Anil V. Yadav

A retrospective analysis of proceduralist-directed, nurse-administered propofol sedation for implantable cardioverter-defibrillator procedures

BACKGROUND There is controversy whether proceduralist-directed, nurse-administered propofol sedation (PDNAPS) is safe. OBJECTIVE To assess the frequency of adverse events when PDNAPS is used for implantable cardioverter-defibrillator (ICD)-related procedures and to determine the patient and procedural characteristics associated with adverse events. METHODS Consecutive ICD-related procedures using PDNAPS from May 2006 to July 2009 at a tertiary-care hospital were evaluated. Serious adverse events were defined as procedural death, unexpected transfer to an intensive care unit, respiratory failure requiring intubation/bag-mask ventilation, or hypotension requiring vasoconstrictor/inotrope support. Nonserious adverse events were defined as hypotension requiring fluid resuscitation or hypoxemia requiring augmented respiratory support with non-rebreather mask, oral airway, or jaw lift. RESULTS Of 582 patients (age 64 ± 14 years, 72.3% males) undergoing ICD-related procedures using PDNAPS, 58 (10.0%) patients had serious adverse events with no procedural death and 225 (38.7%) had nonserious adverse events. Longer procedure duration (relative risk [RR] = 2.1 per hour; 95% confidence interval [CI] = 1.6-2.8; P < .001) and biventricular implant (RR = 2.7; CI = 1.4-5.3; P = .003) were independent predictors of serious adverse events. A longer procedure duration (RR = 1.4 per hour; CI = 1.1-1.7; P = .001), heart failure class (RR = 1.4 per 1 class; CI = 1.1-1.7; P = .002), and use of propofol infusion (RR = 3.5; CI = 2.2-5.7; P < .001) were independent predictors of nonserious adverse events. CONCLUSION PDNAPS for shorter ICD procedures including single- and dual-chamber implants, generator changes, and defibrillation threshold testing have acceptable rates of serious adverse events and manageable nonserious adverse events and should be considered for further study. Biventricular implants and other complex procedures should be done with an anesthesiologist.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is a cardiac disease characterized by fibrofatty replacement of the cardiac myocytes. Patients with ARVD/C frequently present with ventricular tachycardia and many are thought to have sudden cardiac death as the initial manifestation of the disease. Over the past decade, our understanding of the disease has increased dramatically along with delineation of the genetic basis of ARVD/C and characteristic features on diagnostic imaging. The management of patients with ARVD/C remains a challenge, especially in the light of incomplete genotype–phenotype characterization, and poor predictors of sudden cardiac death. In this article, we review the pathologic and genetic basis of ARVD/C, focusing on the diagnostic features and therapeutic challenges emerging with our enhanced knowledge of this rare disease.

Catecholamine Dependent Accessory Pathway Automaticity

Automaticity from extra nodal accessory pathways appears to be rare. We report the case of a man with the WPW syndrome who presented for repeat electrophysiological study and catheter ablation. After successful ablation of a para‐Hisian accessory pathway, an isoproterenol challenge produced an accelerated wide complex rhythm that was dissociated from sinus rhythm and matched the previous pattern of maximal preexcitation. This automatic rhythm was transient and dependent on catecholamine administration. One month after successful ablation, an exercise treadmill test (ETT) did not demonstrate any pre‐excitation or ectopy. (PACE 2004; 27:1005–1007)

Atrial Fibrillation: Future Directions

Atrial fibrillation (AF) remains the most common sustained cardiac rhythm disorder, affecting more than 2 million Americans. Successful treatment and possible cure of this rhythm will require continued research into the mechanisms of AF, including the role of the autonomic nervous system. Further studies will also be required into the potential role of genetics as it pertains to identifying those at greatest risk of AF, as well as for the development of genetically directed pharmacotherapy. Other new drug approaches include those that are atrial selective and those that prevent atrial fibrosis, clearly a trigger for AF. Nonpharmacological management of AF will continue to have a rapid expansion of novel technologies for mapping and ablation, including cryoablation, high-frequency ultrasound, and laser ablation. These innovations will improve treatment and create cures for AF.

Mechanism of transition from irregular to regular supraventricular tachycardia.

A 60-year-old woman with history of ischemic cardiomyopathy, presented with recurrent episodes of symptomatic supraventricular tachycardia (SVT). Resting 12-lead ECG revealed normal sinus rhythm with right bundle branch block (RBBB) and no preexcitation. During EP testing, antegrade dual AV nodal physiology was demonstrated. No evidence of accessory pathway could be observed. An irregular SVT with RBBB pattern was easily inducible with catheter manipulation