Alexander Feldman

Incidence of Postdischarge Symptomatic Paroxysmal Atrial Fibrillation in Patients Who Underwent Coronary Artery Bypass Graft

The aim of this retrospective study was to determine the incidence of symptomatic AF of patients who had undergone coronary artery bypass grafting (CABG) during long‐term follow‐up. The study population included 305 post‐CABG patients who were regularly followed in the outpatient clinic. Paroxysmal AF (PAF) was defined as an episode of symptomatic AF when symptoms were prolonged enough for the patient to request medical care. Perioperative AF occurred in 88 (28.9%) patients. Postdischarge symptomatic PAF occurred in 25 (8.2%) patients with an annual incidence of 2% during a mean follow‐up of 48 ± 30 months. Eighteen (20.4%) patients also experienced perioperative AF with an annual incidence of 5.1%, while only 7 (3.2%) of 217 patients, without perioperative AF, had postdischarge AF (P < 0.0003). During long‐term follow‐up, postdischarge AF has a low incidence and prophylactic antiarrhythmic therapy is not recommended. The method of follow‐up and retrospective analysis may understate PAF and even miss some symptomatic episodes. Perioperative AF is a predictor of symptomatic late PAF recurrences, particularly in patients with reduced left ventricular function. (PACE 2004; 27:365–367)

Acute pericardial tamponade due to screw-in atrial lead heart perforation

A case of peri-procedural perforation of right atrium following the implantation of atrial screw-in lead in a 74-year-old man is reported. The perforation caused acute pericardial tamponade and worsening of the patients clinical and haemodynamic conditions. Urgent surgical intervention with lead extraction was performed.

Permanent Pacing in Nonagenarians Over 20-Year Period

Life expectancy increases progressively and nonagenarians are a growing population. We report trends in pacing and long‐term outcome in nonagenarians over a 20‐year period in a single center compared with those of younger patients.

Successful right ventricular lead placement using a right ventricular septal stylet in a patient with persistent left superior vena cava

Persistence of the left superior vena cava can cause technical difficulties during a left-sided approach to placement of a right ventricular (RV) endocardial lead. We describe a new approach for RV endocardial lead implantation using a 58 cm stylet shaped in a form similar to the right ventricular septal stylet (Mond® RVOT Stylet, model 4140; St Jude Medical, St Paul, MN, USA). In a patient, a left axillary …

Prognostic significance of implantable defibrillator shock: are all shocks created equal?

Michel Mirowski’s visionary concepts for the prevention of sudden cardiac death by automatic delivery of electrical shock led to the development of the implantable cardioverter defibrillator (ICD) more than 3 decades ago. Electrical shock, while often lifesaving, is traumatic for patients and their families, particularly when the shock is inappropriate. Since the inception of the ICD, proper patient selection in view of the competing risks of arrhythmic and heart failure death has been passionately debated.1-4 In decompensated heart failure (frequently accompanied by high adrenergic tone, ischemia, and atrial arrhythmias), most of the ventricular life-threatening arrhythmias are markers of clinical deterioration. In that scenario, termination of arrhythmia by ICD therapy would merely transform death by arrhythmia to death by heart failure. It was demonstrated in the Defibrillation in Acute Myocardial Infarction Trial (DINAMIT) that in patients early after acute myocardial infarction, most of the ventricular arrhythmias are of this nature. In an adjusted timedependent analysis, having appropriate ICD therapy had a 15.1% yearly hazard of mortality, compared with 5.2% in ICD patients with no appropriate therapy (P < 0.001). The reduction of sudden death in ICD patients was completely offset by increase in nonarrhythmic deaths, which was greatest in patients receiving ICD shock therapy (hazard ratio, 6.0; 95% confidence interval, 2.8-12.7).5 In contrast, in patients with chronic myocardial scarring, sustained monomorphic ventricular tachycardia (VT) might be initiated by a premature beat with no other participating factors.6 In these patients, rapid termination of the arrhythmia by the ICD may prevent clinical deterioration secondary to the arrhythmia. Several landmark randomized controlled studies have demonstrated ICD efficacy in primary and secondary prevention of sudden death in these patients. Thus, in accordance with the current guidelines,7 ICD must be implanted in stable patients 3 months af-