Pedro Marques

Triple-site pacing for cardiac resynchronization in permanent atrial fibrillation – Acute phase results from a prospective observational study

INTRODUCTION AND AIM Multi-site pacing is emerging as a new method for improving response to cardiac resynchronization therapy (CRT), but has been little studied, especially in patients with atrial fibrillation. We aimed to assess the effects of triple-site (Tri-V) vs. biventricular (Bi-V) pacing on hemodynamics and QRS duration. METHODS This was a prospective observational study of patients with permanent atrial fibrillation and ejection fraction <40% undergoing CRT implantation (n=40). One right ventricular (RV) lead was implanted in the apex and another in the right ventricular outflow tract (RVOT) septal wall. A left ventricular (LV) lead was implanted in a conventional venous epicardial position. Cardiac output (using the FloTrac™ Vigileo™ system), mean QRS and ejection fraction were calculated. RESULTS Mean cardiac output was 4.81±0.97 l/min with Tri-V, 4.68±0.94 l/min with RVOT septal and LV pacing, and 4.68±0.94 l/min with RV apical and LV pacing (p<0.001 for Tri-V vs. both BiV). Mean pre-implantation QRS was 170±25 ms, 123±18 ms with Tri-V, 141±25 ms with RVOT septal pacing and LV pacing and 145±19 with RV apical and LV pacing (p<0.001 for Tri-V vs. both BiV and pre-implantation). Mean ejection fraction was significantly higher with Tri-V (30±11%) vs. Bi-V pacing (28±12% with RVOT septal and LV pacing and 28±11 with RV apical and LV pacing) and pre-implantation (25±8%). CONCLUSION Tri-V pacing produced higher cardiac output and shorter QRS duration than Bi-V pacing. This may have a significant impact on the future of CRT.

Adapting to test structure: Letting testing teach what to learn

We propose that we encode and store information as a function of the particular ways we have used similar information in the past. More specifically, we contend that the experience of retrieval can serve as a powerful cue to the most effective ways to encode similar information in comparable future learning episodes. To explore these ideas, we did two studies in which all participants went through study–test cycles of single category lists while we manipulated the nature of the recognition tests. The recognition tests either included only same-category lures or only different-category lures. The experience of repeated testing leads participants to avoid conceptual-based strategies but only when conceptual knowledge was poorly diagnostic for recognition (i.e., in the same-category lures condition). In a second study with a similar manipulation, we showed that repeated testing with lures from the same category as study items improved performance in a final recall surprise test compared to conditions in which different-category lures were used. Such a difference is akin to the one obtained when encoding instructions focus on distinctive item features compared to cases in which the focus is on relational processing. We suggest that testing requirements lead to adaptive changes at encoding.

Triple-site pacing for cardiac resynchronization in permanent atrial fibrillation: follow-up results from a prospective observational study

Aims Cardiac Resynchronization Therapy (CRT) is associated with a particularly high non-response rate in patients with atrial fibrillation (AF). We aimed to assess the effectiveness of triple-site (Tri-V) pacing CRT in this population. Methods and results Prospective observational study of patients with permanent AF who underwent CRT implantation with an additional right ventricle lead in the outflow tract septal wall. After implantation, programming mode (Tri-V or biventricular pacing) was selected based on cardiac output determination. Patients were classified as responders if NYHA class was reduced by at least one level and echocardiographic ejection fraction (EF) increased ≥ 10%, and as super-responders if in NYHA class I and EF ≥ 50%. Forty patients (93% male, mean age 72 ± 10 years) were included. Thirty-three were programmed in Tri-V. The following results pertain to this subgroup. At baseline, 58% were in NYHA class III and 36% NYHA class II. At 1 year follow-up, Minnesota QoL score was reduced (36 ± 23 vs. 8 ± 6; P = 0.001) and the 6MWT distance improved (384 ± 120 m to 462 ± 87 m, P = 0.003). Mean EF increased (26% ± 8 vs. 39 ± 10; P < 0.001 at 6 months and 41 ± 10; P < 0.001 at 12 months). Responder rate was 59% at 6 months and 79% at 12 months. Super-responder rate was 9% at 6 months and 16% at 12 months. One year survival free from heart failure hospitalization was 87.9%. Conclusion Tri-V CRT yielded higher response and super-response rates than usually reported for CRT in patients with permanent AF using clinical and remodeling criteria.

Overcoming a subclavian complete occlusion: Simple single lead extraction by the subclavian vein allowing implantation of two new leads and upgrade to CRT-P with multi-site pacing.

Central venous obstruction following pacemaker implantation is not uncommon, and can prove challenging in the case of system upgrade. We report a case of DDDR to CRT-P (with multi-site pacing) upgrade, where a subclavian occlusion was overcome resorting to an atrial lead extraction (using only a locking stylet). This allowed regaining of the venous access with subsequent implantation of not just one, but two new leads and subsequent successful upgrade.

Ownership of individual retirement accounts – an empirical analysis based on SHARE

Abstract This paper examines the household retirement saving decisions in what concerns to the ownership of Individual Retirement Accounts (IRAs) in eight European Union (EU) countries. IRAs are more and more seen as an alternative to public pension benefits, which are decreasing. Therefore, understanding the enrolment in IRAs, both the socio-economic factors and over time, is most important. Detailed empirical analysis of the factors that might influence the ownership of IRAs is presented based on Survey of Health Ageing and Retirement in Europe (SHARE), using data from Wave 2 (2006–2007) and Wave 4 (2010–2011). Further, to analyse the impact of legal retirement age in the ownership of IRAs, two subsamples are considered: people aged between 50 and 64 years old (50–64 years) and people aged 65 or over (≥ 65 years). The results suggest that age, years of education, income and ownership of dwelling influence positively and significantly household saving, while number of children, marital status and risk aversion have a negative effect. Marital status and income are not statistically significant for retired people. Policy implications are derived.

Persistent left superior vena cava : a vascular access without limitations

© 2018 Sociedade Portuguesa de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Veia cava superior esquerda persistente – Um acesso vascular sem limitações

A veia cava superior esquerda persistente (VCSEP) é a malformação venosa congénita torácica mais frequente e o seu diagnóstico costuma ser incidental. Casos clínicos demonstrativos de implantação de pacemakers de dupla câmara (DDD), cardioversores desfibrilhadores implantáveis e sistemas de ressincronização cardíaca através desse acesso venoso foram já descritos na literatura. Contudo, na grande maioria dos casos apresentados o posicionamento do eletrocater (ECT) ventricular direito (ECT-VD) ficou restrito ao apéx do ventrículo direito (VD). Até ao momento estão descritos na literatura apenas quatro casos de posicionamento do ECT VD no trato de saída do VD através da VCSEP. Os autores apresentam o caso de uma doente do sexo feminino, de 79 anos, com diagnóstico de síncope e bloqueio de ramo esquerdo proposta para implantação de pacemaker DDD. Durante o procedimento obteve-se acesso venoso pela veia cefálica esquerda, verificou-se que o ECT progredia à esquerda da coluna vertebral, sugestivo da presença de VCSEP. Através desse acesso foi possível implantar sequencialmente o ECT-VD no trato de saída do VD e o ECT auricular no apêndice auricular direito, ambos com sistema de fixação ativa (Figura 1).Persistent left superior vena cava (PLSVC) is the most common thoracic congenital malformation and its diagnosis usually occurs by chance. Demonstrative clinical cases of dual-chamber (DDD) pacemaker implantation, implantable cardioverter defibrillators and cardiac resynchronization systems through PLSVC access have already been described in the literature. However, in most of the cases presented, the positioning of the lead in the right ventricle (RV) was restricted to the RV apex. To date, the literature reports only four cases of RV lead positioning in the right ventricular outflow tract (RVOT) via the PLSVC. The authors present the case of a 79-year-old female patient, diagnosed with syncope and left branch bundle block, in whom implantation of a DDD pacemaker was proposed. During the procedure, venous access was obtained via the left cephalic vein, and the lead was found to progress to the left of the spinal column, suggesting the presence of PLSVC. Through this access,

Memory and conceptual learning of relevant and non-relevant items in item-method directed forgetting

ABSTRACT The present research investigates the fate of non-target information when people are trying to either intentionally memorise or forget target information. By using an object-based attentional manipulation within a directed forgetting paradigm (item-method), we show a directed forgetting effect (DFE, i.e., better memory for to-be-remembered (TBR) than for to-be-forgotten (TBF) items) for items that participants are explicitly instructed to attend but not for irrelevant items that happen to be part of the context. Alongside the classic DFE, we investigate how the category of the attended and unattended items are learned. The results obtained in three experiments, show that people can successfully learn only the category of the TBR attended items and that the DFE extends to new items that are related to the old TBR and TBF items (an effect that we call conceptual DFE). These results give us new insight about how TBR and TBF items are processed and conceptually learned.

Active fixation coronary sinus lead extraction – A safe procedure

© 2016 Sociedade Portuguesa de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Twiddler's syndrome, a rare cause of pacemaker malfunction

© 2015 Sociedade Portuguesa de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.