Barbara Bellmann

Electromagnetic Interference With Implantable Cardioverter-Defibrillators at Power Frequency An In Vivo Study

Background— The number of implantable cardioverter-defibrillators (ICDs) for the prevention of sudden cardiac death is continuing to increase. Given the technological complexity of ICDs, it is of critical importance to identify and control possible harmful electromagnetic interferences between various sources of electromagnetic fields and ICDs in daily life and occupational environments. Methods and Results— Interference thresholds of 110 ICD patients (1-, 2-, and 3-chamber ICDs) were evaluated in a specifically developed test site. Patients were exposed to single and combined electric and magnetic 50-Hz fields with strengths of up to 30 kV·m−1 and 2.55 mT. Tests were conducted considering worst-case conditions, including maximum sensitivity of the device or full inspiration. With devices being programmed to nominal sensitivity, ICDs remained unaffected in 91 patients (83%). Five of 110 devices (5%) showed transient loss of accurate right ventricular sensing, whereas 14 of 31 (45%) of the 2- and 3-chamber devices displayed impaired right atrial sensing. No interference was detected in 71 patients (65%) within the tested limits with programming to maximum sensitivity, whereas 20 of 110 subjects (18%) exhibited right ventricular disturbances and 19 of 31 (61%) subjects exhibited right atrial disturbances. Conclusions— Extremely low-frequency daily-life electromagnetic fields do not disturb sensing capabilities of ICDs. However, strong 50-Hz electromagnetic fields, present in certain occupational environments, may cause inappropriate sensing, potentially leading to false detection of atrial/ventricular arrhythmic events. When the right atrial/right ventricular interferences are compared, the atrial lead is more susceptible to electromagnetic fields. Clinical Trial Registration— URL: http://clinicaltrials.gov/ct2/show/NCT01626261. Unique identifier: NCT01626261.

Bronchial Injury After Atrial Fibrillation Ablation Using the Second-Generation Cryoballoon

Cryoballon ablation of atrial fibrillation may be associated with bronchial damage, but the factors causing this are poorly characterized.1–5 Eleven consecutive patients were included in this prospective, single-center pilot study (German Clinical Trials Register No. DRKS00011273). All patients experienced paroxysmal (n=9; 82%) or persistent atrial fibrillation and were treated with the second-generation 28 mm cryoballon (Medtronic, Inc, Minneapolis, MN). The day after cryoballon ablation, a bronchoscopy was performed to assess for bronchial injury (BI) in all patients. In addition, body plethysmography was conducted before and after the procedure. The evaluations of the bronchoscopies were performed in a blinded fashion by 2 independent pulmonologists (R.-H.H., M.P.). This study conforms to the guiding principles of the Declaration of Helsinki of 2014 and was approved by the local ethics committee (EA/111/16). In all 11 patients (6 women; mean age, 66±8.8 years), pulmonary vein isolation (PVI) of all pulmonary veins (PVs) was successfully performed. Preexisting diseases were coronary artery disease (9.1%) and arterial hypertension (55%). The mean left atrial diameter was 50.4±7.2 mm. Five patients (45%) were under anticoagulation with apixaban and 6 (55%) with rivaroxaban. The mean CHA2DS2-Vasc Score was 1.9±1.1. The procedure was performed under deep sedation using propofol, midazolam, and fentanyl. All patients were breathing spontaneously. After transseptal puncture, anatomic localization of the PVs was identified with intravenous contrast injection under fluoroscopy. The Achieve catheter (Medtronic, …

Eine Case Serie – Zu alt für einen Schrittmacher?@@@A series of cases—too old for a pacemaker?

ZusammenfassungWir berichten über drei Patientinnen mit einem Lebensalter über 90 Jahre, die sich mit symptomatischen Bradykardien bei höhergradigen AV-Blockierungen in unserer Klinik vorstellten. Die älteste Patientin war 100 Jahre alt. Alle drei Patientinnen konnten sicher und komplikationslos mit einem Zweikammerschrittmacher versorgt werden. Unsere Fallserie zeigt, dass eine Zweikammerschrittmacherimplantation auch bei Patienten im weit fortgeschrittenen Lebensalter sicher und durchführbar ist. Ein operatives Management mit Lokalanästhesie, Fentanyl und im Einzelfall Midazolam ist möglich. Dies und eine kurze stationäre Verweildauer vermindern das Risiko eines Delirs. Es handelt sich um ein Patientenkollektiv, welches in der Zukunft mutmaßlich zunehmen wird und eine intensivere Betreuung benötigt als der Standard-Schrittmacherpatient.SummaryWe report three patients with an age above 90 years presented with symptomatic bradycardia and higher grade AV block in our clinic. The oldest patient was 100 years. All three patients could be supplied safely and without complications with a dual chamber pacemaker. Our case series shows that a dual chamber pacemaker implantation is safe and feasible in patients in very advanced age. A surgical management with local anesthetic (lidocaine), fentanyl and midazolam in individual cases is possible. This and a short hospital stay reduce the risk of delirium. It is a group of patients, which will increase in the future and requires more intensive care than the standard pacemaker patient.We report three patients with an age above 90 years presented with symptomatic bradycardia and higher grade AV block in our clinic. The oldest patient was 100 years. All three patients could be supplied safely and without complications with a dual chamber pacemaker. Our case series shows that a dual chamber pacemaker implantation is safe and feasible in patients in very advanced age. A surgical management with local anesthetic (lidocaine), fentanyl and midazolam in individual cases is possible. This and a short hospital stay reduce the risk of delirium. It is a group of patients, which will increase in the future and requires more intensive care than the standard pacemaker patient.

Transseptale Punktion nach PFO-Verschluss@@@Transseptal puncture after device closure of patent foramen ovale: Geht das?@@@Is it feasible?

CASE REPORT The case of a 40-year-old woman with paroxysmal symptomatic atrial fibrillation and implanted occluder of a patent foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) is reported. Due to the symptomic atrial fibrillation, pulmonary vein isolation was planned. METHODS Under transesophageal, echocardiographic control the transseptal puncture was performed posterior inferior of the occluder without any complications. The pulmonary vein was successfully isolatedusing radiofrequency energy. CONCLUSION This case demonstrates that transseptal puncture in pulmonary vein isolation with an inserted PFO occluder under additional transesophageal, echocardiographic monitoring is safe and feasible.ZusammenfassungFallberichtEs wird über eine 40 Jahre alte Patientin mit paroxysmalem, symptomatischem Vorhofflimmern und implantiertem Occluder eines persistierenden Foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) berichtet, welche sich bei bestehender antiarrhythmischen Therapie mit Flecainid zur Pulmonalvenenisolation vorstellte.MethodenUnter transösophagealer echokardiographischer Kontrolle erfolgte eine komplikationslose transseptale Punktion posterior inferior des Occluders. Die geplante Pulmonalvenenisolation konnte erfolgreich mittels Radiofrequenzenergie durchgeführt werden.SchlussfolgerungDieses Fallbeispiel zeigt eindrucksvoll, dass eine transseptale Punktion im Rahmen einer Pulmonalvenenisolation bei PFO-Occluder unter zusätzlicher transösophagealer echokardiographischer Kontrolle sicher durchführbar ist.AbstractCase reportThe case of a 40-year-old woman with paroxysmal symptomatic atrial fibrillation and implanted occluder of a patent foramen ovale (PFO; AMPLATZER™ Septal Occluder, St. Jude Medical) is reported. Due to the symptomic atrial fibrillation, pulmonary vein isolation was planned.MethodsUnder transesophageal, echocardiographic control the transseptal puncture was performed posterior inferior of the occluder without any complications. The pulmonary vein was successfully isolatedusing radiofrequency energy.ConclusionThis case demonstrates that transseptal puncture in pulmonary vein isolation with an inserted PFO occluder under additional transesophageal, echocardiographic monitoring is safe and feasible.

Late deterioration of left ventricular function after right ventricular pacemaker implantation.

Objectives: Right ventricular (RV) pacing induces a left bundle branch block pattern on ECG and may promote heart failure. Patients with dual chamber pacemakers (DCPs) who present with progressive reduction in left ventricular ejection fraction (LVEF) secondary to RV pacing are candidates for cardiac resynchronization therapy (CRT). This study analyzes whether upgrading DCP to CRT with the additional implantation of a left ventricular (LV) lead improves LV function in patients with reduced LVEF following DCP implantation. Methods: Twenty-two patients (13 males) implanted with DCPs and a high RV pacing percentage (>90%) were evaluated in term of new-onset heart failure symptoms. The patients were enrolled in this retrospective single-center study after obvious causes for a reduced LVEF were excluded with echocardiography and coronary angiography. In all patients, DCPs were then upgraded to biventricular devices. LVEF was analyzed with a two-sided t-test. QRS duration and brain natriuretic peptide (BNP) levels were analyzed with the unpaired t-test. Results: LVEF declined after DCP implantation from 54±10% to 31±7%, and the mean QRS duration was 161±20 ms during RV pacing. NT-pro BNP levels were elevated (3365±11436 pmol/L). After upgrading to a biventricular device, a biventricular pacing percentage of 98.1±2% was achieved. QRS duration decreased to 108±16 ms and 106±20 ms after 1 and 6 months, respectively. There was a significant increase in LVEF to 38±8% and 41±11% and a decrease in NT-pro BNP levels to 3088±2326 pmol/L and 1860±1838 pmol/L at 1 and 6 months, respectively. Conclusion: Upgrading to CRT may be beneficial in patients with DCPs and heart failure induced by a high RV pacing percentage.

Kardiale Resynchronisation mit VDD-Elektrode@@@Cardiac resynchronisation with atrial sensing: Geht das?@@@Is it feasible?

ZusammenfassungIn diesem Beitrag berichten wir über zwei Patientinnen mit hochgradig eingeschränkter systolischer linksventrikulärer (LV) Funktion, intrinsischem komplettem Linksschenkelblock, Herzinsuffizienzsymptomatik (NYHA III) und implantiertem primärprophylaktischem 1-Kammer-ICD mit VDD-Sonde. Bei Sinusrhythmus mit erhaltener Chronotropie und gutem atrialem Sensing wird die Indikation zur Systemaufrüstung auf eine kardiale Resynchronisation (CRT) mit Verwendung der VDD-Sonde gestellt. Nach problemloser Implantation der LV-Sonden können stabile Messwerte mit hohem biventrikulärem Stimulationsanteil erzielt werden. Die Kasuistiken zeigen, dass in selektierten Patienten die Verwendung einer VDD-Elektrode zur kardialen Resynchronisation möglich ist.AbstractIn this article the cases of two female patients with heart failure (functional class III) and an intrinsic complete left bundle branch block are reported. Both patients have had an implanted cardioverter defibrillator (ICD) connected to a VDD lead for primary prevention of sudden cardiac death. Atrial sensing was good/acceptable with a physiological frequency histogram and normal PQ time. A system upgrade to cardiac resynchronization therapy device (CRT) was planned. The VDD lead was directly connected to the Bivent ICD. The follow up showed stable measurements and a high biventricular pacing rate. Thus, usage of VDD leads for atrial sensing in CRT seems to be possible in a selected patient population.In this article the cases of two female patients with heart failure (functional class III) and an intrinsic complete left bundle branch block are reported. Both patients have had an implanted cardioverter defibrillator (ICD) connected to a VDD lead for primary prevention of sudden cardiac death. Atrial sensing was good/acceptable with a physiological frequency histogram and normal PQ time. A system upgrade to cardiac resynchronization therapy device (CRT) was planned. The VDD lead was directly connected to the Bivent ICD. The follow up showed stable measurements and a high biventricular pacing rate. Thus, usage of VDD leads for atrial sensing in CRT seems to be possible in a selected patient population.

Ein Patient ohne intrakardiales EKG@@@A patient without intracardiac ECG: Vena-azygos-Kontinuität@@@Persistent azygos vein

ZusammenfassungEine Vena-azygos-Kontinuität ist eine seltene Gefäßanomalie. Wir berichten über einen 17-jährigen Patienten mit einem offenen Wolff-Parkinson-White-Syndrom und einer persistierenden Vena azygos. Trotz der komplexen anatomischen Situation was es möglich, über einen retrograden, arteriellen Zugangsweg die laterale Leitungsbahn komplikationslos und erfolgreich mittels Radiofrequenz-Energie zu abladieren.AbstractInterruption of inferior vena cava with azygos continuation is a rare venous anomaly. We report the case of a 17 old male with Wolf–Parkinson–White syndrome and a persistent vena azygos. Despite the complex anatomical situation, it was possible to safely ablate a lateral accessory pathway with radiofrequency energy using a femoral retrograde approach.Interruption of inferior vena cava with azygos continuation is a rare venous anomaly. We report the case of a 17 old male with Wolf-Parkinson-White syndrome and a persistent vena azygos. Despite the complex anatomical situation, it was possible to safely ablate a lateral accessory pathway with radiofrequency energy using a femoral retrograde approach.

Erfolgreiche Ablation einer AV-Knoten-Reentry-Tachykardie 2 Jahre nach orthotoper Herztransplantation@@@Successful ablation of an atrioventricular nodal reentrant tachycardia ablation 2 years after orthotopic heart transplantation

We report the case of a 48-year-old woman with an orthotopic heart transplantation. Two years after transplantation, the patient reported intermittent palpitations and dyspnea. The results of the 12-lead electrogram provided suspicion of AV nodal reentrant tachycardia (AVNRT), which was confirmed in the electrophysiological examination. The AVNRT was successfully eliminated without complications by radiofrequency catheter ablation of the slow pathway. The case shows that an AVNRT, even with existing sinus rhythm of the original heart, can also occur on the transplanted heart and ablation is safe and feasible.ZusammenfassungDieser Beitrag beschreibt den Fall einer 48-jährigen Patientin nach orthotoper Herztransplantation bei terminaler Herzinsuffizienz auf dem Boden einer ischämischen Kardiomyopathie. Zwei Jahre nach der Transplantation berichtete die Patientin über intermittierendes Herzrasen. Im 12-Kanal-EKG wird der Verdacht auf eine AV-Knoten-Reentry-Tachykardie (AVNRT) gestellt. Dies bestätigt sich in der elektrophysiologischen Untersuchung. Es erfolgt eine Slow-pathway-Modifikation mit Radiofrequenzenergie. Der Fall zeigt, dass sich eine AVNRT am transplantierten Herzen auch während fortlaufendem Sinusrhythmus im Empfängervorhof etablieren und konventionell abladiert werden kann.AbstractWe report the case of a 48-year-old woman with an orthotopic heart transplantation. Two years after transplantation, the patient reported intermittent palpitations and dyspnea. The results of the 12-lead electrogram provided suspicion of AV nodal reentrant tachycardia (AVNRT), which was confirmed in the electrophysiological examination. The AVNRT was successfully eliminated without complications by radiofrequency catheter ablation of the slow pathway. The case shows that an AVNRT, even with existing sinus rhythm of the original heart, can also occur on the transplanted heart and ablation is safe and feasible.

Breitkomplex-Tachykardie bei einem Patienten mit ischämischer Kardiomyopathie und stattgehabter Ablation einer ventrikulären Tachykardie@@@Wide QRS complex tachycardia in a patient with ischemic cardiomyopathy and prior ventricular tachycardia ablation

CASE REPORT This article reports the case of a 76-year-old patient with multiple implantable cardioverter defibrillator (ICD) interventions of the single chamber ICD. On admission the 12-lead electrocardiogram (ECG) documented a wide QRS complex tachycardia without clearly identifiable P waves. The patient had previously had two ventricular tachycardia (VT) ablations due to VT storms. The resting ECG revealed a sinus rhythm with a wide QRS complex. During the electrophysiological investigation typical atrial flutter could be detected and an ablation of the cavotricuspid isthmus was performed. During the follow-up period, the patient has been free from tachycardia. CONCLUSION The case described emphasizes that a differentiation between supraventricular tachycardia (SVT) and VT based on a stored ECG without an atrial channel can be challenging.