G. Giannola

New-Onset Ventricular Tachycardia After Cardiac Resynchronization Therapy

It is well established that coronary artery disease with healed myocardial infarction is the most common backdrop for ventricular tachycardia (VT). Although the clinical benefits of biventricular pacing (BivP) in the treatment of severe heart failure are well documented, exact relation with ventricular arrhythmias remains still unclear. We describe a case of a patient, whitout a previous history of arrhythmic episodes, in which the onset of several episodes of VT presented immediatly after cardiac resynchronization therapy (CRT) and did not occur after BivP discontinuation.

Outsourcing of remote management of cardiac implantable electronic devices: a medical care quality improvement project. (Preprint)

Background Remote management is partially replacing routine follow-up in patients implanted with cardiac implantable electronic devices (CIEDs). Although it reduces clinical staff time compared with standard in-office follow-up, a new definition of roles and responsibilities may be needed to review remote transmissions in an effective, efficient, and timely manner. Whether remote triage may be outsourced to an external remote monitoring center (ERMC) is still unclear. Objective The aim of this health care quality improvement project was to evaluate the feasibility of outsourcing remote triage to an ERMC to improve patient care and health care resource utilization. Methods Patients (N=153) with implanted CIEDs were followed up for 8 months. An ERMC composed of nurses and physicians reviewed remote transmissions daily following a specific remote monitoring (RM) protocol. A 6-month benchmarking phase where patients’ transmissions were managed directly by hospital staff was evaluated as a term of comparison. Results A total of 654 transmissions were recorded in the RM system and managed by the ERMC team within 2 working days, showing a significant time reduction compared with standard RM management (100% vs 11%, respectively, within 2 days; P<.001). A total of 84.3% (551/654) of the transmissions did not include a prioritized event and did not require escalation to the hospital clinician. High priority was assigned to 2.3% (15/654) of transmissions, which were communicated to the hospital team by email within 1 working day. Nonurgent device status events occurred in 88 cases and were communicated to the hospital within 2 working days. Of these, 11% (10/88) were followed by a hospitalization. Conclusions The outsourcing of RM management to an ERMC safely provides efficacy and efficiency gains in patients’ care compared with a standard in-hospital management. Moreover, the externalization of RM management could be a key tool for saving dedicated staff and facility time with possible positive economic impact. Trial Registration ClinicalTrials.gov NCT01007474; http://clinicaltrials.gov/ct2/show/NCT01007474

Overcoming an impossible anatomy with a novel left ventricular active fixation lead in the coronary sinus: A case report

Introduction Cardiac resynchronization therapy (CRT) has proved to be beneficial for patients with moderate-to-severe heart failure with prolonged QRS duration and reduced left ventricular ejection fraction. Placement of a left ventricular (LV) lead in an adequate location has been shown to increase response to CRT but can become a complex procedure because of challenging coronary vein anatomies. We report the case of a patient in whom a novel LV lead was successfully implanted in a very-large-diameter coronary vein.

Effectiveness and safety of a personal approach to transvenous lead extraction

CS guide sheath or venogram. Methods: A broad curve was fashioned on the stylet of a unipolar left ventricular lead (Medtronic 4193). The lead was then advanced through a 9 French peel-away subclavian vein sheath into the CS by rotating the stylet together with lead body. Once in the CS, the stylet was withdrawn 1cm and a side branch was cannulated by advancing and rotating the lead. If this failed, the stylet was substituted with a 0.014 guidewire which was used to interrogate side-branches and implant the lead. An anterolateral lead position was not accepted. If this sheathless technique had not succeeded after 20 min, the operator switched to the conventional CS guide sheath technique. Results: The sheathless approach was used in 30 consecutive patients referred for cardiac resynchronization (17 male, median age 65 (35-82) years). This technique succeeded in 12/30 (40 %) patients in a median of 8 (5-20) min. Access was from the right side in 1 case. The mean left ventricular R wave was 11.7 (6.8-14.9) mV, threshold 1.0 (0.6-4.9) Volts at 0.5ms. Among failures, the CS was not cannulated in 6/18 (33 %) patients, a posterolateral branch was not cannulated in 10/18 (66 %) patients, and, in 2/18 patients, a posterolateral branch was cannulated but there were suboptimal thresholds or phrenic nerve stimulation. In these failures, subsequent venogram showed either acutely angled side-branches or very small caliber veins, and a stable lead position was not achieved in 4/18 (22%) of these patients despite crossover to the conventional technique. There were no cases of CS dissection or other complications. Conclusion: This sheathless technique appears to be successful in patients with favorable CS anatomy and may result in cost and time savings as well as a reduction in radio-contrast administration.

Sleep Apnea: New Insights

Sleep apnea is the most common disorder of breathing during sleep. It is defined as repeated episodes of obstructive apnea and hypopnea during sleep, together with daytime sleepiness or altered cardiopulmonary function [1]. There are three syndromes of upper airway closure during sleep: obstructive sleep apnea (OSA), obstructive sleep hypopnea, and upper airway resistance. These three syndromes share two features: excessive daytime sleepiness and arousal associated with increased ventilatory effort in response to upper airway closure. The specific sites of narrowing or closure and upper airway dysfunction are influenced by the underlying neuromuscular tone, upper airway muscle synchrony, and the stage of sleep. Sleep apnea may be classified as two major forms: obstructive sleep apnea and central sleep apnea (CSA). Heart failure (HF) affects about 5 million people in the USA [2], and the largest epidemiologic studies in patients with HF found rates of prevalence of OSA of 37% and 11% respectively [3, 4]. Thus, OSA and CSA have a heavy impact on the health of these patients and on public health resources.

How to Detect and Manage Pacemaker/ICD Failure and Infections

Device therapy involving pacemakers for bradyarrhythmias and implantable cardioverter defibrillators (ICDs) for tachyarrhythmias has undergone a surprising evolution. System failure and infection, however, are still possible complications. In contrast to the relative frequency of lead failure, either as a result of implantation error or of deterioration of the lead materials, primary malfunction of the pulse generator is rare. The key to diagnosing device failure lies in meticulous assessment of the integrity of the leads and an understanding of the timing cycles of the specific device, which is facilitated by access to bidirectional telemetry. Infection is another complication of implanted devices; it is reported to occur in 0–19% of patients with pacemakers [1, 2] and in 2%–7% of patients with ICDs.