Przemysław Stolarz

The prevalence of superior vena cava anomalies as detected in cardiac implantable electronic device recipients at a tertiary cardiology centre over a 12-year period.

INTRODUCTION The vast majority of cardiac implantable electronic device (CIED) recipients require transvenous lead insertion, which may be hindered by the presence of venous anomalies. The aim of this study was to determine the prevalence and variations of persistent left superior vena cava (PLSVC) and to conduct subsequent outpatient follow-up in terms of device function and the clinical condition of the recipients using data from CIED placement procedures conducted over a 12-year period. METHODS The study population included patients undergoing first-time transvenous implantation of cardiac pacemakers and implantable cardioverter-defibrillators (ICDs). The presence of PLSVC was determined based on intra-procedure venography. Outpatient follow-up involved assessments of patient condition, radiological imaging, and CIED function. RESULTS Of a total of 4708 CIED recipients, PLSVC was detected in eight patients (mean age 65.5±13.9); five of them had double superior vena cava (DSVC), including three cases in which the vessels were bridged with a brachiocephalic vein (BCV). Three patients presented PLSVC associated with the absence of the right superior vena cava (RSVC), a very rare anomaly. Seven patients remain under observation, for a total of 78.4±48.4 months of follow-up. CONCLUSIONS The rate of venous anomalies in the form of PLSVC detected in the evaluated population was 0.17%. These PLSVC cases were asymptomatic, which hindered their earlier detection. The presence of these anomalies made the procedures more challenging for the operator and increased the perioperative complication rates; however, neither patient condition nor CIED function was affected based on the long-term outpatient follow-up.

Selected clinical challenges of a supraclavicular cephalic vein in cardiac implantable electronic device implantation.

BACKGROUND Supraclavicular variations of the cephalic vein (CV) are detected sporadically. A somewhat more common finding is a CV variation with the typical course of the main vessel but with an additional supraclavicular branch, called the jugulocephalic vein (JCV). The aim of the study was to detect supraclavicular CVs or JCVs via intra-operative venography as well as assess their effects on primary and later revision cardiac implantable electronic device (CIED) procedures in our patients. MATERIALS AND METHODS We analysed venographic images obtained during CIED procedures at our centre between 2011 and 2015. Out of the 324 venographies conducted during first-time CIED implantation, we identified 14 showing either a supraclavicular course of the CV itself or a persistent JCV. Among revision procedure venographies, we identified 1 case of pertinent CV variations. These vessels had been morphometrically altered by previous medical interventions. RESULTS Based on topography and morphometric parameters, we identified three anatomical variations of supraclavicular vessels: 2 cases of a supraclavicular CV and 12 cases of an infraclavicular CV accompanied by a persistent supraclavicular JCV (with the diameter larger than that of the main CV in 5 cases and smaller in 7 cases). In 2 cases the enlarged diameter of the JCV was probably due to increased collateral venous flow resulting from thrombotic lesions in the subclavian vein. CONCLUSIONS Supraclavicular CV variations are rare. Nonetheless, they may significantly affect both first-time and later revision CIED procedures. The presence of a supraclavicular vein is an indication for diagnostic venography in the area of the clavipectoral triangle before the CIED procedure.

Influence of echocardiographic and radiographic characteristics on atrial sensing amplitude in patients with Linox Smart S DX defibrillation leads.

BACKGROUND Single-lead for implantable cardioverter-defibrillator (ICD) with floating atrial sensing dipole is a new diagnostic tool with the potential advantage in terms of arrhythmia discrimination. We sought to determine whether right heart size and dipole position influence atrial sensing. METHODS Atrial sensing (AS) amplitude was measured during implantation (PP, periprocedural), predischarge (IHFU, in-hospital follow-up) and 3-6 months after the procedure (AFU, ambulatory follow-up). Results were related to atrial dipole position in the right atrium (RA) on the basis of chest X-ray examination as well as right heart dimensions at echocardiography. RESULTS Twenty-four patients were included into final analysis. In 14 (58.3%) patients, sensing dipole was located in regions 1 and 2 of the RA. AS amplitude was greater in regions 1 and 2 when com¬pared to other locations (3.15 vs. 1.2 mV, p = 0.045, 7.53 vs. 3.8 mV, p < 0.001 and 5.63 vs. 2.44 mV, p = 0.017 for PP measurements, IHFU and AFU, respectively). There was a significant negative correlation between AS-PP and short RA dimension (RADs) (r = -0.56, p = 0.02), AS-IHFU and RA area (RAA) (r = -0.45, p < 0.05), AS-AFU and long RA dimension (RADl) (r = -0.46; p = 0.02), AS-AFU and RADs (r = -0,48, p = 0.02), and AS-AFU and RAA (and r = -0.52, p < 0.01). There was no relationship between AS and other right heart dimensions. CONCLUSIONS Larger RA size and low sensing dipole location were associated with lower AS amplitude in single-lead dual chamber ICD.

A rare vascular anomaly in the form of double left brachiocephalic vein detected incidentally during cardiac implantable electronic device (CIED) placement

The growing number of transvenous cardiac implantable electronic device (CIED) implantation procedures helps detect rare vascular anomalies. Genetic disturbances in vascular development can produce systemic vein anomalies, including the left brachiocephalic vein (BCV). BCV anomalies commonly coexist with a persistent left superior vena cava (PLSVC), detected in 0.3-0.5% of the general population. The three known anatomical variations of PLSVC are two variations involving a BCV bridge and the third with BCV agenesis. BCV anomalies occur in 1% of patients with congenital heart defects, whereas the estimated proportion of BCV anomalies in the population with no cardiovascular symptoms is below 0.4%. A rarely observed, and thus rarely reported, BCV variation is a double left BCV, with the additional vessel typically found inferior and posterior to the ascending aorta prior to draining into the superior vena cava. This case report presents a previously unreported variation of double left BCV, with both vessels coursing parallel to each other, superior to the aortic arch. (Folia Morphol 2018; 77, 1: 161-165).

Clinical implications of cephalic vein morphometry in routine cardiac implantable electronic device insertion

BACKGROUND Morphometric parameters of the venous vasculature constitute an important aspect in successful cardiac implantable electronic device (CIED) insertion. The purpose of this study was to present morpho-anatomical variations of the cephalic vein (CV) and their effect on the course of CIED implantation procedures, based on the patients from our centre. MATERIALS AND METHODS We analysed contrast venography results obtained during first-time lead placement. Venography was indicated in the cases of problematic lead introduction with either the CV cutdown or axillary/subclavian vein puncture techniques. The 214 cases of venography (15%) performed out of 1425 first-time lead placement in the period 2011-2013 were divided into 9 subgroups according to the most commonly observed CV variations of similar morpho-anatomical features that limited the use of the CV cutdown technique for lead insertion. RESULTS The following CV morphometric parameters were found to be unfavo-urable in terms of lead placement: CV diameter of ≤ 1 mm (18%), sharp curva-ture of the terminal CV segment as it joined the axillary vein (14%), terminal CV bifurcation (9%), additional CV branches (7%) or tributaries (7%), stenoses (5%), sharply winding course (5%), single CV with a supraclavicular course (4%). CONCLUSIONS The radiographic records obtained during the procedures allowed us to assess the prevalence of those atypical CV variations in our study group, with graphic presentation of characteristic types and sporadically reported CV variations.

Radiographic implications of procedures involving cardiac implantable electronic devices (CIEDs) – Selected aspects

BACKGROUND Some cardiac implantable electronic device (CIED) implantation procedures require the use of X-rays, which is reflected by such parameters as total fluoroscopy time (TFT) and dose-area product (DAP - defined as the absorbed dose multiplied by the area irradiated). MATERIAL AND METHODS This retrospective study evaluated 522 CIED implantation (424 de novo and 98 device upgrade and new lead placement) procedures in 176 women and 346 men (mean age 75±11 years) over the period 2012-2015. The recorded procedure-related parameters TFT and DAP were evaluated in the subgroups specified below. The group of 424 de novo procedures included 203 pacemaker (PM) and 171 implantable cardioverter-defibrillator (ICD) implantation procedures, separately stratified by single-chamber and dual-chamber systems. Another subgroup of de novo procedures involved 50 cardiac resynchronization therapy (CRT) devices. The evaluated parameters in the group of 98 upgrade procedures were compared between 2 subgroups: CRT only and combined PM and ICD implantation procedures. RESULTS We observed differences in TFT and DAP values between procedure types, with PM-related procedures showing the lowest, ICD - intermediate (with values for single-chamber considerably lower than those for dual-chamber systems) and CRT implantation procedures - highest X-ray exposure. Upgrades to CRT were associated with 4 times higher TFT and DAP values in comparison to those during other upgrade procedures. Cardiac resynchronization therapy de novo implantation procedures and upgrades to CRT showed similar mean values of these evaluated parameters. CONCLUSIONS Total fluoroscopy time and DAP values correlated progressively with CIED implantation procedure complexity, with CRT-related procedures showing the highest values of both parameters. Med Pr 2017;68(3):363-374.

Altered topography of systemic veins following lung tissue resection: the effect on de novo cardiac implantable electronic device implantation

Venous anomalies discovered on cardiac implantable electronic device (CIED) implantation may hinder both the insertion of cardiac leads and the selection of their optimal intraventricular placement. Such venous anomalies may be a result of congenital vascular defects, e.g. anomalies of the foetal venous system, or be a consequence of earlier cardio- or thoracosurgical procedures. In the case of the latter, the extent of morphometric changes to mediastinal structures may depend on the extent of prior lung tissue resection. This paper presents 3 cases of CIED implantation procedures performed in patients with systemic veins topographically and morphometrically altered post lung surgery.

Mechaniczna kompresja lewej żyły ramienno-głowowej wykryta podczas implantacji stymulatora

Significant morphometric and/or topographic anomalies of the veins used during cardiac implantable electronic device implantation procedures may affect the course of the procedure and increase the risk of postoperative complications. Congenital venous anomalies, post-thrombotic lesions, or compression by upper mediastinal lesions may alter the diameter and shape of the lumen in systemic veins. Vein compression by adjacent anatomical structures prompts blood drainage compensation via collateral circulation, slows blood flow, and causes localized blood stagnation. We present a case report of pacemaker implantation in a patient with a significantly reduced patency of the left brachiocephalic vein due to mechanical compression of the vessel by the brachiocephalic trunk and the sternum.

Sprint Fidelis implantable cardioverter-defibrillators lead patient management and survival: Single center study

BACKGROUND Over the last several years significant rises in the use of implanted cardioverter-defibrillators (ICD) have also resulted in a number of associated complications. This number includes lead failure. Sprint Fidelis (SF) ICD lead is regarded as a lead with elevated failure risk. Every center acting in accordance with the guidelines should observe patients more thoroughly especially with recalled leads and run a registry of their follow-up. The aim of this research was to present follow-up of the patients with SF leads (types 6948, 6949) from a single implantation center. METHODS There were 36 SF leads implanted in 36 patients. Mean follow-up period was 76 months (IQR 40.3-86.8). Patients were subjected to regular check-ups in 3 to 6 month intervals. RESULTS Patients were implanted at a median age of 66.5 years and majority of them had ischemic cardiomyopathy (72%). A majority of the studied population were men (72.2%). Predominantly dual-chamber ICD (ICD-DR) were implanted (50% ICD-DR vs. 47.2% ICD-VR). The guidelines for management of patients implanted with SF were fully implemented. During the follow-up 14 (38.9%) patients died. No deaths were noted that could be attributed to lead failure. In 5 cases lead failure was identified and of these 4 leads were replaced. Median time from implantation to the detection of lead dysfunction was 52 months (IQR 49; 83). The symptoms of failure consisted of: inappropriate shocks, alternating ventricular lead signal, or loss of ventricular stimulation. CONCLUSIONS The follow-up of patients with recalled SF leads in a single center supports that implementation SF management guidelines could be effective in clinical practice.

Single persistent left superior vena cava compressed by an aortic graft on the route for lead insertion — difficulties in attempted pacemaker implantation

Address for correspondence: Roman Steckiewicz, MD, PhD, Department of Cardiology, Medical University of Warsaw, ul. Banacha 1A, 02–097 Warszawa, Poland, tel: +48 22 599 29 58, e-mail: r.steckiewicz@pro.onet.pl Conflict of interest: none declared Kardiologia Polska Copyright