Yoav Turgeman

Pacing and Defibrillation Lead Exchange Without Vein Puncture

Background: During lead implantation, venous access is generally achieved by puncturing the subclavian or axillary vein. Sometimes, although rarely, after lead positioning, the lead must be changed because of its inadequate mechanical stability or poor pacing parameters. This report concerns a technique of lead exchange that avoids an additional vein puncture.

Supraclavicular vein approach to overcoming ipsilateral chronic subclavian vein obstruction during pacemaker–ICD lead revision or upgrading

AIMS We report our experience with the supraclavicular vein approach of subclavian vein puncture to overcome ipsilateral chronic obstruction when implanting pacemaker or implantable cardioverter defibrillator leads. METHODS AND RESULTS The subclavian vein obstruction was documented by venography. The skin was punctured with an 18-gauge needle, 1 cm lateral to the lateral head of the sternocleidomastoid muscle and 1 cm cranial to the clavicle. The needle was directed under and close to the clavicle pointing to the sternal notch. Once the vein was successfully punctured, medial to the obstruction, a 0.38 in. guidewire was inserted into the venous bed. A peel-away sheath was indwelled using the Seldinger technique. The leads were placed in the standard fashion; they were secured by suture to the subcutaneous tissue of the fossa supraclavicularis major using a protective sleeve. The proximal portion of the lead was tunnelled over the clavicle down to the devices prepectoral pocket. Lead insertion was performed in four patients (twice in one patient) with total left subclavian vein obstruction; the site of the obstruction was in the mid-segment of the left subclavian vein in two patients, in the axillary and distal segment of the subclavian vein in one patient, and in the distal segment of the subclavian vein in one patient. There were no complications with the surgical wound and the lead parameters remained stable. CONCLUSION The supraclavicular approach of the subclavian vein puncture to overcome ipsilateral total occlusion is feasible and safe.

Supraclavicular Vein Approach for Upgrading an Implantable Cardioverter Defibrillator to a Biventricular Device

Total occlusion of the left subclavian vein was found in a 52‐year‐old patient, 5 years after implantation of an implantable cardioverter defibrillator (ICD). During replacement, the ICD was upgraded to a biventricular device for worsening of the patients congestive heart failure to New York Heart Association class III. Insertion of the left ventricular lead in the ipsilateral vein system was successfully achieved by using the supraclavicular approach, enabling puncturing of the left subclavian vein medially to the obstruction. (PACE 2010; 634–636)

Infarct artery distribution and clinical outcomes in occluded artery trial subjects presenting with non-ST-segment elevation myocardial infarction (from the long-term follow-up of Occluded Artery Trial [OAT]).

We hypothesized that the insensitivity of the electrocardiogram in identifying acute circumflex occlusion would result in differences in the distribution of the infarct-related artery (IRA) between patients with non-ST-segment elevation myocardial infarction (NSTEMI) and STEMI enrolled in the Occluded Artery Trial. We also sought to evaluate the effect of percutaneous coronary intervention to the IRA on the clinical outcomes for patients with NSTEMI. Overall, those with NSTEMI constituted 13% (n = 283) of the trial population. The circumflex IRA was overrepresented in the NSTEMI group compared to the STEMI group (42.5 vs 11.2%; p <0.0001). The 7-year clinical outcomes for the patients with NSTEMI randomized to percutaneous coronary intervention and optimal medical therapy versus optimal medical therapy alone were similar for the primary composite of death, myocardial infarction, and class IV congestive heart failure (22.3% vs 20.2%, hazard ratio 1.20, 99% confidence interval 0.60 to 2.40; p = 0.51) and the individual end points of death (13.8% vs 17.0%, hazard ratio 0.82, 99% confidence interval 0.37 to 1.84; p = 0.53), myocardial infarction (6.1 vs 5.1%, hazard ratio 1.11, 99% confidence interval 0.28 to 4.41; p = 0.84), and class IV congestive heart failure (6.7% vs 6.0%, hazard ratio 1.50, 99% confidence interval 0.37 to 6.02; p = 0.45). No interaction was seen between the electrocardiographically determined myocardial infarction type and treatment effect (p = NS). In conclusion, the occluded circumflex IRA is overrepresented in the NSTEMI population. Consistent with the overall trial results, stable patients with NSTEMI and a totally occluded IRA did not benefit from randomization to percutaneous coronary intervention.

Anginal syndrome due to giant unruptured sinus of Valsalva aneurysm

This paper presents a rare cause of angina pectoris in a 43-year-old woman. Her evaluation revealed a compressed and proximally occluded right coronary artery by a giant, unruptured, right sinus of Valsalva aneurysm. The aneurysm was surgically resected and the sinus was successfully reconstructed. On follow-up the patient is asymptomatic.This paper presents a rare cause of angina pectoris in a 43-year-old woman. Her evaluation revealed a compressed and proximally occluded right coronary artery by a giant, unruptured, right sinus of Valsalva aneurysm. The aneurysm was surgically resected and the sinus was successfully reconstructed. On follow-up the patient is asymptomatic.

Cardiovascular Involvement in Behçet Disease: Clinical Implications

Behçet disease (BD) is a multisystem disorder, with vasculitis as its underlying pathological process, in contrast to the classic triad of recurrent oral and genital ulcerations, with uveitis. Vascular involvement in BD includes venous thrombosis, arterial occlusion, and pulmonary artery and aortic aneurysm formation. Cardiac involvement is rare and often obscure. It includes intracardiac thrombi formation, and is associated with a poor prognosis. Our objectives are to describe two cases with BD, complicated with vascular and cardiac involvement, and to raise awareness of these rare complications, the needed routine surveillance, and thus to prevent inappropriate interventions, serious outcomes, and mortality. We present two male patients from the Mediterranean Basin with BD. The first was diagnosed early as a BD patient. The second was diagnosed at the time of cardiovascular (CV) involvement. We recommend that patients who are diagnosed, or even suspected of suffering from BD, especially in endemic areas along the Silk Route pathway, should be followed up routinely for CV involvement, even if rare, obscure, or with a bizarre presentation.

The Future Role, Clinical and Economic Implications of Cardiac MagneticResonance (CMR) Imaging in Non-Ischemic Dilated Cardiomyopathy

The use of cardiovascular magnetic resonance (CMR) imaging for assessing and evaluating cardiovascular pathologies is growing rapidly. This non-invasive, non-ionizing technology has multiple advantages compared with the X-ray or gamma ray derived technologies. For instance, CMR is a non-invasive and sensitive tool for detecting islands of fibrosis. Cardiac fibrosis may occur in both ischemic and non-ischemic cardiac pathologies.This finding has a negative impact on sudden cardiac arrhythmic death. A correlation has been found between CMR data and histo-pathologic findings. The presence of this pathology among normal looking fibers indicates the presence of non-functional areas that may evoke malignant arrhythmia, and contribute to deterioration in cardiac mechanical function. By using this non-invasive modality, the role of cardiac fibrosis as a potential source for cardiac arrhythmia and or LV dysfunction can be better evaluated and managed. This finding may serve as a useful tool for risk stratification of patients with borderline indication for primary AICD implantation.