Ashwani Gupta

Subcutaneous Implantable Cardioverter-Defibrillator Implantation in a Patient with a Left Ventricular Assist Device Already in Place

A 56-year-old man with ischemic cardiomyopathy, a biventricular implantable cardioverter-defibrillator (ICD), and a left ventricular assist device (LVAD) developed a pocket hematoma and infection after an ICD generator change. The biventricular ICD was extracted, and the patient was given a full course of antibiotics. Because he had no indications for bradycardia pacing or biventricular pacing, he was implanted with a subcutaneous ICD under full anticoagulation. There was no interference in sensing or shock delivery from the ICD. The LVAD readings were unchanged during and after the procedure. The patient had an uneventful postoperative course, and both devices were functioning normally. To our knowledge, this is the first reported case of the implantation of a subcutaneous ICD in the presence of an LVAD. This report illustrates that both devices can be implanted successfully in the same patient. In addition, the subcutaneous ICD minimizes the risk of bloodstream infections, which can be fatal in patients who have life-supporting devices such as an LVAD.

Biventricular paced QRS predictors of left ventricular lead locations in relation to mortality in cardiac resynchronization therapy.

BACKGROUND Left ventricular (LV) lead location during cardiac resynchronization therapy (CRT) has influenced mortality and heart failure events; however the biventricular paced QRS morphology has not been established as a predictor of LV lead location or mortality. METHODS We evaluated the biventricular paced QRS morphology in 306 patients undergoing CRT in relation to specific anatomic locations. A logistic regression model and Kaplan-Meier survival estimates were used to determine predictors of LV lead location and survival. RESULTS The mean age was 68±13years. Predictors of LV lead location from anterior, lateral, and posterior segments were: absence of R in V1, QS in aVL; and R in aVL, respectively. Absence of an R in II, III, or aVF predicted an inferior site. A QS in V4-V6 differentiated apical from basal sites (p=0.01). LV pacing from sites along the middle cardiac vein revealed a higher mortality (34%), than lateral sites (20%, p=0.02). CONCLUSIONS Biventricular paced QRS criteria were predictive of LV lead locations. The proposed algorithm enhanced the predictive accuracy of these criteria. LV pacing sites along the middle cardiac vein were associated with increased mortality.

Mortality in African-Americans Following Cardiac Resynchronization Therapy: A Single Center Experience

BACKGROUND Cardiac resynchronization therapy (CRT) improves clinical outcomes and reduces mortality in heart failure patients who remain symptomatic despite optimal medical therapy. CRT trials have reported significant hemodynamic benefits, improvement in functional status, and reduced mortality and heart failure hospitalizations. However, African-American patient representation in these studies is limited thus the results may not be applicable to them. We described baseline clinical characteristics of African-American patients undergoing CRT and determined their outcomes relative to those reported in clinical trials. METHODS We evaluated 131 African-American patients with New York Heart Association functional class II-IV heart failure undergoing CRT and determined predictors of all-cause mortality. Kaplan-Meier survival estimates and a Cox proportional hazards model determined mortality and risk of death. RESULTS The mean age was 65 ± 12 years. Over a 6-year period, total mortality in African-Americans was 23% as compared with 29% in the MADIT-CRT trial. Increased mortality was associated with older age (hazard rate (HR) 1.04, 95% confidence interval (CI) 1.01-1.07, P=.01), ischemic cardiomyopathy (HR 2.86, 95% CI 1.36-6.04, P=.006), and absence of treatment with either an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (HR 2.75, 95% CI 1.30-5.80, P=.008), or beta-blocker (HR 2.56, 95% CI 0.98-6.69, P=.05). Hydralazine plus nitrate therapy was used in a small number of patients and did not influence mortality outcomes. CONCLUSION African-Americans experience the same survival benefits from CRT as Caucasian patients reported in major clinical trials. Publication indices used to find publications listed in references: PubMed.

Erratum to “Mortality in African-Americans Following Cardiac Resynchronization Therapy: A Single Center Experience” Journal of the National Medical Association 2016:108(1) February 30-39

he publisher regrets the second paragraph of the discussion section was incorrect. The sentence beginning with the word “Fifteen.” should read as follows: T“Fifteen percent of our patients received hydralazine plus nitrates and this may be in-part responsible for the improved survival observed in our study compared to survival reported in the substudy population. However, we did not note any difference in mortality between our patients who received such therapy as opposed to those who didn’t.” Also, Figure 1, Panel B appeared incorrectly. The correct version, with all data included, appears below. The publisher would like to apologize for any inconvenience caused.

UTILITY OF INTRACARDIAC ECHOCARDIOGRAPHY IN SETTING OF CARDIAC DEVICE-RELATED ENDOCARDITIS AND LEAD EXTRACTION

Transesophageal echocardiography (TEE) is currently the gold standard for diagnosis of cardiac device- related endocarditis (CDE) with a sensitivity of 94-96%. Intracardiac echocardiography (ICE) is routinely used during lead extraction procedures for early identification of procedural complications