Automatic Defibrillator Implantation Research Articles

Vasospastic Angina: The Journey to Understanding and Easy Management

Vasospastic angina (VSA), initially described by Prinzmetal as a form of angina occurring at rest, in the second part of the night and associated with transient changes in repolarization such as ST segment elevation on the electrocardiogram. The phenomenon of coronary spasm can occur in patients with or without coronary atherosclerosis. It can be focal or diffuse in one or more epicardial arteries. Its incidence is unknown and highly dependent on the population studied, with higher rates in Asian populations. Several pathophysiological mechanisms have been put forward to explain its occurrence, in particular endothelial dysfunction and hyperreactivity of smooth muscle cells related to damage to Rhokinase. Increased sympathetic nerve activity at night has shown to be involved in the mechanism underlying multivessel coronary spasm and predisposing genetic factors. Diagnosis can be easily establish using Coronary Artery Vasospastic Disorders Summit diagnostic criteria for vasospastic angina; adapted from Beltrame et al. VSA is one of the main aetiologies of MINOCA as stipulated in the last guidelines of ESC on ACS. Management of vasospastic angina is well codified based on lifestyle changes, established pharmacological therapies, control of risk factors, avoidance of triggering factors and possibly the use of percutaneous coronary intervention in cases of associated obstructive coronary artery disease, or an automatic implantable defibrillator.

Automatic implantable defibrillators: an update for emergency physicians

Automatic implantable defibrillators: an update for emergency physicians

QRS Morphology and the Risk of Ventricular Tachyarrhythmia in Cardiac Resynchronization Therapy Recipients

BackgroundThere are conflicting data on the effect of cardiac resynchronization therapy with a defibrillator (CRT-D) on the risk of life-threatening ventricular tachyarrhythmia in heart failure patients. ObjectivesThe authors aimed to assess whether QRS morphology is associated with risk of ventricular arrhythmias in CRT recipients. MethodsThe study population comprised 2,862 patients implanted with implantable cardioverter defibrillator (ICD)/CRT-D for primary prevention who were enrolled in 5 landmark primary prevention ICD trials (MADIT-II [Multicenter Automated Defibrillator Implantation Trial], MADIT-CRT [Multicenter Automated Defibrillator Implantation Trial-Cardiac Resynchronization Therapy], MADIT-RIT [Multicenter Automated Defibrillator Implantation Trial-Reduction in Inappropriate Therapy], MADIT-RISK [Multicenter Automated Defibrillator Implantation Trial-RISK], and RAID [Ranolazine in High-Risk Patients With Implanted Cardioverter Defibrillators]). Patients with QRS duration ≥130 ms were divided into 2 groups: those implanted with an ICD only vs CRT-D. The primary endpoint was fast ventricular tachycardia (VT)/ventricular fibrillation (VF) (defined as VT ≥200 beats/min or VF), accounting for the competing risk of death. Secondary endpoints included appropriate shocks, any sustained VT or VF, and the burden of fast VT/VF, assessed in a recurrent event analysis. ResultsAmong patients with left bundle branch block (n = 1,792), those with CRT-D (n = 1,112) experienced a significant 44% (P < 0.001) reduction in the risk of fast VT/VF compared with ICD-only patients (n = 680), a significantly lower burden of fast VT/VF (HR: 0.55; P = 0.001), with a reduced burden of appropriate shocks (HR: 0.44; P < 0.001). In contrast, among patients with non-left bundle branch block (NLBBB) (N = 1,070), CRT-D was not associated with reduction in fast VT/VF (HR: 1.33; P = 0.195). Furthermore, NLBBB patients with CRT-D experienced a statistically significant increase in the burden of fast VT/VF events compared with ICD-only patients (HR: 1.90; P = 0.013). ConclusionsOur data suggest a potential proarrhythmic effect of CRT among patients with NLBBB. These data should be considered in patient selection for treatment with CRT.

Anton Bruckner: the Linz cathedral organist, university teacher, symphonic musician : Could modern intensive care medicine have helped him and his illnesses?

Anton Bruckner was afamous cathedral organist, university teacher, and symphonic composer, but his life, illnesses, death and dying are little or not known to many. Which illnesses determined Bruckner's life and did lifestyle and illnesses influence his compositional work? From today's perspective, could modern intensive care medicine have helped him? Adetailed analysis of Bruckner's diseases was carried out using the scientific databases PubMed® and MEDLINE®. All published articles were evaluated and examined in detail. In addition, data from aconcert tour of the author to Linz and the St. Florian Abbey Basilica were collected. Anton Bruckner was born on 4September 1824 in Ansfelden, Austria. As achild he received piano and organ lessons. After his father's death, he devoted himself to playing the organ and became in 1855 cathedral organist in Linz. His further career took him to Vienna, where he became aprofessor at the conservatory and turned to composition. His symphonies, his masses, and his Te Deum are his most famous works. During the first 40years of his life, Bruckner suffered from psychopathological illnesses, including depression, delusions of persecution, and neuroses. Later, he suffered from chronic heart failure with recurrent right and left heart decompensation up to the development of cardiac cachexia, possibly caused by dilated cardiomyopathy due to alcohol toxicity. He died on 11October 1896 in Vienna. Bruckners life was marked by awide variety of illnesses. His penchant for death and the dead was also striking. Modern medicine would probably have improved his quality of life through consequent heart failure therapy; an implantable automatic defibrillator with resynchronization therapy would probably have prolonged his life.

Implantable automatic defibrillators and their deactivation, a necessary conversation. Literature review

The use of implantable cardioverter-defibrillators (ICDs) has been on the rise. Patients using ICDs inevitably transit towards the end of life at some point, including some who develop terminal illnesses. In this context, it is relevant to discuss and evaluate the deactivation of these devices with the aim of addressing patients' comfort and avoiding shocks during the end-of-life phase. There are multiple communicational and operational barriers when considering ICDs deactivation. Firstly, many patients have not discussed this issue with their physicians despite international guidelines recommending such discussions before device installation. Secondly, there is a significant lack of knowledge among patients, family members, and even doctors about the benefits of ICDs, as well as the deactivation process and ethics considerations, which leads them to believe that immediate death will occur, considering it as euthanasia or assisted suicide. Finally, the management of hospice patients or end-of-life ICDs users is poorly standardized, with low rates of deactivation, resulting in shocks in the last minutes of life, which can cause marked distress to patients and families. It is necessary to address these barriers and discuss these issues with patients to inform and educate them about the functioning of their devices, with the ultimate goal of enabling informed and shared decision-making for patient well-being.

QRS complex and T wave planarity for the efficacy prediction of automatic implantable defibrillators

ObjectiveTo test the hypothesis that in recipients of primary prophylactic implantable cardioverter-defibrillators (ICDs), the non-planarity of ECG vector loops predicts (a) deaths despite ICD protection and (b) appropriate ICD shocks.MethodsDigital...

État de l'activité de rythmologie interventionnelle en France et conséquences des réformes des seuils sur les autorisations d'activité

BackgroundInterventional rhythmology activity (electrophysiology and pacing) has progressed in France during the last decade. The objective of this article is to assess the distribution of this activity depending on the type of centre (public, university or non-university, private). As the French government issued a new regulation regarding rhythmology activity in 2022, the impact of this regulation on activity distribution has been evaluated. MethodologyAll French data activity can be evaluated after accessing to a national database called PMSI [Programme de Médicalisation des Systèmes d'Information]. Based on data collected in year 2021, the level of activity of the different centres, and the impact of the new criteria of the French regulation regarding rhythmology activity have been analysed. ResultsAbout 200,000 arrhythmias interventions have been done in France in 2021 in 382 centres. According to the new criteria of the French regulation, 66% responded to level A (diagnostic electrophysiology, single- and dual-chamber pacing), 68% for level B (A+ right atrial ablation, implantable automatic defibrillator, cardiac resynchronisation therapy) and 70% for level C (B + left atrial and ventricular ablation). 1/4 of the centres do not meet criteria for level A activity, and 1/5 of them for levels B and C ConclusionsThis work showed that immediat and systematic application of new threshold could be threatening for 1/4 of A center and 1/5 of B or C center. The priority will be to reinforce existing centres before allowing new centres to perform arrhythmias management activity in France.

Primary prevention implantable cardioverter defibrillator in cardiac resynchronization therapy recipients with advanced chronic kidney disease.

The implantable cardioverter defibrillator (ICD) is effective for the prevention of sudden cardiac death (SCD) in patients with heart failure and a reduced ejection fraction (HFrEF). The benefit of the ICD in patients with advanced CKD, remains elusive. Moreover, the benefit of the ICD in patients with advanced chronic kidney disease (CKD) and HFrEF who are cardiac resynchronization therapy (CRT) recipients may be attenuated. We hypothesized that patients with CKD who are CRT recipients may derive less benefit from the ICD due to the competing risk of dying prior to experiencing an arrhythmia. The study population included 1,015 patients receiving CRT with defibrillator (CRT-D) device for primary prevention of SCD who were enrolled in either (Multicenter Automated Defibrillator Implantation Trial) MADIT-CRT trial or the Ranolazine in High-Risk Patients with Implanted Cardioverter Defibrillator (RAID) trial. The cohort was divided into two groups based on the stage of CKD: those with Stage 1 to 3a KD, labeled as (S1-S3a)KD. The second group included patients with Stage 3b to stage 5 kidney disease, labeled as (S3b-S5)KD. The primary endpoint was any ventricular tachycardia (VT) or ventricular fibrillation (VF) (Any VT/VF). The cumulative incidence of Any VT/VF was 23.5% in patients with (S1-S3a)KD and 12.6% in those with (S3b-S5)KD (p < 0.001) The incidence of Death without Any VT/VF was 6.6% in patients with (S1-S3a)KD and 21.6% in patients with (S3b-S5)KD (p < 0.001). A Fine and Gray multivariate competing risk regression model showed that Patients with (S3b-S5)KD had a 43% less risk of experiencing Any VT/VF when compared to those with (S1-S3a)KD (HR = 0.56, 95% CI [0.33-0.94] p = 0.03. After two years of follow up, there was almost a 5-fold increased risk of Death without Any VT/VF among patients with (S3b-S5)KD when compared to those with (S1-S3a)KD [HR = 4.63, 95% CI (2.46-8.72), p for interaction with time = 0.012]. Due to their lower incidence of arrhythmias and higher risk of dying prior to experiencing an arrhythmia, the benefit of the ICD may be attenuated in CRT recipients with advanced CKD. Future prospective trials should evaluate whether CRT without a defibrillator may be more appropriate for these patients.

Où se fait l'activité de rythmologie interventionnelle en France et quelle est son évolution ?

IntroductionInterventional rhythmology activity (electrophysiology and pacing) has progressed in France during the last decade. The objective of this article was to assess the distribution of this activity depending on the type of centre (public, university or non-university, private). As the French government issued a new regulation regarding rhythmology activity in 2022, the impact of this regulation on activity distribution has been evaluated. MethodologyAll French data activity can be evaluated after accessing to a national database called PMSI [Programme de médicalisation des systèmes d'information]. Based on data collected in year 2019, the level of activity of the different centres, and the impact of the new criteria of the French regulation regarding rhythmology activity have been analysed. ResultsAbout 180,000 arrhythmias interventions have been done in France in 2019 in 377 centres. According to the new criteria of the French regulation, only 76% responded to level A (diagnostic electrophysiology, single- and dual-chamber pacing), 52% for level B (A+ right atrial ablation, implantable automatic defibrillator, cardiac resynchronisation therapy) and 54% for level C (B + left atrial and ventricular ablation). ConclusionsThis work showed that approximately a quarter of the centres do not meet criteria for level A activity, and approximately half of them for levels B and C. The priority will be to reinforce existing centres before allowing new centres to perform arrhythmias management activity in France.

Catheter ablation of well tolerated ventricular tachycardia in patients with structural heart disease: long term follow-up of 62 cases without automatic defibrillator implantation

Abstract Funding Acknowledgements Type of funding sources: None. Background The occurrence of a sustained monomorphic ventricular tachycardias (SMVT) in patients with underlying structural heart disease (SHD) is considered correlated to a poor prognosis, based on historical data in patients with heterogeneous heart disease and clinical presentation; therefore the recommendation for implantation of automatic implantable cardioverter defibrillator (AICD) is strong. Information about prognosis of patients with SMVT is still limited, but recent studies have established that these patients represent a low-risk subgroup for sudden death that could benefit from radiofrequency (RF) ablation of the arrhythmic substrate and the AICD implantation could be deferred during the follow up. Purpose Patients with well-tolerated SMVT, SHD and left ventricular ejection fraction (LVEF) over 30% can benefit from a primary VT ablation strategy without the immediate need for AICD implantation. Methods We reviewed consecutive SHD patients with LVEF over 30% admitted for the occurrence of SMVT and who were treated by RF ablation as a first-choice therapy in a single Italian center, between 2009 and 2020 and who were discharged without AICD implantation. The primary outcome of the study was a composite of all-cause death and recurrence of VT. The secondary outcome was death from all causes. Patients with similar characteristics but who underwent AICD implantation during the same period served as control group. Results Clinical and electrophysiological features of 62 patients were analyzed (Table 1). In the study group, 88% were male; the median age was 72 years (IQR 55-81) and the median LVEF was 50.0% (IQR 40.0-55.0). The estimated success rate of ablative procedures (defined as VT no longer inducible) was around 82%. After a median follow-up of 38.8 months (IQR 15.6-76.1), the primary outcome occurred in 24 patients and the secondary outcome in 11 patients. All-cause mortality was 17%, corresponding to an annual mortality rate of 4.3%. Ten patients died for non-cardiovascular causes and one for advanced heart failure. No patient in the study died from sudden death. During the follow-up, 10 patients (16.1%) underwent AICD implantation due to VT relapse. At 36 months, between study and control groups, there was no difference in either the primary composite outcome (HR 1.03, 95% CI 0.45-2.21, p = 0.98) or in the secondary outcome (HR 1.4, 95% CI 0.48-4.54, p = 0.49). Conclusions Patients with well-tolerated SMVT, SHD and LVEF over 30% represent a subgroup of patients at lower risk that can benefit of RF ablation as a first-choice therapy. Delay in AICD implantation, after a possible VT relapse or clinical worsening, appears to represent a safe therapeutic strategy. Therefore, it is ethical and desirable to start a prospective randomized clinical trial to evaluate the benefit and cost-effectiveness of this strategy, as an alternative to AICD implantation.

Enigma of Huge mass filling the apical wall of the left ventricle. Is it thrombus, tumor or endomyocardial fibrosis?

Background: Cardiac masses have a wide range of etiologies with the most common being thrombi and less commonly tumors. Certain areas of the heart have specific tumor predilections. We present an interesting case in which the diagnosis of the ventricular mass was difficult given the initial symptomatology and the patient's phobia. Case summary: A 45-year-old male patient with medical history of smoking, was admitted to the emergency room complaining of severe breathlessness, However, the patient declined any chest discomfort or pain. On physical examination he was dyspneic, with vital signs revealed heart rate of 110 beats/min, blood pressure of 125/90 mmHg. Cardiovascular examination showed regular heart rhythm and normal heart sounds. Electrocardiogram revealed sinus tachycardia, chest X-ray was suggestive of cardiomegaly. Transthoracic Echocardiography demonstrated a dilated left ventricle with severely reduced ejection fraction and diffuses kinetic disturbances. The presence of a huge mass filling the apical wall of the left ventricle, hyperechogenic in appearance and very adherent to the ventricle. In front of this doubtful appearance at the echocardiography the patient was programmed for a cardiac magnetic resonance imaging which could not be carried out because of the claustrophobic state of the patient. In the meantime, the patient had a cardiac arrest due to refractory ventricular fibrillation successfully resuscitated. In front of this complication, he benefited from an automatic implantable defibrillator as a secondary prevention. Subsequently, a coronary angiography was performed in the context of the patient's smoking habits and kinetic disorders, to our surprise showed a complete occlusion of the left anterior descending artery knowing that the patient is not diabetic and he never complained of any painful symptomatology, primary coronary intervention was successfully performed to the left anterior descending artery. The patient was started on therapeutic anticoagulation and heart failure therapy. Follow-up imaging after 6months showed a significant improvement of the left ventricular systolic function and thrombus regression to apical segment without embolic events. Conclusion: The diagnosis of a ventricular mass remains difficult, the orientation can be done initially by the ground of the patient while being helped by the transtoracic echography and the multimodality imagery at the end to specify the nature of the intra-cardiac mass for an adequate and fast management. Keywords: Thrombus, ventricular mass, coronary angiography, heart failure, oral anticoagulation. DOI: 10.7176/JHMN/98-05 Publication date: March 31 st 2022

Device-detected nonsustained ventricular tachycardia in adult congenital heart disease without tetralogy of fallot.

To evaluate any association between non-sustained ventricular tachycardia (NSVT) detected by intra-cardiac device and clinical outcomes in repaired adult congenital heart disease (ACHD) without tetralogy of Fallot (TOF). NSVT portends a higher risk of serious ventricular tachyarrhythmia in TOF. However its clinical significance when incidentally detected by implantable cardiac device is not well elucidated in non-TOF ACHD cohort. We performed a single center, retrospective, longitudinal follow-up study in repaired ACHD (≥18 years) patients without TOF who hosted a pacemaker or automatic implantable cardiac defibrillator (AICD). The cohort was divided based on presence/absence of device detected NSVT. The primary end-point was a composite of sustained ventricular tachycardia (VT), ventricular fibrillation (VF), or sudden cardiac death (SCD). One hundred fifty eight patients (male 56.3%, median [IQR] age of 35 [28-43] years at last follow-up] with longitudinal post-implant follow-up duration of 8 (5-12) years were included. NSVT was detected in 52 (33%) patients. The primary composite end-point was more frequent in NSVT group [11.5% vs. 2.8%; p = .04]. Patients with NSVT were (i) older at the time of initial implant (age 25 vs. 18 years, p = .011) and more frequently demonstrated (ii) systemic ventricular dysfunction (44% vs. 26%; p = .015), as well as (iii) history of ventriculotomy (38% vs. 21%; p = .017). In our repaired ACHD cohort, we noted a significant association between device-detected-NSVT and the primary composite end-point of sustained VT/VF or SCD. Systemic ventricular dysfunction and history of ventriculotomy were more frequent in the NSVT group and likely constituted the clinical milieu.

Ventricular Tachycardia Unveiling an Obstructive Cardiomyopathy Complicated with an Apical Aneurysm

Background: We report the case of a 58-year-old hypertensive patient under treatment who presented with a ventricular tachycardia unveiling an obstructive cardiomyopathy complicated with an apical aneurysm. Aim: Highlight the rarity of the case and the difficulty of management. Case Presentation: This patient was transferred from Regional Hospital of Ziguinchor in southern Senegal for a brutal dizzy spell without loss of consciousness. The electrocardiogram showed a wide monomorphic QRS complex regular tachycardia with a rate of 215 beats/min. An external electrical cardio version at 300 joules was applied which led to the recovery of a sinus rhythm on the electrocardiogram. The Doppler echocardiography showed an asymetricalmedio-ventricular hypertrophy with a maximum left intraventricular gradient at 10 mm Hg at rest. The coronarography via the radial artery was normal. The evolution was labeled with a recurrence of the ventricular tachycardia. The patient was then put on amiodarone 200 mg, beta-blocker (bisoprolol 10 mg) and anti-vitamin K (acenocoumarol 4 mg). Facing rhythmic instability, an implantable automatic defibrillator was fitted. No complication has been reported after one year of evolution. Conclusion: HCM with medio ventricular obstruction and apical aneurysm complicated with ventricular arrhythmias is a rare entity. Its management is difficult and controversial.

First appropriate implantable defibrillator shocks in patients with Chagasic heart disease

ResumenObjetivos:Determinar si los pacientes con cardiopatía chagásica (CCh) presentaron choques apropiados del desfibrilador automático implantable (DAI) de manera más precoz que los pacientes con cardiopatía isquémica (CI).Métodos:Estudio de cohorte retrospectivo que incluyó los pacientes con CCh y CI en quienes se implantó un DAI entre los años 2009 y 2018 en un hospital de alta complejidad. El seguimiento se realizó hasta los 36 meses, evaluándose el momento del primer choque apropiado del dispositivo.Resultados:Se incluyeron 64 pacientes, 20 con CCh y 44 con CI. Se observó que una mayor proporción de pacientes con CCh presentaron choques apropiados durante el primer año (hazard ratio [HR]: 8.4; intervalo de confianza del 95% [IC95%]: 2.09-34.02; p = 0.0027) y a 3 años (HR: 4.61; IC95%: 1.51-14.07; p = 0.0072). El 100% de la población con CCh e implante del DAI como prevención secundaria de muerte súbita presentaron choques apropiados durante los primeros 26 meses de seguimiento.Conclusiones:Los pacientes con CCh presentaron choques apropiados del DAI de manera más precoz que los pacientes con CI. Todos los pacientes con CCh y DAI como prevención secundaria presentaron choques apropiados, representando una población de mayor riesgo. Esta información apoya la indicación del DAI en estos pacientes a pesar de la escasa evidencia en ensayos aleatorizados.

Protocolo diagnóstico de las canalopatías

Channelopathies are a set of anomalies that affect cellular ion channels. Although they can be acquired, those which are most cardiologically relevant are of genetic origin. They affect certain channels of the myocytes or the specific cardiac conduction system. Although their prevalence may not be very high, their clinical repercussions are very important, because most of them are associated with the onset of polymorphic ventricular tachycardias and sudden death, many times in children and young adults. The baseline ECG has a key diagnostic role as it is the phenotypic/electrical expression of the affected channels, giving rise on many occasions to anomalies in the J point, ST segment, T wave, or QT interval. The diagnosis of the affected genes is another key element in its management, given the possible familial repercussions. Therapeutic management can be both primary, for preventing lethal arrhythmic events, and secondary, if the patient has survived one. For many, an implantable automatic defibrillator is a first-line indication.

"LEADING TO DANGER": A CASE OF INFECTIVE ENDOCARDITIS INVOLVING AN AUTOMATIC IMPLANTABLE CARDIAC DEFIBRILLATOR LEAD

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Patients with presence of intracardiac devices are at an increased risk of developing endocarditis. In this report we present a patient with an automatic implantable cardiac defibrillator (AICD) who presented with atypical symptoms found to have a significant vegetation involving the AICD lead who required emergent removal of the cardiac device and ultimately expired. CASE PRESENTATION: A 58-year-old male with history of lung cancer and ischemic cardiomyopathy status post AICD placement presented to the emergency department with low back pain. Physical exam was remarkable for tenderness to palpation of his lumbar region. The patient was found to have a leukocytosis, but was afebrile and without other signs of infection. Imaging of his spine did not reveal any apparent etiology for his back pain. Blood cultures obtained at presentation grew gram positive cocci in four of four bottles and ultimately speciated as MSSA. A transthoracic echocardiogram was performed and revealed a large vegetation on the tricuspid valve with concern for involvement of the AICD lead. Given these findings he underwent emergent surgery for lead and device extraction. During the procedure the patient became bradycardic and hypotensive and went into cardiac arrest. Despite maximum resuscitative efforts the patient expired. DISCUSSION: Infective endocarditis (IE) is a highly morbid and deadly infection involving the endocardium, the lining of the inside of the heart and heart valves. Right-sided endocarditis is less common, making up approximately 5% to 10% of all cases. It is most commonly associated with intravenous drug use, central venous catheters, and the presence of intracardiac devices. The prevalence of right-sided endocarditis has increased over the past several decades due to the increase in the aforementioned risk factors. Unique complications of right-sided endocarditis include the risk of septic pulmonary emboli, pneumonia, and the formation of a pulmonary abscess. In cases where implantable cardiac devices are present the mainstay of treatment includes not only antibiotics, but also the complete extraction of the device and leads. Studies have shown that early diagnosis and lead extraction of infected cardiac devices are associated with lower in-hospital mortality. CONCLUSIONS: Patients with intracardiac devices are at increased risk of developing infective endocarditis and their clinical presentation maybe atypical, such as back pain in our patient. It is of paramount importance to perform early diagnostic tests and prompt device removal in such cases. Clinicians must be aware of the increased risk in such a population in order to facilitate early detection and appropriate intervention. REFERENCE #1: Cahill TJ, Prendergast BD. Infective endocarditis. Lancet. 2016;387(10021):882-893. doi:10.1016/S0140-6736(15)00067-7 REFERENCE #2: Hubers SA, DeSimone DC, Gersh BJ, Anavekar NS. Infective Endocarditis: A Contemporary Review. Mayo Clin Proc. 2020;95(5):982-997. doi:10.1016/j.mayocp.2019.12.008 REFERENCE #3: Shmueli H, Thomas F, Flint N, Setia G, Janjic A, Siegel RJ. Right-Sided Infective Endocarditis 2020: Challenges and Updates in Diagnosis and Treatment. J Am Heart Assoc. 2020;9(15):e017293. doi:10.1161/JAHA.120.017293 DISCLOSURES: No relevant relationships by Ahmed Aladham, source=Web Response No relevant relationships by Kyle Brockman, source=Web Response No relevant relationships by Navitha Ramesh, source=Web Response

50 years of electrophysiology and cardiac pacing

During the last 50 years a continuous improvement was observed in the field of cardiac pacing and electrophysiology as for as both technological and clinical aspects were concerned. We moved from the first recording of the His bundle electrogram to the identification of the various mechanisms and sites of supraventricular and ventricular tachyarrhythmias, to three-dimensional mapping and ablation of different reentry circuits and eventually to pulmonary vein isolation for the treatment of atrial fibrillation. As far as cardiac pacing is concerned, we moved from single chamber to dual chamber pacing, to ventricular pacing and implantable automatic defibrillators provided by sophisticated diagnostic and therapeutic algorithms and by remote control. Recently a family of leadless devices (loop recorders, endocavitary pacemakers, subcutaneous defibrillators) have become available for diagnostic and therapeutic purposes and brought a significant benefit in the reduction and management of many device-related troubles.

P1475Impact of automatic screening and parasternal rights positions in the eligibility of patients with hypertrophic cardiomyopathy for subcutaneous automatic cardioverter defibrillator implant

Abstract Background A high percentage of failures in the detection of QRS and T wave in patients (pts) with hypertrophic cardiomyopathy (HCM) have been reported. This finding would prevent them from being eligible for an implantable subcutaneous automatic defibrillator (S-ICD). However, recently 2 changes in the detection have been proposed, automatic screening and the use of right parasternal position of the lead. The aim of our work was to study if the elegibility proportion of patients was increased with both 2 advacements. Methods We included 31 patients (18 male)with a diagnosis of HCM and at least 1 risk factor for sudden death, in follow-up at the outdoor clinic of of 2 cardiology centers. We performed elegibility screening test in supine position and standing using both the automatic screening (AS) obtained by Boston Scientific Zoom Latitude programmer) and the manual (MS), to simulate the detection of the 3 vectors utilized in S-ICD detection. And both screens were registered with the surface electrodes in parasternal left and right position. A pte was considered eligible if at least one vector was correct in supine position and in standing position, well in parasternal left or right position. Results Using MS with left parasternal position, 22 patients (71%) were eligible. Adding the right parasternal lead, the eligibility increased by 10%, reaching 81%. In addition, in automatic screening, eligibility in right shifts (81%) it is 7% more than in the left and, with the addition of the rights to the left, the eligibility reaches up to 84%. Figure shows the three-lead ECG factors influencing screening pass vs failure. Conclusion AS, right parasternal lead position and the combination of right and left parasternal lead position, increase the eligibility of sICD candidates with HCM. Abstract Figure. ECG factors influencing screening pass

Complications of implantable cardioverter defibrillator: Diagnosis and management

Implantable Automatic Defibrillator (ICD) has become the treatment of choice in the prevention of sudden rhythmic cardiac death. Its superiority over medical treatment has been demonstrated. However, this efficiency is offset by the occurrence of serious complications. In Tunisia and in the absence of a national register on implantable electronic cardiac devices, data on ICD are not listed. The aim of our study was to investigate the short and long-term complications of ICDs, and to discuss the means and solutions proposed in order to prevent them and reduce their incidence. This was a retrospective study over 15 years enrolling 183 patients with ICDs implanted and followed in the cardiology department of the Military hospital of Tunis. Data were retrieved from medical records and ICD memories. Analyses were conducted using SPSS version 21.0. The mean age of our predominately male patients was 56 ± 15 years. The major cardiac diseases were ischemic (43%), dilated non-ischemic cardiomyopathies (34%) and genetic (23%). CDs were implanted in secondary prevention in 51% of patients. They were double rooms (50%), triple rooms (30%) and single rooms (20%). The perioperative mortality rate is 0.9%. During an average follow-up of 54 months, 21% of patients received appropriate treatment while 11% received inappropriate shocks. The other short- and long-term complications were observed in 9.4% of patients; lead dysfunction (3.8%), lead dislodgements (2.2%), infectious endocarditis (1.1%) and venous thrombosis (1.1%). All these complications resulted in a re-hospitalization rate of 29%. ICD-related complications cause severe morbidity and mortality and indirectly reduce the blunted benefit of preventing sudden rhythmic death. Increased effort and vigilance in patient selection, implantation, programming and follow-up should be maintained to reduce these complications.

Video-assisted thoracoscopic cardiac sympathetic denervation for prolonged QT syndrome—a case report

Congenital long QT syndrome (LQTS) is a rare genetic disorder associated with multiple mutations causing life-threatening cardiac arrhythmias and sudden death. The treatment of choice for LQTS is therapy with beta blockers. Individuals for whom beta blockers are unsuccessful may be treated by implantable automatic cardioverter defibrillator or left cardiac sympathetic denervation. Video-assisted thoracoscopic left cardiac sympathetic denervation is a simple and minimally invasive technique that results in good long-term benefits in patients with congenital long QT syndromes. Although there is substantial literature about this therapy in adults, few reports detail the outcomes in children who undergo left thoracoscopic sympathectomy to treat LQTS.