Nahum Adam Freedberg

Incidence of Postdischarge Symptomatic Paroxysmal Atrial Fibrillation in Patients Who Underwent Coronary Artery Bypass Graft

The aim of this retrospective study was to determine the incidence of symptomatic AF of patients who had undergone coronary artery bypass grafting (CABG) during long‐term follow‐up. The study population included 305 post‐CABG patients who were regularly followed in the outpatient clinic. Paroxysmal AF (PAF) was defined as an episode of symptomatic AF when symptoms were prolonged enough for the patient to request medical care. Perioperative AF occurred in 88 (28.9%) patients. Postdischarge symptomatic PAF occurred in 25 (8.2%) patients with an annual incidence of 2% during a mean follow‐up of 48 ± 30 months. Eighteen (20.4%) patients also experienced perioperative AF with an annual incidence of 5.1%, while only 7 (3.2%) of 217 patients, without perioperative AF, had postdischarge AF (P < 0.0003). During long‐term follow‐up, postdischarge AF has a low incidence and prophylactic antiarrhythmic therapy is not recommended. The method of follow‐up and retrospective analysis may understate PAF and even miss some symptomatic episodes. Perioperative AF is a predictor of symptomatic late PAF recurrences, particularly in patients with reduced left ventricular function. (PACE 2004; 27:365–367)

Lead Insertion by Supraclavicular Approach of the Subclavian Vein Puncture

ANTONELLI, D., et al.: Lead Insertion by Supraclavicular Approach of the Subclavian Vein Puncture. Total occlusion of the left subclavian vein was diagnosed in a 76‐year‐old patient, 6 years after implantation of an ICD with VVI pacing backup. Replacement of the ICD included upgrading of the ICD system because of the presence of pacemaker syndrome when the patient was VVI paced. Insertion of an atrial lead through the ipsilateral vein system was made possible by using the supraclavicular approach of the subclavian, enabling puncturing of the left subclavian vein medially to the obstruction.

Role of defibrillation threshold testing during implantable cardioverter-defibrillator placement: Data from the Israeli ICD Registry

BACKGROUNDnDefibrillation threshold (DFT) testing during placement of an implantable cardioverter-defibrillator (ICD) has been considered mandatory. Accumulating data suggest a more limited role for DFT.nnnOBJECTIVEnThe purpose of this study was to compare the outcome of ICD recipients who underwent DFT testing compared with those who did not.nnnMETHODSnIn this prospective cohort analysis of patients who received an ICD between July 2010 and March 2013, we compared patients who underwent DFT testing and those who did not. Primary end-points were death and malignant ventricular arrhythmias. Secondary end-points included the composite end-points and inappropriate ICD discharges.nnnRESULTSnOf the 3596 patients in the registry, 614 patients (17%) underwent DFT testing during ICD placement vs 2982 (83%) who did not. Variables associated with ICD testing were implantation for secondary prevention (relative risk [RR] 1.87), prior ventricular arrhythmias (RR 1.81), use of antiarrhythmic medication (RR 1.59), and sinus rhythm (RR 2.05). Factors predisposing against testing were cardiac resynchronization therapy defibrillator implantation (RR 0.56) and concomitant diuretic use (RR 0.71). ICD testing was not associated with 1-year mortality (5.3% vs 5.1%, P = .74), delivery of appropriate shocks (8.6% vs 5.6%, P = .16), combined outcomes of ventricular arrhythmias and death (12.9% vs 11.3%, P = .45), or inappropriate ICD discharges (3.9% vs 2.1%, P = .2) compared to no DFT testing.nnnCONCLUSIONnNo significant differences in the incidence of mortality, malignant ventricular arrhythmias, or inappropriate ICD discharges were observed between patients who underwent DFT testing compared to those who did not. Our results may support avoiding DFT testing during ICD placement, but this requires confirmation by additional prospective studies.

Torsades de Pointes and QT Prolongation Due to a Combination of Loratadine and Amiodarone

ATAR, S., et al.: Torsades de Pointes and QT Prolongation Due to a Combination of Loratadine and Amiodarone. Torsades de pointes (TdP) has not been previously reported with loratadine. A 73‐year old woman on chronic treatment with amiodarone for atrial fibrillation received loratadine and presented with syncope and multiple episodes of TdP. We suggest that QT interval should be monitored whenever loratadine is co‐administered with drugs that may potentially prolong QT. (PACE 2003; 26:785–786)

Acute Loss of Capture Due to Flecainide Acetate

ANTONELLI, D., et al.: Acute Loss of Capture Due to Flecainide Acetate. Antiarrhythmic drugs increase pacing threshold, but this is rarely of clinical significance. Administration of flecainide acetate in a 75‐year‐old woman with an implanted AAIR pacemaker because of sick sinus syndrome caused an abrupt rise of pacing threshold and failure of pacing. Pacing threshold returned to the normal value a few days after flecainide treatment was stopped.

Renal dysfunction and clinical outcomes of patients undergoing ICD and CRTD implantation: data from the Israeli ICD registry.

Implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) reduce mortality in patients with heart failure (HF) and left ventricular dysfunction. However, their efficacy in patients with chronic kidney disease (CKD) is controversial.

Bivalirudin versus Unfractionated Heparin during Percutaneous Coronary Intervention in Patients at High Risk for Bleeding.

Low/medium-bleeding-risk populations undergoing percutaneous coronary intervention (PCI) show significantly less bleeding with bivalirudin (BIV) than with unfractionated heparin (UFH), but this has not been established for high-risk patients. We performed a randomized double-blind prospective trial comparing efficacy and safety of BIV versus UFH combined with dual antiplatelet therapy during PCI among 100 high-risk patients with non-ST elevation myocardial infarction (NSTEMI) or angina pectoris. The baseline characteristics were similar in both treatment arms. A radial approach was used in 84% of patients with a higher rate in the BIV group (90 vs. 78%, pu2009<u20090.05). Study end points were: major and minor bleeding, port-of-entry complications, major adverse cardiac events (MACE) in-hospital, and at long-term follow-up. There was one case of major gastrointestinal bleeding in the BIV group and 7% minor bleeding complications in both categories. Rate of periprocedural myocardial infarction (PPMI) in the BIV group was twice that in the UFH group (20 vs. 10%, pu2009<u20090.16). In-hospital MACE rate was higher in BIV patients as well (12 vs. 2%, pu2009=u20090.1). By univariate analysis, the femoral approach was the predictor of PPMI and in-hospital MACE. In a multivariate model, the independent predictor of PPMI was previous MI (odds ratio, 7.7; pu2009<u20090.0158). PPMI was 49.7 times more likely with the femoral approach plus BIV than the nonfemoral approach plus UFH (pu2009<u20090.0021). At 41.5u2009±u200914 months follow-up, end points did not significantly differ between the groups. In patients at high risk for bleeding undergoing PCI, BIV was not superior to UFH for bleeding complications, and early and late clinical outcomes.

Endocardial Ventricular Pacing Through a Bioprosthetic Tricuspid Valve

A patient with bioprosthetic tricuspid valve was treated with ventricular endocardial pacing using a new delivery system consisting of a steerable catheter and a 4.1 F bipolar, fixed‐screw, steroid eluting lead. The functioning of the lead and bioprosthetic tricuspid valve was excellent during the following year.

Permanent Pacing in Nonagenarians Over 20-Year Period

Life expectancy increases progressively and nonagenarians are a growing population. We report trends in pacing and long‐term outcome in nonagenarians over a 20‐year period in a single center compared with those of younger patients.

Clinical Outcomes in Patients with Severe Renal Dysfunction Including Dialysis Following Defibrillator Implantation.

Background: Renal dysfunction is associated with increased mortality in heart failure (HF) patients. However, there are limited data regarding clinical and arrhythmic outcomes associated with implantable cardioverter defibrillator (ICD) therapy in this population. Methods: We evaluated outcomes associated with the severity of renal dysfunction with or without dialysis among 2,289 patients who were enrolled and prospectively followed up in the Israeli ICD Registry. The primary endpoint of the study was all-cause mortality. Secondary endpoints included cardiac mortality, HF hospitalization, non-cardiac hospitalization, and appropriate and inappropriate ICD therapy. Results: Severe renal dysfunction patients (estimated glomerular filtration rate <30 ml/min/1.73 m2; n = 144 patients; 6%) were older, with higher comorbidities prevalence, and more likely to suffer from advanced HF. Among severe renal dysfunction patients, those on dialysis had a lower prevalence of wide QRS and complete left bundle branch morphology, resulting in lower cardiac resynchronization therapy defibrillator (CRTD) implantation rates. Dialysis was associated with an overall increased risk for all-cause mortality (hazard ratio (HR) 3.22; 95% CI 1.69-6.13; p < 0.01) and for noncardiac hospitalizations (HR 2.80; p < 0.001) compared to all other study patients. However, within the subgroup of patients with severe renal dysfunction, the presence of dialysis was not an independent risk factor for all-cause mortality (HR 0.99; p = 0.97) as compared to non-dialysis. The rate of appropriate ICD therapy for ventricular tachyarrhythmias increased with declining renal function, with the highest rate observed among those undergoing dialysis. Conclusions: The present findings suggest that dialysis does not significantly modify the adverse outcomes associated with severe renal dysfunction following ICD/CRTD implantation.