Luca Tomasi

General anaesthesia for external electrical cardioversion of atrial fibrillation: experience of an exclusively cardiological procedural management

AIMS External electrical cardioversion (EC) usually requires brief general anaesthesia involving anaesthetists. The aim of this study was to evaluate the feasibility and safety of inducing anaesthesia for EC of atrial fibrillation (AF) exclusively by the cardiologic team with anaesthetists on-hand. METHODS AND RESULTS A retrospective analysis of 624 elective EC, over a 6-year period, was made. No patients were excluded due to the severity of pathology or comorbidities. The protocol of the intravenous anaesthesia was 5 mg bolus of midazolam and subsequent increasing doses of propofol starting from 20 mg to achieve the desired sedation level. After delivering DC shock, a direct observation period followed in order to assess the post-sedation recovery and to detect the procedure-related complications. Electrical cardioversion was effective in 98.9% of the cases. General anaesthesia was effective in 100% of cases with a dosage of propofol, ranging between 20 mg to a maximum of 80 mg, after 5 mg of midazolam was administered. All patients generally showed a fast recovery waking up in a few minutes. The anaesthesiology team was never called for assistance. All the procedures were carried out by the cardiologic team as planned. No thrombo-embolic and allergic complications were observed. Arrhythmic complications were uncommon and essentially bradyarrhythmias. CONCLUSION A general anaesthesia for outpatient EC of AF can be safely handled by a cardiologist having adequate experience with anaesthetical agents. Moreover, the association of midazolam and a very small dosage of propofol, given their synergic action, is effective and safe in inducing anaesthesia. Arrhythmic complications are rare and limited to bradyarrhythmias.

Physiopathologic Correlates of Intrathoracic Impedance in Chronic Heart Failure Patients

Background: Increased plasma levels of amino‐terminal fraction of brain natriuretic peptide (NT‐proBNP) and alterations of diastolic filling as described by Doppler transmitral flow pattern are well‐known markers of decompensated heart failure (HF). Recently, some implantable defibrillators have allowed monitoring of intrathoracic impedance, which is related to lung water content, potentially indicating HF deterioration. The aim of this study was to assess the correlation between intrathoracic impedance and NT‐proBNP and echo‐Doppler transmitral flow indexes.

Pitfalls in electrogram interpretation: Subcutaneous cardioverter defibrillator malfunction in Brugada syndrome: MORANI et al .

A patient with Brugada syndrome implanted with subcutaneous implantable cardioverter defibrillator (S‐ICD) had oversensing episodes treated with S‐ICD shocks. Comparable artifacts were not evocable with S‐ICD pocket manipulation. The fluoroscopy excluded S‐ICD macroscopic damage.

Long-term independent predictors of positive response to cardiac resynchronization therapy.

Aims Cardiac resynchronization therapy (CRT) is currently considered an important breakthrough in the treatment of selected patients with refractory heart failure. However, long-term predictors of mortality, morbidity and time to recovery of ventricular function for those patients who respond positively to CRT remain poorly investigated. Methods This is a retrospective follow-up study involving one hospital. Between August 2004 and October 2008, 211 consecutive patients with refractory heart failure received a CRT device in the Cardiology Division of Ospedale Civile Maggiore in Verona. The clinical characteristics studied were age, sex, heart rhythm, left ventricular end-systolic volume/body surface area (LVESV/BSA), left ventricular ejection fraction, QRS duration, type of bundle-branch block, cause, New York Heart Association functional class, pharmacological therapy and lead position. The objective of this study was to evaluate the effect of several baseline characteristics on long-term prognosis in heart failure patients treated with CRT. Results Non ischemic cause, left bundle-branch block and a basal LVESV/BSA ⩽106 ml/m2 or less were the only independent predictors of a positive response to CRT (P < 0.005). Additionally, a reduction in LVESV/BSA after CRT was associated both with increased survival and reduced rehospitalization for heart failure (P < 0.005). Conclusion A better selection of patients on the basis of cause, type of bundle-branch block and basal LVESV/BSA can increase the number of patients that would benefit from CRT.

Subaxillary approach to cardiac electronic device implantation using a single surgical incision: a single-centre experience

OBJECTIVES Pacemakers and implantable cardioverter defibrillators have become more common in younger individuals, owing to broader indications and technological advances. Our goal was to report our long-term experience of implanting cardiac devices in young adults via a subaxillary approach with a hidden single incision, to minimize the aesthetic impact of the device. METHODS From 2003 to 2012, 23 patients underwent cardiac device implantation via a subaxillary approach while they were under general anaesthesia. The axillary vein was punctured under contrast-medium radiological guidance. The devices were positioned into the pocket under the pectoralis major muscle and over the fascia that envelopes the pectoralis minor muscle, through a lateral surgical access along the midaxillary line. RESULTS Twenty-two single- and dual-chamber implantable cardioverter defibrillator and 1 dual-chamber pacemaker were implanted (mean age 32.2 ± 13.4 years). All procedures were successfully performed without complications; overall hospitalization after implantation was 3.3 days. During mean a follow-up of 65 ± 18 months, no deaths, infections or device migrations occurred. Two ventricular lead dislodgements requiring repositioning occurred within 1 month, and 1 defibrillation lead fracture occurred 5 years after implantation. All patients were extremely satisfied with the aesthetic result. A mild increase in the pacing threshold (0.88 ± 0.6 V at 0.4/0.5 ms at implantation vs 1.00 ± 0.3 V at 0.4/0.5 ms at 2-year follow-up, P = 0.063) and a statistically significant decrease in the pacing impedance (637 ± 161 ohm at implantation vs 499 ± 81 ohm at 2-year follow-up, P = 0.001) were observed, without any consequences. CONCLUSIONS The subaxillary approach is a safe, feasible technique that requires a simple surgical procedure. The implantable cardioverter defibrillator functions properly at implantation and at long-term follow-up.

Performance and clinical comparison between left ventricular quadripolar and bipolar leads in CRT: observational research

AIM To evaluate Attain Performa (Medtronic, Dublin, Ireland) quadripolar lead performance in clinical practice and, secondarily, to compare its long term clinical outcomes vs bipolar leads for left ventricular (LV) pacing. METHODS AND RESULTS We retrospectively analyzed clinical, procedural and follow-up data of 215 patients implanted with a quadripolar lead. One hundred and twenty one patients implanted with bipolar lead were selected to compare long-term clinical outcomes. The quadripolar lead was implanted in the target vein in 196 patients (91%) without acute dislodgements. In 50% of patients the chosen final pacing configuration at implant would not have been available with bipolar leads. A dedicated quadripolar pacing vector was chosen more frequently when the LV tip location was apical than otherwise (65.6% vs 42.7%, p=0.003). After a median follow-up of 14 months, the LV pacing threshold was less than 2.5V at 0.4ms in 98 patients (90%) with a safety margin between phrenic nerve and LV pacing threshold >3V in 97 patients (89%). We observed a slight trend toward a lower risk of heart failure worsening and a lower incidence of ventricular arrhythmias and pulmonary congestion in patients implanted with quadripolar leads compared with the control group. CONCLUSION Quadripolar leads improve the management of phrenic nerve stimulation at no trade-off with pacing threshold and lead stability. Quadripolar leads seems to be associated with a lower incidence of VT/VF and pulmonary congestion, when compared with bipolar leads, but further investigations are necessary to confirm that this positive effect is associated with better LV reverse remodeling.

Leadless pacemaker implantation in achondroplastic dwarfism and recurrent cardiac implantable electronic device infections: a case report

The safety and performance of the micra thranscatheter pacing system (MTPS) seems to be very high both in the investigational studies and in the real world setting. Much of currently available data comes from normal-sized adults, with only limited data on small-sized patients. We describe the MTPS implantation in a 71-year-old male, suffering from recurrent pacemaker infections and lead failure, who is affected by achondroplastic dwarfism with the pathognomonic phenotypical signs characterized by small size (height 120 cm; weight 39 kg), disproportionately short upper limbs, often limiting self-care skills, with an abnormal limb-to-trunk ratio. Other comorbidities include type 2 diabetes and severe thoracolumbar kyphosis. Previously, in 1970, the patient underwent a single-chamber pacemaker implantation via the right subclavian vein for complete atrioventricular block. Due to recurrent ventricular lead failure, a contralateral pacemaker implantation via the left subclavian vein was performed in

Relationship between early administration of abciximab and TIMI flow in STEMI patients undergoing primary angioplasty: findings from a large regional STEMI network.

Aims The aim of this study is to assess whether in S-T Elevation Myocardial Infarction (STEMI) a relationship between early administration of abciximab and Thrombolysis In Myocardial Infarction (TIMI) flow before and after primary percutaneous coronary intervention (PCI) in 960 consecutive patients exists. Methods From 1 February 2001 onward, in the Province of Mantua it has been operating a ‘Cardiology Network for the Acute Infarction Care’ having its Hub in the Central Coronary ICU/Cath Lab of Mantua Hospital and being its Spokes centers represented by the emergency rooms and Central Coronary ICUs of the four territorial hospitals. Results T1 (time from symptoms onset to first medical contact) and T2 (time from first medical contact to angioplasty) are shorter for patients rescued by first aid units rather than for those presented in emergency rooms as well as Ta (time from symptoms onset to abciximab administration). Furthermore, the patients that received abciximab before hospital arrival had less frequently a coronary occlusion [odds ratio = 0.74, 95% confidence interval (0.57–0.96), P = 0.013]. The patients with T1 less than 4 h are 753/960 (78.4%). For this type of patients, there was a significant Ta difference between the pre-PCI TIMI-flow classes (F = 4.467, df = 3, P = 0.04). Planned contrasts revealed that mean time of TIMI flow 0 (M = 104.2) is statistically different from mean time of TIMI flow 3 (M = 85.7), P = 0.013. Conclusion Our results suggest that the use of abciximab, free from pharmacokinetic limits of oral P2Y12 inhibitors, should be considered in STEMI patients with early presentation before primary PCI.

A case of removal of a “dancing” Micra

Micra (Medtronic Inc) transcatheter pacing system (TPS) is a leadless pacemaker with a nitinol tine-based fixation mechanism. Growing scientific evidences seem to confirm safety and effectiveness in acute and mid-term settings. While TPS implantation, requiring a specialized skill set, is a well-established step by step procedure, far most challenging seems to be TPS retrieval, after cutting the tether. In addition to the fact that there is no specialized system for TPS retrieval, there is some evidence of early endothelialization of the TPS that raises the question about how and until when the TPS removal is feasible. We describe a case of an 80-year-old man with hypertensive cardiopathy and permanent atrial fibrillation (AF) who underwent TPS implantation and then TPS removal 1 month later. During the first implant the TPS was deployed to the interventricular mid-septum and successfully recaptured for three times, due to unsatisfying pacing thresholds (2 V/0.24 ms), until final mid-septal position under the septomarginalis trabeculation was achieved with

Association between Beta1‐Adrenergic Receptor Polymorphism and Risk of ICD Shock in Heart Failure Patients

Sympathetic activation in heart failure patients favors the development of ventricular arrhythmias, thus leading to an increased risk of sudden cardiac death. β1‐ and β2‐adrenergic receptor polymorphisms have been linked to the risk of sudden death. Implantable cardioverter‐defibrillators (ICD) are implanted in a large percentage of heart failure patients, and beyond preventing sudden cardiac death they provide a continuous monitoring of major ventricular arrhythmias and of their own interventions. We investigated whether functionally relevant β1‐ and β2‐adrenergic receptor polymorphisms are associated with risk of ICD shocks, as evidenced in ICD memory.