Cardiac Pacemaker Insertion Research Articles

Andersen-Tawil syndrome: deep phenotyping reveals significant cardiac and neuromuscular morbidity.

Andersen-Tawil syndrome is a neurological channelopathy caused by mutations in the KCNJ2 gene that encodes the ubiquitously expressed Kir2.1 potassium channel. The syndrome is characterized by episodic weakness, cardiac arrythmias and dysmorphic features. However, the full extent of the multisystem phenotype is not well described. In-depth, multisystem phenotyping is required to inform diagnosis and guide management. We report our findings following deep multimodal phenotyping across all systems in a large case series of 69 total patients, with comprehensive data for 52. As a national referral centre, we assessed point prevalence and showed it is higher than previously reported, at 0.105 per 100 000 population in England. While the classical phenotype of episodic weakness is recognized, we found that a quarter of our cohort have fixed myopathy and 13.5% required a wheelchair or gait aid. We identified frequent fat accumulation on MRI and tubular aggregates on muscle biopsy, emphasizing the active myopathic process underpinning the potential for severe neuromuscular disability. Long exercise testing was not reliable in predicting neuromuscular symptoms. A normal long exercise test was seen in five patients, of whom four had episodic weakness. Sixty-seven per cent of patients treated with acetazolamide reported a good neuromuscular response. Thirteen per cent of the cohort required cardiac defibrillator or pacemaker insertion. An additional 23% reported syncope. Baseline electrocardiograms were not helpful in stratifying cardiac risk, but Holter monitoring was. A subset of patients had no cardiac symptoms, but had abnormal Holter monitor recordings which prompted medication treatment. We describe the utility of loop recorders to guide management in two such asymptomatic patients. Micrognathia was the most commonly reported skeletal feature; however, 8% of patients did not have dysmorphic features and one-third of patients had only mild dysmorphic features. We describe novel phenotypic features including abnormal echocardiogram in nine patients, prominent pain, fatigue and fasciculations. Five patients exhibited executive dysfunction and slowed processing which may be linked to central expression of KCNJ2. We report eight new KCNJ2 variants with in vitro functional data. Our series illustrates that Andersen-Tawil syndrome is not benign. We report marked neuromuscular morbidity and cardiac risk with multisystem involvement. Our key recommendations include proactive genetic screening of all family members of a proband. This is required, given the risk of cardiac arrhythmias among asymptomatic individuals, and a significant subset of Andersen-Tawil syndrome patients have no (or few) dysmorphic features or negative long exercise test. We discuss recommendations for increased cardiac surveillance and neuropsychometry testing.

A case report of pleuro‐pericardial effusion in a patient on hemodialysis and a cardiac pacemaker

There are multiple causes of pleuro-pericardial effusion (PPEF) and more so in a patient with end-stage renal disease (ESRD). Postcardiac injury syndrome (PCIS) is a loosely defined term for occurrence of pericardial and/or pleural effusion (PLEF), low-grade fever, with or without systemic upset, which occurs after myocardial infarction (MI), and other cardiac interventions. PPEF is one of its salient manifestations. We report occurrence of PCIS, presenting as pericardial effusion and massive PLEF, after insertion of cardiac pacemaker in a patient with ESRD, on maintenance hemodialysis (MHD). It was successfully managed with a short course of oral steroids.

Azygos Vein Dissection during Pacemaker Electrode Lead Insertion: A Case Report

The invention of pacemakers has saved lives and improved the quality of life of countless patients. As the number of implantations has increased, so has the number of cases of post-implantation complications. To improve the ability to identify the complications of cardiac pacemaker insertion, it is necessary to remember that any type of intervention, however small, requires constant caution to achieve optimal surgical safety, minimal intraoperative risk, and individualized surgical methods, all of which can reduce the risk of complications of cardiac pacemaker insertion and maximize therapeutic benefits.

Racial Disparities in the Utilization and Outcomes of Transcatheter Mitral Valve Repair: Insights From a National Database

BackgroundThere is paucity of data on racial disparities in the utilization and outcomes of transcatheter mitral valve repair (TMVR). MethodsWe queried the National inpatient Sample database (2012–2016) for TMVR hospitalizations among Caucasian and African American patients. We conducted a propensity score matching analysis to compare outcomes of Caucasians versus African Americans. The main study outcome was in-hospital mortality. ResultsAmong 7940 TMVR procedures performed, 680 (8.6%) were performed in African Americans. TMVR was increasingly performed for both Caucasians and African Americans (Ptrend = 0.01), although the proportion of African Americans did not change significantly over time (Ptrend = 0.45). Compared to African Americans, Caucasians undergoing TMVR were significantly older (77.7 ± 10.8 vs. 67.2 ± 14.28, p < .001) and less likely to be women (45.3% vs.60.3%, p < .001). Caucasians undergoing TMVR had a higher in-hospital mortality compared with African Americans before matching (2.5% vs. 1.5%, odds ratio [OR] 1.75; 95% confidence interval [CI] 1.17:2.63, p = .01) as well as after matching (4.7% vs. 1.6%, OR 3.10; 95% CI 1.61:5.97, p < .001). Caucasians had higher in-hospital cardiac arrest and pacemaker insertion and shorter median length of stay. There was no difference in the incidence of other in-hospital outcomes between Caucasians and African Americans. ConclusionThis nationwide observational analysis showed a steady increase in number of TMVRs among Caucasians and African Americans. TMVR was performed in a select cohort of African Americans who were significantly younger and more likely to be women compared with Caucasians. Caucasians undergoing TMVR had higher in-hospital mortality compared with African Americans. Further research is needed to explore the reasons behind the racial disparities in the utilization and outcomes of TMVR.

Ictal Bradyarrhythmia in a 2-Year-Old Male with Brainstem Embryonal Tumor

AbstractIctal bradyarrhythmia can be challenging to diagnose when motor features of seizures are absent. Associated bradycardia can involve periods of asystole requiring cardiac pacemaker placement. Here, we report a 2-year-old male with a brainstem embryonal tumor with more than 30 seizures per day manifesting as bradycardia, loss of tone, and decreased responsiveness, followed by vomiting. Associated electrographic changes were localized to the right temporal head region, where the patient's tumor exerted mass effect. The patient was treated with lacosamide at higher doses than previously reported (24 mg/kg/d) and became seizure-free on a combination of this medication with clobazam. Oral albuterol was also used to augment his heart rate as the patient was not a candidate for cardiac pacemaker insertion.

Attention for insertion of temporary cardiac pacemaker in liver transplant patients.

Attention for insertion of temporary cardiac pacemaker in liver transplant patients.

Successful conversion of complete atrioventricular block to sinus rhythm without cardiac pacemaker: A case report

Complete atrioventricular (AV) block is a medical emergency, which is related to cardiac arrest if left untreated. The insertion of permanent cardiac pacemaker is strongly indicated for its treatment. However, on the rarest occasion, this condition can be treated without a cardiac pacemaker. A 56 year old male with a history of chronic kidney disease, was admitted to our emergency department due to the decrease of consciousness. Complete AV block and severe hypotension were detected. Laboratory examination showed severe hyperkalemia and metabolic acidosis. Unexpectedly, the cardiac rhythm was returned into sinus after the serial correction of hyperkalemia using calcium gluconate, insulin, dextrose, and bicarbonate sodium. This case illustrates that hyperkalemia can be a reversible cause of complete AV block, which can be converted into sinus rhythm without a cardiac pacemaker. Routine examination and correction of hyperkalemia can be considered as the alternative initial management before the insertion of the cardiac pacemaker.

Investigating the Manifestation of Coronary Artery Disease and Determining the Role of Effective Factors in the Need for Pacemaker Insertion in These Patients.

BACKGROUND:Many patients who are candidates for a pacemaker are also at the same time risk factors for coronary artery disease such as high blood pressure, hypertension, diabetes, and hyperlipidemia, and therefore the probability of having coronary artery disease is significant. Effective diagnostic measures can be taken to prove the factors affecting the incidence of CAD in patients undergoing pacemakers at high-risk, including angiography. Therefore, it can prevent complications during and after pacemaker implantation, which leads to an increase in the quality of treatment in patients requiring pacemaker implantation.AIM:Therefore, the purpose of this study was to determine the predictive factors of significant coronary artery disease in patients with pacemaker implantation to identify patients in need of coronary angiography at the time of pacemaker implantation.METHODS:This retrospective study was carried out to examine the patients’ files that were placed at the heart of Imam Reza Hospital during the period between March 2017 and September 2017. Demographic data, risk factors, echocardiography findings, and angiography, were collected and then recorded using a checklist. Statistical analysis was performed using SPSS software version 22 and Chi-square, and Mann-Whitney tests were used for determining significates variables.RESULTS:A group of 102 patients who had undergone a permanent cardiac pacemaker insertion due to an atrioventricular (AV) Block were included in the study, and also coronary anatomy was determined coronary angiography. Based on the results, 13.7% of patients with cardiac pacemaker had obstructive coronary artery disease (stenosis > 70%). Factors affecting coronary artery stenosis on angiography include gender, chest pain, history of myocardial infarction, angioplasty, diabetes, smoking, history of aspirin intake, calcium blocker and Plavix, high hematocrit, ST elevation and ST depression in the ECG, and severe mitral regurgitation.CONCLUSION:It seems that in most patients requiring permanent pacemaker insertion because of the atrioventricular (AV) Block, angiography does not change the patient’s fate, and so can be ignored. However, in patients who have several risk factors from the listed above, coronary angiography is recommended during admission.

Familial Clustering of Cardiac Conduction Defects and Pacemaker Insertion

The etiopathogenesis of electrocardiographic bundle branch and atrioventricular blocks is not fully understood. We investigated familial clustering of cardiac conduction defects and pacemaker insertion in the FHS (Framingham Heart Study). Additionally, we assessed familial clustering of pacemaker insertion in the Danish general population. In FHS, we used multivariable-adjusted logistic regression models to investigate the association of parental atrioventricular block (PR interval, ≥0.2 s), complete bundle branch block (QRS, ≥0.12 s), or pacemaker insertion with the occurrence of cardiac conduction abnormalities in their offspring. The Danish nationwide administrative registries were interrogated to assess the relations of parental pacemaker insertion with offspring pacemaker insertion. In FHS (n=371 cases with first-degree atrioventricular block, complete bundle branch block, or pacemaker insertion, and 1471 age- and sex-matched controls), individuals with at least 1 affected parent with a conduction defect had a 1.65-fold odds (odds ratio, 95% CI, 1.32-2.07) for manifesting an atrioventricular block and a 1.62-fold odds (95% CI, 1.08-2.42) for developing a complete bundle branch block. If at least 1 parent had any electrocardiographic conduction defect or pacemaker insertion, the offspring had a 1.62-fold odds (95% CI, 1.31-2.00) for experiencing any of these conditions. In Denmark (n=2 824 199 individuals; 5397 incident pacemaker implantations), individuals with at least 1 first-degree relative with history of pacemaker insertion had a multivariable-adjusted 1.68-fold (incidence rate ratio, 95% CI, 1.49-1.89) risk of undergoing a pacemaker insertion. If the affected relative was ≤45 years of age, the incidence rate ratio was markedly increased to 51.0 (95% CI, 32.7-79.9). Cardiac conduction blocks and risk for pacemaker insertion cluster within families. A family history of conduction system disturbance or pacemaker insertion should trigger increased awareness of a similar propensity in other family members, especially so when the conduction system disease occurs at a younger age.

Effective Use of PEC I and PEC II Blocks for Subcutaneous Cardiac Pacemaker Insertion: A Case Series

Effective Use of PEC I and PEC II Blocks for Subcutaneous Cardiac Pacemaker Insertion: A Case Series

The influence of cholinesterase inhibitor therapy for dementia on risk of cardiac pacemaker insertion: a retrospective, population-based, health administrative databases study in Ontario, Canada.

BackgroundCholinesterase inhibitors are used to treat the symptoms of dementia and can theoretically cause bradycardia. Previous studies suggest that patients taking these medications have an increased risk of undergoing pacemaker insertion. Since these drugs have a marginal impact on patient outcomes, it might be preferable to change drug treatment rather than implant a pacemaker. This population-based study determined the association of people with dementia exposed to cholinesterase inhibitor medication and pacemaker insertion.MethodsWe used data from the Ontario health administrative databases from January 1, 1993 to June 30, 2012. We included all community-dwelling seniors who had a code for dementia and were exposed to cholinesterase inhibitors (donezepil, galantamine, and rivastigmine) and/or drugs used to treat co-morbidities of hypertension, diabetes, depression and hypothyroidism. We controlled for exposure to anti-arrhythmic drugs. Observation started at first exposure to any medication and continued until the earliest of pacemaker insertion, death, or end of study.Results2,353,909 people were included with 96,000 (4.1%) undergoing pacemaker insertion during the observation period. Case–control analysis showed that pacemaker patients were less likely to be coded with dementia (unadjusted OR 0.42 [95%CI 0.41-0.42]) or exposed to cholinesterase inhibitors (unadjusted OR 0.39 [95%CI 0.37-0.41]). That Cohort analysis showed patients with dementia taking cholinesterase inhibitors had a decreased risk of pacemaker insertion (unadj-HR 0.58 [0.55-0.61]). Adjustment for patient age, sex, and other medications did not notably change results, as did restricting the analysis to incident users.ConclusionsPatients taking cholinesterase inhibitors rarely undergo, and have a significantly reduced risk of, cardiac pacemaker insertion.

P0051 : Perioperative white blood cell count as a marker for patient and graft survival after orthotopic liver transplantation

Methods: Medical records from TTR-FAP adult patients submitted to liver transplant in a single center more than eight years ago were reviewed (until December 2006, 681 LT were performed, 179 by FAP; 125 patients are still alive, 28 of them with neurological syndrome de novo). All the patients were submitted to a thorough neurological workup, and almost all had normal exams. MRIs were not performed due to protocol cardiac pacemaker insertion prior to liver transplant. Results: 28 patients (22%) developed the same transitory, sporadic “de novo” neurological symptoms such as generalized absence, drowsiness, headache, unilateral paresthesias, hemiparesis, aphasia, dysarthria, slurred speech, double vision, blurred vision, partial seizures and myoclonic, dizziness and vertigo syndrome, behavior changes and mental confusion. All patients are treated or have been in the past with calcineurin inhibitors (CNI), 26 with cyclosporine and 2 with tacrolimus; those in which CNI were suspended improved or remained without these symptoms. Antiepileptic drugs were prescribed with partial remission of the symptoms. Conclusions: Neurological syndrome de novo have a significant impact on quality of life of these patients. These symptoms may be due to the natural progression of the disease apparently due to the increased survival of these patients with the LT. We must review the immunosuppression of these patients. Further studies are needed to improve treatment and quality of life of the transplanted TTR-FAP.

Abstract 386: 30-day Readmission Rates For Patients Discharged After Insertion, Revision, Replacement And Removal Of Cardiac Pacemaker Or Cardioverter/defibrillator: Analysis Of Nationwide Inpatient Sample Data

Introduction: Hospital readmission after pacemaker or cardioverter/defibrillator procedure (insertion, revision, replacement or removal) has a major impact on quality of patient’s life and cost-effectiveness of care. However, the data for 30-day readmission for patients undergoing these procedures is very limited. Methods: We queried Agency of Healthcare Research and Quality sponsored Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) data using Clinical Classification Software procedure Code 48 for insertion, revision, replacement and removal of cardiac pacemaker or cardioverter/defibrillator, which included ICD 9 codes of 00.50, 00.51, 00.52, 00.53, 00.54, 00.56, 00.57, 17.51, 17.52, 37.70, 37.71, 37.72, 37.73, 37.74, 37.75, 37.76, 37.77, 37.78, 37.79, 37.80, 37.81, 37.82, 37.83, 37.85, 37.86, 37.87, 37.89, 37.94, 37.95, 37.96, 37.97 and 37.98 to extract data for admissions secondary to pacemaker or cardioverter/defibrillator procedure. NIS represents 20% of all hospital data in US. Data was extracted for years 2009-2011 and 30-day readmissions secondary to these procedures identified. Statistical analysis was done using chi-square to determine parameters associated with increased 30-day readmissions. Results: We identified 443,719 admission for pacemaker or cardioverter/defibrillator procedure during the study period with total 30-day readmission rate of 15.38%. Females (15.91%), patients aged more than 65 years (15.78%), patients under Medicaid (17.65%), having low median income for zip code (16.44%) and staying in metropolitan areas (15.71%) were more likely to have total 30-day readmissions than other groups (P&lt;0.01). Most common cause for readmission was congestive heart failure in 14,042 patients (20.57%), followed by complication of device in 8,244 patients (12.08%), arrhythmia in 5,750 patients (8.43%). Septicemia was responsible for readmission in 2,346 patients (3.44%) Conclusions: Strategies to reduce 30-day readmissions secondary to pacemaker or cardioverter/defibrillator procedure should be focused on more susceptible population including females, aged more than 65 years, covered under Medicaid, having low median income for zip code and staying in metropolitan areas and stringent control of risk factors for congestive heart failure and arrhythmia.

Reply

Sir: We read with great interest the comments from Dr. Persichetti and colleagues regarding our article, “Inframammary Cardiac Pacemaker Insertion in Women: An Aesthetic Alternative.”1 As the authors affirm, the placement of cardiac pacemakers in young women can be associated with unsatisfactory aesthetic outcomes and adverse psychological sequelae, and our report is one of several that describe technical modifications for placing the device under the breast mound in the subglandular or subpectoral position. The excellent outcomes using the subpectoral approach reported by Dr. Giudici and colleagues, by Dr. Persichetti and colleagues, and by others support the success of these techniques. We are very grateful indeed to the authors for sharing their technique with us and will certainly consider using this in suitable cases in the future. We strongly agree with the authors that plastic surgeons should look to work in collaboration with their cardiologist colleagues to utilize these techniques when cardiac pacemakers are required in young women to improve the aesthetic outcomes and minimize adverse psychological sequelae. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Mark Schaverien, F.R.C.S.(Plast.) Alex Munnoch, F.R.C.S.Ed.(Plast.) Department of Plastic Surgery Ninewells Hospital Dundee, United Kingdom

EComment. Surgical complications of permanent cardiac pacemaker insertion

We read with interest the manuscript by Wu and Chen and we would like to comment on the surgical complications of intracardiac pacemaker implantation [1]. The use of permanent pacemakers (PPM) and implantable cardioverter-defibrillators (ICD) is increasing due to the expansion of indications and aging of the population. As a consequence, cardiologists and cardiothoracic surgeons have to deal with a broad spectrum of complications, which are sometimes under-estimated and life-threatening. The surgical complications of PPM and ICD may occur during the immediate or early post-operative period and can be related to venous access process (pneumothorax, hemothorax, air embolism, haematoma, arterial puncture, wound healing problems, infection, pain), to the pacemaker lead (cardiac perforation, tamponade, malposition or dislodgement of the lead), or to the generator device. In addition, other complicationed that may occur during the late post-operative period are related to infections, thrombosis, endocarditis, pulmonary embolism, superior vena cava (SVC) syndrome (due to thrombus formation and/or fibrosis of the pacing wires within the SVC) and pericarditis [2-5]. Ostovan and Aslani have reported on the successful treatment of massive pulmonary air embolism during a PPM implantation with air suctioning by the guide catheter inserted into main pulmonary artery via the left femoral vein. Treatment for air embolisms includes oxygen treatment, haemodynamic support and prevention of further air entry in the systemic circulation. The left lateral decubitus position can prevent the air obstruction of the pulmonary outflow tract (air can be moved toward the right ventricular apex) [2]. Aggarwal et al. found no difference in the incidence of intraoperative and early postoperative complications (up to two months after implantation) between single and dual chamber pacing systems [3]. Sohail et al., in their retrospective review of 189 patients with pacemaker related infections, found out that the most common clinical presentations were generator pocket infection (69%) and device-related endocarditis (23%). The leading pathogens were Coagulase-negative Staphylococci and Staphylococcus aureus, in 42% and 29% of cases, respectively. There was a broad spectrum of related complications such us septic arthritis, sternal or vetebral or femoral osteomyelitis, and abscesses in lung, spleen, liver, brain and perinephric area. Twenty-two (11.6%) patients had thrombosis of the subclavian vein or superior vena cava and 6 of them developed clinical manifestations of pulmonary embolism. Ninety-eight percent of patients underwent complete device removal combined with antibiotic treatment and 96% of patients were treated successfully [4]. Nineteen patients had lead extraction via a median sternotomy and the rest underwent percutaneous lead extraction. Interventional complications were more common in patients with a history of multiple device-related procedures and were related to tricuspid valve failure, laceration of subclavian vein, hemothorax, haematoma, fracture of lead tip, ventriculotomy and bleeding [4]. Right atrial thrombosis and pulmonary embolism are infrequent complications (0.6%-3.5%) and its therapeutic modalities include anticoagulation, thrombolysis and or surgery [5]. In conclusion, the knowledge of all potential complications of the PPM/ICD and its multidisciplinary approach is very important for its prevention and definitive treatment. Conflict of interest: none declared

Pneumopericardium With Cardiac Tamponade as a Complication of Cardiac Pacemaker Insertion One Year After Procedure

Background: Lead dislodgement has been shown to be the most common complication in the first 30 days after pacemaker insertion. Although it is rare, pneumopericardium with tamponade can also result. Objectives: We present a case of an extremely rare delay from cardiac pacemaker insertion to lead migration with resulting pneumopericardium and cardiac tamponade. Case Report: A 65-year-old woman with a past medical history significant for congestive heart failure, chronic obstructive pulmonary disease, and third-degree heart block, requiring pacemaker insertion 2 years prior with a revision 1 year prior, presented to the Emergency Department complaining of sudden-onset pleuritic chest pain. Her work-up revealed a pneumopericardium with atrial pacemaker lead migration into the right middle lobe of the lung. She suddenly developed hypotension and respiratory distress and required pericardiocentesis and, ultimately, surgical repair for a perforated right atrium. Conclusion: Pacemaker migration can lead to pneumopericardium and tamponade, even up to 1 year after placement.

Right Ventricular Outflow Tract Pacing: An Alternative, Safe, and Effective Pacing Site

The right ventricular apex (RVA) has traditionally been preferred for the insertion of permanent cardiac pacemaker leads because of vast experience with their use, their ease of implantation, and the stability of passive fixation leads in the RVA trabeculae. However, prolonged RVA pacing is associated with progressive left ventricular dysfunction due to dysynchronous ventricular activation, and often results in substantial functional, hemodynamic, electrical, and structural changes, as previously demonstrated in many studies. Only in recent years has interest in the use of alternate pacing sites developed. The right ventricular outflow tract (RVOT) is now the preferred site of pacing because of potential advantages such as ease of application, better hemodynamics, synchronous activation, fewer myocardial perfusion defects, and a narrower QRS complex compared with RVA pacing. This review article comprehensively discusses this novel technique in terms of its beneficial effects, long-term safety, and performance measures compared with RVA pacing, and as an alternative method for biventricular pacing.

Bradicardia asociada a crisis epilépticas: Casos clínicos

Cardiac rate and rhythm due to autonomic activation, may occur during epileptic seizures. They are probably a consequence of the spreading seizure activity to structures involved in the autonomic control of cardiac rhythm. Sinus tachycardia is the most frequent finding (90%). letal bradycardia is rare and Ufe threatening asystoles require cardiac pacemaker insertion. We report two patients with a right frontal seizure associated to bradycardia, during simultaneous EEG/ECG monitoring. Interictal autonomic function tests showed preserved sympathetic and cardiac vagal responses. Normal interictal autonomic function tests, suggested a transient failure of sympatho-vagal balance .

Cardiac pacemaker treatement of heart block in Enugu: a 5 year review

Symptomatic heart block is a treatable cardiac cause of death which occurs globally. In Nigeria it is increasingly diagnosed and treated with permanent artificial cardiac pacemaker insertion and pulse generator implantation, sometimes after a period of misdiagnosis and inappropriate treatment. Twenty-three patients who were diagnosed with symptomatic heart block and surgically treated with permanent artificial cardiac pacemaker in National Cardiothoracic Centre, Enugu, between April 2001 and March 2006 had their case notes retrospectively reviewed and information entered into a proforma. This was analyzed. Patients diagnosed with symptomatic heart block but not treated with artificial cardiac pacemaker insertion were excluded from the study. There were eight such patients who could not afford the cost of surgical treatment during the period under review. The mean age of the patients was 70 years and the commonest presentation was shortness of breath (100%). Hypertensive heart disease was present in 65% of the patients and a history of chronic chloroquine usage was positive in 73% of the patients. Predominant pretreatment pulse rate was in the range of 30-40 per minute (43%) while 21% of the patients had pulse rate below 30 per minute. These categories of patients commonly had Stoke-Adams syndrome. Sixty-seven per cent of the patients had predominantly systolic hypertension on admission and 16% had hypotension. Third degree heart block was present in 65% of the patients and 89% of all patients needed pre-pacing haemodynamic stabilization with positive inotropic/chronotropic drug(s). Treatment consisted of permanent endocardial pacing in 65% and epicardial pacing in 35% of the patients with equally good response in symptoms, haemodynamic parameters and electrocardiographic features. Permanent artificial cardiac pacing is, the reliable treatment of symptomatic heart block and should be included in the National Health Insurance Scheme list.

Absence of Device‐Device Interaction (DDI) in a Patient with Cardiac and Diaphragmatic Pacemakers for Congenital Central Hypoventilation Syndrome

Autonomic control of ventilation is impaired in patients with Ondine's curse or congenital central hypoventilation syndrome (CCHS), but voluntary control remains intact. Bradyarrhythmias can be life threatening. In a patient with CCHS and long sinus pause requiring cardiac pacemaker insertion, a diaphragmatic pacemaker inserted in early childhood caused diaphragmatic pacer spikes observed during the interrogation of the cardiac pacemaker. Diaphragmatic pacing did not interfere with the cardiac pacemaker function.