Andrzej Cacko

Influence of echocardiographic and radiographic characteristics on atrial sensing amplitude in patients with Linox Smart S DX defibrillation leads.

BACKGROUND Single-lead for implantable cardioverter-defibrillator (ICD) with floating atrial sensing dipole is a new diagnostic tool with the potential advantage in terms of arrhythmia discrimination. We sought to determine whether right heart size and dipole position influence atrial sensing. METHODS Atrial sensing (AS) amplitude was measured during implantation (PP, periprocedural), predischarge (IHFU, in-hospital follow-up) and 3-6 months after the procedure (AFU, ambulatory follow-up). Results were related to atrial dipole position in the right atrium (RA) on the basis of chest X-ray examination as well as right heart dimensions at echocardiography. RESULTS Twenty-four patients were included into final analysis. In 14 (58.3%) patients, sensing dipole was located in regions 1 and 2 of the RA. AS amplitude was greater in regions 1 and 2 when com¬pared to other locations (3.15 vs. 1.2 mV, p = 0.045, 7.53 vs. 3.8 mV, p < 0.001 and 5.63 vs. 2.44 mV, p = 0.017 for PP measurements, IHFU and AFU, respectively). There was a significant negative correlation between AS-PP and short RA dimension (RADs) (r = -0.56, p = 0.02), AS-IHFU and RA area (RAA) (r = -0.45, p < 0.05), AS-AFU and long RA dimension (RADl) (r = -0.46; p = 0.02), AS-AFU and RADs (r = -0,48, p = 0.02), and AS-AFU and RAA (and r = -0.52, p < 0.01). There was no relationship between AS and other right heart dimensions. CONCLUSIONS Larger RA size and low sensing dipole location were associated with lower AS amplitude in single-lead dual chamber ICD.

NT-proCNP as a new indicator of asthenozoospermia

PURPOSE C-type natriuretic peptide (CNP) is a proinflammatory peptide. The highest concentration of CNP is found in male reproductive organs. This study aims to analyze the role of N-terminal C-type natriuretic propeptide (NT-proCNP) as a new indicator of asthenozoospermia. MATERIAL/METHODS Semen was collected after 3-5 days of sexual abstinence from 86 men. The participants were between 25 and 38 years old, 51 of which had asthenozoospermia and 35 of which had normal sperm motility. Semen was analyzed for the concentrations of NT-proCNP, spermatozoa, percentages of live sperm, and sperm exhibiting a specific type of movement. The laboratory tests and analyses were performed using accepted methods and under appropriate conditions. RESULTS A significant difference in the concentration and motility of spermatozoa was observed between the focus and control groups. The concentration of spermatozoa in the focus group was significantly lower than in the control group (median: 38.5 vs. 69.8mln/ml [p=0.016] respectively). The progressive motility of spermatozoa demonstrated a significantly lower performance in the focus group than in the control group (median: 10.4% vs. 45% respectively). The concentration of NT-proCNP was significantly higher in the focus group (median: 29.1 vs. 17.9pmol/l; p<0.001). The Area under the Receiver Operating Characteristic (AUROC) curve for the concentration of NT-proCNP - as an indicator of asthenozoospermia - was 0.733. Participants with a concentration of NT-proCNP higher than 28.8pmol/l had asthenozoospermia with 52.9% sensitivity and 94.3% specificity. CONCLUSIONS NT-proCNP - an indicator of inflammatory reaction - should be evaluated as an indicator of asthenozoospermia.

Pregnancy-related physiological changes in cardiovascular system observed with implantable cardioverter-defibrillator

A 30-year-old woman was implanted with a single chamber implantable cardioverter-defibrillator (ICD) system in 2006 due to successfully resuscitated ventricular fibrillation. In 2009, she underwent ICD replacement with another defibrillation lead implantation due to lead failure. She had no comorbidities and the function of the heart was normal, with left ventricular ejection fraction at 65%. In February 2012, the patient became pregnant. From the 5th week of pregnancy, the beta-blocker (bisoprolol 2.5 mg o.d.) was stopped and she did not take any other medications until delivery. On the 39th week, she underwent an elective caesarean section due to obstetric indications. Delivery and postpartum period were uncomplicated. Present ICD device (Medtronic, Virtuoso VR) was equipped with several diagnostic functions known as Cardiac Compass®. Parameters such as heart rate (HR), HR variability (HRV), daily activity, thoracic impedance and OptiVol® fluid index were measured automatically every day and produced some long-term trends. All the trends are stored up to 14 months, allowing us to observe some physio logical changes in the cardiovascular system that were occurring during pregnancy. Normal pregnancy is linked with several structural and functional changes in the cardiovascular system that are necessary to meet the increasing metabolic demands of mother and developing foetus. The main changes include increases in blood volume and cardiac output, and decreases in systemic vascular resistance and blood pressure. Total body water of a pregnant woman increases by 6–8 L and is located mostly in extracellular space. There is about a 40% increase in blood volume caused mainly by an increase in plasma volume. The heart muscle undergoes a mild remodelling that leads to ventricular hypertrophy as well as dilatation. We present trends of cardiovascular parameters received during routine follow-up that have been done six months after delivery (Figs. 1A–E). Typical HR acceleration during pregnancy by about 15 bpm and its normalisation after childbirth was noted (Fig. 1A). HRV is decreased in a pregnant woman due to a shift in autonomic balance and it returns to the pregestational state after delivery, as in this case (Fig. 1C). Patient’s activity at 4–6 h per day was maintained during the course of pregnancy until delivery, where a sudden drop was noted corresponding to convalescence following the c-section (Fig. 1B). The first and most pronounced change observed was rapid and prolonged decrease of thoracic impedance (Fig. 1E) which translated into a corresponding rise of fluid index above the alarm threshold (Fig. 1D). Several factors may play a role in these observations, e.g. fluid retention in thorax and lungs and heart enlargement. A similar but slighter reduction in thoracic impedance observed at the time of delivery may be explained by a sudden increase in venous return secondary to decompression of vena cava inferior as well as increased vascular tone due to sympathetic system activation. The high amplitude and rate of impedance changes that are associated with pregnancy result in inadequate fluid overload alarms, and make this method inappropriate in monitoring pregnant women.

Risk factors for adverse outcomes of patients with acute coronary syndrome: single-centre experience with long-term follow-up of treated patients

BACKGROUND For patients experiencing an acute coronary syndrome (ACS), a crucial time to assess their prognosis and to plan management is at discharge from hospital. AIM The aim of the study was to identify risk factors of mortality during post-discharge period following a hospitalisation for ACS. METHODS We studied 672 consecutive ACS patients hospitalised and discharged alive between 2002 and 2004. The analysis was done with respect to the type of ACS, i.e. unstable angina/non-ST-segment elevation myocardial infraction (UA/NSTEMI; n = 255) vs. ST-segment elevation myocardial infarction (STEMI; n = 417). All patients underwent coronary angiography and, if indicated, primary angioplasty (STEMI: 417 patients; UA/NSTEMI: 157 patients). The Cox proportional hazards regression model was used to evaluate the independent effect of the risk factors on the occurrence of primary endpoint, i.e. all-cause mortality during six-year follow-up. Survival status and date of death were obtained from the National Registry of Population (PESEL database). RESULTS A total of 123 patients (18.3%) died within the post-discharge period. The multivariate analysis identified 11 highly significant independent predictors of mortality (in order of predictive strength): diabetes mellitus (all types), higher creatinine level, older age, and more frequent occurrence of: supraventricular arrhythmias during hospitalisation, peripheral artery disease, recurrent angina pectoris with documented ischaemia on electrocardiogram, male sex, prior myocardial infarction, treatment with intra-aortic balloon pump counterpulsation, heart failure, and higher peak levels of creatine kinase-MB. CONCLUSIONS The risk factors obtained from the medical history and during the hospitalisation improve the risk stratification during the post-discharge period after hospitalisation for ACS.

How to achieve good atrial sensing in DX ICDs

In Pacing and Clinical Electrophysiology we have read with great interest the article by Worden et al. on long-term stability and reliability of atrial sensing in Biotronik’s implantable cardioverter defibrillator (ICD) DX system.1 The data on that topic are still very limited. On the other hand, more and more electrophysiologists choose the DX system instead of the classic single-chamber ICDs because of its diagnostic and potential therapeutic advantages. Unfortunately, there are no specific recommendations on patient selection and technique of implantation (type of lead, apical vs. other lead position) of DX leads. Proper atrial signal plays a crucial role for both atrial arrhythmia diagnosis and arrhythmia discrimination. Worden et al. showed that suitable atrial sensing with floating atrial dipole is achievable and stable in time in the majority of patients. Authors report mean amplified atrial sensing of 8.7 mV during the implantation procedure. However, data on the type of ICD device are not provided. It might be important because early devices (e.g., Lumax 540 VR-T DX) measured maximal sensing value of 8 mV and next generations show the exact amplified value. There is also no information about the type of lead used in the study. So far, in the biggest report on DX devices Safak et al. compared atrial sensing values between two types of LinoxSmart S DX leads and showed significantly higher sensing values when the version with atrial dipole mounted 15 cm away from the tip was used.2 In our recently published study we used only the “15 cm version” of the lead and in most of the patients final dipole position was in the high right atrium or at the border of the right atrium and superior vena cava.3 We also proved that dipole position in the high right atrium gave best sensing values in each timepoint of the study. We hypothesize that the “15 cm version” of LinoxSmart S DX is the lead of choice and the “17 cm version” may be considered for patients with significantly enlarged right heart. Worden et al. also showed that atrial sensing amplitude was comparable between different tip locations in the right ventricle. It is also consistent with our experience that atrial dipole position and atrial size rather than lead type or tip position are the most important factors for achieving high atrial signal.

Pre-hospital cardiac arrest treated successfully with automated external defibrillator

A twenty-eight-year-old woman with a history of mitral prolapse, palpitations, and unexplained syncope in the past was admitted to hospital after cardiac arrest, which was successfully reanimated with an automated external defibrillator (AED) device by witnesses in the patient’s workplace. She was resuscitated immediately by her co-worker, a paramedic, using an AED available at public place. The first recorded rhythm was ventricular fibrillation. Figure 1 shows the electrical signal recorded by AED. We can see ventricular fibrillation and artefacts from chest compressions in the middle of the figure. The artefacts allow us to determine if chest compressions were performed. Some devices and pads additionally give information about chest compression efficacy. During the resuscitation three shocks were delivered by AED (120 J, 150 J, and 200 J, respectively). A haemodynamically stable rhythm was restored with the last shock about 7 min after the beginning of resuscitation. During the hospitalisation no cause of tachyarrhythmia was diagnosed despite intensive cardiac and extra-cardiac diagnostic procedure including electrophysiological investigation. An electrophysiological investigation was undertaken and atrioventricular nodal reentrant tachycardia with heart rate 220/min was evoked and subjected to ablation procedure. Ventricular tachycardia was induced during the electrophysiological examination. As secondary prevention, with respect to expected long survival, the patient was implanted with a subcutaneous implantable cardioverter-defibrillator.

Sprint Fidelis implantable cardioverter-defibrillators lead patient management and survival: Single center study

BACKGROUND Over the last several years significant rises in the use of implanted cardioverter-defibrillators (ICD) have also resulted in a number of associated complications. This number includes lead failure. Sprint Fidelis (SF) ICD lead is regarded as a lead with elevated failure risk. Every center acting in accordance with the guidelines should observe patients more thoroughly especially with recalled leads and run a registry of their follow-up. The aim of this research was to present follow-up of the patients with SF leads (types 6948, 6949) from a single implantation center. METHODS There were 36 SF leads implanted in 36 patients. Mean follow-up period was 76 months (IQR 40.3-86.8). Patients were subjected to regular check-ups in 3 to 6 month intervals. RESULTS Patients were implanted at a median age of 66.5 years and majority of them had ischemic cardiomyopathy (72%). A majority of the studied population were men (72.2%). Predominantly dual-chamber ICD (ICD-DR) were implanted (50% ICD-DR vs. 47.2% ICD-VR). The guidelines for management of patients implanted with SF were fully implemented. During the follow-up 14 (38.9%) patients died. No deaths were noted that could be attributed to lead failure. In 5 cases lead failure was identified and of these 4 leads were replaced. Median time from implantation to the detection of lead dysfunction was 52 months (IQR 49; 83). The symptoms of failure consisted of: inappropriate shocks, alternating ventricular lead signal, or loss of ventricular stimulation. CONCLUSIONS The follow-up of patients with recalled SF leads in a single center supports that implementation SF management guidelines could be effective in clinical practice.

Tool for BiV capture diagnosis

We read with interest the article by Jastrzebski et al. on the universal algorithm for the diagnosis of biventricular (BiV) capture in patients with cardiac resynchronization therapy (CRT).1 Authors proposed an algorithm based on the standard 12-lead electrocardiogram (ECG) with high sensitivity and specificity for detection of the loss of left ventricle (LV) capture, 97% and 90%, respectively. First, let us congratulate Jastrzebski et al. on their very important and successful initiative. The problem of lost LV capture is clinically significant. In our opinion every general practitioner should be able to assess effectiveness of BiV capture, as losing LV capture may be a reason of worsening of the patient’s condition. This is why we have prepared an application for mobile devices to diagnose BiV capture using the algorithm proposed by Jastrzebski et al. We called it BiVCapture. The tool is available online for Android devices (version 3.0 or higher) for free on dedicated website: http://bivcapture.cardiozimit. com/bivcapture.apk (Fig. 1). To install the application first enter device settings, then tap Applications menu and if the check box for Unknown Sources is unchecked, check it. BiVCapture for iPhone (iOS 7.0 or higher) is waiting for publishing in Apple App Store and according to our best knowledge it will be available with no charges in July 2014. The application is simple and intuitive. User is asked to take a photo of the QRS complex in lead I, then mark the isoelectric line, maximum positive and maximum negative amplitude. Based on predominantly positive or negative QRS, the user may be asked for repeating these same steps for lead V1 and V6 and assess QRS complex duration.

The long-term prognosis following acute coronary syndromes: a prospective observational study of unselected group treated in the 24/7 cardiac catheterization laboratory at university hospital

BACKGROUND Risk stratification in acute coronary syndrome (ACS) is usually based on clinical data obtained during hospi-talisation. To date, there is a limited number of prospective observational studies assessing long-term prognosis of patients discharged from hospital after ACS. AIM This study is to investigate long-term follow-up of unselected ACS patients treated at the 24-hour/7-day (24/7) cardiac catheterisation laboratory and discharged from referral university hospital. METHODS We studied 672 consecutive ACS patients (median age 61 years, 66.7% men) hospitalised and discharged be-tween 2002 and 2004. The analysis was done in respect of the type of ACS, i.e. non-ST-segment elevation: unstable angina non-ST-segment elevation myocardial infarction (UA/NSTEMI; n = 255) vs. ST-segment elevation myocardial infarction (STEMI; n = 417). All patients underwent coronarography and, if indicated, primary angioplasty (417 patients with STEMI and 157 pa-tients with UA/NSTEMI). The primary endpoint was defined as all-cause mortality during six years of follow-up. Survival status and date of death were obtained from the National Death Registry of Poland and presented as Kaplan-Meier survival curves. RESULTS Despite a significantly higher one-year mortality of patients with UA/NSTEMI compared to those with STEMI (7.1% vs. 3.1%, p = 0.018), the overall mortality assessed throughout follow-up until 2009 was comparable between UA/NSTEMI and STEMI patients (18.8% vs. 18%, p = 0.79). CONCLUSIONS The long-term (several years) survival did not depend on the type of ACS.

Initial experience with the subcutaneous implantable cardioverter-defibrillator with the real costs of hospitalization analysis in a single Polish center

BACKGROUND The recent introduction of an entirely subcutaneous implantable cardioverter-defibrillator (S-ICD) represents an important progress in the defibrillation technology towards a less invasive approach. This is a single-center observational study of S-ICD implantations in Poland. METHODS The S-ICD was implanted in 11 patients with standard indications for an ICD. Patients in whom the device was implanted were evaluated for adverse events and device function at hospital discharge. All hospitalization costs were calculated and summed up for all patients. Costs were divided into following categories: medical materials, pharmaceuticals, operating theatre staff, cardiology department staff, laboratory tests, non-laboratory tests and additional non-medical costs. RESULTS The mean age of patients was 51.6 ± 16.4 years, 9 were men and 2 were women. Four patients had atrial fibrillation as the basal rhythm, 1 patient had atrial flutter and 6 patients had sinus rhythm. All patients had at least one condition that precluded the use of a traditional ICD system or the S-ICD was preferred due to other conditions, i.e. a history complicated transvenous ICD therapy (18%), anticipated higher risk of infection (27%), lack or difficult vascular access (18%), young age and anticipated high cumulated risk of lifetime device therapy (36%). The mean duration of the implantation procedure was 2 h. One patient developed a postoperative pocket hematoma. Mean total time of hospitalization was 28 (6-92) days. Average cost of hospitalization per patient was 21,014.29 EUR (minimal = 19,332.71 EUR and maximal = 24,824.14 EUR). CONCLUSIONS S-ICD implantation appears to provide a viable alternative to transvenous ICD, especially for patients without pacing requirements.