Non-Cardiac Sudden Death in a Patient With Arrhythmogenic Right Ventricular Cardiomyopathy

We herein present the case of a 70-year old lady with arrhythmogenic right ventricular cardiomyopathy (ARVC) and recurrent episodes of syncope. She was referred to our department due to an episode of sustained ventricular tachycardia (VT) which caused haemodynamic collapse and was converted electrically. During diagnostic investigation, echocardiography revealed evidence of right ventricular dysfunction. She underwent risk stratification and sustained monomorphic VT was easily induced during electrophysiology study. An implantable cardioverter-defibrillator (ICD) device was subsequently implanted, but she died suddenly three months later. ICD device interrogation did not reveal any arrhythmic event and death was attributed to carbon monoxide poisoning

Ενδοκαρδιακή μέσω Καθετήρα Κατάλυση με Υψίσυχνο Ρεύμα σε Μετεμφραγματικό Ασθενή με Ηλεκτρική Θύελλα πριν από την Εμφύτευση Απινιδωτού: Μακροχρόνια Πορεία και Έκβαση

Περιγράφεται η περίπτωση ενός ασθενούς, 66 ετών, που παρουσιάσθηκε με πολλαπλά επεισόδια εμμένουσας μονόμορφης κοιλιακής ταχυκαρδίας 30 και 14 έτη μετά δύο εμφράγματα του κατωτέρου και του προσθίου τοιχώματος του μυοκαρδίου. Αφού η ηλεκτρική θύελλα κατεστάλη με ένα μεικτό σχήμα τριπλής αντιαρρυθμικής αγωγής, ο ασθενής υπεβλήθη σε ενδοκαρδιακή κατάλυση της αρρυθμιογόνου εστίας με τη βοήθεια του ηλεκτροανατομικού συστήματος χαρτογράφησης στο ηλεκτροφυσιολογικό εργαστήριο. Ακολούθησε η εμφύτευση ενός αντιταχυκαρδιακού βηματοδότου απινιδωτού που στους επακόλουθους 30 μήνες παρακολούθησης κινητοποιήθηκε αθόρυβα σε ένα μοναδικό στιγμιότυπο αντιταχυκαρδιακής βηματοδότησης

Achievement of Right Ventricular Pacing by Use of a Long Guiding Catheter in a Hemodialysis Patient Presenting Significant Tortuosity of Vasculature

Increased vascular calcification and tortuosity are rather common in end-stage renal failure patients who are on hemodialysis. It renders manipulation of catheters and performance of percutaneous transluminal interventions more difficult than expected. Such vascular alterations may be evident in large veins and pose significant difficulties in placement of pacing leads as shown in our case. To overcome such difficulties, we demonstrated in this patient case that long guiding catheters may be of particular value

Have we Made Any Progress in Preventing Sudden Cardiac Death in the Community? A Review on Automatic External Defibrillators

ABSTRACT:  Automated External Defibrillators (AEDs) have been recognised lately as an important link in the chain of survival of patients experiencing Sudden Cardiac Arrest (SCA) still remaining a major public health problem in the Western countries, being responsible for more than 250,000 out-of-hospital deaths annually. Due to the fact that survival rates following SCA are still unacceptably poor and that in most of the cases the underlying heart rhythm in out-of-hospital SCA is Ventricular Fibrillation/ pulseless Ventricular Tachycardia, introduction of AEDs seems to open a new prospective. Since the early 1990’s, when first launched, significant improvement has been made in AEDs technology and in many countries Public Access Defibrillation programs are now widespread. After minimal training, lay rescuers and first responder who might not be health professionals effectively provide early defibrillation using AEDs, resulting in many cases in improved survival rates. In the present paper we review the status of AEDs in clinical practice in the year of 2010 emphasizing on their key role for the widespread prevention of sudden cardiac death in the community

Left Atrial Appendage Closure: Initial Experience with the Watchman Device

We herein present the first left atrial appendage (LAA) percutaneous closure procedure performed in our Institution with use of the Watchman device in an 82-year old woman with atrial fibrillation, unable to continue receiving anticoagulation therapy due to bleeding complications. A propos with this case, we discuss the data related to this therapeutic approach geared to prevent thromboembolism in patients with atrial fibrillation and contraindications to treatment with anticoagulants

Cardiac Resynchronization Therapy and Proarrhythmia: Weathering the Storm

In patients with significant left ventricular (LV) dysfunction and congestive heart failure despite optimal medical therapy, implantation of cardiac resynchronization therapy-defibrillator (CRT-D) devices has been shown to improve symptoms and diminish ventricular tachyarrhythmia susceptibility.We describe the case of a patient with dilated cardiomyopathy who developed ventricular tachycardia storm (VTS) one month after the implantation of a CRT-D device. VTS was initially controlled with pharmacotherapy, allowing the patient to continue with biventricular pacing. Two months later the patient was readmitted due to multiple episodes of polymorphic ventricular tachycardia. VTS was refractory to various intravenous antiarrhythmic drugs and it was finally controlled only when LV pacing was turned off.In patients with heart failure treated with CRT-D, VTS can occur and is best managed by turning off LV pacing. Our report raises an important and concerning issue of biventricular pacing causing ‘proarrhythmia’ in rare instances

Decreased Deceleration Capacity of Heart Rate Detects Heart Failure Patients at Risk for Malignant Ventricular Arrhythmias

BACKGROUND: Deceleration capacity (DC) of the heart rate has proved an independent predictor of total mortality in post-myocardial infarction (post-MI) patients but it is unknown whether DC predicts the arrhythmic risk as well. OBJECTIVE: Our aim was to investigate whether DC can predict the arrhythmic sudden cardiac death (SCD) surrogate in patients with heart failure (HF). PATIENTS AND METHODS: We prospectively screened 145 HF patients with electrocardiogram (ECG), signal averaged ECG, echocardiography, and 24-hour Holter ECG. After 41.2 months, patients were divided into high (n=43) and low risk (n=102) groups according to three arrhythmic surrogates: clinical ventricular tachyarrhythmia (ventricular tachycardia -VT/ ventricular fibrillation-VF) (n=18), appropriate activation of the implantable cardioverter defibrillator (ICD) device (n=23) and confirmed SCD (n=2). RESULTS: High risk patients had impaired DC with significantly lower values (3.2±1.8 ms vs 4.0±2.1 ms, p=0.025). In the Cox regression analysis model adjusted for age, gender, diabetes, left ventricular ejection fraction (LVEF), filtered QRS, QTc, nonsustained VT episode(s) ≥ 1/24 h, ventricular premature beats ≥240/24 and DC, DC emerged as an important SCD surrogate predictor with a hazard ratio of 0.804, (95% confidence intervals-CI: 0.671- 0.963, p = 0.018). The cutoff point of DC≤3.352 ms (median) presented a hazard ratio of 2.885 (95% CI: 1.342 - 6.199, p=0.007, log rank test: p=0.003) for SCD surrogate. CONCLUSION: Decreased DC was found to be an important and independent SCD surrogate predictor. The cutoff point of DC≤3.352 ms detects HF patients at increased arrhythmic risk.

Effect of Transient Myocardial Ischemia on QT Interval Dispersion Among Patients with Unstable Angina

Objective: Our aim was to examine the effect of transient myocardial ischemia on QT interval and QT interval dispersion in patients presenting with unstable angina.Methods: We studied 31 patients (mean age 64±10, 22 men, 16 with an old myocardial infarction, 6 with previous coronary bypass surgery) admitted with unstable angina manifestations. Patients with a history of complex ventricular ectopy, malignant ventricular arrhythmias, advanced congestive heart failure or antiarrhythmic drug therapy were excluded. The uncorrected and corrected QT interval and QT dispersion were measured during angina as well as after the relief of pain.Results: The RR intervals were not significantly changed by the ischemic event (879±121 ms at rest to 877±173 ms during angina). However, both the uncorrected and corrected QT intervals were significantly increased during angina (from 410±45 ms and 440±41 ms at rest to 425±53 ms and 460±42 ms during angina respectively, p<0.05 for both). Similarly, both the uncorrected (QTd) and the corrected (QTcd) QT dispersion values were significantly prolonged during ischemia (QTd: 58±23 ms at rest to 83±33 ms during ischemia, p<0.001, QTcd: 63±26 ms at rest to 95±36 ms during ischemia, p<0.001). The observed increment in the QTd and QTcd provoked by ischemia was not different among the unstable angina patients with and without old myocardial infarction.Conclusion: Transient myocardial ischemia besides an increase in the QT and QTc intervals provokes an increase in both the corrected and uncorrected QT interval dispersion. Under certain circumstances, this may contribute to the genesis of serious reentry ventricular arrhythmias

Εμφυτεύσιμος Διαφλέβιος Καρδιομετατροπέας Απινιδωτής- Η Απινίδωση στην Κλινική Πρακτική

Η πρόοδος στη φαρμακευτική θεραπεία της χρόνιας καρδιακής ανεπάρκειας οδήγησε σε αξιοσημείωτη βελτίωση της επιβίωσης και της ποιότητας ζωής. Παρόλα αυτά, ο κίνδυνος του αιφνίδιου καρδιακού θανάτου (SCD) παραμένει υψηλός στο γηράσκοντα πληθυσμό. Πρόσφατες εκτιμήσεις της ετήσιας επίπτωσης των καρδιακών θανάτων στις ΗΠΑ κυμαίνονται μεταξύ των 184.000 και 400.000 περιπτώσεων. Οι τυχαιοποιημένες κλινικές μελέτες δεν έχουν δείξει πειστικά ότι η αντιαρρυθμική θεραπεία μπορεί να μειώσει αποτελεσματικά τη θνητότητα σε ασθενείς με καρδιακή ανεπάρκεια. Δυστυχώς, η προσπάθεια ταυτοποίησης πληθυσμών υψηλού κινδύνου είχε πενιχρά αποτελέσματα ως προς τη μείωση της συνολικής επίπτωσης του SCD γενικά στον πληθυσμό, επειδή η πλειοψηφία των θανάτων αυτών συνέβαιναν σε ασθενείς, οι οποίοι δεν είχαν ταυτοποιήσιμους παράγοντες κινδύνου. Ο κίνδυνος SCD κυμαίνεται ανάμεσα στο 20% και στο 30% μεταξύ των ασθενών με μειωμένη συστολική λειτουργία της αριστερής κοιλίας. Επιπρόσθετα, ο κίνδυνος για SCD αυξάνει σχεδόν εκθετικά, όταν το ΚΕ μειώνεται <30%.            Παράλληλα με τη βαρύτητα της δυσλειτουργίας της αριστερής κοιλίας, ο βαθμός της λειτουργικής βλάβης, σύμφωνα με τη λειτουργική ταξινόμηση του New York Heart Association (NYHA) φαίνεται επίσης ότι είναι ένας ισχυρός ανεξάρτητος προγνωστικός παράγοντας του SCD. Παρά το γεγονός ότι ο απόλυτος αριθμός των SCD είναι μεγαλύτερος στους ασθενείς με class IV κατά NYHA, ο SCD ανέρχεται μόλις στο 35% της συνολικής θνητότητας στη συγκεκριμένη ομάδα ασθενών... (excerpt