Wagner Tetsuji Tamaki

Incidência de choques e qualidade de vida em jovens com cardioversor-desfibrilador implantável

OBJECTIVES To analyze the incidence and causes of ICD therapies in children and young adults and verify their impact on the quality of life (QoL). METHODS From March/1977 to February/2006, 29 patients (15.7+/-5.4 years old) were submitted to ICD implants. Aborted cardiac arrest (41.5%), sustained ventricular tachycardia (27.6%) and primary prophylaxis of sudden cardiac death (30.9%) indicated device therapy. The number of therapies was evaluated by interviewing patients and by ICD diagnostic data. The SF-36 questionnaire was used to measure the QoL and the results were compared to healthy population. The expectative of freedom from ICD therapies were estimated by the Kaplan-Meier method. RESULTS After 2.6+/-1.8 years follow-up, 8 (27.6%) patients received 141 appropriate ICD shocks due to ventricular tachycardia (6) or ventricular fibrillation (2), and 11 (37.9%) patients received 152 inappropriate ICD shocks due to supraventricular tachyarrhythmias (8) or oversensing (3). Expectative of freedom from appropriate shocks was 74.2+/-9.0% and 66.7+/-10.7% after one and three years, respectively. Compared to healthy population, QoL decreased in physical function (61.7+/-28.7), vitality (64.7+/-19.1), mental health (65.9+/-22.7) and role-emotional domains (66.7+/-38.5). All patients referred fear and concern related to ICD use. CONCLUSION Despite the efficacy of ICD therapies, the high incidence of appropriate and inappropriate shocks interfered in patients QoL and adaptation to the device.

Biventricular Pacing Improves Clinical Behavior and Reduces Prevalence of Ventricular Arrhythmia in Patients with Heart Failure

PURPOSE To analyze the influence of biventricular pacing (BP) on clinical behavior, ventricular arrhythmia (VA) prevalence, and left ventricular ejection fraction (LV EF) by gated ventriculography. METHODS Twenty-four patients with left bundle branch block (LBBB) and NYHA class III and IV underwent pacemaker implantation and were randomized either to the conventional or BP group, all receiving BP after 6 months. RESULTS Sixteen patients were in NYHA class IV (66.6%) and 8 were in class III (33.4%). After 1-year follow-up, 14 patients were in class II (70%) and 5 were in class III (25%). Two sudden cardiac deaths occurred. A significant reduction in QRS length was found with BP (p=0.006). A significant statistical increase, from a mean of 19.13 +/- 5.19% (at baseline) to 25.33 +/- 5.90% (with BP) was observed in LVEF Premature ventricular contraction prevalence decreased from a mean of 10,670.00 +/- 12,595.39 SD or to a mean of 3,007.00 +/- 3,216.63 SD PVC/24 h with BP (p<0.05). Regarding the hospital admission rate over 1 year, we observed a significant reduction from 60. To 16 admissions with BP (p<0.05). CONCLUSION Patients with LBBB and severe heart failure experienced, with BP, a significant NYHA class and LVEF improvement. A reduction in the hospital admission rate and VA prevalence also occurred.

Transfemoral pediatric permanent pacing: Long-term results

COSTA, R., et al.: Transfemoral Pediatric Permanent Pacing: Long‐term Results. The femoral vein has been used as an alternative conduit to implant pacemakers in children of any weight. Such method associates endocardial pacing and good cosmetics. The aim of this study was to evaluate prospectively, since 1981, the long‐term follow‐up of 99 children, from newborn to 13 years old (average = 4.1 ± 3.6 years, 56 girls), who underwent the implantation of pacemakers via the femoral vein. Atrioventricular block was present in 88% of patients, of congenital etiology in 39% and postoperative in 54%. Single chamber pacemakers were implanted in 92% of patients. During a mean follow‐up of 5.3 ± 5.0 years (maximum = 18.2 years), 5 patients died of cardiac causes, 4 of infection, 2 suddenly, and 3 of unknown causes. The 5‐, 10‐ and 15‐year actuarial survival rates were 83.7%, 75.7%, and 75.7%, respectively. Transfemoral leads were used for a mean of 48.9 ± 44.0 months. Reasons for lead explantations were pacing failure in five patients, infection in eight, and elective in nine. The 2‐, 5‐ and 10‐year actuarial survivals of transfemoral leads were 87.6%, 73.8%, and 31.8%, respectively. The mean lead survival was 97 months. Overall, 105 reoperations were performed, 38 for battery depletion, 24 for body growth, 14 for infection or pocket revisions, and 27 for miscellaneous reasons. In conclusion, the durability and overall long‐term performance of transfemoral leads were excellent. (PACE 2003; 26[Pt.II:487–491)

Effects of cardiac resynchronization therapy on muscle sympathetic nerve activity.

Muscle sympathetic nerve activity (MSNA) is an independent prognostic marker in patients with heart failure (HF). Therefore, its relevance to the treatment of HF patients is unquestionable.

Endocarditis Secondary to Microsporidia Giant Vegetation in a Pacemaker User

A 60-year-old white man was admitted with a 2-week history of shivering and fever (38°C). He had had a dual-chamber pacemaker implanted in 1996 because of complete atrioventricular block, with an elective pulse generator replaced 3 months before admission. Medications taken on a daily basis included amiodarone for atrial fibrillation rhythm control and atenolol for hypertension. His blood pressure was normal; his heart rate was 80 bpm; and he was febrile (38.5°C). Chest auscultation revealed a systolic murmur at the left and right sternal borders with respiratory shifting in the heart sound, not previously described in this patient. ECG showed a normally functioning pacemaker (Figure 1). Chest x-ray was normal (Figure 2), as were renal function and differential white cell count. Figure 1. Twelve-lead surface ECG showed a normally functioning dual-chamber pacemaker. Figure 2. A, Frontal anterior-posterior chest x-ray showed a pacemaker in the right infraclavicular region with no other abnormality. B, Normal frontal posterior-anterior chest x-ray after surgical intervention. Endocarditis was confirmed by a transesophageal echocardiography …A 60-year-old white man was admitted with a 2-week history of shivering and fever (38°C). He had had a dual-chamber pacemaker implanted in 1996 because of complete atrioventricular block, with an elective pulse generator replaced 3 months before admission. Medications taken on a daily basis included amiodarone for atrial fibrillation rhythm control and atenolol for hypertension. His blood pressure was normal; his heart rate was 80 bpm; and he was febrile (38.5°C). Chest auscultation revealed a systolic murmur at the left and right sternal borders with respiratory shifting in the heart sound, not previously described in this patient. ECG showed a normally functioning pacemaker (Figure 1). Chest x-ray was normal (Figure 2), as were renal function and differential white cell count. Figure 1. Twelve-lead surface ECG showed a normally functioning dual-chamber pacemaker. Figure 2. A, Frontal anterior-posterior chest x-ray showed a pacemaker in the right infraclavicular region with no other abnormality. B, Normal frontal posterior-anterior chest x-ray after surgical intervention. Endocarditis was confirmed by a transesophageal echocardiography …

Quality of Life and Functional Capacity after Long-Term Right Ventricular Pacing in Pediatrics and Young Adults with Congenital Atrioventricular Block

Although several studies have demonstrated deleterious consequences of chronic right ventricular (RV) pacing on ventricular function and synchronicity, its effects on health‐related quality of life (HRQoL) and functional exercise capacity remain uncertain. We aimed to evaluate the effect of RV pacing on HRQoL and functional capacity of children and young adults with congenital complete atrioventricular block (CCAVB).

Images in cardiovascular medicine. Endocarditis secondary to microsporidia: giant vegetation in a pacemaker user.

A 60-year-old white man was admitted with a 2-week history of shivering and fever (38°C). He had had a dual-chamber pacemaker implanted in 1996 because of complete atrioventricular block, with an elective pulse generator replaced 3 months before admission. Medications taken on a daily basis included amiodarone for atrial fibrillation rhythm control and atenolol for hypertension. His blood pressure was normal; his heart rate was 80 bpm; and he was febrile (38.5°C). Chest auscultation revealed a systolic murmur at the left and right sternal borders with respiratory shifting in the heart sound, not previously described in this patient. ECG showed a normally functioning pacemaker (Figure 1). Chest x-ray was normal (Figure 2), as were renal function and differential white cell count. Figure 1. Twelve-lead surface ECG showed a normally functioning dual-chamber pacemaker. Figure 2. A, Frontal anterior-posterior chest x-ray showed a pacemaker in the right infraclavicular region with no other abnormality. B, Normal frontal posterior-anterior chest x-ray after surgical intervention. Endocarditis was confirmed by a transesophageal echocardiography …A 60-year-old white man was admitted with a 2-week history of shivering and fever (38°C). He had had a dual-chamber pacemaker implanted in 1996 because of complete atrioventricular block, with an elective pulse generator replaced 3 months before admission. Medications taken on a daily basis included amiodarone for atrial fibrillation rhythm control and atenolol for hypertension. His blood pressure was normal; his heart rate was 80 bpm; and he was febrile (38.5°C). Chest auscultation revealed a systolic murmur at the left and right sternal borders with respiratory shifting in the heart sound, not previously described in this patient. ECG showed a normally functioning pacemaker (Figure 1). Chest x-ray was normal (Figure 2), as were renal function and differential white cell count. Figure 1. Twelve-lead surface ECG showed a normally functioning dual-chamber pacemaker. Figure 2. A, Frontal anterior-posterior chest x-ray showed a pacemaker in the right infraclavicular region with no other abnormality. B, Normal frontal posterior-anterior chest x-ray after surgical intervention. Endocarditis was confirmed by a transesophageal echocardiography …

Marca-passo cardíaco definitivo em crianças com bradicardia pós-operatória: resultados tardios

Objective: To evaluate the long-term outcomes of children submitted to permanent cardiac pacing due to postoperative bradycardia and to identify risk factors for mortality. Methods: From 1980 to 2004, 120 children were submitted to permanent pacemaker implantation. Interval between the defect correction and pacemaker implantation was 1.2 ± 2.8 years on average (median = 21 days). Atrioventricular blocks were present in 94.2% of patients. Transvenous leads (78.3%) and ventricular pacemaker systems (79.2%) were used in most cases. Risk factors were studied using the Cox proportional model. The Kaplan-Meier method and the LogRank test were used to analyze survival. Results: After a mean of 5.7 ± 5.9 years (maximum = 22.5 years) of follow-up, 97 patients were alive and 23 were lost from the follow-up study. The main causes of death were terminal heart failure (10), infection not related to implantation (six), and sudden death (three). The 5-, 10-, and 15-year survival rates were 80.9 ± 4.1%, 75.4 ± 5.5% and 67.2 ± 7.4%, respectively. The persistence of hemodynamic problems (palliative procedures, the use of valve prostheses or the presence of residual defects) was identified as the only independent risk predictors for mortality, with significant alterations in the survival curves (p=0.0123). Conclusion: The implant of permanent pacemakers in children provided good survival expectancy, mainly depending on the underlying disease and the type of the correction made. Palliative corrections, such as the presence of residual defects or the use of valve prostheses were the only predictors of poor results in these children.

Effectiveness of epicardial atrial pacing using a bipolar steroid-eluting endocardial lead with active fixation in an experimental model

PURPOSE To assess the effectiveness of bipolar epicardial atrial pacing using an active fixation bipolar endocardial lead implanted on the atrial surface in an experimental model. METHODS A total of ten Large White adult pigs underwent pacemaker implantation under general anesthesia. Atrial pacing and sensing parameters were obtained at the procedure, immediate postoperative period and on the 7th and the 30th postoperative in unipolar and bipolar configurations. RESULTS All procedures were successfully performed. There were no perioperative complications and no early deaths. Atrial pacing and sensing parameters for both unipolar and bipolar modes remained stable throughout the study. We observed a progressive increase in atrial thresholds, ranging from 0.49 ± 0.35 (at implantation) to 1.86 ± 1.31 volts (30th postoperative day), in unipolar mode. Atrial impedance measurements decreased slightly over time, ranging from 486.80 ± 126.35 Ohms (at implantation) to 385.0 ± 80.52 Ohms (30th postoperative day). Atrial sensing measures remained stable from the immediate postoperative period until the end of the study. CONCLUSION The bipolar active fixation endocardial lead implanted epicardially can provide stable conditions of pacing and sensing parameters throughout the postoperative follow-up.

Response to Letter Regarding Article, “Endocarditis Secondary to Microsporidia: Giant Vegetation in a Pacemaker User”

We appreciate Dr Henrikson’s interest in our study1 and the opportunity to clarify several issues. Dr Henrikson had a very precise observation concerning the electrocardiogram, and we agree with the comments made. Indeed, it was a normofunctioning dual-chamber pacemaker, and the electrocardiogram was taken just before open heart surgery, with the pacemaker programmed to asynchronous ventricular pacing mode considering atrial lead manipulation. Moreover, in our article, we report a novel agent for implantable pacemaker infection in a patient with persistent bacteremia despite the fact that blood cultures were all negative, as highlighted by Dr Henrikson. Most cases of pacemaker lead infections are due to pathogens from the skin flora, with positive blood culture ranging in the literature from 80% to 100% of the cases. Making a parallel with heart valves in the human, there are many causes of culture-negative endocarditis. The causative agents of culture-negative endocarditis in the heart are fastidious bacteria (Bartonella quintana, Coxiella burnetii, or brucella species), fungi, and the usual organisms (mainly streptococci) found in patients who have received antibiotic treatment before blood samples are obtained for culture.2 Thus, we present here another possible etiology in this context, now related to pacemaker infections. While these fastidious bacteria yield negative hemocultures requiring different diagnostic approaches such as serology, in the case of microsporidium, electron microscopy is fundamental and should be complemented by polymerase chain reaction.1 Dr Henrikson also pointed out that no signs of endocarditis were present even though a large vegetation was disclosed. Pacemaker endocarditis may be limited to the pacemaker lead or involve the cardiac valves, generally the tricuspid, which can be demonstrated by the echocardiogram or intraoperatively. In our case there was no vegetation in this valve by both methods, but the mass entailed in valve insufficiency, present in 25% of the cases in one series.3 We cannot rule out that microscopic endocarditis was present because no biopsy specimens were taken from the valve. Nonetheless, the good clinical outcome after a long-term follow-up period makes this possibility unlikely.