Robert E. Eckart

Large, single-center, single-operator experience with transvenous lead extraction: outcomes and changing indications.

BACKGROUND Lead extraction is increasingly necessary given the exponential growth in cardiac device implantation. Meanwhile, the tools, indications, and outcomes of this procedure continue to change. OBJECTIVE The purpose of this study was to examine contemporary indications, outcomes, and complications of transvenous lead extraction in a large series of patients at a high-volume lead extraction center. METHODS We performed a retrospective cohort study of consecutive patients undergoing lead extraction at a single, high-volume center. Patient and lead characteristics and the indications, outcomes, and need for laser assistance were analyzed. RESULTS From January 2000 to March 2007, a total of 975 chronic endovascular leads were removed from 498 patients. Median implant duration was 5.7 years (range 0.5-32.7 years). Indications were infection (60.3%), mechanical lead failure (29.3%), and upgrade of device system (8.8%). Over the study period, lead malfunction decreased relative to other indications. Laser assistance for extraction was more likely with leads implanted longer than 3.4 years compared to less than 3.4 years (odds ratio 6.15, 95% confidence interval 3.35-11.28) and with implantable cardioverter-defibrillator leads compared to pacemaker leads (odds ratio 3.44, 95% confidence interval 1.84-6.43). Overall, 97.5% of the leads were completely removed. Major complications occurred in 2 (0.4%) patients. Only one patient required cardiac surgery. No deaths occurred. CONCLUSION In a high-volume center, lead extraction has a high success rate and low complication rate. Infection was the most common indication overall. Lead failure has decreased in relative proportion. Implantable cardioverter-defibrillator leads and longer lead implant time are associated with a requirement for laser lead extraction.

Sudden Death in Young Adults: An Autopsy-Based Series of a Population Undergoing Active Surveillance

OBJECTIVES The purpose of this study was to define the incidence and characterization of cardiovascular cause of sudden death in the young. BACKGROUND The epidemiology of sudden cardiac death (SCD) in young adults is based on small studies and uncontrolled observations. Identifying causes of sudden death in this population is important for guiding approaches to prevention. METHODS We performed a retrospective cohort study using demographic and autopsy data from the Department of Defense Cardiovascular Death Registry over a 10-year period comprising 15.2 million person-years of active surveillance. RESULTS We reviewed all nontraumatic sudden deaths in persons 18 years of age and over. We identified 902 subjects in whom the adjudicated cause of death was of potential cardiac etiology, with a mean age of 38 ± 11 years. The mortality rate for SCD per 100,000 person-years for the study period was 6.7 for males and 1.4 for females (p < 0.0001). Sudden death was attributed to a cardiac condition in 715 (79.3%) and was unexplained in 187 (20.7%). The incidence of sudden unexplained death (SUD) was 1.2 per 100,000 person-years for persons <35 years of age, and 2.0 per 100,000 person-years for those ≥ 35 years of age (p < 0.001). The incidence of fatal atherosclerotic coronary artery disease was 0.7 per 100,000 person-years for those <35 years of age, and 13.7 per 100,000 person-years for those ≥ 35 years of age (p < 0.001). CONCLUSIONS Prevention of sudden death in the young adult should focus on evaluation for causes known to be associated with SUD (e.g., primary arrhythmia) among persons <35 years of age, with an emphasis on atherosclerotic coronary disease in those ≥ 35 years of age.

Fluoroscopic localization of the femoral head as a landmark for common femoral artery cannulation

We sought to determine the reliability of frequently used landmarks for femoral arterial access in patients undergoing cardiac catheterization. The common femoral artery (CFA) is the most frequently used arterial access in cardiac catheterization. Arterial sheath placement into the CFA has been shown to decrease vascular complications. Some authors recommend locating the inferior border of the femoral head using fluoroscopy due to the relationship of the femoral head and the bifurcation of the CFA. We performed a descriptive study in a prospective design of 158 patients undergoing catheterization from the femoral approach. A femoral angiogram was performed, and the CFA bifurcation location was recorded in relation to the inguinal ligament, middle and inferior border of the femoral head, and the inguinal skin crease. The CFA bifurcation was distal to the inguinal ligament, middle femoral head, and inferior femoral head in most patients with mean distances (cm ± SD) of 7.5 ± 1.7, 2.9 ± 1.5, and 0.8 ± 1.2, respectively. The inguinal skin crease was below the bifurcation in 78% of patients (−1.8 ± 1.6 cm). The CFA overlies the femoral head in 92% of cases. The femoral head has a consistent relationship to the CFA, and localization using fluoroscopy is a useful landmark.

Sustained Ventricular Tachycardia Associated With Corrective Valve Surgery

Background— The causes of sustained monomorphic ventricular tachycardia (VT) after cardiac valve surgeries have not been studied extensively, although bundle-branch reentry has been reported. Methods and Results— Records of 496 patients referred for electrophysiology study and catheter ablation of recurrent VT were reviewed. Twenty patients (4%) had VT after aortic or mitral valve surgery in the absence of known myocardial infarction. The median age was 53 years, and the median ejection fraction was 45%. In 4 patients, VT occurred early after surgery, and electrophysiology study was performed 3 to 10 days later. In the remaining patients, electrophysiology study was performed a median of 12 years (interquartile range 5 to 15 years) after surgery. Sustained VT was inducible in 17 patients. VT was attributed to scar-related reentry in 14 patients (70%) and to bundle-branch reentry in 2 (10%). Multiple VTs were present in 9 of 14 patients with scar-related reentry. A total of 42 induced VTs were targeted for ablation. Of the 14 patients with scar-related reentry, 9 (64%) had periannular scar, and 10 (71%) had an identifiable endocardial circuit isthmus. Ablation abolished 41 (98%) of the 42 targeted VTs. At a median follow-up of 2.1 years, 3 deaths occurred 8 to 14 months after ablation. One patient with incessant VT early after valve surgery suffered a stroke with residual hemianopsia. Of the 20 patients, 3 required repeat ablation after recurrence, and 2 of these who were not inducible during electrophysiology study had clinical recurrence that necessitated ablation. Conclusions— Sustained VT after valve surgery appears to be bimodal in presentation, occurring either early after surgery or years later. In this referral population, reentry in a region of scar is more common than bundle-branch reentry. Catheter ablation can be successful.

Sudden death associated with anomalous coronary origin and obstructive coronary disease in the young.

Sudden cardiac death in a young patient is a catastrophic occurrence. Anomalous coronary origin (ACO) is a significant cause of sudden cardiac death among individuals under the age of 35 years. We sought to define the premortem clinical and postmortem histopathologic findings in victims of sudden cardiac death resulting from either ACO or obstructive atherosclerotic coronary artery disease (CAD) among U.S. military recruits (ages 17–35 years). The autopsy records of all sudden cardiac deaths occurring among recruits during their basic military training period from 1977 through 2001 were reviewed. Twenty-one deaths were associated with ACO and 10 with CAD. Recruits with ACO were more likely to have prodromal symptoms of exertional syncope and/or chest pain (48% vs. 0%, P = 0.011). All sudden cardiac deaths resulting from ACO involved a left main coronary artery takeoff from the right coronary sinus with a course between the aorta and the right ventricular outflow tract and an otherwise normal distribution of the major epicardial coronary arteries. Myocardial fibrosis was seen equally in those with both CAD and ACO (30% vs. 20%, P = 0.66), but the finding of necrosis tended to be more common among recruits with CAD (50% vs. 15%, P = 0.08). In conclusion, review of autopsy data of sudden cardiac deaths among U.S. military recruits reveals myocardial fibrosis or necrosis occurred in 70% of cases with CAD and 35% of cases with ACO. Sudden cardiac deaths resulting from ACO were more likely to be associated with premortem exertional chest discomfort and/or syncope compared with deaths resulting from CAD.

Effect of monitoring of physician performance on door-to-balloon time for primary angioplasty in acute myocardial infarction.

In the present report, progressive patients had increases in calcium score when compared with stable patients. There seems to be an interesting association between the change in calcium score and angiographic changes; however, study of a large, nonselected population is necessary for further clarifi cation.

Pulmonary Arterial Embolization of Pacemaker Lead Electrode Tip

Complications with extraction of abundant endovascular systems increase with time since implantation. As the number of implanted devices increases, successful management of complications needs to be disseminated. We present a 46‐year‐old woman with endovascular leads placed 15 years previously requiring extraction. Using laser‐assistance the leads were removed, although the passive lead tips were unable to be extracted, and were retained in the superior vena cava. One lead tip embolized to the distal pulmonary bed within 24 hours of her operative procedure. Computed tomography and pulmonary arteriography suggested a near immediate thrombogenic process. A multidisciplinary approach was utilized to identify management strategies that allowed for a satisfactory patient outcome.

Sinoatrial Arrest Associated With Tokutsobe Cardiomyopathy

T okutsobe cardiomyopathy, or apical ballooning syndrome, is a distinct nonischemic cardiomyopathy mimicking an ST-elevation myocardial infarction, with mid to apical left ventricular hypokinesis and basal hyperkinesis, most commonly seen in postmenopausal women and frequently associated with significantly stressful events. Most remarkable is the near complete reversal of the cardiomyopathy within a few weeks to months. Only recently have there been any reports of conduction abnormalities associated with this transient phenomenon.

Myopotentials Leading to Ventricular Fibrillation Detection After Advisory Defibrillator Generator Replacement

We present an unusual source of oversensing following an internal cardioverter‐defibrillator generator change. The early appearance of reproducible myopotentials in the defibrillator sensing channel is usually due to a technical complication at the time of device implantation. Clues such as abrupt impedance change or reproduction with mechanical stimulation can help to localize a problem. Frequently the complication requires reoperation to examine the system. What do you do when everything seems to be working fine?

Surface electrocardiography and histologic rejection following orthotopic heart transplantation.

Background: Intraventricular conduction delay and QT interval dispersion may be related to electrical instability and the risk of ventricular arrhythmogenesis. The interlead variability of the QT interval on a surface 12‐lead electrocardiogram (ECG) has been associated with an increased likelihood of sudden death in patients with long QT syndromes, in patients recovering from myocardial infarction, and dilated cardiomyopathy. We sought to determine the incidence of increased QTc dispersion (QTc‐d) relative to biopsy grade of severity of rejection.