Permanent Pacemaker Placement Research Articles

SINUS PAUSE SECONDARY TO ACUTE COVID-19 INFECTION

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sinus pause/arrest most commonly occurs in medication toxicity, cardiac ischemia, infiltrative or fibrotic disease of SA node, structural heart disease, PE, sleep apnea, electrolyte disturbance (hyperkalemia), Lyme disease. We present to you a case of sinus pause/arrest in a patient with COVID-19 infection. CASE PRESENTATION: Patient is a 59 year male who presented to hospital with complaints of chest pain and dyspnea. Past medical history was significant for recent COVID-19 infection one week ago. Vital signs and physical examination on presentation were normal. Initial workup including CBC, INR, PTT, CMP, troponin and EKG were normal. Chest x-ray was remarkable for reticular nodular infiltrate in the right perihilar lung field. Patient was started on IV antibiotic for suspected pneumonia. On day 1, patient started experiencing skipped heartbeats. Cardiac telemetry demonstrated multiple sinus pauses with greatest pause duration of about 5 seconds. EKG showed normal sinus rhythm without any significant ST/T wave changes, Recent transthoracic echocardiogram was normal. Upon literature review, it was noted that there were cases of severe COVID-19 infection affecting the electrical system of the heart, resulting in sinus pauses. Hence, after ruling out some of the common differential diagnosis for sinus pauses including medications, ischemia, inflammatory, infiltrative or fibrotic disease of the SA node, structural heart disease, PE, OSA (obstructive sleep apnea), electrolyte disturbance (especially hyperkalemia), Lyme disease, patient's sinus pauses were attributed to underlying COVID-19 infection. Patient was discharged with 30 days cardiac event monitor which showed sinus rhythm with no significant pauses. DISCUSSION: SA nodal dysfunction typically results from either abnormality in impulse generation by the P cells or abnormalities in conduction across perinodal transitional (T cells). Hypoxemia, cytokine storm, direct viral infiltration, myocardial inflammation are thought to be responsible for sinus pause in COVID-19 disease, although exact mechanism is not known. Patients are symptomatic when longer episodes of sinus arrest occur resulting in dizziness, syncope, and death. Asymptomatic patients with SA nodal pauses or arrest often do not require treatment. Symptomatic patients are treated with a permanent pacemaker placement. CONCLUSIONS: Moderate to severe COVID-19 infection could be an uncommon cause of sinus pauses. However, before attributing COVID-19 as a cause of sinus pauses, common differential diagnosis for sinus pauses including medications toxicity (digoxin, antiarrhythmics-procainamide, quinidine), cardiac ischemia, infiltrative or fibrotic disease of SA node, structural heart disease, PE, sleep apnea, electrolyte disturbance and Lyme disease should be ruled out. REFERENCE #1: Peigh, Graham, et al. 'Novel Coronavirus 19 (COVID-19) Associated Sinus Node Dysfunction: A Case Series'. European Heart Journal - Case Reports, vol. 4, no. FI1, Oct. 2020, pp. 1–6. Silverchair, doi:10.1093/ehjcr/ytaa132. REFERENCE #2: Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, Jain SS, Burkhoff D, Kumaraiah D, Rabbani L, Schwartz A, Uriel N. Coronavirus disease 2019 (COVID-19) and cardiovascular disease. Circulation 2020;doi: 10.1161/CIRCULATIONAHA.120.046941 REFERENCE #3: Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol 2020;17:259–260. DISCLOSURES: No relevant relationships by Luna Khanal, source=Web Response No relevant relationships by Adarsha Ojha, source=Web Response

Assessment of the effects of cardiac rhythm device implantation on right sided heart function and tricuspid valve

Abstract Objective To assess the effects of trans-tricuspid placement of permanent pacemaker (PPM), on the right-sided heart function and tricuspid valve function. Background Over the last decade there has been a significant increase in the number of cardiac device implantation as permanent pacemakers (PPM) worldwide in patients with cardiac rhythm disorders. Tricuspid regurgitation (TR) due to the endocardial lead is a known complication of this procedure, however the incidence of new or worsening TR had not been well studied. Patients and Methods We reviewed patients who underwent permanent pacemaker implantation in our cardiology department in Ain Shams University. Patients who had pacemaker implantation less than one year ago, had severe tricuspid regurgitation before implantation or had previous tricuspid valve repair were excluded. A total of one hundred patients with an echocardiographic study before and another echocardiographic study at least one year after device implantation were included in our study. TR severity was graded as (0 none/trace, 1 mild, 2 moderate, 3 severe). Results Of the 100 patients (Mean age: 53.10 ± 16.04, 50% of patients were males) 65 had DDD and 35 had VVI. Before implantation 25 patient had trace TR (grade 0) vs. 6 patients after, 75 patients had mild TR (grade 1) vs. 82 after, with no patient had moderate TR (grade 2) vs. 12 patients after. TR worsened by one grade in 25 patients, (16 patients from grade 0 to grade 1 and 9 patients from grade 1 to grade 2) and by 2 grades in 3 patients (from grade 0 to grade 2), Pvalue < 0.01. TR jet area size (Mean ± SD: 2.80 ± 0.77 before vs. 4.15 ± 1.29 after, P-value < 0.01). Also, 99 patients had normal RV size and one had dilated RV before implantation vs. 95 patient had normal RV and 5 had dilated RV (p-value= 0.097). RV size, LVEF (Mean ± SD: 56.41% ± 7.52 before vs. 55.77% ± 8.00 after), RV function by TASPE (Mean ± SD: 19.15 ± 1.00 before vs. 18.96 ± 0.96 after), RVSP (Mean ± SD: 29.48mmHg ± 5.54 before vs. 29.81 ± 5.09 after) and diastolic function by E/A ratio (Mean ± SD: 1.60 ± 0.39 before vs. 1.57 ± 0.38 after implantation) did not show significant change. Conclusion Permanent pacemaker (PPM) implantation is associated with worsening of tricuspid regurgitation. Echocardiography plays an important role in assessing and grading this condition. Further studies are needed in order to illustrate the effects of these finding on patients outcomes.

COCAINE-INDUCED COMPLETE HEART BLOCK THAT WAS REVERSED BY NALOXONE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cocaine is largely known for its abuse potential and its toxicity. We present a unique case of cocaine induced complete heart block (CHB) that resolved with IV naloxone administration. CASE PRESENTATION: 49-year-old woman with history of coronary artery disease, mechanical mitral valve, heart failure, anxiety, and depression on aspirin, warfarin, furosemide, gabapentin, citalopram, quetiapine, and clonazepampresented with 3 days history of abdominal pain, diarrhea, and vomiting. The initial vital signs showed heart rate of 32 bpm and blood pressure of 133/69 mmHg. Examination remarkable for epigastric tenderness. Initial labs were significant for WBC of 13.6 x10(3)/mcL, hemoglobin of 8.3 gm/dL, elevated creatinine of 1.24 mg/dL, BUN of 40.6 mg/dL, AST of 206 IU/L, ALT of 280 IU/L and lactic acid 3.7 mmol/L. EKG showed CHB. Urine toxicology was positive for cocaine and benzodiazepines. CT scan of abdomen and pelvis showed mild colitis. Patient was started on IV fluids, IV antibiotics for acute colitis and morphine for pain. Transvenous pacing and dopamine infusion were initiated for bradycardia and hypotension. Patient underwent permanent pacemaker placement due to persistent CHB and during the procedure, patient received fentanyl. Post procedure patient became lethargic, IV naloxone 0.4 mg was given for opioid toxicity with observed conversion of heart rhythm to normal sinus rhythm. Narcotics were discontinued. Patient was discharged in stable condition after 13 days of hospitalization. On follow up visits her EKG recordings showed normal sinus rhythm with no dependency on pacemaker. DISCUSSION: One of the very detrimental effects of cocaine toxicity is cardiovascular sequalae including tachyarrhythmias as well as bradyarrhythmias. Cocaine blocks the fast sodium current and reduces sinus node automaticity and leads to bradycardia. The treatment of tachyarrhythmia related to cocaine intoxication includes benzodiazepine which blunts the hyper sympathetic state mediated by cocaine. From literature review there is no clear guidelines in the management of cocaine induced bradyarrhythmia.Naloxone is used for opioid intoxication, thought to be competitive antagonist at opioid receptors. Our patient received IV naloxone with immediate resolution of CHB. From literature review, we found a case report on perindoprilintoxication inducing severe bradycardia and profound hypotension completely resolved with naloxone infusion. This is the first case of cocaine induced bradycardia that was treated with IV naloxone. We are not sure of the exact mechanism, but administration of naloxone has been associated with increase heart rate, cardiac output, and arterial blood pressure due to increased catecholamines. CONCLUSIONS: In conclusion, naloxone might be a possible treatment for cocaine induced CHB, but further studies are required to further elicit this observed effect. REFERENCE #1: Kariyanna PT, Jayarangaiah A, Al-Sadawi M, Ahmed R, Green J, Dubson I, McFarlane SI. A Rare Case of Second Degree Mobitz Type II AV Block Associated with Cocaine Use. Am J Med Case Rep. 2018;6(7):146-148. doi: 10.12691/ajmcr-6-7-7. Epub 2018 Aug 21. PMID: 30294672; PMCID: PMC6173318. REFERENCE #2: Robert M, De Bels D, Chaumont M, Honoré PM, Gottignies P. Angiotensin converting enzyme inhibitor intoxication: Naloxone to the rescue? Naloxone for ACE inhibitor intoxication. Am J Emerg Med. 2019 Jun;37(6):1217.e1-1217.e2. doi: 10.1016/j.ajem.2019.03.046. Epub 2019 Mar 28. PMID: 30952604. REFERENCE #3: Franklin SM, Thihalolipavan S, Fontaine JM. Sinus Bradycardia in Habitual Cocaine Users. Am J Cardiol. 2017 May 15;119(10):1611-1615. doi: 10.1016/j.amjcard.2017.02.018. Epub 2017 Mar 1. PMID: 28341362. DISCLOSURES: No relevant relationships by Oluwafemi Ajibola, source=Web Response No relevant relationships by Matthew Apedo, source=Web Response No relevant relationships by Susan Collins, source=Web Response No relevant relationships by Ayesha Iqbal, source=Web Response No relevant relationships by Pang Lam, source=Web Response

Pacemaker Lead Migration and Ventricular Perforation in a Patient Presenting with Chest Pain.

Case PresentationWe describe a middle-age male with a past medical history of second-degree atrioventricular block type II status post permanent pacemaker placement the day prior who presented to the emergency department complaining of chest pain. Electrocardiography showed a non-paced ventricular rhythm. Chest radiograph showed the ventricular pacemaker lead located distally overlying the right ventricle apical area. On further investigation, chest computed tomography showed a perforation of the ventricular wall by the pacemaker lead prompting urgent intervention by the cardiothoracic surgery team for lead replacement and right ventricular repair.DiscussionOur case illustrates the importance of timely recognition of a perforated pacemaker lead in a patient presenting with chest pain after device implantation. We additionally describe the risk factors for ventricular perforation, initial clinical presentation, and management approach.

Intrapleural Pocket for Pediatric Epicardial Pacemaker Through Right Axillary Incision

Congenital complete heart block and acquired complete heart block are serious conduction abnormalities that may necessitate permanent pacemaker placement. Small patient size and anatomy preclude transvenous pacemaker insertion and risk subcutaneous generator pocket complications. This report describes a case of placement of a pediatric bipolar epicardial pacemaker through a right axillary incision with an intrapleural polytetrafluoroethylene membrane pocket to facilitate future generator exchange.

B-PO05-033 PACEMAKER IMPLANTATION AFTER SELECTIVE ALCOHOL SEPTAL ABLATION

Complete heart block (CHB) with permanent pacemaker (PPM) placement is a known risk of alcohol septal ablation (ASA) for hypertrophic cardiomyopathy. Historically, the incidence has been around 10% in all-comer populations. However, rates of 25% are reported in centers that selectively target older, higher risk patients (pts). Understanding predictors of CHB in this evolving cohort is important. Report baseline characteristics, associated factors (AF) of PPM placement, longer-term pacing need following ASA in a high-volume HCM center. 94 consecutive pts underwent ASA from 2/2017 to 12/2020. 25 were excluded due to prior septal reduction or device. Criteria for PPM included persistent post-ASA CHB >24 hours, recurrent pacing due to 2nd degree HB/ transient CHB >24 hours. 69 pts (mean age 65.7 ± 11 years, females 53.6%) were included. 19 (27.5%) required PPM prior to discharge, 6 (31.5%) of whom were prohibitive surgical risk for myectomy (20.3% PPM rate in pts not at prohibitive surgical risk). All had reduction in peak provoked gradient (pre-procedure mean 149.8 mm Hg vs. post-procedure mean 10.5 mmHg, p<0.01) and improved NYHA class. Comparison of baseline clinical, ECG, and procedural characteristics (e.g., peak troponin and gradient reduction) yielded no AF of PPM implantation, with exception of intraprocedural CHB (OR 12.4, 95% CI 3.4 - 45.3, p<0.0001). Post procedure PR prolongation >50 ms (OR 6.1, 95% CI 1.5 - 24.5, p = 0.01), first-degree AV block with RBBB and LAFB (OR 6.1, 95% CI 1.5 - 24.5, p = 0.01) and change in QRS axis >700 (OR 5.3, 95% CI 1.4 - 18.9, p= 0.01) was also associated with PPM. At 1 month, 16 pts (84.2%) required >1% RV pacing (mean 59.2%) suggesting appropriateness of PPM implantation. At 3 months 10 pts (52.6%) required pacing (mean 52.4%) indicating some late recovery. No procedural factors were associated with PPM following ASA with exception of intraprocedural CHB. Daily ECGs identified dynamic abnormalities associated with PPM. Short term follow up suggests PPM criteria are appropriate, with longer term follow up showing some recovery. As higher risk cohorts are targeted for ASA, PPM risk factors of long term pacing will be vital.

Utilization and Outcomes of the Nikaidoh, Rastelli, and REV Procedures: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database

BackgroundAortic root translocation (Nikaidoh), Rastelli, and réparation à l’etage ventriculaire (REV) are repair options for transposition of the great arteries (TGA) with ventricular septal defects and left ventricular outflow tract obstruction (VSD-LVOTO) or double outlet right ventricle TGA type (DORV-TGA). MethodsThis retrospective study using The Society of Thoracic Surgeons Congenital Heart Surgery Database evaluates surgical procedure utilization and outcomes of patients undergoing repair of TGA-VSD-LVOTO and DORV-TGA with a Nikaidoh, Rastelli, or REV procedure. ResultsA total of 293 patients underwent repair at 82 centers (January 2010 to June 2019). Most patients underwent a Rastelli (n = 165, 56.3%) or a Nikaidoh (n = 119, 40.6%) operation; only 3.1% (n = 9) underwent a REV. High-volume centers performed the majority of the repairs. Fewer Nikaidoh than Rastelli patients had prior cardiac operations (n = 57 [48.7%] vs n = 102 [63.0%]; P = .004). Nikaidohs had longer median cardiopulmonary bypass time (227 [interquartile range (IQR), 167-299] minutes vs 175 [IQR, 133-225] minutes; P < .001) and median aortic cross-clamp times (131 [IQR, 91-175] minutes vs 105 [IQR, 82-141] minutes; P = .0015). Operative mortality was 3.1% (95% confidence interval [CI], 1.0%-7.0%; n = 5) for Rastelli, 4.4% (95% CI, 1.4%-9.9%; n = 5) for Nikaidoh, and 11.1% (95% CI, 0.3%-48.3%, n = 1) for REV. The rates of cardiac arrest, unplanned reoperation, mechanical circulatory support, prolonged ventilation, and permanent pacemaker placement were higher in the Nikaidoh population but with 95% CIs overlapping those of the other procedures. ConclusionsRastelli and Nikaidoh procedures are the prevalent repair strategies for patients with DORV-TGA and TGA-VSD-LVOTO. Most are performed at high-volume institutions, and early outcomes are similar.

Outcomes and Contemporary Trends in Surgical vs Transcatheter Aortic Valve Replacement in Patients with Chronic Obstructive Pulmonary Disease

ABSTRACT Background Chronic obstructive lung disease (COPD) is a common morbidity among patients referred for aortic valve replacement. The objective of the present study is to assess trends and outcomes of COPD patients undergoing either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) for severe aortic stenosis. Methods We analyzed the National Inpatient Sample database from January 2012 to December 2017 using the International Classification of Diseases, 9th and 10th Revision Clinical Modifications to identify all patients with COPD aged ≥50 years who underwent either TAVR or SAVR for aortic stenosis. To account for potential bias, 1:1 propensity-matched analysis was performed. Logistic regression was used for predictors of mortality in the cohort. Linear regression was used for trend analysis. Results Of the total of 95,555 cases, 40,080 underwent TAVR whereas 49,985 underwent SAVR. In-hospital mortality for the propensity-matched cohorts was higher in the SAVR cohort compared to the TAVR group (4.6% vs. 2.5%; p < 0.001). Respiratory complications were also higher in the SAVR group (7.5% vs. 3.7%; p < 0.001) but were less likely to have a permanent pacemaker placement (5.3% vs. 10.8%, p < 0.001). Length of stay (11.8 days [standard deviation (SD), 8.8] vs. 6.4 days [SD, 6.8]) and cost of stay ($244,657 [SD, $183,333] vs. $229,524 [SD, $146,994]) were favorable toward TAVR as compared to SAVR. In-hospital mortality has declined over the study period in the TAVR group from 4.8% to 1.5%. Conclusion TAVR has more favorable in-hospital outcomes in patients with COPD compared to SAVR.

Permanent pacemaker placement following valve surgery is not independently associated with worse outcomes

BackgroundPermanent pacemaker placement (PPM) is associated with morbidity following cardiac surgery. This study identified associations between PPM placement and 5-year outcomes for patients that require PPM following valvular surgery. MethodsAll patients who underwent valvular surgery at our medical center from 2011 to 2018 were considered for analysis. Multivariable analysis identified associations between PPM placement, mortality, and readmissions. Primary outcomes were operative complications and mortality. Secondary outcomes included 5-year survival and readmission. ResultsA total of 175 (4.86%) of 3602 valvular surgery patients required postoperative PPM. The PPM cohort had significantly worse baseline comorbidities, including greater Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) scores (3.8 vs 2.4 P < .0001). The PPM cohort had greater rates of blood product transfusion, prolonged ventilation, and new-onset atrial fibrillation. PPM placement was significantly associated with third-degree heart block (5.26; 95% confidence interval [95% CI], 1.00-27.53; P = .0496), ventricular fibrillation/tachycardia (3.90; 95% CI, 1.59-9.59; P = .01), and atrial fibrillation/flutter (1.53; 95% CI, 1.05-2.24; P = .03). On Kaplan-Meier estimates, 5-year survival (68.8% vs 83.1%; P = 01) was significantly reduced in the PPM cohort. Five-year all-cause readmission (60.4% vs 50.04%; P = .01) and heart failure readmission (35.5% vs 20.1%; P < .000) occurred more frequently in the PPM cohort. On multivariable Cox regression analysis, PPM placement (hazard ratio, 1.12; 95% CI, 0.84-1.50; P = .444) was not an independent predictor of mortality. On competing risk analysis, PPM (hazard ratio, 1.33; 95% CI, 0.99-1.80; P = .062) was not a predictor of hospital readmission. ConclusionsValvular surgery patients who required postoperative PPM had elevated baseline operative risk. However, PPM implantation was not associated with mortality or readmission.

Ten Years’ Experience of Transcatheter Aortic Valve Replacement at the Faculty of Medicine Siriraj Hospital: Transapical vs. Transfemoral Approach

Objective: To compare 30 days mortality and clinical outcomes between transapical transcatheter aortic valve replacement (TA-TAVR) and transfemoral transcatheter aortic valve replacement (TF-TAVR) in Thai patients who underwent transcatheter aortic valve replacement (TAVR). Materials and Methods: The observational study included 83 consecutive patients that attended the authors’ center for TAVR between January 2009 and December 2019. The patients’ baseline demographic data and surgical risks were recorded. The clinical outcomes at 30 days and one year were prespecified targets. Results: Eighty-three patients underwent TAVR at the authors’ center between 2009 and 2019, with 77% of them considered inoperable or at high surgical risk by the authors’ heart team. Of the 83 patients, 40 had a porcelain aorta (48.2%). The median Society of Thoracic Surgeons (STS) score and logistic EuroSCORE were 5.7 (4.6, 8.3) and 21.7 (15.2, 31.2), respectively. Twenty-two patients had a transapical approach (26.5%). The cardiovascular (CV) mortality rate was 2.4% at 30 days. The all-cause mortality 30-day rate and 1-year rate were 3.6% and 12.0%, respectively. Comparing between TA-TAVR and TF-TAVR, TA-TAVR had a significantly lower incidence of new permanent pacemaker placement after TAVR (p=0.032), but a longer length of hospital stay (p=0.087). There was a trend for a higher incidence of new onset atrial fibrillation in TA-TAVR. The all-cause mortality 30-day rate and 1-year rate were similar between TA-TAVR and TF-TAVR. Conclusion: In Thai symptomatic severe aortic stenosis patients, of whom most patients were considered inoperable or at high surgical risk, both TA-TAVR and TF-TAVR showed acceptable short- and long-term clinical outcomes. Keywords: Severe aortic stenosis (severe AS), Transcatheter aortic valve replacement (TAVR), Transfemoral (TF), Transapical (TA)

Meningitis and high-grade, second-degree atrioventricular block in an adolescent: causal effect or coincidence?

We describe an adolescent with Streptococcus pneumoniae meningitis and symptomatic high-grade, second-degree atrioventricular block requiring permanent pacemaker placement. It is difficult to ascertain if these two diagnoses were independent or had a causal relationship though ongoing symptoms were not present prior to the infection. Because of this uncertainty, awareness that rhythm disturbances can be cardiac in origin but also secondary to other aetiologies, such as infection, is warranted.

Cardiac Surgery Outcomes: A Case for Increased Screening and Treatment of Obstructive Sleep Apnea

BackgroundBecause of the limited published information on complications that obstructive sleep apnea (OSA) patients experience during and after cardiac surgery, we investigated OSA as a risk factor for postoperative outcomes. MethodsThis project used the Northern New England Cardiovascular Disease Study Group’s data collected between 2011 and 2017 based on The Society of Thoracic Surgeons Adult Cardiac Surgery Database Data Collections form. A retrospective analysis of 1555 patients with OSA and 10,450 patients without OSA across 5 medical centers undergoing isolated coronary artery bypass grafting, isolated valve surgery, and combined coronary artery bypass grafting valve surgery was conducted. We used 1:1 nearest-neighbor propensity score matching with no replacement to balance characteristics among patients with and without OSA. ResultsThere was a statistically significant increased risk of postoperative pneumonia, increased length of total and postoperative stay, and time to initial extubation. Two outcomes trended toward significance: intra- and postoperative intraaortic balloon pump use. Outcomes that failed to show statistical significance were surgical site infection, atrial fibrillation, cerebrovascular accident, permanent pacemaker placement, and blood products given. A chart review conducted on a subset of the study cohort revealed that more than 40% of OSA patients did not receive continuous positive airway pressure or bilevel positive airway pressure therapy postoperatively during their hospitalization. ConclusionsOur study aligns with the literature in concluding that OSA has deleterious effects on postoperative outcomes of cardiac surgery patients. Further research to better stratify OSA patients by severity are still needed. Additionally heightened awareness of the need to screen, diagnose, and properly treat patients for OSA is needed.

The association of multimorbidity to mortality in older adults after permanent pacemaker placement.

In the United States 2018 bradycardia guideline, the current class III recommendation that patients with permanent pacemaker (PPM) indications and high multimorbidity burden may not have meaningful clinical benefit from PPM therapy is based on limited data. Observational study (January 1, 2008-December 31, 2015) of adults ≥65 years (N=16,678) who underwent PPM implantation. Exposure variable: Elixhauser comorbidity number (ECN, 29 well-validated conditions). ≤1-year mortality; secondary outcome:>1-year mortality. Those who died ≤1-year were older, had a lower body mass index (BMI), and higher ECN (p<.001). Cumulative survival at 1-year was 92.3% (95% confidence interval [CI]: 91.9-92.7). One-year survival decreased by increasing ECN-with a difference at 1-year between lowest and highest ECN category of 17.3% (ECN 0-1: 97.1% [95% CI: 96.3-97.7]; ECN ≥8: 79.8% [95% CI: 77.9-81.5]). For those who survived the first year, cumulative survival at 8-years was 51.2% (95% CI=49.8-52.6) with a difference between ECN 0-1 and ≥8 of 43.4%. Increasing ECN was associated equally with ≤1-year (HR 1.28 [95% CI: 1.25-1.30]) and>1-year (HR 1.19 [95% CI: 1.17-1.20]) mortality. A predictive model including age, sex, BMI, PPM type, race, and ECN had greater discriminative ability (p<.0001) than a bedside model (age, sex) for the primary outcome. Across the heterogeneity of indications for PPM placement, multimorbidity is increasingly common. The association of multimorbidity to mortality (≤1-year,>1-year) should be routinely discussed during the shared decision-making process as an important prognostic geriatric domain variable.

Vancomycin Induced Thrombocytopenia Complicating Permanent Pacemaker Placement: A Case Report

Introduction: Vancomycin is widely used in patients with methicillin resistant staphylococcus aureus (MRSA) infections or with other infections unresponsive to other antibiotics. Vancomycin-related adverse effects, including nephrotoxicity, ototoxicity, red-man syndrome, and neutropenia have been reported. Vancomycin induced thrombocytopenia is a rare complication of vancomycin that many physicians are unaware of. When an acute decline in platelet count or bleeding occur in patients on vancomycin, vancomycin- induced thrombocytopenia should be considered. Case: We present a case of acute severe thrombocytopenia that occurred within 12 hours after vancomycin infusion in a patient that received permanent pacemaker placement. Vancomycin was discontinued and patient’s platelets returned to baseline five days after vancomycin was discontinued. Conclusion: This case report highlights the importance of physicians being aware of vancomycin induced thrombocytopenia, a rare but reversible complication of vancomycin, which if diagnosed early will lead to early discontinuation of vancomycin, early resolution of thrombocytopenia and reduced hospital stay.

Long-term outcomes of mitral valve replacement in patients weighing less than 10\u2009kg

BackgroundThe outcomes of mitral valve replacement (MVR) in pediatrics especially in the patients weighing less than 10 kg are not always favorable. This study aimed to measure long-term outcomes of MVR in our institution.MethodsNine young children weighing less than 10 kg underwent MVR with mechanical prostheses were enrolled in this retrospectively study. Kaplan–Meier survival analysis was used for the prediction of freedom from death and adverse events. Chi-square test was performed to compare outcomes for patients with different ratios of mechanical prosthesis size and body weight. Fourteen related literatures were also reviewed to support our study.ResultsAll patients received bileaflet mechanical prostheses replacement. The surgical technique varied among the patients with prostheses implanted in the intra-annular (n = 5), supra-annular (n = 1), or with a Dacron conduit segment in the supra-annular position (n = 3). The valve size/weight ratio ranged from 2.11 to 5.00. There were two early death and one late death post-operation. The mean follow-up period was 80.67 ± 63.37 months, the transvalvular gradient was 10.5 ± 1.76 mmHg (range 8 to 12) and the peak gradient of LVOT was 5.00 ± 0.64 mmHg. One (11.1%) patient underwent an immediate revision MVR after initial MVR due to the periprosthetic leak. No patients required surgical reintervention or permanent pacemaker placement during long-term follow-up.ConclusionsThe tailored surgical strategy utilized for MVR in infants resulted in reliable valve function and excellent survival. Although revision is inevitable due to somatic growth, the bileaflet mechanical prostheses displayed appropriate durability.

A minimally invasive approach for atrial and ventricular sew-on epicardial lead placement.

Permanent pacemaker (PPM) placement in pediatric patients is rare. Indications for permanent pacing in children include congenital and postsurgical atrioventricular block, symptomatic sick sinus syndrome, and select neuromuscular disorders.1,2 PPMs are traditionally placed using transvenous systems in adults and larger children. However, young children are often not suitable candidates due to their size or history of congenital cardiac surgery.

Permanent pacemaker implantation following mitral valve surgery: a retrospective cohort study of risk factors and long-term outcomes.

Conduction disturbances requiring permanent pacemaker (PPM) implantation remain a complication following valvular surgery. PPMs confer the risk of infection, tricuspid valve regurgitation and pacing-induced cardiomyopathy. Literature examining PPM placement in mitral valve surgery (MVS) is limited. Our institutional mitral valve (MV) database was retrospectively reviewed for adult patients undergoing surgery from 2011 to 2019. Patients with preoperative PPM were excluded. Patients were stratified by the receipt of PPM following their index operations. Multivariable logistic regression was performed to determine patient and operative risk factors for PPM. Subgroup analysis was performed on patients who underwent isolated MVS. Kaplan-Meier analysis and a multivariable Cox proportional hazards model were utilized to assess the association between PPM implantation and long-term survival. A total of 3391 (2991 non-PPM and 400 PPM) patients met the study criteria. Significant predictors of PPM included increased decade of age (odds ratio: 1.23; 95% confidence interval: 1.12-1.35), concomitant aortic (1.44; 1.10-1.90) and tricuspid valve procedures (2.21; 1.64-2.97) and prior history of myocardial infarction (1.48; 1.07-1.86). In the isolated MV repair population, annuloplasty with ring prosthesis was associated with PPM (3.09; 1.19-8.02). Patients in the replacement population did not have significant identifiable risk factors. There was no survival difference found, and postoperative PPM placement was not found to be an independent predictor of mortality. Our primary aim was to elucidate predictors for PPM implantation in MVS and found increasing age and concomitant procedures to be risk factors. Receipt of PPM is associated with worse long-term survival but does not independently predict survival. Among patients undergoing isolated MV repair, use of an annuloplasty ring confers a higher risk of PPM compared to an annuloplasty band.

Pacemaker following transcatheter aortic valve replacement and tricuspid regurgitation:A single-center experience.

As transcatheter aortic valve replacement (TAVR) procedures increase, more data is available on the development of conduction abnormalities requiring permanent pacemaker (PPM) implantation post-TAVR. Mechanistically, new pacemaker implantation and incidence of associated tricuspid regurgitation (TR) post-TAVR is not well understood. Studies have evaluated the predictability of patient anatomy towardsrisk for needing permanent pacemaker (PPM) post-TAVR; however, little has been reported on new PPM and TR in patients post-TAVR. This retrospective study identified patients at our health system who underwent PPM following TAVR from January 2014 to June 2018. Data from both TAVR and PPM procedures as well as patient demographics were collected. Echocardiographic data before TAVR, between TAVR and PPM placement, and the most recent echocardiogram at the time of chart review were analyzed. Of 796 patients who underwent TAVR between January 2014 and June 2018, 89 patients (11%) subsequently required PPM. Out of the 89 patients who required PPM implantation, 82 patients had pre-TAVR and 2-year post-TAVR echocardiographic imaging data. At baseline, 22% (18/82) of patients had at least moderate TR. At 2-year post-TAVR echocardiographic imaging follow-up; 27% (22/82) of patients had at least moderate TR. Subgroup analysis was performed according to the TAVR valve size implanted. In patients who received a TAVR device < 29 mm in diameter in size, 25% (11/44) had worsening TR. In patients who received a TAVR device ≥ 29 mm in diameter, 37% (14/38) had worsening TR. We have demonstrated a patient population that may be predisposed to developing worsening TR and right heart function after TAVR and Pacemaker implantation.

Outcomes of Transcarotid Versus Trans-Subclavian Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

ObjectivesThis study aimed to perform the first meta-analysis of studies comparing transcarotid (TC) and trans-subclavian (TSc) transcatheter aortic valve replacement (TAVR). BackgroundThe safety and feasibility of a TC and a TSc approach for performing TAVR in patients with prohibitive femoral anatomy have been well described. The potential advantage of one approach over the other is yet to be ascertained. MethodsA computerized literature search of key medical databases through September 2020 was performed. Randomized controlled trials (RCTs) and observational studies comparing TC and TSc TAVR with reported 30-day outcomes were considered. The primary endpoint was a composite of all-cause mortality, stroke, life-threatening, and/or major bleeding or major vascular complications. Statistical analysis using random-effects models to report the odds ratio (OR) with 95% confidence interval (CI) was performed. ResultsA total of 5 observational studies inclusive of 4164 patients (TC = 1788 and TSc = 2376) met the eligibility criteria. The average age of patients was 81.1 years. There was no difference in the occurrence of the composite endpoint between the groups at 30-days. A statistically insignificant trend towards higher rates of major vascular complications (OR 1.65; 95% CI 0.94–2.89; P = 0.08; I2 = 0%) and the need for permanent pacemaker placement was observed with the TSc approach. ConclusionsThis meta-analysis of studies comparing TC and TSc TAVR showed similar 30-day outcomes between the 2 approaches. A notable trend towards higher rates of major vascular complications and the need for permanent pacemaker placement was observed with the TSc approach.

First Case Report of Transvenous Pacemaker Placement in a Patient with Congenital Absence of the Clavicles Due to Cleidocranial Dysplasia

Cleidocranial dysplasia is a rare, autosomal dominant disease that is associated with clavicular absence or hypoplasia. Permanent pacemakers are most commonly implanted using percutaneous subclavian venous access. The clavicle is typically used as a bony landmark to guide venous access. Transvenous pacemaker implantation in the setting of clavicular hypoplasia, resection or other anomalies has not been described in literature. This is the first case report of a patient with clavicular absence undergoing transvenous permanent pacemaker implantation. This patient has a rare condition called cleidocranial dysplasia resulting in the congenital absence of his clavicles, along with other skeletal abnormalities. Cardiac anomalies are not associated with this disorder. This patient presented for permanent pacemaker placement in the setting of trifascicular block, symptomatic intermittent second-degree Mobitz type II atrioventricular block, and syncope. Using intra-procedural subclavian venography and intraprocedural Sonosite ultrasound imaging to identify vascular anatomy and surrounding anatomic landmarks, this patient underwent successful placement of a dual chamber transvenous pacemaker. Images from the intraprocedural venogram and the post-procedure chest x-ray illustrate the anatomy in this patient with congenital absence of the clavicles. This case has important implications in subclavian access and pacemaker placement in patients with clavicular abnormalities that may include absent, deformed, or resected clavicles.