L. Dei Cas

16. ICD: Defibrillation Threshold Testing & Other Issues

The aim of this study was to evaluate efficacy and safety of propofol (P) direct administration by the physician performing ICD implant (ICDI) or transthoracic electrical cardioversion (TEC) without an anaesthesiologist attending the procedure.nnBefore starting this evaluation, a pilot experience was made since September 2004 to December 2004. During this phase, 25 patients underwent ICDI (18 patients) or TEC (7 patients) with an anestesiological assistance, in order to teach electrophysiologist team use of P and possible adverse effect.nnAfter this preliminary phase, the study was begun.nnSince January 2005, 31 pts (23 male, mean age 59 ± 13 yrs, range 25 – 80 yrs) underwent ICDI with defibrillation threshold evaluation (20 pts) or TEC (11 pts). Sedation induction was obtained with propofol. The drug was administered starting with a 40 mg injection and increasing the dose until sedation was obtained.nnMean dose administered was of 64 ± 19 mg, with a mean weight adjusted dose of 0.84 ± 0.21 mg/kg.nnIn heavier patients (considering patients whose weight was higher than median weight value of 78 kg) we observed a lower weight adjusted P dose (0.79 ± 0.21 mg/kg vs 0.89 ± 0.21 mg/kg) even if the difference didnt reach statistical significance.nnNo adverse effects were observed during the study phase.nnIn conclusion, after adequate training period, P use during electrophysiological procedures without direct anaesthesiologist attendance in the surgical room seems to be efficacious and safe.

16. ICD: Defibrillation Threshold Testing & Other Issues16.3 Safety of Propofol Use by Cardiologists During Defibrillation Threshold Test and Transthoracic Electrical Cardioversion

The aim of this study was to evaluate efficacy and safety of propofol (P) direct administration by the physician performing ICD implant (ICDI) or transthoracic electrical cardioversion (TEC) without an anaesthesiologist attending the procedure.nnBefore starting this evaluation, a pilot experience was made since September 2004 to December 2004. During this phase, 25 patients underwent ICDI (18 patients) or TEC (7 patients) with an anestesiological assistance, in order to teach electrophysiologist team use of P and possible adverse effect.nnAfter this preliminary phase, the study was begun.nnSince January 2005, 31 pts (23 male, mean age 59 ± 13 yrs, range 25 – 80 yrs) underwent ICDI with defibrillation threshold evaluation (20 pts) or TEC (11 pts). Sedation induction was obtained with propofol. The drug was administered starting with a 40 mg injection and increasing the dose until sedation was obtained.nnMean dose administered was of 64 ± 19 mg, with a mean weight adjusted dose of 0.84 ± 0.21 mg/kg.nnIn heavier patients (considering patients whose weight was higher than median weight value of 78 kg) we observed a lower weight adjusted P dose (0.79 ± 0.21 mg/kg vs 0.89 ± 0.21 mg/kg) even if the difference didnt reach statistical significance.nnNo adverse effects were observed during the study phase.nnIn conclusion, after adequate training period, P use during electrophysiological procedures without direct anaesthesiologist attendance in the surgical room seems to be efficacious and safe.

21. Cardiac Resynchronization Therapy: Implanting & Clinical Aspects

Cardiac resynchronization therapy (CRT) has been proven to significantly reduce all – cause mortality in patients affected with severe congestive heart failure refractory to optimized medical therapy.nnAlthough proved efficacy, some concerns remain regarding skillness required to correctly perform the implant and prolonged fluoro time (FT) necessary to complete leads positioning.nnIn our centre, to date, 251 patients (181 male, mean age 69 ± 9 yrs), implanted with a biventricular device (131 PM, 120 ICD) since October 1998, are strictly followed – up.nnWe evaluated FT necessary to complete CRT implant in our patients, analyzing if different lead design, over – the – wire (OTW, exclusively Guidant leads) or combined (OTW+S: Medtronic 4193 and 4194 models and St. Jude 1056K leads), could affect FT or if this parameters was more influenced by operator experience.nnFT was available for 142 patients, in whom OTW leads were used in 69 pts and OTW + S leads were used in 73 pts. Furthermore, mean FT was evaluated for every physician who performs CRT implant in our Lab.nnMean FT in the whole population was 16 ± 7 minutes and FT was not affected by the kind of LV lead used. In fact, mean FT in the OTW group was 16 ±7 minutes and in the OTW+S group was 15 ± 6 minutes (p NS).nnInstead, FT seems to be strictly related to operator experience. In fact, the greater the number of devices implanted, the shorter the FT. Operator 1 performed 79 implants, with a mean FT of 13 ± 7 minutes; operator 2 performed 41 implants with a mean FT of 15 ± 6 minutes and operator 3 performed 22 implant with a mean FT of 21 ± 6 minutes. Therefore, both operator 1 and 2 have FT that are significantly lower than operator 3 FT (respectively, 1 vs 3 p = 0.01 and 2 vs 3 p < 0.001), and there are no statistically significant differences between operator 1 and 2 FT.nnIn conclusion, reduction of FT during CRT implant it is a matter of operator experience more than of lead technology.

21. Cardiac Resynchronization Therapy: Implanting & Clinical Aspects21.3 Importance of Operator Experience in Reducing Fluoro-Time During Biventricular Device Implantation

Cardiac resynchronization therapy (CRT) has been proven to significantly reduce all – cause mortality in patients affected with severe congestive heart failure refractory to optimized medical therapy.nnAlthough proved efficacy, some concerns remain regarding skillness required to correctly perform the implant and prolonged fluoro time (FT) necessary to complete leads positioning.nnIn our centre, to date, 251 patients (181 male, mean age 69 ± 9 yrs), implanted with a biventricular device (131 PM, 120 ICD) since October 1998, are strictly followed – up.nnWe evaluated FT necessary to complete CRT implant in our patients, analyzing if different lead design, over – the – wire (OTW, exclusively Guidant leads) or combined (OTW+S: Medtronic 4193 and 4194 models and St. Jude 1056K leads), could affect FT or if this parameters was more influenced by operator experience.nnFT was available for 142 patients, in whom OTW leads were used in 69 pts and OTW + S leads were used in 73 pts. Furthermore, mean FT was evaluated for every physician who performs CRT implant in our Lab.nnMean FT in the whole population was 16 ± 7 minutes and FT was not affected by the kind of LV lead used. In fact, mean FT in the OTW group was 16 ±7 minutes and in the OTW+S group was 15 ± 6 minutes (p NS).nnInstead, FT seems to be strictly related to operator experience. In fact, the greater the number of devices implanted, the shorter the FT. Operator 1 performed 79 implants, with a mean FT of 13 ± 7 minutes; operator 2 performed 41 implants with a mean FT of 15 ± 6 minutes and operator 3 performed 22 implant with a mean FT of 21 ± 6 minutes. Therefore, both operator 1 and 2 have FT that are significantly lower than operator 3 FT (respectively, 1 vs 3 p = 0.01 and 2 vs 3 p < 0.001), and there are no statistically significant differences between operator 1 and 2 FT.nnIn conclusion, reduction of FT during CRT implant it is a matter of operator experience more than of lead technology.