Implantable Cardio-defibrillator Research Articles

Subcutaneous versus transvenous implantable cardioverter defibrillator in hypertrophic cardiomyopathy: a systematic review and meta-analysis.

A subcutaneous implantable cardioverter-defibrillator (S-ICD) is an alternative to a transvenous implantable cardio defibrillator (TV-ICD). An S-ICD reduces the risk of transvenous lead placement. However, further research is required to determine how S-ICDs affect patients with hypertrophic cardiomyopathy (HCM). In this study, we investigated the comparative efficacy and safety of S-ICDs versus TV-ICDs in HCM. On December 6th, 2023, we performed a comprehensive search of the PubMed, Embase, Scopus, and Cochrane databases to identify randomized clinical trials (RCTs) and observational studies comparing S-ICDs with TV-ICDs in HCM patients published from 2004 until 2023. No language restrictions were applied. The primary outcome was appropriate shocks (AS), with inappropriate shocks (IAS), and device-related complications considered as secondary outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled using a random effects model. The ROBINS-I tool was used to assess the risk of bias of the studies. The search yielded 1,114 records. Seven studies comprising 4,347 HCM patients were included, of whom 3,325 (76.0%) had TV-ICDs, and 1,022 (22.6%) had S-ICDs. There were 2,564 males (58.9%). The age range was from 39.1 to 49.4 years. Compared with the TV-ICD group, the S-ICD cohort had a significantly lower incidence of device-related complications (OR 0.52; 95% CI: 0.30-0.89; P=0.02; I2=4%). Contrastingly, there were no statistically significant differences in the occurrences of AS (OR 0.49; 95% CI: 0.22-1.08; P=0.08; I2=75%) and IAS (OR 1.03; 95% CI: 0.57-1.84; P=0.93; I2=65%) between the two device modalities. In the analysis of the overall risk of bias in the studies, we found 42% of them with several, 28% with moderate, and 14% with low risk of bias. In HCM patients, S-ICDs were associated with a lower incidence of device-associated problems than TV-ICDs. AS and IAS incidence rates were similar between groups. These findings may assist clinicians in determining the most suitable device for treating patients with HCM.

Progression of definite and non-definite Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) and risk of major adverse cardiac events

Abstract Background In patients with Arrhythmogenic right ventricular cardiomyopathy (ARVC, also called"Arrhythmogenic Cardiomyopathy"), it is a challenge to predict those at greatest risk of major adverse cardiac events (MACE). Our hypothesis is that risk of arrhythmia may be preceded by change in ventricular structure and function. Purpose To assess the association between change in ventricular structure and function over time and risk of (MACE) in ARVC. Methods 101 definite and non-definite ARVC patients (defined as per Revised Task Force criteria (TFC)) were included with at least two sequential echocardiography and ECGs between 2010 and 2022. Structural progression was defined as development of new 2010 TFC on echocardiography during follow-up. MACE were defined as ventricular fibrillation (VF), sustained ventricular tachycardia (Sus VT), appropriate implantable cardio-defibrillator (ICD) therapy (shock/anti-tachycardia pacing (ATP)), heart failure, cardiac transplantation and death. Results Of the 101 patients, 51 had a definite diagnosis of ARVC, and 50 had a non-definite ‘early’ diagnosis, of whom a total of 66 (68%) carried a pathogenic variant associated with ARVC. Most were male 58 (57%), and the median age at presentation was 39 years (IQR: 27 - 53). Palpitations 41 (41%) and syncope 25 (25%) were the most common symptoms at baseline. 21 (23%) of the entire population were engaged in competitive exercise. At baseline, 22/101 (22%) patients presented with MACE, in which 20 (91%) definite patients met either minor or major imaging criteria at inclusion. During 4 years follow up (IQR: 2 – 6), 22 patients experienced MACE, in which 11 with history of MACE and 11 without, of those (15 (68%)) had structural progression. Additionally, 9 patients had structural progression of which 5 patients had history of MACE and no second event during follow up and 4 patients had no MACE at baseline or during follow up. Results showed that the odds of structural progression were significantly higher in patients with MACE than without (Table 1). Conclusion Structural progression was strongly associated with MACE events. This finding raises the possibility that tracking change over time identifies those patients at greatest risk of arrhythmia, with significant changes in right ventricular measurements.

Permanent pacemaker implantation after alcoholic septal ablation induced complete heart block: Long-term impact

Introduction and objectivesPatients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy often undergo alcohol septal ablation (ASA). One of the most frequent complications is complete heart block (CHB), requiring a permanent pacemaker (PPM) in variable rates of up to 20% of patients. The long-term impact of PPM implantation in these patients remains unclear. This study aimed to evaluate the long-term clinical outcomes in patients who implant PPM after ASA. MethodsPatients who underwent ASA at a tertiary center were consecutively and prospectively enrolled. Patients with previous PPM or implantable cardio-defibrillator were excluded from this analysis. Patients with and without PPM implantation after ASA were compared based on their baseline characteristics, procedure data and three-year primary endpoint of composite of all-cause mortality and hospitalization and secondary endpoint of composite of all-cause mortality and cardiac cause hospitalization. ResultsBetween 2009 and 2019, 109 patients underwent ASA, 97 of whom were included in this analysis (68% female, mean age 65.2 years old). 16 patients (16.5%) required PPM implantation for CHB. In these patients, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics of comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with higher mean age (70.6±10.0 years vs. 64.1±11.9 years) and lower beta-blocker therapy rate (56% vs. 84%) in the PPM group. Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692 U/L vs. 1243 U/L), with no significant difference in the alcohol dose. At three years after ASA procedure, there were no differences in the primary and secondary endpoints between the two groups. ConclusionsPermanent pacemaker after ASA induced CHB do not affect long term prognosis in hypertrophic obstructive cardiomyopathy patients.

3 year outcomes of permanent pacemaker implantation after alcoholic septal ablation

Abstract Introduction Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy are often submitted to alcohol septal ablation (ASA). One of the most frequent complications is the complete hear block (CHB), requiring permanent pacemaker (PPM) in variable rates, up to 20% of the patients. The long-term impact of PPM implantation in these patients remains unclear. Objectives This study aims to evaluate the long-term clinical outcomes in patients who implant PPM after ASA. Methods In a tertiary center, patients who underwent ASA were consecutively enrolled prospectively. Patients with previous PPM or implantable cardio-defibrillator were from this analysis. The groups with and without PPM implantation after ASA were compared regarding baseline characteristics, procedure data and 3-year primary and secondary endpoints. Results Between 2009 and 2020, 109 patients underwent ASA. 97 patients were included in this analysis (68% female, mean age 65.2 years-old). 16 patients (16.5%) required PPM implantation for CHB. In those, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics regarding comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with statistically significant differences in the mean age (70.6y/o in the PPM group versus 64.1y/o) and in the beta-blocker therapy rates previously to the intervention (56% in the PPM group versus 84%). Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692U/L versus 1243U/L, p0.05), without significant differences in the alcohol dose (2.1ml in both groups, p0.33). At 3 years after ASA procedure, the primary endpoint (composite of all-cause mortality and all-cause re-hospitalization) showed a statistical tendency to a lower event rate in the group who implanted PPM (p-value 0.097, Graphic 1). The secondary endpoint (composite of all-cause mortality and cardiac cause re-hospitalization) did not show any significant statistical difference between the two groups (p-value 0.216, Graphic 2). Conclusions The long-term endpoint analysis suggests that the outcomes in patients who implant PPM after ASA are non-inferior to those who do not, with a tendency to a lower rate of the endpoint composite of all-cause mortality and all cause re-hospitalizations. Funding Acknowledgement Type of funding sources: None.

Permanent pacemaker implantation after Alcoholic Septal Ablation: long-term outcomes

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy are often submitted to alcohol septal ablation (ASA). One of the most frequent complications is the complete heart block (CHB), requiring permanent pacemaker (PPM) in variable rates, up to 20% of the patients. The long-term impact of PPM implantation in these patients remains unclear. Objectives This study aims to evaluate the long-term pacemaker dependency in patients with PPM after ASA and to assess the long-term impact of PPM in these patients. Methods In a tertiary center, patients who underwent ASA were retrospectively analyzed. Patients with previous PPM or implantable cardio-defibrillator were excluded. The groups with and without PPM implantation after ASA were compared regarding baseline characteristics, procedure data and outcomes. In the group who implanted PPM, the long-term pacing rates were evaluated. Results Between 2009 and 2020, 109 patients underwent ASA. 97 patients were included in this analysis (68% female, mean age 65.2 years-old). 16 patients (16.5%) required PPM implantation for CHB. In those, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics regarding co-morbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with statistically significant differences in the mean age (70.6y/o in the PPM group versus 64.1y/o) and in the beta-blocker therapy rates previously to the intervention (56% in the PPM group versus 84%). Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692U/L versus 1243U/L, p0.05), without significant differences in the alcohol dose (2.1ml in both groups, p0.33). In the PPM group, the mean pacing rates at 1 month, 1 year and 2 years were 66.6±38.0, 50.4±44.1 and 50.8±42.5, respectively, with 2 patients (12.5%) having 1-5% pacing and none having pacing <1% at 2 years. In the group without PPM, 5 patients (6.2%) required posteriorly PPM implantation during the follow-up. There were no statistically significant differences in the two groups regarding in-hospital mortality, 1 year mortality or 1 year re-hospitalization. Despite a lower mean follow-up period in the PPM group (2.3±1.5 years versus 3.5±2.2 years, p0.05), there were no differences in the groups regarding all-cause mortality, cardiac cause mortality and cardiac cause re-hospitalization, with a statistical tendency to a lower all cause re-hospitalization in the PPM group (19% versus 43%, p0.07). Conclusions The registered pacing rates shows that all devices were adequately implanted. The long-term impact analysis suggests that the outcomes in patients who implant PPM after ASA are non-inferior to those who do not, with a tendency to reduce all cause re-hospitalizations.

Modified technique for left ventricular assist device insertion in the setting of apical calcification.

Modified technique for left ventricular assist device insertion in the setting of apical calcification.

INTERVENE-HF: feasibility study of individualized, risk stratification-based, medication intervention in patients with heart failure with reduced ejection fraction.

AimsDetermine the feasibility of implementing a heart failure (HF) management strategy that (i) uses a device‐based, remote, dynamic, multimetric risk stratification model to predict the risk of HF events and (ii) uses a standardized, centrally administered, ambulatory medication intervention protocol to reproducibly and safely decrease elevated risk scores.Methods and resultsProspective, non‐randomized, single‐arm, multicenter feasibility study (Intervene‐HF) was conducted in HF patients implanted with a cardiac resynchronization therapy with implantable cardio defibrillator (CRT‐D) with TriageHF risk score feature. Certified HF nurses (CHFN) in the Medtronic Care Management Services Program implemented an ambulatory medication intervention strategy by following a standardized guided action pathway triggered by risk‐based alert. When CHFN received notification of increased risk score (HF care alert), they implemented a 3 day course of diuretic up‐titration (PRN) previously prescribed by a physician. Safety was monitored daily. Recovery after PRN was defined as ≥70% recovery of impedance toward baseline levels. Sixty‐six patients followed for 8.2 ± 3.9 months had 49 HF care alerts. Twenty‐three of 49 alerts did not receive PRN due to protocol‐mandated criteria. Twenty‐six of 49 alerts received PRN, 22 were completed, and 19 led to impedance recovery. Four interventions were stopped for safety without leading to an adverse event (AE). One of 26 PRNs was followed by a HF event. Eighty‐five per cent (22/26) of PRNs were completed without an AE; 69% (18/26) met the recovery criteria.ConclusionsThe Intervene‐HF study supports the feasibility of testing, in a large randomized clinical trial, an ambulatory medication intervention strategy that is physician‐directed, CHFN‐implemented, and based on individualized device risk stratification.

A Comparative Survey of Pacemaker Implantation in Trinidad and Tobago in 2005 and 2009.

The indications for permanent pacemaker implantations in Trinidad have expanded from initially symptomatic bradycardia to now include complex devices. A retrospective review of the available data was conducted to better understand the evolving trends in device implantation in Trinidad and Tobago. Data were collated from the two major implanting teams in Trinidad for the years 2005 and 2009. The two implanting centres were the Advanced Cardiovascular Institute (ACI) at Westshore Medical Centre and the Catheterization Laboratory of the Eric Williams Medical Sciences Complex (EWMSC). Data were based on retrospective collation using the implantation records. The implantation rate for new devices increased from 39 per million to 103 per million population. The most common indications for new device implants in 2009 were high degree atrioventricular (AV) block (53%) and sick sinus syndrome (22%) with the notable appearance of congestive cardiomyopathy (13%) which was not present in the earlier cohort. Of particular note, 23 high-end devices were implanted in 2009. These were five cardiac-resynchronization therapy (CRT-P) devices, 14 automatic implantable cardio-defibrillator (AICD) devices and four combined cardiac-resynchronization therapy with defibrillator (CRT-D) devices versus none in 2005. In summary, over the period 2005 to 2009, a substantial increase in device implantation rates has occurred which now include high-end, complex devices. Absolute rates, however, remain far below that of developed countries, indicating that the true need remains underserved. Furthermore, adjustment for gross domestic product suggests that the relatively buoyant economy of Trinidad and Tobago is capable of servicing a greater proportion of this need than is currently met.

Selvester scoring in patients with strict LBBB using the QUARESS software

BackgroundEstimation of the infarct size from body-surface ECGs in post-myocardial infarction patients has become possible using the Selvester scoring method. Automation of this scoring has been proposed in order to speed-up the measurement of the score and improving the inter-observer variability in computing a score that requires strong expertise in electrocardiography. In this work, we evaluated the quality of the QuAReSS software for delivering correct Selvester scoring in a set of standard 12-lead ECGs. MethodStandard 12-lead ECGs were recorded in 105 post-MI patients prescribed implantation of an implantable cardiodefibrillator (ICD). Amongst the 105 patients with standard clinical left bundle branch block (LBBB) patterns, 67 had a LBBB pattern meeting the strict criteria. The QuAReSS software was applied to these 67 tracings by two independent groups of cardiologists (from a clinical group and an ECG core laboratory) to measure the Selvester score semi-automatically. Using various level of agreement metrics, we compared the scores between groups and when automatically measured by the software. ResultsThe average of the absolute difference in Selvester scores measured by the two independent groups was 1.4±1.5 score points, whereas the difference between automatic method and the two manual adjudications were 1.2±1.2 and 1.3±1.2 points. Eighty-two percent score agreement was observed between the two independent measurements when the difference of score was within two point ranges, while 90% and 84% score agreements were reached using the automatic method compared to the two manual adjudications. ConclusionThe study confirms that the QuAReSS software provides valid measurements of the Selvester score in patients with strict LBBB with minimal correction from cardiologists.

IMPLANTABLE DEFIBRILLATOR EARLY AFTER PRIMARY PERCUTANEOUS INTERVENTION FOR ST-ELEVATION MYOCARDIAL INFARCTION: THE DEFIBRILLATOR AFTER PRIMARY ANGIOPLASTY (DAPA) TRIAL

It is not known which patients after primary Percutaneous Coronary Intervention (PCI) for ST elevation myocardial infarction (STEMI) have survival benefit of prophylactic implantable cardio defibrillator(ICD). The aim of the DAPA trial is to evaluate the efficacy and safety of ICD in high risk

Abstract 18639: Ventricular Tachycardia Events Are Associated With Admissions for Infection or Heart failure in Patients With Left Ventricular Assist Devices and Implantable Cardio-Defibrillators

Background: Left ventricular assist devices (LVAD) have dramatically affected the treatment of end stage heart failure (HF), however preventing readmissions remains critical to optimize patient quality of life. Following LVAD implantation, pts are readmitted most commonly for infection, HF, arrhythmia and anemia. We designed a novel implantable cardio-defibrillator (ICD) programming protocol for pts with LVADs and ICDs to maximize ventricular arrhythmias (VA) detection and minimize shocks. We hypothesized that increasing detection of VA in LVAD pts may reduce readmission rates. Methods: Forty-two pts at UNC with an LVAD and ICD underwent reprogramming. The protocol included: ventricular fibrillation >220 bpm; ventricular tachycardia (VT) >185 bpm with 12 bursts of ATP then a single shock; VT monitor >150 bpm. Device interrogations were performed at LVAD clinic follow up, for symptoms, and at the time of readmission. Data was collected with an approved institutional IRB. Results: During an average follow up of 11.3 months before and 7.4 months after reprogramming, there were 53 unplanned admissions (21 admissions after ICD reprogramming). After reprogramming 5 admissions (23% - 1438 patient-days/admit) were for HF or VA. Prior to reprogramming there were 15 HF/VA admissions (728 patient-days/admit). After reprogramming 4 admissions (18%) were for bacterial infections (5 prior to reprogramming). The remaining were primarily for anemia (17%) or neurologic symptoms (36%). After reprogramming, arrhythmias were detected on ICD interrogation in 3 of 5 HF and 2 of 4 bacterial infection admissions. 40% were due to sustained VA >10 sec and 60% were due to supraventricular tachycardia. By comparison 0/13 of the other admissions had documented ICD arrhythmias. Conclusions: Following implementation of a novel ICD programming protocol to increase detection of VA, there was a marked decrease in admissions for cardiac diagnoses. ICD interrogations found VA events were associated with admissions for HF and infection. HF and infections may cause hemodynamic perturbations that result in arrhythmias detected by ICDs with appropriate programming. Our data suggests that ICD data may augment available techniques to assess and triage this patient population.

Acquired Fontan Physiology Secondary to Acute Mechanical Tricuspid Valve Failure in a Patient With Massive Right Heart Enlargement and Ebstein’s Anomaly

A 25-year-old man with Ebstein’s anomaly and a secundum atrial septal defect had a mechanical tricuspid valve replacement (St. Jude 31-mm valve) and atrial septal defect closure when he was 15 years old. He was under long-term specialist follow-up and had recently been admitted with symptoms and signs of right heart failure secondary to new onset atrial flutter. He was direct-current cardioverted and commenced on ramipril and metoprolol. He then went to have an electrophysiological study and successful atrial flutter ablation. At review 6 months later he reported good exercise tolerance and was now able to play 18 holes of golf, whereas previously he could only manage 9 holes. However, he commented that since the electrophysiological procedure he had been unable to hear his prosthetic valve clicks. On clinical examination he was not cyanosed, the jugular venous pressure was elevated at 4 cm without prominent V waves, there was a soft first heart sound, no audible mechanical valve clicks, and a pansystolic murmur. There were no signs of heart failure or peripheral edema. An electrocardiogram demonstrated sinus rhythm, right axis deviation, first-degree heart block, and right bundle-branch block with QRS duration of 200 ms. Echocardiography and fluoroscopy (Figure 1) showed that the leaflets of the …

Fabry disease: is there a role for enzyme replacement therapy?

Fabry disease: is there a role for enzyme replacement therapy?

905 Cost Effectiveness of Cardiac Resynchronization Therapy (CRT) for Mild to Moderate Heart Failure

BackgroundThe objective of this study was to assess the cost effectiveness of ICD-CRT versus ICD alone in patients with left ventricular dysfunction and a wide QRS complex. In a recent randomized controlled trial (RAFT), the addition of CRT to an implantable cardiodefibrillator (ICD) in this group of patients was shown to reduce rates of death and hospitalization for heart failure.MethodsAnalysis assessed the health care related costs and quality adjusted life years for both the ICD-CRT and ICD groups over a 40 year time horizon. The time horizon was facilitated by a Markov model developed by combining data for the 1798 patients enrolled within the RAFT with long term data on the longevity of the devices. Costs and benefits in terms of quality adjusted life years (QALYs) were discounted at 3% per annum. Health care resources included the initial device plus device replacements, cardiovascular and non cardiovascular related hospitalizations in addition to drug costs, physician visits and long term care. Resource use was weighted by appropriate unit costs from the USA. Uncertainty concerning cost effectiveness was assessed through Monte Carlo simulation and deterministic sensitivity analysis.ResultsModels for Canadian resource utilization and costing have been developed and are currently being conducted. For the US models, the use of ICD-CRT was estimated to lead to an average increase in costs of $35,308 and an average increase in QALYs of 1.07. The incremental cost per QALY gained was $33,025. ICD-CRT was not cost effective for patients with atrial fibrillation and those with preexisting ventricular pacing.ConclusionsICD-CRT is cost effective for the population studied within the RAFT clinical trial. BackgroundThe objective of this study was to assess the cost effectiveness of ICD-CRT versus ICD alone in patients with left ventricular dysfunction and a wide QRS complex. In a recent randomized controlled trial (RAFT), the addition of CRT to an implantable cardiodefibrillator (ICD) in this group of patients was shown to reduce rates of death and hospitalization for heart failure. The objective of this study was to assess the cost effectiveness of ICD-CRT versus ICD alone in patients with left ventricular dysfunction and a wide QRS complex. In a recent randomized controlled trial (RAFT), the addition of CRT to an implantable cardiodefibrillator (ICD) in this group of patients was shown to reduce rates of death and hospitalization for heart failure. MethodsAnalysis assessed the health care related costs and quality adjusted life years for both the ICD-CRT and ICD groups over a 40 year time horizon. The time horizon was facilitated by a Markov model developed by combining data for the 1798 patients enrolled within the RAFT with long term data on the longevity of the devices. Costs and benefits in terms of quality adjusted life years (QALYs) were discounted at 3% per annum. Health care resources included the initial device plus device replacements, cardiovascular and non cardiovascular related hospitalizations in addition to drug costs, physician visits and long term care. Resource use was weighted by appropriate unit costs from the USA. Uncertainty concerning cost effectiveness was assessed through Monte Carlo simulation and deterministic sensitivity analysis. Analysis assessed the health care related costs and quality adjusted life years for both the ICD-CRT and ICD groups over a 40 year time horizon. The time horizon was facilitated by a Markov model developed by combining data for the 1798 patients enrolled within the RAFT with long term data on the longevity of the devices. Costs and benefits in terms of quality adjusted life years (QALYs) were discounted at 3% per annum. Health care resources included the initial device plus device replacements, cardiovascular and non cardiovascular related hospitalizations in addition to drug costs, physician visits and long term care. Resource use was weighted by appropriate unit costs from the USA. Uncertainty concerning cost effectiveness was assessed through Monte Carlo simulation and deterministic sensitivity analysis. ResultsModels for Canadian resource utilization and costing have been developed and are currently being conducted. For the US models, the use of ICD-CRT was estimated to lead to an average increase in costs of $35,308 and an average increase in QALYs of 1.07. The incremental cost per QALY gained was $33,025. ICD-CRT was not cost effective for patients with atrial fibrillation and those with preexisting ventricular pacing. Models for Canadian resource utilization and costing have been developed and are currently being conducted. For the US models, the use of ICD-CRT was estimated to lead to an average increase in costs of $35,308 and an average increase in QALYs of 1.07. The incremental cost per QALY gained was $33,025. ICD-CRT was not cost effective for patients with atrial fibrillation and those with preexisting ventricular pacing. ConclusionsICD-CRT is cost effective for the population studied within the RAFT clinical trial. ICD-CRT is cost effective for the population studied within the RAFT clinical trial.

Angiotomografia coronariana multislice na avaliação da origem anômala das artérias coronarianas

Anomalous origin of coronary arteries is a relatively rare entity, which may show different clinical forms and develop an adverse outcome. Multislice coronary angiotomography has gained importance in daily clinical practice, representing an important patient assessment method with great potential in the anatomical evaluation of these arteries.This study aimed to describe angiotomographic findings and evolution of patients with anomalous origin of coronary arteries.From January 2008 to March 2011 404 patients were evaluated consecutively, who had been referred for coronary angiotomography for several reasons, with a mean follow-up of 21 months.Nine patients (2.2%) had anomalous origin of coronary arteries, of which four had an anomalous origin of the Circumflex (Cx) artery in the Right Coronary Artery (RCA), two had anomalous origin of the RCA (one originating from the Cx and one in the left coronary sinus), a patient with single coronary trunk (anterior descending and Cx out of the left coronary sinus), one had anomalous left main coronary artery trajectory between the aorta and pulmonary artery and one patient with left coronary trunk originating from the right coronary sinus. Of the evaluated patients, one received an implantable cardiodefibrillator; one died due to sudden death during hospitalization; and the others showed no complications.The multislice coronary angiotomography represents minimally invasive assessment method that allows detecting the origin, course and termination of anomalous coronary arteries with excellent accuracy, allowing the correct diagnosis and aiding therapeutic planning.

From syncope to ICD: clinical paths of the Brugada syndrome

This review summarizes the evidences in the literature on the management of the Brugada syndrome (BS), an arrhythmogenic disease caused by genetic channelopathies, predisposing to syncope and sudden cardiac death in young, apparently healthy, typically male subjects, in the third and fourth decade of their life. Sudden cardiac death (SCD) is defined as natural death from cardiac causes, heralded by abrupt loss of consciousness within one hour of the onset of symptoms. It ranks among the main causes of death in the western world, with an incidence ranging from 0.36 and 1.28‰ inhabitants per year, equal to 300,000 cases a year in the USA. In the majority of the cases it is due to the onset of arrhythmia in subjects with structural cardiac diseases, especially ischemic heart disease. However, in a non-negligible percentage of the cases, about 5-10%, the SCD arises in relatively young individuals in whom cardiac anomalies cannot be detected using traditional diagnostic techniques. About 20% of these cases can be attributed to SB. In spite of the many efforts produced to identify an effective pharmacological treatment, to date the only aid to reduce the mortality rate in subjects with SB is an implantable cardio-defibrillator (ICD). Since this approach often entails complications, the efforts of the scientific community is now focused on the assessment of the arrhythmic risk. The identification of high-risk subjects is one of the chief objectives in the therapeutic decision-making process. ABSTRACT clinica e terapia emergency

219 Follow-up of Brugada syndrome patients without implantable cardioverter-defibrillator: the “Achilles’ heel” of current studies?

Risk stratification for sudden cardiac death in asymptomatic Brugada syndrome (BS) patients is not perfect. Although follow-up of patients with an implantable cardio-defibrillator (ICD) is reliable, follow-up for patients without an ICD is less accurate. All patients seen at the Bordeaux CHU between 1999 and 2009 with BS (spontaneous type 1 or after flecainide or ajmaline test) were included prospectively in the database, i.e. 187 patients (76% men, 44 ±12 years). Follow-up of non-implanted patients was carried out by consultation or annual telephone contact. All patients seen over the last 6 months were recontacted for this study. One hundred and two patients (55% BS, 76% men, 43 ±13 years) did not have an ICD. In 50% of cases the BS had been discovered by chance, after lipothymia or syncope in 32% of cases and during family assessment in 18% of cases. A spontaneous type 1 was present in 68%. Electrophysiological Study (EPS) had been carried out in 79% of patients (Negative in 75 pts and positive in 5pts who had refused the ICD). Average follow-up was 52 ±37 months, and no subject was lost to follow-up (follow-up<6months for all patients), 89 were asymptomatic, 7 presented with lipothymia, 1 with syncope (without arrhythmia on loop recorder), 1 had supra-ventricular tachycardia and 3 had died (septic shock, overdose, and one young patient called in for a family assessment died suddenly, even though his EPS was negative). After an exhaustive 4.3 year follow-up, 3/102 patients with BS and with no ICD had died, 1 suddenly, despite following risk stratification recommendations.

Prognostic impact of demographic factors and clinical features on the mode of death in high-risk patients after myocardial infarction - A combined analysis from multicenter trials

Contemporary information is lacking on the effect of demographic features and clinical features on the specific mode of mortality after myocardial infarction (MI) in the thrombolytic era. The aims of this study were (1) to examine the risk and trend of a different mode of mortality (i.e., all-cause, arrhythmic, and nonarrhythmic cardiac mortality) in high-risk patients post MI with reduced left ventricular ejection fraction (LVEF) or ventricular arrhythmias; and (2) to assess the predictive value of demographic and clinical variables in the prediction of specific modes of death in high-risk patients post MI in the thrombolytic era. In all, 3,431 patients receiving placebo (2,700 men, median age 64 +/- 11 years) from the EMIAT, CAMIAT, SWORD, TRACE, and DIAMOND-MI studies, with LVEF < 40% or ventricular arrhythmia were pooled. Risk factors for mortality among patients surviving > or = 45 days after MI up to 2 years were examined using Cox regression. Short-term survival (from onset of MI to Day 44 after MI) was also examined for TRACE and DIAMOND-MI, in which patients were recruited within 2 weeks of MI. After adjustment for treatment and study effects, age, previous MI/angina, increased heart rate, and higher New York Heart Association functional class increased the risk of all-cause, arrhythmic, and cardiac mortality. Male gender, history of hypertension, low baseline systolic blood pressure, and Q wave were predictive of all-cause and arrhythmic mortality, whereas diabetes was only predictive of all-cause mortality. Smoking habit and atrial fibrillation had no prognostic value. Similar parameters were also predictive of short-term mortality, but not identical. Our study has shown that in high-risk patients post MI, who have been preselected using LVEF or frequent ventricular premature beats, demographic and clinical features are powerful predictors of mortality in the thrombolytic era. We propose that demographic and clinical factors should be considered when designing risk stratification or survival studies, or when identifying high-risk patients for prophylactic implantable cardiodefibrillator therapy.

Confirmation of correct placement of the endocardial lead in cardiodefibrillator implantation by intraoperative transesophageal echocardiography.

Correct positioning of the endocardial lead in the apex of the right ventricle during the insertion of an implantable cardiodefibrillator (ICD) under general anesthesia, when cardiac function is generally poor, is most important. We describe herein a method of using intraoperative esophageal echocardiography in combination with fluoroscopy to confirm fixation of the endocardial ICD lead in the right ventricular apex.

Cardiomyopathy and the Use of Implanted Cardio‐Defibrillators in Children

Children and adults with cardiomyopathy and ventricular dysrhythmias have a uniformly poor prognosis, despite medical therapy. The use of automatic implantable cardio-defibrillators in adult patients with medically resistant ventricular dysrhythmias has resulted in a positive impact on survival. Because of its size and former lack of programmability, the device has been used rarely in children. Four patients with cardiomyopathy, in whom refractory ventricular dysrhythmias were managed with automatic implantable cardio-defibrillators, are presented. Two of these children are the youngest and smallest known in whom the device has been used; one of them received the first programmable model. The use of the automatic implantable cardio-defibrillator may enhance survival in selected young patients.