Daniel A.N. Mascarenhas

Reuse of Explanted, Resterilized Implantable Cardioverter-Defibrillators: A Cohort Study

BACKGROUND Implantable cardioverter-defibrillators (ICDs) often have clinically useful battery life remaining when explanted because of upgrades, infection, or patient death. OBJECTIVE To show that explanted ICDs can be resterilized and reused. DESIGN Retrospective cohort study. SETTING Multicenter ICD acquisition and single-center ICD reimplantation. PATIENTS Indigent persons in India who had class I indications for cardiac resynchronization therapy with an ICD and were unable to afford such a device. MEASUREMENTS Device longevity after reimplantation, device-related complications, number of appropriate therapies, patient clinical characteristics, and deaths. RESULTS Eighty-one consecutive consenting patients (mean age, 52.6 years; 66 male patients) received 106 explanted devices. Twenty-two patients received a second device and 3 patients received a third device after the prior one reached replacement voltage. Mean time to ICD replacement was 1287.4 days. Follow-up data were available for 75 of 81 (92.6%) patients. Mean follow-up duration for all devices was 824.9 days. No infectious complications occurred; 1 lead dislodgement and 1 lead fracture required repeated surgery. Appropriate therapy (shocks or antitachycardia pacing) was delivered by 64 of 106 (60.4%) devices in 44 of 81 (54.3%) patients. Nine of 81 (11.1%) patients died; mean time from implantation to death was 771.3 days. LIMITATIONS This is a retrospective report of a single-center experience with a modest number of patients and devices. Follow-up data were missing for 6 patients. No records were kept of the number of devices obtained through postmortem versus antemortem explantation or whether explantation was due to infection or upgrade. Complete data were not available on exact battery voltage at the time of reimplantation, left ventricular ejection fraction, or number of inappropriate shocks. A control group was not possible. CONCLUSION Explanted ICDs with 3 or more years of estimated remaining battery life can be reused after they are cleaned and resterilized. These devices functioned normally and delivered life-saving therapies, without an increased risk for complications. These preliminary data deserve further validation and, if confirmed, could have important societal and economic implications. PRIMARY FUNDING SOURCE None.

Intracoronary abciximab use in patients undergoing PCI at a community hospital: a single operator experience.

Objective: To evaluate the safety of intracoronary (IC) abciximab during percutaneous coronary intervention (PCI). Background: Adjunctive treatment with glycoprotein IIb/IIIa inhibitors, especially abciximab, during PCI has been shown to improve clinical and procedural outcomes in numerous studies. However, significant bleeding complications exist with its use and this has limited its standard use. Interest has grown in local (IC) use with studies showing safety and long-term effectiveness, especially in patients with high thrombus loads. Methods: A retrospective review of records in a database of patients who had PCI by a single operator at the Easton Hospital. Results: 611 patients received IC abciximab, and there were no complications in 610 (98.3%) patients; only 1 had an allergic reaction. Conclusions: IC abciximab is safe and has a unique role in the catheterization lab and in patients at high risk of bleeding complications who would benefit from its limited use.

Ticagrelor Associated Heart Block: The Need for Close and Continued Monitoring

Ticagrelor is an antiplatelet agent prescribed to prevent the development of adverse cardiac events after acute coronary syndrome (ACS). According to the PLATO trial, ticagrelor is associated with ventricular pauses in the first week of treatment; however, these episodes were felt to be asymptomatic and nonfatal to the patient. We present a case of ticagrelor related second-degree type II heart block causing severe dizziness and diaphoresis that resolved after discontinuation of the medication.

Role of cardiovascular implantable electronic devices in delivering individualized disease-guided management of patients with non-valvular atrial fibrillation and high bleeding risk

Abstract Background: Many patients with non-valvular atrial fibrillation (NVAF) with high risk for thromboembolic stroke and bleeding may not wish to continue long-term oral anticoagulants (OACs) to avoid bleeding complications. We aimed to investigate whether AF burden assessment by cardiovascular implantable electronic devices (CIEDs) would allow an individualised disease-guided approach for safe withdrawal of long-term OAC in high-risk patients. Methods and results: We studied 145 patients (age 77.6 ± 10.6 years; 49.7% females) with NVAF, CHA2DS2-VASc score ≥2, HAS-BLED score ≥3, in whom CIEDs were implanted. These patients wished to stay off long-term OAC based on their previous adverse bleeding event/s or due to similar events witnessed in the family or friend circle. These patients were grouped into ‘low AF burden’ [n = 121 (83%)], or ‘high AF burden’ [n = 24 (17%)] defined as <24 hours or >24 hours cumulatively in 30 consecutive days respectively, and followed for 51.2 ± 29.8 months. All patients with ‘low AF burden’ were allowed to discontinue OAC, but OAC was resumed in 1 patient who experienced TIA. Bleeding events developed in 9 out of 24 (37.5%) patients with ‘high AF burden’ who were maintained on OAC, as compared to 3 out of 121 (2.47%) patients with ‘low AF burden’ who were off OAC (p <.05). There were 9 (6.2%) deaths unrelated to AF treatment approach. Conclusions: In NVAF patients, AF burden assessment by CIEDs allows an individualised disease-guided approach to safe withdrawal of long-term OAC in patients with high bleeding risk who do not wish to continue long-term anticoagulation.

Do all patients with atrial fibrillation need long-term anticoagulation?

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide with an estimated number of 2.7-6.1 million cases in the United States (US) alone. The incidence of AF is expected to increase 2.5 fold over the next 50 years in the US. The management of AF is complex and includes mainly three aspects; restoration of sinus rhythm, control of ventricular rate and prevention of systemic thromboembolism. AF as a cause of systemic embolization has been well known for many years, and majority of patients are on oral anticoagulants (OACs) to prevent this. Many times, a patient may not be in AF chronically, nor is the AF burden (the amount of time patient is in AF out of the total monitored time) calculated. We present three cases of new onset transient AF triggered by temporary stressors. We were able to restore normal sinus rhythm (NSR) with chemical cardioversion. As per 2014 American College of Cardiology (ACC)/American Heart Association (AHA) recommendations, we started all three patients on OACs based on CHA2DS2VASc score ≥2. However, the patients refused long term OACs after restoration of NSR and correction of the temporary enticing stressors. In any case, the decision to start OACs would have had its own risks. Here we describe how antiarrhythmic drugs were used to maintain NSR, all while they were continuously monitored to determine the need to continue OACs.

Do all critical aortic stenosis with chest pain need aortic valve replacement? A case report

Aortic valve replacement (AVR) remains the cornerstone of treatment for symptomatic critical aortic stenosis (AS). It is a Class I indication that symptomatic patients with critical AS undergo either surgical or transcatheter aortic valve replacement (TAVR). We present a patient with critical AS and new angina that was managed successfully with percutaneous coronary intervention (PCI) of the Right coronary artery. Physicians should consider that not all patients with critical AS and angina necessarily require AVR. Concomitant pathology leading to the symptoms should be carefully ruled out. This leads to a less invasive, cost effective care plan especially in patients with advanced age and comorbidities for which any type of surgical valvular intervention may pose high risk.