T. Bottio

Submuscular Approach for Subcutaneous Implantable Cardioverter Defibrillator: A Potential Alternative Technique

A 46-year-old man with cardiac amyloidosis underwent implantable cardioverter defibrillator (ICD) after an episode of ventricular fibrillation at rest. Because of device infection, lead extraction was performed. Subsequently, we decided to implant a subcutaneous ICD (S-ICD; SQ-RX 1010, Cameron Health). We developed a submuscular approach to avoid potential pocket complications due to the size of the device. Using local anesthesia and conscious sedation, the pulse generator was placed posterolaterally between the anterior surface of the serratus anterior and the posterior surface of the latissmus dorsi over the left sixth rib between the mid and anterior axillary lines. The pocket was created by blunt dissection between the two muscles in the absence of any problems (Fig. 1, Panel A). The lead was tunneled subcutaneously such that the proximal sensing electrode, shock coil, and distal sensing electrode occupied a left parasternal position between the xiphoid process and the manubriosternal junction. At the end of the procedure, ventricular fibrillation (50 Hz stimulation between shock coil and generator) was induced and successfully terminated by a 65-J shock (15-J safety margin). The insertion of the system was guided only by anatomical landmarks, and no fluoroscopy was required. In our case, the total duration of the procedure was about 45 minutes. A postoperative chest radiography confirmed lead position (Fig. 1, Panels B and C) and subsequent course

A word of caution for patients undergoing lung transplantation with associated mitral regurgitation.

1. Kamalakkannan G, Petrilli CM, George I, et al. Clenbuterol increases lean muscle mass but not endurance in patients with chronic heart failure. J Heart Lung Transplant 2008;27:457–61. 2. Harrington D, Chua TP, Coats AJ. The effect of salbutamol on skeletal muscle in chronic heart failure. Int J Cardiol 2000;73: 257–65. 3. Deligiannis A, Björnstad H, Carre F, et al. ESC study group of sports cardiology position paper on adverse cardiovascular effects of doping in athletes. Eur J Cardiovasc Prev Rehabil 2006;13:687–94.

The Vietnamese pig as a translational animal model to evaluate tissue engineered heart valves: promising early experience

Several animal models are currently used for the surgical implantation of either biologic or biopolymeric scaffolds in order to provide in vivo assessment of tissue-engineered heart valves. The Vietnamese pig (VP) is herein proposed as a suitable recipient to test the function of novel bioengineered valve substitutes, in the reconstruction of the right ventricular outflow tract (RVOT). This review aims to provide a complete and exhaustive panel of physiological parameters and methodological information for preclinical studies of tissue-engineered heart valves in the VP animal model.

Carotid Artery Stenting in a Patient With a Continuous-Flow Left Ventricular Assist Device.

Purpose: To demonstrate the safety and feasibility of carotid artery stenting (CAS) in a patient with a continuous-flow left ventricular assist device (LVAD). Case Report: A 54-year-old woman with a LVAD was referred for a 90% stenosis of the right internal carotid artery (ICA). The patient was offered CAS, and oral anticoagulant was not discontinued in the periprocedural period. Because of absent arterial pulses, percutaneous transfemoral access was obtained under ultrasound guidance. Particular attention was paid to cannulation of the innominate artery; a 7-F guiding catheter was advanced from the descending aorta into the innominate artery under road-mapping, avoiding maneuvers in the ascending aorta where the outflow Dacron graft of the LVAD was anastomosed. To avoid cerebral flow modifications, the Angioguard RX was used as the cerebral protection device rather than other devices such as the flow reversal or flow-clamping systems. At this point, CAS was performed in a standard fashion using the 7×30-mm Precise ProRX stent. The computed tomography angiogram at 6 months showed patency of the stented right ICA. Conclusion: With adequate planning, CAS appears feasible in patients with a LVAD.