Winoc Fonteyne

Long term results of cardioverter-defibrillator implantation in patients with right ventricular dysplasia and malignant ventricular tachyarrhythmias

OBJECTIVE To study the outcome of patients with arrhythmogenic right ventricular dysplasia treated with an implantable cardioverter-defibrillator (ICD) for ventricular tachyarrhythmias complicated by haemodynamic collapse. DESIGN Observational study. SETTING University hospital. PATIENTS Nine consecutive patients (eight male, one female; mean (SD) age, 36 (18) years) with arrhythmogenic right ventricular dysplasia presenting with ventricular tachycardia and haemodynamic collapse (n = 6) or ventricular fibrillation (n = 3), treated with an ICD. MAIN OUTCOME MEASURES Survival; numbers of and reasons for appropriate and inappropriate ICD interventions. RESULTS After a mean (SD) follow up of 32 (24) months, all patients were alive. Six patients received a median of 19 (range 2–306) appropriate ICD interventions for events detected in the ventricular tachycardia window; four received a median of 2 (range 1–19) appropriate ICD interventions for events detected in the ventricular fibrillation window. Inappropriate interventions were seen for sinus tachycardia (18 episodes in three patients), atrial fibrillation (three episodes in one patient), and for non-sustained polymorphic ventricular tachycardia (one episode in one patient). CONCLUSIONS Patients with arrhythmogenic right ventricular dysplasia and malignant ventricular arrhythmias have a high recurrence rate requiring appropriate ICD interventions, but they also often have inappropriate interventions. Programming the device is difficult because this population develops supraventricular and ventricular tachyarrhythmias with similar rates.

Use of an Implantable Cardioverter Defibrillator in a Patient with Two Implanted Neurostimulators for Severe Parkinson's Disease

We report a patient with Parkinsons disease treated with two pectorally implanted neurostimulators (NSs) who presented with a life‐threatening ventricular tachyarrhythmia in whom an abdominal ICD was implanted. Testing during implantation showed that the NS did not affect the bipolar sensing of the ICD. even when the NSs were set at a frequency of 130 pulses/s with an output of 5 V and pulse width of 0.21 ms in a bipolar and a unipolar configuration. The ICD shock, however, did affect both NSs: there was a reset to the output Off state and there was a reset of the electrode polarities.

Prevalence of Potential Candidates for Biventricular Pacing Among Patients with Known Coronary Artery Disease: A Prospective Registry from a Single Center

A Prospective Registry from a Single Center. New forms of ventricular pacing are increasingly studied as an option in the management of patients with heart failure. Coronary artery disease (CAD) is the most frequent cause of heart failure, and patients with complete left or right bundle branch block (LBBB and RBBB) and a reduced left ventricular ejection fraction (LVEF) are the best candidates for this new therapy. However, the prevalence of this clinical presentation is uncertain. During a 1‐year period, 433 patients with documented CAD (mean age 64 ± 10 years, 79% men) who were referred for myocardial perfusion imaging were prospectively studied. All patients underwent a 2‐day stress‐rest gated 99mTc‐Tetrofosmin SPECT study with evaluation of resting LV enddiastolic (LVEDV) and endsystolic (LVESV) volumes and LVEF. The resting ECG was examined in all patients for the presence of complete LBBB or RBBB. Of the 433 patients with CAD 36 patients (8.3%) had LBBB (n = 14) or RBBB (n = 22) and a QRS width >120 ms. These 36 patients were in general older and more frequently had diabetes and atrial fibrillation. Patients with LBBB or RBBB had a significantly lower LVEF (41 ± 16%vs 48 ± 14%, P < 0.01) and significantly higher LV volumes compared to patients without LBBB or RBBB (177 ± 79 mL vs 131 ± 53 mL, P < 0.001 for LVEDV and 116 ± 76 mL vs 73 ± 49 mL, P < 0.001 for LVESV). In total, 112 /433 (26%) had an LVEF ≤ 40%; 16 had also a LBBB or RBBB (3.7% of the whole population, 14% of the patients with a LVEF ≤ 40%). Within the group of patients with a LVEF ≥ 40%, patients with BBB had comparable LVEF (26 ± 9% vs 30 ± 8%, P = NS) but significantly higher LVEDV and LVESV (230 ± 70 mL vs 190 ± 64 mL, P < 0.05 for LVEDV and 170 ± 65 mL vs 135 ± 56 mL, P < 0.05 for LVESV). In this prospective registry 3.7% of all patients with known CAD had LBBB or RBBB in combination with a LVEF ≤ 40%. This represented 14% of all patients with a LVEF ≥ 40%. These limited numbers should be kept in mind when considering biventricular pacing as a new therapeutic options in patients with heart failure.

Factors Determining Long-Term Outcomes and Survival in Patients with Coronary Artery Disease and Ventricular Tachyarrhythmias: A Single Center Experience

A Single‐Center Experience. The influence, after ICD implantation, of concomitant CABG, angioplasty, and other antiischemic therapeutic interventions, like treatment with β‐blockers, on outcome and mortality of patients with VT or VF due to CAD remains uncertain. The univariate and multivariate risks of recurrence of ventricular arrhythmias requiring ICD interventions or death associated with baseline clinical and functional variables were studied in 160 consecutive patients with CAD of whom 30 underwent CABG or angioplasty at ≤ 2 weeks before ICD implantation. ICD interventions occurred in 98 (61%) patients over a mean follow‐up of 1,065 days. In univariate and multivariate analysis, VT as the presenting arrhythmia was the only clinical factor predictive of recurrences. Treatment with β‐blockers at hospital discharge reduced the probability of recurrences. Kaplan‐Meier analysis confirmed the effect of β‐blockers (P < 0.005) and of VT as the presenting arrhythmia (P < 0.01). Overall mortality was 61 % (29/160). In multivariate analysis a low ejection fraction (≤ 0.20) and omission of angiotensin‐converting enzyme inhibitors at discharge were associated with excess mortality. In Kaplan‐Meier analysis, a low ejection fraction (borderline between 0.30 and 0.21, significant < 0.21) was the single predictor of mortality. Revascularization by CABG or angioplasty had no influence on ventricular arrhythmia recurrences or survival. During long‐term follow‐up, VT as the presenting arrhythmia and the omission of β‐blocker therapy were associated with excess recurrences of ventricular arrhythmias after ICD implantation. In contrast, survival depended primarily on left ventricular function at discharge. Revascularization did not prevent recurrences of arrhythmias and had no significant effect on survival in the small group of patients who underwent CABG or angioplasty.