Marco Breschi

Early mobilization after pacemaker implantation.

Background There are no international guidelines indicating how long a patient should stay strictly in bed after pacemaker implantation. In the present study, we tested a new protocol concerning the mobilization of patients 3 h after receiving a single or a dual-chamber pacemaker. Methods Consecutive patients who underwent single or dual-chamber pacemaker implantation were randomized to a 3 or 24 h immobilization protocol. Only bipolar passive fixation leads were computed. After the implant, an elastic bandage was put on the homolateral shoulder of all patients for 24 h. A complete clinical and electronic follow-up was performed before discharge and repeated 2 months later. End-points considered were the displacement of the lead, high pacing thresholds (> 3.5 V/0.4 ms at the discharge or > 2.5 V/0.4 ms at the 2-month follow-up), sensing defects not corrigible by programming and clinical complications of the pocket. Results One hundred and thirty-four patients were included in the study: 57 in group A (mobilization after 3 h) and 77 in group B (24 h). In group A, one haematoma and two displacements occurred in three patients. In group B, we registered one haematoma, one subclavian vein thrombosis, three displacements and three high stimulation thresholds. No statistical differences were observed between the end-points of group A versus B. Conclusions The present study shows that an early mobilization protocol is feasible because no statistical differences resulted from the two groups of study as regards clinical outcome, complications and electronic measurements of the implanted devices, which have been followed up for 2 months.

Intrinsic bleeding risk in patients with uninterrupted oral anticoagulation undergoing cardiac implantable electronic device procedures: A pilot study

The number of cardiac implantable electronic device (CIED) proce-duresisdramaticallyincreasingworldwide[1].Upto37–46%ofpatientsrequiringdevicesurgeryareonchronicoralanticoagulation(OAC)ther-apy [2]. Perioperative anticoagulation managementrepresentsadilem-mafor physicians, particularly in the subset of patients with moderate-to-high risk of arterial thromboembolic events. Current guidelinesrecommend interruption of anticoagulation and bridging with heparin[3]. However, such strategy has been associated with increased risk ofpocket hematoma(up to 20%) [4]. More recently, observational studiesshowed that continuing warfarin for cardiac rhythm device implanta-tion is safe and is associated with lower incidence of pocket hematoma[5,6]. Noteworthy, evidence from randomized controlled studies con-firmed the efficacy and safety of uninterrupted OAC as compared withheparin bridging [7,8]. Although uninterrupted OAC is associated withreduced bleeding, a large proportion of patients remain exposed to asubstantialriskofhemorrhagiccomplications.Preventionofhematomaformation duringCIEDsurgery is animportant challenge nowadays. In-deed,pockethematomarepresentsoneofthemainriskfactorsforlocaland systemic device-related infections, leading to increased patientmorbidity and health care costs [9,10]. To further reduce bleeding riskin this setting, some experts suggest that CIED procedures should beperformed within the safest INR ranges, thus maintaining INR valuesas low as possible, according to the type of procedure [11]. However, asystematic assessment of intrinsic bleeding risk is lacking in patientswith uninterrupted OAC undergoing CIED surgery. Therefore, the iden-tification of patients at higher bleeding risk would be advantageous tooptimize perioperative management. In recent years, the bleedingscores HASBLED, ATRIA and HEMORR

5. Atrial Tachycardia, Atrial Flutter & WPW Syndrome

Aim cavo-tricuspidal isthmus (CTI) block assessment using right ventricular (RV) pacing in pts with ventriculo-atrial conduction. Methods pts submitted to CTI ablation for typical atrial flutter were studied with a quadruple catheter in RV, a decapolar in the coronary sinus (CS), an eicosapolar around the tricuspidal annulus and an 8 mm ablator. Circumannular activation (CA) was analysed during CS and RV pacing in pts with spontaneous sinus rhythm or cardioverted during ablation. Pts without ventriculo-atrial conduction were excluded. The linear lesion was performed during RV pacing, looking at atrial signals splitting. CTI block was confirmed by analysis of CA during CS and RV pacing. Results out of 15, 9 (60%) pts were included. Before ablation, during RV stimulation, the collision front of CA shifted counter clockwise with respect to CS pacing, without variation of Halo-like catheter activation time (82±31 ms vs 77±26, p = 0.49). After ablation, CA was similar during CS and RV pacing, showing fully descending lateral right atrium activation (115±33 ms vs. 103±29, p = 0.09). Double potentials on the ablation line were more splitted during CS pacing than RV pacing (126±24 ms vs. 108±20 ms, p = 0.009), but less detached from the V wave. All pts were successfully ablated. Conclusions in pts with ventriculo-atrial conduction, RV pacing can substitute CS pacing in the assessment of isthmus block.

A New Approach to Cavo-Tricuspidal Isthmus Ablation

Aim cavo-tricuspidal isthmus (CTI) block assessment using right ventricular (RV) pacing in pts with ventriculo-atrial conduction. Methods pts submitted to CTI ablation for typical atrial flutter were studied with a quadruple catheter in RV, a decapolar in the coronary sinus (CS), an eicosapolar around the tricuspidal annulus and an 8 mm ablator. Circumannular activation (CA) was analysed during CS and RV pacing in pts with spontaneous sinus rhythm or cardioverted during ablation. Pts without ventriculo-atrial conduction were excluded. The linear lesion was performed during RV pacing, looking at atrial signals splitting. CTI block was confirmed by analysis of CA during CS and RV pacing. Results out of 15, 9 (60%) pts were included. Before ablation, during RV stimulation, the collision front of CA shifted counter clockwise with respect to CS pacing, without variation of Halo-like catheter activation time (82±31 ms vs 77±26, p = 0.49). After ablation, CA was similar during CS and RV pacing, showing fully descending lateral right atrium activation (115±33 ms vs. 103±29, p = 0.09). Double potentials on the ablation line were more splitted during CS pacing than RV pacing (126±24 ms vs. 108±20 ms, p = 0.009), but less detached from the V wave. All pts were successfully ablated. Conclusions in pts with ventriculo-atrial conduction, RV pacing can substitute CS pacing in the assessment of isthmus block.

5. Atrial Tachycardia, Atrial Flutter & WPW Syndrome5.2 A New Approach to Cavo-Tricuspidal Isthmus Ablation

Aim cavo-tricuspidal isthmus (CTI) block assessment using right ventricular (RV) pacing in pts with ventriculo-atrial conduction. Methods pts submitted to CTI ablation for typical atrial flutter were studied with a quadruple catheter in RV, a decapolar in the coronary sinus (CS), an eicosapolar around the tricuspidal annulus and an 8 mm ablator. Circumannular activation (CA) was analysed during CS and RV pacing in pts with spontaneous sinus rhythm or cardioverted during ablation. Pts without ventriculo-atrial conduction were excluded. The linear lesion was performed during RV pacing, looking at atrial signals splitting. CTI block was confirmed by analysis of CA during CS and RV pacing. Results out of 15, 9 (60%) pts were included. Before ablation, during RV stimulation, the collision front of CA shifted counter clockwise with respect to CS pacing, without variation of Halo-like catheter activation time (82±31 ms vs 77±26, p = 0.49). After ablation, CA was similar during CS and RV pacing, showing fully descending lateral right atrium activation (115±33 ms vs. 103±29, p = 0.09). Double potentials on the ablation line were more splitted during CS pacing than RV pacing (126±24 ms vs. 108±20 ms, p = 0.009), but less detached from the V wave. All pts were successfully ablated. Conclusions in pts with ventriculo-atrial conduction, RV pacing can substitute CS pacing in the assessment of isthmus block.