Permanent Cardiac Pacemaker Implantation Research Articles

His-Purkinje system pacing reduced tricuspid regurgitation in patients with persistent atrial fibrillation after left-sided valve surgery.

Tricuspid regurgitation after left-sided valve surgery was a common and difficult problem. Atrial fibrillation was considered to be an important etiology of tricuspid regurgitation. His-Purkinje system pacing (HPSP) was a physiological pacing method, which could prevent and treat heart failure and might reduce tricuspid regurgitation. Our study aimed to investigate the effect of HPSP on tricuspid regurgitation in patients with persistent atrial fibrillation after left-sided valve surgery. This study was a retrospective study. The 3-year patient review focused on those who underwent permanent cardiac pacemaker implantation of HPSP after mitral valve and/or aortic valve replacement from Jan 1st, 2019 to Jan 1st, 2022. HPSP included His bundle pacing (HBP) or left bundle branch pacing (LBBP). Clinical data collected included electrocardiogram, pacing parameters, ultrasonic cardiogram parameters and chest x-ray at implantation and 3-month follow up. Univariate and multivariate linear regression analysis of tricuspid regurgitation velocity were performed. A total of 44 patients was retrospectively reviewed. Eight patients who had undergone implantation of HPSP after left-sided heart valve replacement were enrolled in the study. All patients had persistent atrial fibrillation. Three of them received HBP and five underwent LBBP. At 3-month follow-up, the tricuspid regurgitation grade was significantly lower than that before implantation (P = 0.007). The tricuspid regurgitation velocity significantly decreased (317 ± 74 cm/s vs. 261 ± 52 cm/s, P = 0.022) and tricuspid valve pressure gradient (PG) reduced (42 ± 21 mmHg vs. 28 ± 10 mmHg, P = 0.040). The cardiothoracic ratio of patients was significantly lower than that before implantation (0.61 ± 0.08 vs. 0.64 ± 0.09, P = 0.017). The NYHA classification of patients also improved (P = 0.013). In multivariate liner regression analysis, the pacing ratio (β = 0.736, P = 0.037) was an independent determinant of tricuspid regurgitation velocity variation. HPSP might reduce tricuspid regurgitation and improve cardiac function in patients with persistent atrial fibrillation after left-sided valve surgery.

Determinants and prognostic value of in-hospital infection in patients waiting for permanent pacemaker implantation

BackgroundIn-hospital delays in permanent cardiac pacemaker (PPM) implantation are common and may result in in-hospital infection among patients waiting for PPM implantation (pre-PPM-HI). This study investigated the predictors and prognostic impact of these events. MethodsWe retrospectively evaluated 905 consecutive patients (68.2 ± 16.0 years; 54% males) who underwent PPM implantation. Clinical characteristics, pre-PPM-HI and 30-day mortality were recorded and a risk score for pre-PPM-HI was generated using multivariable logistic regression coefficients. ResultsEigthy-nine patients (10% of the sample) developed pre-PPM-HI. Multivariable logistic regression analysis identified urinary catheter use, complete atrioventricular block, implantation of temporary pacemaker and diabetes mellitus as independent predictors of pre-PPM-HI. The generated score (range 0–10.1) played a better role in predicting pre-PPM-HI than individual factors, yielding an area under the curve [95%CI] of 0.754 [0.705–0.803]. Patients with score ≥ 7.5 had 18-fold greater risk of developing pre-PPM-HI than those with score < 2.5. Furthermore, multivariable Cox-regression analysis showed that patients who developed pre-PPM-HI had greater 30-day mortality after PPM implantation (hazard ratio [95%CI] = 2.90 [1.18–7.16], p = 0.021) compared with their counterparts. ConclusionsThis study reveals that pre-PPM-HI is an independent predictor of early mortality after PPM implantation. In addition, a clinical score developed from simple clinical variables accurately identified patients at high risk of pre-PPM-HI. In scenarios where delays in PPM implantation are unavoidable, such as reference hospitals with high demand, the use of this tool can potentially help in the hierarchy of patients and in the reduction of this adverse event.

The success rate of His-Purkinje system pacing in patients with various sites of atrioventricular block

Objective: To evaluate the success rate of His-Purkinje system pacing (HPSP) in patients with various sites of atrioventricular block (AVB) and provide clinical evidence for the selection of HPSP in patients with AVB. Methods: This is a retrospective case analysis. 637 patients with AVB who underwent permanent cardiac pacemaker implantation and requiring high proportion of ventricular pacing from March 2016 to September 2021 in the Department of Cardiology, General Hospital of Northern Theater Command were enrolled. The site of AVB was determined by electrophysiological examination. His bundle pacing (HBP) was performed in the first 130 patients (20.4%) who were classified as the HBP group and HPSP included HBP and/or left bundle branch pacing (LBBP) was performed in later 507 patients (79.6%) and these patients were classified as the HPSP group. The basic clinical information such as age and sex of the two groups was compared, and the success rates of HBP or HPSP in patients with different sites of AVB and QRS intervals were analyzed. Results: The age of HBP group was (66.4±15.9) years with 75 males (57.7%). The age of HPSP group was (66.8±13.6) years with 288 (56.8%) males. Among 637 patients, 63.0% (401/637) had atrioventricular node block; 22.9% (146/637) had intra-His block; 14.1% (90/637) had distal or inferior His bundle block. Totally, the success rate of HPSP was higher than that of HBP [93.9% (476/507) vs. 86.9% (113/130), P<0.05]. In each group of patients with various AVB sites, the success rate of HPSP was higher than that of HBP respectively and both success rates of HBP and HPSP showed a declining trend with the distant AVB site. The success rate of HBP in patients with atrioventricular node block and intra-His block was higher than that in patients with distal or inferior His bundle block [95.2% (79/83) vs. 47.1% (8/17), P<0.001; 86.7% (26/30) vs. 47.1% (8/17), P=0.010]. The success rate of HPSP was higher than that of HBP in patients with distal or inferior His bundle block [87.7% (64/73) vs 47.1% (8/17), P=0.001]. In patients with QRS<120 ms, 94.9% (520/548) of AVB sites were in atrioventricular node or intra-His, and HBP had a similar high success rate with HPSP [95.6% (109/114) vs. 96.3% (418/434), P=0.943] in these patients. In patients with QRS ≥ 120 ms, 69.7% (62/89) of AVB sites were at distal or inferior His bundle, and the success rate of HBP was only 25.0% (4/16), while the success rate of HPSP was as high as 79.5% (58/73), P<0.001. Conclusions: In patients with QRS<120 ms and atrioventricular node block or intra-His block, success rates of HBP and HPSP are similarly high and HBP might be considered as the first choice. In patients with QRS ≥ 120 ms and AVB site at distal or inferior His bundle, the success rate of HPSP is higher than that of HBP, suggesting LBBP should be considered as the first-line treatment option.

Effect of Continuation Care on Self-care Ability and Quality of Life of Patients Undergoing Permanent Artificial Cardiac Pacemaker Implantation

Effect of Continuation Care on Self-care Ability and Quality of Life of Patients Undergoing Permanent Artificial Cardiac Pacemaker Implantation

Learning curve of left bundle branch area pacing with standard stylet-driven pacing leads: a single center prospective observational study in Korea

Abstract Funding Acknowledgements Type of funding sources: None. Background Although cardiac pacing is an essential therapy for bradycardia, conventional right ventricular pacing (CRVP) can cause electrical-mechanical dyssynchrony. Left Bundle Branch Area Pacing (LBBAP) is a new conduction system pacing strategy that includes a normal conduction system and therefore maintains synchronous ventricular contraction. Most of the experience with LBBAP is done in a lumen-less lead with fixed helix design, and this device is not available in sometimes. Purpose This study aimed to evaluate the learning curve of LBBAP using standard stylet-driven lead with extendable helix design. Methods This study enrolled patients who underwent permanent cardiac pacemaker implantation at a University Hospital in South Korea from December 2020 to October 2021. LBBAP was performed with a 5.6Fr stylet-driven pacing lead with an extendable helix. The learning curve was assessed by analyzing fluoroscopy time and procedure time. Results In 65 patients who underwent LBBAP during the observation period, mean fluoroscopy time and procedural time were 17.1 ± 17.2 minutes and 64.2 ± 33.5 minutes, respectively in this study. The learning curve for achieving LBBAP appears to plateau after around 24th case with a progressive reduction in procedure time. This is a significantly shorter period of time when compared to the previously reported learning curves of his bundle pacing (30-50cases), previously developed conduction system pacing strategy. Conclusion During initial experience with LBBAP, fluoroscopy and procedural time continue to improve with operator experience. For physicians who are experienced at cardiac pacemaker implantation, the steepest part of the learning curve of LBBAP appears to be over the first 20-25 cases.

Image Mosaic Algorithm-Based Analysis of Effects of Low-Dose X-Rays on Blood Immune Cells

This work aimed to explore the effects of image mosaic algorithm- (IMA-) based low-dose X-rays on deoxyribonucleic acid (DNA) damage of peripheral blood lymphocytes in cardiovascular patients. 84 patients with interventional cardiovascular surgeries were selected as the research objects and divided into coronary intervention surgery (A) group, coronary angiography (B) group, radiofrequency ablation (C) group, and permanent cardiac pacemaker implantation (D) group. They were treated with IMA-based low-dose X-rays, DNA damage indicators of lymphocytes were detected, and the relationship was analyzed between those indicators and radiation dose. Results showed that the cumulative dose (CD) and dose area product (DAP) of group A were the lowest, and those of group D were obviously higher than those of the other three groups ( P &lt; 0.01 ). Besides, the results also showed that the values of CD and DAP of patients from group A and group D were 0.38 ± 0.08 (Gy) and 0.38 ± 0.08 (Gy/cm2) and 1.37 ± 0.21 (Gy) and 1.37 ± 0.21(Gy/cm2), respectively. The comet tail DNA content (TDNA) and tail moment (TM) of each group after surgery increased dramatically compared with before surgery ( P &lt; 0.01 ), and the TDNA and TM of group D were greatly higher than those of the other three groups ( P &lt; 0.01 ). Therefore, TDNA and TM were markedly positively correlated with DAP and CD ( P &lt; 0.01 ). IMA-based X-ray radiotherapy caused reliable DNA damage to peripheral blood lymphocytes of cardiovascular patients, and the greater the radiation dose, the more serious the DNA damage.

Correlation between Deep Venous Thrombosis and Inflammation in Patients after Implantation of Permanent Pacemaker

The correlation between postoperative deep venous thrombosis (DVT) and inflammation in patients with permanent cardiac pacemaker implantation was analyzed. A total of 130 cases undergoing permanent pacemaker implantation in the 305 Hospital of Chinese PLA and Fuwai Hospital from May 2014 to February 2017 were selected. Of the 130 cases, 60 patients complicated with DVT were selected as the observation group, and the remaining 70 cases without complications of DVT were selected as the control group. The relationship and influence of various factors were explored. The number of patients smoking and the number of subjects with DVT history in the observation group were higher than those in the control group. In the observation group, plasminogen activator inhibitor (PAI)-1: Ag, PAI-1: Ac, thrombin-activated fibrinolysis inhibitor (TAFI): Ag, and TAFI: Ac levels were higher than those in control group (P<0.05). The levels of inflammatory factors of the peripheral blood of the observation group were significantly higher than those of the control group (P<0.05). In the correlation analysis of serum inflammatory factors and coagulation factors, CRP, IL-6, IL-10 were positively correlated with PAI-1: Ag level. Age, BMI, smoking history, number of implanted electrodes, DVT history, duration of immobilization and inflammatory factor levels had independent predictive value on postoperative complicated DVT. The serum inflammatory factors are closely associated with postoperative DVT in patients implanted with permanent cardiac pacemaker, and the serum inflammatory factors are a good reference for the evaluation of DVT.

Case of successful treatment of second-degree AV block in patient with gastroesophageal reflux disease associated with hiatal hernia

Clinical observation of a young patient without an organic pathology of the heart, who repeatedly sought medical help in connection with complaints of episodes of dizziness, lability of blood pressure and pulse numbers, is presented. The medical survey revealed a link between clinical symptoms and progressive retardation of AV conduction (from first-degree AV block to second-degree Mobitz II), and therefore the patient was recommended to be implanted with permanent artificial cardiac pacemaker. To clarify the nature of the conduction disorders, an invasive electrophysiology study was performed, which revealed a proximal AV block due to vagal influences. As the most likely cause of stimulation n. vagus was considered identified in a patient gastroesophageal reflux disease associated with hiatal hernia. Surgical treatment (laparoscopic fundoplication) led to a regression of the clinical and electrocardiographic picture, avoiding the implantation of permanent artificial cardiac pacemaker. The tactic chosen is consistent with the algorithm for managing patients with AV conduction abnormalities (2018 ACC / AHA / HRS Guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay), which involves eliminating potentially reversible causes of bradyarrhythmia before deciding whether to install permanent artificial cardiac pacemaker.

Bradidisrritmia puramente iatrogénica…existe?

IntroductionIn iatrogenic or potentially reversible bradyarrhythmia, drug discontinuation or metabolic correction is recommended before permanent cardiac pacemaker (PM) implantation. These patients often have conduction system disease and there are few data on recurrence or the need for a permanent PM. ObjectiveTo analyze the need for PM implantation in patients with iatrogenic bradyarrhythmia or bradyarrhythmia associated with other potentially reversible causes. MethodsWe assessed consecutive symptomatic patients admitted to the emergency department with a primary diagnosis of bradyarrhythmia (atrioventricular [AV] node disease – complete or second‐degree AV block (AVB) [CAVB: 2nd‐degree AVB – 2:1], sinus bradycardia [SB] and atrial fibrillation [AF] with slow ventricular response [SVR]) in the context of iatrogenic causes or metabolic abnormalities. We determined the percentage of patients who required PM implantation. ResultsWe studied 153 patients (47% male) admitted for iatrogenic or potentially reversible bradyarrhythmia. Diagnoses were SB 16%, CAVB 63%, second‐degree AVB 12%, and AF with SVR 10%. Eighty‐five percent of patients were under negative chronotropic therapy, 3% had hyperkalemia and 12% had a combined etiology. After correction of the cause, 55% of patients (n=84) needed a PM. In these patients the most common type of bradyarrhythmia was CAVB, in 77% (n=65) patients. ConclusionIn a high percentage of patients with bradyarrhythmia associated with a potentially reversible cause, the arrhythmia recurs or does not resolve during follow‐up. Patients with AV node disease constitute a subgroup with a higher risk of recurrence who require greater vigilance during follow‐up and should be considered for PM implantation after the first episode.

Permanent cardiac pacing for patients with iatrogenic or potentially reversible bradyarrhythmia

Abstract Introduction Introduction: In iatrogenic or potentially reversible bradyarrhythmia, drug discontinuation or metabolic correction is recommended before permanent cardiac pacemaker (PM) implantation. These patients often have conduction system disease and there are few data on recurrence or the need for a permanent PM. Objective To analyze the need for PM implantation in patients with iatrogenic bradyarrhythmia or bradyarrhythmia associated with other potentially reversible causes. Methods We assessed consecutive symptomatic patients admitted to the emergency department with a primary diagnosis of bradyarrhythmia (atrioventricular [AV] node disease – complete or second-degree AV block (AVB) [CAVB: 2nd-degree AVB – 2:1], sinus bradycardia [SB] and atrial fibrillation [AF] with slow ventricular response [SVR]) in the context of iatrogenic causes or metabolic abnormalities. We determined the percentage of patients who required PM implantation. Results We studied 153 patients (47% male) admitted for iatrogenic or potentially reversible bradyarrhythmia. Diagnoses were SB 16%, CAVB 63%, second-degree AVB 12%, and AF with SVR 10%. Eighty-five percent of patients were under negative chronotropic therapy, 3% had hyperkalemia and 12% had a combined etiology. After correction of the cause, 55% of patients (n=84) needed a PM. In these patients the most common type of bradyarrhythmia was CAVB, in 77% (n=65) patients. Conclusion In a high percentage of patients with bradyarrhythmia associated with a potentially reversible cause, the arrhythmia recurs or does not resolve during follow-up. Patients with AV node disease constitute a subgroup with a higher risk of recurrence who require greater vigilance during follow-up and should be considered for PM implantation after the first episode.

Using quality indicators to compare outcomes of permanent cardiac pacemaker implantation among publicly and privately funded patients.

Funding source/insurance status has been associated with disparity in the management and outcomes of cardiovascular disease, with poorer outcomes among disadvantaged groups. Using proposed quality indicators for permanent pacemaker (PPM) implantation and administrative data, this study aimed to determine whether quality indicator-based outcomes of PPM implantation were comparable for publicly and privately funded patients within Australia's two-tier health system. A population-based cohort study of adults implanted with a PPM between 1995 and 2009 in Western Australia. The association of funding outcomes derived from linked administrative data was tested in multivariate logistic regression models. There were 9748 PPMs implanted, 48% being among privately funded patients. The mean age was 75 years for both public and private patients. Private patients had better health status (fewer with cardiac conditions and lower non-cardiac comorbidity scores), were less likely to be an emergency admission (33% vs 60%, P < 0.001) and more likely to have dual- or triple-chamber pacing. Mean length of stay was significantly greater for private patients (4.3 (standard deviation 6.3) vs 5.1 (6.8) days <0.001), related to longer elective admissions. Crude mortality was lower for private patients in-hospital (0.7 vs 1.3%), 30-day post-procedure (1.3 vs 2.1%) and at 1 year (7.3 vs 9.5%). Emergency admission, comorbidity and other demographic and clinical factors, not funding source, were significant predictors of these outcomes. There was no difference between publicly and privately funded patients in study outcomes, after adjustment for demographic and clinical factors. The exception was longer hospital stay for elective PPM among privately funded patients.

The nature and course of illness perception following cardiac pacemaker implantation: A self‐regulatory approach

This study was designed to explore the relationship between illness perceptions and educational intervention based on the Leventhal's model in pacemaker patients. Fifty-one consecutive patients who were admitted for implantation of permanent cardiac pacemaker were recruited to receive an educational intervention, which consisted of two sessions delivered in the hospital and clinic, respectively. Participants completed a pacemaker-specific Brief Illness Perception Questionnaire (BIPQ) twice, one prior to educational intervention and the other 10 weeks following the pacemaker implantation. Data regarding the dimensions of cognitive and emotional representations based on the Leventhal's model have demonstrated the relationship between the patients' perception before and after the educational intervention. Overall, after the educational intervention, the patients have considered the illness as having a moderate impact on their life and have known their illness as a chronic condition that was responsive to treatment and influenced by personal behavior. Participants believed they had a good understanding of their illness and had less 'concern' and 'emotional representation'. Based on the results of the present study, pacemaker patients had a more benign view about their illness after educational intervention compared with before this intervention. These explanations might affect the acceptance and treatment seeking and even lead to lower complications.

PP150. Pregnancy outcome in women with heart disease in a single tertiary care center

The number of women presenting with cardiac disease during pregnancy is increasing because more women with repaired congenital heart disease are reaching childbearing age and because of more pregnancies occurring in women with ischemic heart disease. Cardiac disease is the leading cause of indirect maternal mortality in the Netherlands. Clinical data of pregnant women with heart disease that received obstetric care and delivered in our center have been obtained with the intention to evaluate the cardiac and obstetric pregnancy outcomes and to provide data for local counseling and management guidelines. Data were collected from all pregnant women with congenital or acquired heart disease who delivered between 2000 and 2010 in the VU University Medical Center Amsterdam. At least one consultation of a cardiologist during pregnancy was advised. The maternal outcomes of these pregnancies were evaluated. Data of 122 women with 160 pregnancies were obtained. In this study the main heart diseases in pregnancy were congenital heart disease (n=75.61%) and arrhythmia (n=22.18%). Rheumatic heart disease was accountable for 6% (n=7) and ischemic heart disease for 4% (n=5) of inclusions. Based on the functional criteria of the New York Heart Association (NYHA), 114/122 patients (93.4%) were classified NYHA Class I-II. Patients in NYHA Class III-IV (n=8/122, 6.6%), mainly had a history of myocardial infarction or pulmonary hypertension. Of all the women, 35 had cardiac surgery before pregnancy, mainly repair of congenital heart disease. In women with acquired heart disease the interventions before pregnancy included permanent cardiac pace-maker implantation (n=2), radiofrequency catheter ablation (RFCA) (n=4) and percutaneous transluminal coronary angioplasty or coronary artery bypass graft (n=4). There were 156 singleton and 4 twin pregnancies. Termination of pregnancy was performed in 3 cases; 1 for maternal cardiac and 2 for obstetric indications. There were 156 life-births of which 100 (64.1%) were spontaneous vaginal deliveries, 17 (10.9%) operative vaginal deliveries and 39 (25%) cesarean sections: 9 for maternal cardiac indication and 30 for obstetric reasons. 36 (36%) women received epidural analgesia during labor and delivery. Cesarean section under general anesthesia was performed in 14 cases (7 for maternal cardiac indication); 25 were performed under spinal/epidural anesthesia. Induction of labour occurred in 48 pregnancies: 10 for maternal cardiac indications and 38 for other maternal and fetal indications. 28 (17.5%) pregnancies were complicated by hypertensive disorders. Cardiac complications such as heart failure developed in 15 (9.4%) pregnancies. There were two maternal deaths (1.6%). Congenital heart disease is the type of heart disease that has the highest incidence in pregnancy, while main types of heart disease that lead to impaired cardiac function during pregnancy are ischemic disease and pulmonary hypertension. Incidence of pregnancy induced hypertensive disorders is increased in women with preexistent cardiac disorders. Maternal outcome is generally favourable for women with cardiac heart in NYHA class I/II.

Tools for Guiding Clinical Practice From the American Heart Association and the American College of Cardiology

Every day, clinicians face difficult decisions on how best to manage a given patient. Important decisions include selection of the appropriate diagnostic tests, procedures, and/or treatments to improve a patient’s outcomes. Ideally, these decisions should be informed and guided by the best medical evidence. In reality, however, clinical practice tends to be highly variable.1 Concerned that a lack of standards for pacemaker implantation was leading to potential overutilization, governmental regulators asked the American Heart Association (AHA) and American College of Cardiology (ACC) in 1984 to evaluate the available evidence and develop recommendations for practice. This led to what became their first clinical practice guideline (CPG).2 Since then, the work of the ACC/AHA Task Force on Practice Guidelines has expanded markedly, currently monitoring ≈17 CPG areas (with a major focus on disease management) and determining when revisions or updates are needed to accurately reflect the evolution of evidence in cardiovascular care. Article p 1330 The process for developing CPGs was outlined in 2003.3,4 The core focus of CPG writing committees is to review and summarize the evidence in the medical literature, relying heavily on randomized controlled trials (RCTs) and when these are not available to turn to other data sources including other forms of trials, meta-analyses, and registry data. The recommendations put forth in a CPG are rigorously classified according to whether a test, procedure, or other treatment is “useful and effective” in a given setting, as well according to the level of evidence supporting this view.3 A notable example of the effort of the Task Force on Practice Guidelines to provide timely responses to a rapidly changing evidence base has been the development of focused updates, the first 3 of which dealt with ST-elevation myocardial infarction, percutaneous coronary intervention, and chronic stable angina, responding to the …

Early Detection of Perforation of the Right Ventricle by a Permanent Pacemaker Lead

Ventricular perforation is a rare complication of permanent cardiac pacemaker implantation. We report here on a 68-year-old woman with a dual chamber permanent pacemaker that had been implanted one month earlier, and she suffered cardiac perforation from the pacemaker lead. Frequent follow-up via12-lead surface electrocardiography and chest radiography and the proper work-up for pacemaker implantation are needed for detecting rare complications after pacemaker implantation. (Korean Circulation J 2007;37:453-457)

Radiation Doses to Patients and Cardiologists from Permanent Cardiac Pacemaker Implantation Procedures

The purpose of this study was to determine the patient and cardiologist doses during the implantation of permanent cardiac pacemakers under fluoroscopic control. For 55 procedures concerning three different types of pacemakers (DDD, VDD, and VVI), the dose-area product (DAP) meter readings and fluoroscopy times were recorded. From these data, the dose to the operating cardiologist was estimated. The median values of DAP and fluoroscopy time for all the procedures monitored were 11.4 Gycm(2) and 6.6 minute, respectively. For the 22 DDD, 21 VDD, and 12 VVI pacemakers implanted, the respective DAP median values were 14.7, 9.9, and 7.3 Gycm(2) and the respective median fluoroscopy times were 8.4, 5, and 2.9 minutes. The median doses to the hands, chest, eyes, and legs of the cardiologist conducting the manipulations were estimated to 0.21, 0.06, 0.03, and 0.11 mGy, respectively, per procedure. Compared to the existing literature, the median DAP value of this study is almost identical to the 11.2 Gycm(2) reported from a sample of 627 patients in 17 different x-ray rooms, whereas the fluoroscopy times are within the range of values reported by other authors. Concerning the cardiologist exposure, the estimated values indicate that the implantation of pacemakers is a procedure that does not involve a severe risk, especially if it is taken into account that lead aprons and collars are routinely used.

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Tiroidektomi Sonrası Gelişen Hiportiroidiye Bağlı Ortaya Çıkan Bir Tam Kalp Bloku Olgusu

A Case Report with Complete Heart Block Related with Hypothyroidism Emerging After Thyroidectomy The development of complete heart block is very rare in hypothyroid patients. A 22 year-old female patient was accepted to our clinic with the symptoms of the dizziness and easy fatigue. It was learned that she had these complaints after the thyroidectomy operation performed 11 months ago because of the cosmetic reasons. She was not using any drug that affects the heart rate. In her physical examination the pulse rate was measured as 34/min. Blood pressure was 90/60 mmHg. Electrocardiographic examination showed the complete heart block. Echocardiographic examination was normal except minimal mitral regurgitation. The biochemical examination showed that thyroid hormones decreased significantly [FT3:1.86 pg/ml (N:2.30-4.20) FT4:0.48 ng/ml (N:0.80-1.50)], TSH was found very high [169.5 IU/ml (N:0.35-5.50 IU/ml)]. Thyroid replacement therapy was begun and the dosage was increased gradually. The hormone levels reached to normal levels at the second month of the therapy (FT3:3.44 pg/ml. FT4:1.78 ng/ml, TSH:0.28 IU/ml). But in spite or these values, me heart block persisted and the permanent cardiac pacemaker implantation was planned and suggested to the patient. But she refused this decision and was discharged from the hospital with her own request. It was learned from her relatives with phone that approximately four months later after her discharge she died suddenly in her home. In conclusion, it can be thought Hipotiroidili hastalarda tam kalp bloku gelismesi cok nadirdir. Yirmi iki yasindaki bayan hasta bas donmesi ve cabuk yorulma nedeniyle klinigimize kabul edildi. Hastanin kozmetik nedenlerden dolayi 11 ay once yapilan tiroidektomi operasyonundan sonra bu sikayetlerinin oldugu ogrenildi. Kalp hizini etkileyen herhangi bir ilac kullanmiyordu. Fizik muayenesinde nabiz hizi 34/dk. kan basinci 90/60 mmHg alindi. EKG'de tam kalp bloku mevcuttu. Ekokardiyografik inceleme hafif mitral yetmezligi disinda normal bulundu. Biyokimyasal inceleme uroid hormonlarinin onemli derecede dustugunu [FT3:1.86pg/ml (N:2.30-4.20), FT4:0.48 ng/ml (N:0.80-1.50)] ve TSH'in cok yuksek [TSH: 169.5 TU/ml (N:0.35-5.50 IU/ml)] oldugunu gosterdi. Tiroid replasman tedavisi baslandi ve doz dereceli olarak artirildi. Hormon duzeyleri tedavinin 2. ayinda normal duzeylere ulasti (FT3-.3.44 pg/ml, FT4:1.78 ng/ml, TSH0.28 IU/ml). Fakat bu degerlere ragmen kalp bloku sebat edince, kalici kalp pili takilmasi planlandi ve hastaya onerildi. Fakat hasta bu karan reddetti ve kendi istegiyle taburcu edildi. Hastanin taburcu olduktan yaklasik 4 ay sonra evde aniden oldugu telefonla hasta yakinlarindan ogrenildi. Sonuc olarak, hormon degerlerinin normale donmesine ragmen, hipotiroidiye bagli gelisen tam kalp blokunun hormon tedavisine direncli, olabilecegi dusunulebilir. Tam kalp bloku, iletim sistemindeki kalici hasardan dolayi normal sinus ritmine donmeyebilir. Mumkun olan en kisa bir surede kalici kalp pili takilmazsa sonuc fatal olabilir.

Prophylactic Mezlocillin-Netilmicin Combination in Permanent Transvenous Cardiac Pacemaker Implantation: a Single-Center, Prospective, Randomized Study

A prospective, randomized study was carried out in order to assess the efficacy and safety of the mezlocillin-netilmicin combination in the prophylaxis of first permanent transvenous cardiac pacemaker implantation. Five hundred and fifty-two consecutive patients were randomly administered either 2 g mezlocillin and 200 mg netilmicin both as an i.v. bolus before implantation or 2g mezlocillin before and then 6 and 12 hours after surgery and 200 mg netilmicin before and then 12 hours after implantation. No adverse events were seen. Neither pocket nor electrode infections were observed in the 457 subjects still alive (mean follow-up: 29.2 months) or in patients who died after 1 year of follow-up (mean follow-up: 20.1 months) or before this time (mean follow-up: 4.7 months). The serum and pocket concentrations of mezlocillin and netilmicin at the end of surgery were found to be adequate to cover microorganisms that most often cause infections, including methicillin-resistant staphylococci.

Permanent Cardiac Pacemaker Implant in the Fetal Lamb

To investigate the feasibility of permanent cardiac pacing in the fetal lamb, we attempted five implants in lambs between 100 and 115 days of gestation. The lambs were approached by a left thoracotomy done through a transverse hysterotomy in the ewe. An epicardial lead was fixed to the left ventricle. Pacing parameters were measured and the lead was connected to an Enertrax implantable pulse generator. A pouch was created for the generator deep to the latissimus dorsi. Documentation of pacing was obtained electrocardiographically; pacing faster than the fetal intrinsic rate. The muscle and the fetal skin were closed. The pacemaker was programmed to a rate of 70 in the ventricular inhibited (VVI) mode and the uterine and abdominal wall incisions were then closed. One lamb was successfully delivered by Cesarean section at term. Pacing parameters were measured at birth and one month later. There were small changes in the pacing lead function parameters as the implant progressed into the chronic phase. They were within the capacity of the generator to pace with a margin of safety. Four lambs died in utero and were delivered 5 to 26 days post-implant. We conclude that permanent cardiac pacemaker implantation is feasible in the fetal lamb and with further development, it may eventually be used in humans in the treatment of fetal congestive heart failure due to bradyarrhythmias.