (TV) repair or bioprosthetic replacement is common. We evaluated outcomes in TV regurgitation (TR) and RV function in this population. Methods: We conducted single-center retrospective study on patients with TV repair or replacement from 2000 to 2020 followed by first-time transvenous RV lead implant. Primary outcomes were change in TR severity (defined as defined as none/trivial, mild, moderate, moderate-severe, or severe) and RV function (normal, mild, moderate, or severe). Baseline and follow-up echocardiogram (ECHO) data was reviewed, as well as time to death. Results: 52 patients were identified (29 female, 47 had hypertension, 41 had atrial fibrillation, 49 had TV repair, 3 had replacement). Median time from surgery to implant was 1.7 months and to last ECHO was 39.7 months. In TV repair, baseline TR was none/trivial in 15 (30.6%) and mild in 21 (42.8%) patients. RV function was normal in 33 (67.3%) patients. 58% had worsened TR (mean 0.9 levels) (Figure). No TR change was seen in TV replacement. Mean worsening RV function was by 0.9 levels. There was statistically significant correlation with RV pacing and RV dysfunction (Spearman correlation coefficient 0.37, p = 0.017), but not with change in TR (p = 0.36). 22 patients died at median follow-up (48.9 months). Conclusion: Presence of an RV lead after TV repair correlated with worsening TR. Higher RV pacing level correlated with RV dysfunction but not TR severity

Sex Differences in Stress-Induced (Takotsubo) Cardiomyopathy

BACKGROUND: Takotsubo cardiomyopathy (TC) affects predominantly women. Prior studies have suggested that men might have worse short-term outcomes, but limited data are available regarding long-term outcomes. We hypothesized that men, compared to women, with TC have worse short- and long-term outcomes. METHODS: A retrospective study of patients diagnosed with TC between 2005 and 2018 in the Veteran Affairs system was performed. Primary outcomes were in-hospital death, 30-day risk of stroke, death, and long-term mortality. RESULTS: A total of 641 patients were included (444 men [69%]; 197 women [31%]). Men had a higher median age (65 vs 60 years; P \u3c 0.001), and women were more likely to present with chest pain (68.7% vs 44.1%; P \u3c 0.001). Physical triggers were more common in men (68.7% vs 44.1%, P \u3c 0.001). Men had a higher in-hospital mortality rate (8.1% vs 1%; P \u3c 0.001). On multivariable regression analysis, female sex was an independent predictor for improved in-hospital mortality, compared to men (odds ratio 0.25, 95% confidence interval 0.06-1.10; P = 0.04). On 30-day follow-up, no difference occurred in a combined outcome of stroke and death (3.9% vs 1.5%; P = 0.12). On long-term follow-up (3.7 ± 3.1 years), female sex was identified as an independent predictor of lower mortality (hazard ratio 0.71, 95% CI 0.51-0.97; P = 0.032). Women were more likely to have TC recurrence (3.6% vs 1.1%; P = 0.04). CONCLUSIONS: In our study with a predominantly male population, men had less-favourable short- and long-term outcomes after TC, compared to those of women

Sex Differences in Stress-Induced (Takotsubo) Cardiomyopathy

Background: Takotsubo cardiomyopathy (TC) affects predominantly women. Prior studies have suggested that men might have worse short-term outcomes, but limited data are available regarding long-term outcomes. We hypothesized that men, compared to women, with TC have worse short- and long-term outcomes. Methods: A retrospective study of patients diagnosed with TC between 2005 and 2018 in the Veteran Affairs system was performed. Primary outcomes were in-hospital death, 30-day risk of stroke, death, and long-term mortality. Results: A total of 641 patients were included (444 men [69%]; 197 women [31%]). Men had a higher median age (65 vs 60 years; P \u3c 0.001), and women were more likely to present with chest pain (68.7% vs 44.1%; P \u3c 0.001). Physical triggers were more common in men (68.7% vs 44.1%, P \u3c 0.001). Men had a higher in-hospital mortality rate (8.1% vs 1%; P \u3c 0.001). On multivariable regression analysis, female sex was an independent predictor for improved in-hospital mortality, compared to men (odds ratio 0.25, 95% confidence interval 0.06-1.10; P = 0.04). On 30-day follow-up, no difference occurred in a combined outcome of stroke and death (3.9% vs 1.5%; P = 0.12). On long-term follow-up (3.7 ± 3.1 years), female sex was identified as an independent predictor of lower mortality (hazard ratio 0.71, 95% CI 0.51-0.97; P = 0.032). Women were more likely to have TC recurrence (3.6% vs 1.1%; P = 0.04). Conclusions: In our study with a predominantly male population, men had less-favourable short- and long-term outcomes after TC, compared to those of women

PATIENT WITH IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR AND HIGH DEFIBRILLATION THRESHOLDS WITH LIMITED OPTIONS!

Background: In patients with implantable cardioverter-defibrillators (ICD) and high defibrillation thresholds (DFT) who fail appropriate shocks, steps should be taken to lower DFT. However, options might be limited. Here, we present a case of a patient whose DFT was lowered using an intuitive method. Case: A 64-year-old male with non-ischemic cardiomyopathy status post ICD implant presented to the ER with ICD shocks. Patient had prior history of ventricular tachycardia (VT) that resulted in multiple ICD shocks. He had VT storm on sotalol with acute renal failure. He had a VT ablation but continued to have VT afterwards while on amiodarone and mexiletine. The ICD was initially implanted in 2005 with a Medtronic 6949 Sprint Fidelis DF-1 lead in the right ventricular (RV) high septum. A Medtronic 6996 subcutaneous (SQ) coil was added in 2011 after some failed shocks. In 2013, a new Medtronic 6935 RV Quattro DF-1 ICD lead in the RV apex was added. A device upgrade to a dual chamber biventricular ICD was done due to being pacer-dependent and due to a secondary prevention indication for his ICD. His Fidelis lead was abandoned. In the ER, his device interrogation showed he failed his first shock at the maximum of 35 J. His following shock at the same output succeeded. Decision-making: Options in this patient included adding a second coil (azygous or coronary sinus vein) or a second SQ, using a generator with a higher output, and/or reversing polarity. A venogram was done that showed extensive occlusion, likely to the azygous vein origin. A Medtronic Cobalt DTPB2D1 ICD 40 J generator was placed. We decided to use a Medtronic DF-1 6726 y-adapter to combine the RV coils of the Quattro and abandoned Fidelis leads. DFT testing was performed twice successfully at 15 J. Due to low RV impedance (24 Ω), we tested DFT twice more without the SQ coil successfully at 15 J (34 Ω). If that failed, we would have added a second SQ coil and merged it with the previous SQ coil. If that failed, extraction and reimplantation of coil in the coronary sinus vein would have been done. Conclusion: Combining 2 RV coils from different locations is an effective way to significantly lower DFT, likely by lowering the shock impedance and increasing the shock tissue surface area

Late onset complete heart block after transcatheter aortic valve replacement treated with permanent His-bundle pacing

Transcatheter aortic valve replacement (TAVR) is a rapidly growing procedure. Conduction disease post-TAVR is frequent and routinely monitored for periprocedurally. Permanent pacemaker placement is relatively common and usually associated with worse outcomes post-TAVR. We report a case of very late presenting complete heart block post-TAVR treated with His-bundle pacing. Our case underscores the need for larger studies to further evaluate the utility of long-term cardiac monitoring post-TAVR and outcomes of His-bundle pacing in this population

Dual-chamber pacing using a hybrid transvenous and leadless pacing approach

An elderly gentleman with a dual-chamber pacemaker presented to our institution with symptoms of symptomatic bradycardia and high-grade atrioventricular (AV) block. Device interrogation revealed failure to capture in the right ventricle (RV) lead with bipolar pacing, high RV pacing threshold with unipolar pacing, and high impedance suggesting lead fracture. The atrial lead function was normal. Given his advanced age, gait instability, and dementia, the decision was made to proceed with Micra AV pacemaker implantation, while programming his dual-chamber pacemaker to AAIR mode, thus maintaining AV synchrony by tracking paced atrial impulses and providing ventricular pacing

Iatrogenic cardiomyopathy in patients with manifest right supero-paraseptal accessory pathways

INTRODUCTION: We describe 2 patients with right supero-paraseptal accessory pathway (SPAP) who developed left ventricular dysfunction associated with increased degree of ventricular pre-excitation and frequent orthodromic reciprocating tachycardia (ORT) due to worsening AV node conduction. METHODS AND RESULTS: Case 1: 48-year-old female with a history of normally functioning mechanical mitral valve, CABG, and ventricular pre-excitation that worsened after her open heart surgery. She presented with frequent palpitations with documented supraventricular tachycardia (SVT) and found to have a new left ventricular dysfunction with decrease in left ventricular ejection fraction (LVEF) from 55% to 46% with dyssynchrony. Electrophysiological study confirmed a right SPAP and ORT. The pathway was successfully ablated from the antegrade approach after careful mapping. After ablation and six month follow up echocardiogram showed improvement of EF to 54% and the LV dyssynchrony resolved. Case 2: 51-year-old male with a history of frequent SVT with recent unsuccessful ablations that resulted in worsening ventricular pre-excitation, more frequent SVT and new left ventricular dysfunction (LVEF from 60% to 40%). He was started on amiodarone which resulted in significant sinus bradycardia, intermittent ventricular pre-excitation and first degree AV block with significant increase in ORT events. His Electrophysiology study confirmed SPAP which was successfully ablated from the antegrade approach after careful mapping. After one month, follow-up echocardiogram showed an improved ejection fraction to 60%. CONCLUSION: Left ventricular dysfunction due to dyssynchrony and symptomatic frequent ORT of right SPAP can develop in the setting of new iatrogenic diminished AV node conduction. Successful ablation will result in LV function recovery to baseline. This article is protected by copyright. All rights reserved