Requiring Pacemaker Implantation Research Articles

How to compare clinical results of different neurosurgical centers? Is a classification of complications in neurosurgery necessary for this purpose?

A classification of complications in neurosurgery, to be approved and validated by the scientific community, has been advocated as the main vehicle for comparing different series of patients having undergone surgery in different centers and/or at different times.[12] The ultimate goal of such a classification would be-in the long period and from the point of view of healthcare policy-the quality improvement of health services to be offered to patients. Such improvement (which would also be relevant with regard to saving economic resources) could be achieved through an analysis-with quantitative (or at least objective) data-to establish which medical center guarantees the best clinical results in a specific surgical procedure. If a simple, practical-and therefore applicable in any medical center-classification of complications could achieve this purpose, it would be logical that all efforts should be made toward developing it. Should this aim not be pursued, or should it be achieved through different tools, the effort of defining a complications’ classification would be a mere intellectual exercise lacking any practical usefulness. Historical overview: The refinement of the definition of surgical complications and of classification of complications in general surgery The question of how to define negative results following invasive therapeutic procedures has been a matter for discussion for many years now in the field of general surgery. A classification of complications to be accepted by the entire scientific community has not been developed yet, even starting from the definition itself of complication; any proposed definition of complication,[4,5,6,16,17] as a matter of fact, has not been approved by those authors who later dealt with this subject. Sokol and Wilson,[17] for example, define as a complication “any undesirable, unintended, and direct result of an operation affecting the patient, which would not have occurred had the operation gone as well as could reasonably be hoped;” the authors themselves admit, however, that establishing in each case if a negative event could or could not be considered as a complication entails wide margins of subjectivity. The attempt to precise a classification of complications faces even harder obstacles, in as much the clarification of categories within which to classify the innumerable unexpected events that might occur in the surgical field will necessarily be either too generic or too specific. In the former case, such classification will include many different negative events not strictly homogeneous with regard to the cause of the complication; in the latter one, such classification will appear fastidious and not handy because of the excessive number of categories to be detailed. The most thorough paper in this field-dealing with cholecystectomies-was published by Clavien in 1992.[4] In this paper, a fundamental concept is introduced, that is, the grading of complications based on patients’ morbidity on the basis of the severity of any residual or lasting disability. Other authors also[8,9] stated that life quality measures should be used to evaluate surgery outcomes. Clavien,[4] moreover, recommended considering as “complications” only unexpected negative events; any predictable unfavorable outcome caused by a specific surgical risk inherent to the procedure being on the contrary a “sequela.” This idea, also approved by other authors,[2,16,10] logically introduces the concept of a definition of surgical risk (i.e., the likelihood that a patient might develop a disability following a technically irreproachable surgical procedure). In the field of general surgery, Dindo et al., in 2004,[5] specified the complexity of surgery in three main categories as follows. Type A: surgical procedures without opening of the abdominal cavity; type B: abdominal procedures except liver surgery, representing instead type C procedures. Complications have been classified in five grades according to the importance of the therapy necessary to treat them. Grade I complications, requiring only routine drugs, include transient atrial fibrillation, atelectasis, transient elevation of serum creatinine; grade II complications, requiring specific drug treatment, include tachyarrhythmia, pneumonia, urinary tract infection; grade III complications, treated with invasive procedures, include bradyarrhythmia requiring pacemaker implantation, bronchopleural fistula, and stenosis of the ureter treated surgically. Grade IV includes single or multiorgan dysfunction and life threatening complications requiring intensive care unit management. Grade V represents the death of the patient. For each of the three classes of risk in which complications have been grouped, every type of negative event occurred much more frequently in group C patients (P < 0.0001).

Management and outcome of topical beta-blocker-induced atrioventricular block.

SummaryBackgroundTopical beta-blockers have a well-established role in the treatment of glaucoma. We aimed to investigate the outcome of patients who developed symptomatic atrioventricular (AV) block induced by topical beta-blockers.MethodsAll patients admitted or discharged from our institution, the Siyami Ersek Training and Research Hospital, between January 2009 and January 2013 with a diagnosis of AV block were included in the study. Subjects using ophthalmic beta-blockers were recruited and followed for permanent pacemaker requirement during hospitalisation and for three months after discontinuation of the drug. A permanent pacemaker was implanted in patients in whom AV block persisted beyond 72 hours or recurred during the follow-up period.ResultsA total of 1 122 patients were hospitalised with a diagnosis of AV block and a permanent pacemaker was implanted in 946 cases (84.3%) during the study period. Thirteen patients using ophthalmic beta-blockers for the treatment of glaucoma and no other rate-limiting drugs were included in the study. On electrocardiography, eight patients had complete AV block and five had high-degree AV block. The ophthalmic beta-blockers used were timolol in seven patients (55%), betaxolol in four (30%), and cartelol in two cases (15%). The mean duration of ophthalmic beta-blocker treatment was 30.1 ± 15.9 months. After drug discontinuation, in 10 patients the block persisted and a permanent pacemaker was implanted. During follow up, one more patient required pacemaker implantation. Therefore in total, pacemakers were implanted in 11 out of 13 patients (84.6%). The pacemaker implantation rate did not differ according to the type of topical beta-blocker used (p = 0.37). The presence of infra-nodal block on electrocardiography was associated with higher rates of pacemaker implantation.ConclusionOur results indicate that topical beta-blockers for the treatment of glaucoma may cause severe conduction abnormalities and when AV block occurs, pacemaker implantation is required in a high percentage of the patients.

Abstract 20041: Single Ventricle Outcome Following Neonatal Palliation of Severe Ebstein’s Anomaly With Modified Starnes Procedure

Background: We have previously shown that neonates in profound cardiogenic shock due to severe Ebstein’s anomaly can be successfully salvaged with fenestrated right ventricular (RV) exclusion and systemic to pulmonary shunt (modified Starnes procedure). The long-term outcome of single ventricle management in these patients is not known. Methods: We retrospectively reviewed the records of 26 patients who underwent neonatal Starnes procedure between 1989 and 2011. Patient demographics, clinical variables and outcome data were collected. Data is presented as mean ± standard errors or median (interquartile ranges). Results: 26 patients (12, 46% boys) underwent Starnes procedure at 7 (5-9) days of life. All were intubated and on prostacyclin infusion, 24 (92%) were inotrope-dependent and 23 (88%) had no antegrade flow from the RV. Two patients had had prior intervention (one tricuspid annuloplasty and one shunt alone). Three patients underwent non-fenestrated RV exclusion, two (67%) of whom died. Of the remaining 23, 3 (13%) died during the same hospitalization. The 21 neonatal survivors have been followed for 7 (6-8) years. One patient died after Glenn. The remaining 20 have successfully undergone Fontan completion with an indexed pulmonary resistance of 1.8 (1.2-2.3) W/m2 and mean pulmonary pressure of 12 (9-18) mm Hg. At last follow-up, all patients have normal left ventricular function, and all but one patient are in NYHA Class I symptoms. Two patients have required pacemaker implantation, while the rest are in sinus rhythm. Survival at 1, 5 and 10 years are 81±4%, 77±3% and 77±3%, respectively. Conclusion: Long-term single ventricle outcomes amongst neonatal survivors of modified Starnes procedure are excellent. There is reliable remodeling of the excluded RV and excellent function of the left ventricle.

Pacemaker implantation after catheter ablation for atrial fibrillation.

Sinus node dysfunction requiring pacemaker implantation is commonly associated with atrial fibrillation (AF), but may not be clinically apparent until restoration of sinus rhythm with ablation or cardioversion. We sought to determine frequency, time course, and predictors for pacemaker implantation after catheter ablation, and to compare the overall rates to a matched cardioversion cohort. We conducted a retrospective analysis using a large US commercial insurance database and identified 12,158 AF patients who underwent catheter ablation between January 1, 2005 and December 31, 2012. Over an average of 2.4 years of follow-up, 5.6 % of the patients underwent pacemaker implantation. Using the Cox proportional hazards models, we found that risk of risks of pacemaker implantation was associated with older age (50-64 and ≥65 versus <50 years), female gender, higher CHADS2 score (≥2 and 1 versus 0), higher Charlson index (≥2 versus 0-1), certain baseline comorbidities (conduction disorder, coronary atherosclerosis, and congestive heart failure), and the year of ablation. There was no significant difference in the risk of pacemaker implantation between ablation patients and propensity score (PS)-matched cardioversion groups (3.5 versus. 4.1 % at 1 year and 8.8 versus 8.3 % at 5 years). Overall, pacemaker implantation occurs in about 1/28 patients within 1 year of catheter ablation. The overall implantation rate decreased between 2005 and 2012. Furthermore, the risk after ablation is similar to cardioversion, suggesting that patients require pacing due to a common underlying electrophysiologic substrate, rather than the ablation itself.

Mouse Model of Human Congenital Heart Disease: Progressive Atrioventricular Block Induced by a Heterozygous Nkx2-5 Homeodomain Missense Mutation.

Heterozygous human NKX2-5 homeodomain (DNA-binding domain) missense mutations are highly penetrant for varied congenital heart defects, including progressive atrioventricular (AV) block requiring pacemaker implantation. We recently replicated this genetic defect in a murine knockin model, in which we demonstrated highly penetrant, pleiotropic cardiac anomalies. In this study, we examined postnatal AV conduction in the knockin mice. A murine knockin model (Arg52Gly, Nkx2-5(+/R52G)) in a 129/Sv background was analyzed by histopathology, surface, and telemetry ECG, and in vivo electrophysiology studies, comparing with control Nkx2-5(+/+) mice at diverse postnatal stages, ranging from postnatal day 1 (P1) to 17 months. PR prolongation (first degree AV block) was present at 4 weeks, 7 months, and 17 months of age, but not at P1 in the mutant mice. Advanced AV block was also occasionally demonstrated in the mutant mice. Electrophysiology studies showed that AV nodal function and right ventricular effective refractory period were impaired in the mutant mice, whereas sinus nodal function was not affected. AV nodal size was significantly smaller in the mutant mice than their controls at 4 weeks of age, corresponding to the presence of PR prolongation, but not P1, suggesting, at least in part, that the conduction abnormalities are the result of a morphologically atrophic AV node. The highly penetrant and progressive AV block phenotype seen in human heterozygous missense mutations in NKX2-5 homeodomain was replicated in mice by knocking in a comparable missense mutation.

Clinical Predictors of Pacemaker Implantation in Patients with Syncope Receiving Implantable Loop Recorder with or without ECG Conduction Abnormalities

Implantable loop recorders (ILR) allow prolonged cardiac rhythm monitoring and improved diagnostic yield in syncope patients. Predictive factors for pacemaker (PM) implantation in the ILR population with unexplained syncope have not been adequately investigated. In this single center, retrospective, observational study we investigated factors that predict PM implantation in this population. We retrospectively analyzed our ILR database of patients aged over 18 years who underwent ILR implantation for unexplained syncope between January 2009 and June 2013. Patient case notes were examined for demographics, history, electrocardiogram (ECG) abnormalities, investigations, and events during follow-up. The primary end-point was the detection of a symptomatic or asymptomatic bradycardia requiring PM implantation. During a period of 4.5 years, 200 patients were implanted with ILR for unexplained syncope, of who n = 33 (16.5%) had clinically significant bradycardia requiring PM implantation. After multivariable analysis, history of injury secondary to syncope was found to be the strongest independent predictor for PM implantation (odds ratio [OR]:9.1; P < 0.001; 95% confidence interval [CI]: (3.26-26.81). Other significant predictors included female sex, PR interval > 200msec, and age >75 years. In patients without conduction abnormalities on the ECG, history of injury secondary to syncope was found to be the strongest independent predictor for PM implantation (OR: 8.16; P = 0.00027; 95% [CI]: (2.67-26.27). A history of injury secondary to syncope and female sex were independent predictive factors for bradycardia necessitating PM implantation in patients receiving an ILR for syncope with or without ECG conduction abnormalities.

Cardiac Interventions in Pregnant Patients without Fluoroscopy.

Cardiac interventions with fluoroscopy during pregnancy carry significant risks for the fetus. This report reviews three pregnant patients: two of them requiring pacemaker implantation and one underwent diagnostic cardiac catheterization without fluoroscopy. The cases were performed using EnSite system (St. Jude Medical Inc., MN, USA) guidance. The necessary cardiac structure geometries were reconstructed with a deflectable quadripolar electrophysiology catheter without fluoroscopy. In two cases, pacemaker leads were connected to the EnSite system for navigation and fixation of leads. In the third case, long sheaths and electrophysiology catheters were used to access the right ventricle and pulmonary artery. Transthoracic echocardiography was also used in all three cases. A 31-year-old woman at 8-week pregnancy was admitted with ventricular septal defect and significant pulmonary hypertension. The patient underwent catheterization to assess for the risk of continuation of pregnancy. There was partial reactivity, it was decided not to terminate the pregnancy, and an uneventful delivery was succeeded at 35 weeks of gestation without complications. The rest of the two pregnant patients were a 28-year-old pregnant woman at 14 weeks of gestation and a 40-year-old woman at 12-week gestation. Both of them presented with symptomatic complete AV block. A single-chamber pacemaker was implanted in the first one, and a dual-chamber pacemaker was implanted in the latter. Pregnancy continued in both without complications. Successful cardiac catheterization and pacemaker implantation can be performed safely in selected pregnant patients using an electroanatomic mapping system guidance without fluoroscopy.

Ten-year outcomes of Fontan conversion in Australia and New Zealand demonstrate the superiority of a strategy of early conversion.

To investigate the benefits of a strategy of early Fontan conversion. Using the Australia and New Zealand Fontan Registry, retrospective analysis of their long-term follow-up data was performed. Between 1990 and 2014, a total of 39 patients underwent surgical conversion in 6 centres at a median age of 23.8 years (IQR: 19.3-28.2), 18.7 ± 5.0 years post-Fontan. One centre tended to perform conversion earlier: interval since first documented arrhythmia 2.9 ± 4.0 vs 4.0 ± 4.2 years, average NYHA Class 2 ± 0.4 vs 3 ± 0.9 (P = 0.008), mean number of preop anti-arrhythmics 1 ± 0.4 vs 2 ± 0.6 (P = 0.05). Two patients underwent conversion to an extracardiac conduit only, while 36 had concomitant right atrial cryoablation, of which 16 also had pacemaker implantation. Nine patients suffered major cardiac-related complications (7 low output syndrome, 3 ECMO, 3 acute renal failure, one stroke) (2/17 from the early conversion centre and 7/22 of the others; P = 0.14). Four patients died in hospital (10.3%) and 4 late after a median of 0.9 years [95% confidence interval (CI): 0.5-1] after conversion. An additional 2 patients needed transplantation at 1 and 8.8 years after conversion, respectively. The 10-year freedom from heart transplantation was 86% (95% CI: 51-97%). Outcomes from the centre with an early conversion strategy were significantly better: 8-year freedom from death or heart transplantation was 86% (95% CI: 53-96) vs 51% (95% CI: 22-74; log-rank P = 0.007). Eight additional patients required pacemaker implantation and 5 had arrhythmia recurrence. Fontan conversion is associated with lasting survival outcomes up to 10 years after conversion. A strategy of surgical conversion at earlier stage of failure may be associated with better survival free from transplantation.

0318 : Left bundle branch block after transcatheter aortic valve implantation: incidence, predictive factors and outcome

Conduction disorders are frequent after transcatheter aortic valve implantation (TAVI). The aim of the study was to assess the incidence, the clinical impact and the predictive factors of new-onset left bundle branch block (LBBB) after TAVI. Between 2010 and 2014, 198 consecutive patients underwent TAVI in our center and 156 were prospectively followed during 1 year (62 CoreValve (CV), 94 Edwards Sapiens valve (ES)). 42 patients were excluded because of a pre-existing PM before TAVI, death or surgery after TAVI. After 156 TAVI, 40 patients (26%) required pacemaker implantation. CV patients were more frequently implanted than ES (35% vs 19%; p=0.03). Out of 116 non-implanted patients, 53 (46%) patients presented with LBBB which persisted in 35 (30%) patients. QRS width increased +27ms in post-procedure, +21ms at hospital discharge, +15ms at 1 month, +11ms at 1 year in the whole cohort. There was no clinical nor echocardiographic difference between the LBBB group and no-LBBB group. Ischemic neurological complication were more frequent during hospitalization in the LBBB group (8.6% vs 3.7%; p=0.007). On multivariate analysis, a pre-existing incomplete LBBB (OR 4.15; IC 1.31-13.11; p=0.015) and a long pre-procedure PR interval (OR 1.023; IC 1.001-1.046; p=0.038) were predictive factors of new persistent LBBB after TAVI and a trend with CV implantation was observed (OR 2.35; IC 0.99- 5.53; p=0.051). NYHA grade was increased in the LBBB group compared to non-LBBB group at 1 (2,1 ± 0,8 vs 1,7 ± 0,6 ; p=0.006), 6 (2,21 ± 0,7 vs 1,53±0,6 ; p=0.001) and 12 months (2.2 vs 1.7, p=0.04). On univariate analysis, a pre-existing atrial fibrillation (OR 2.1; IC 1.12- 4.01; p=0.021), an initial mean aortic gradient (OR 0.78; IC 0.65-0.93; p=0.006) and new LBBB after TAVI (OR 2.06; IC 1.05-4.04; p=0.036) were predictive factors of mortality at 12 months. On multivariate analysis, LBBB after TAVI was an independent predictor of mortality (OR 3.52; IC 1.17- 10.58, p=0.025). New-onset LBBB is frequent after TAVI and persists in a great proportion of patients. In our study, LBBB after TAVI was an independent predictor of mortality.

One-year follow-up of conduction disturbances following transcatheter aortic valve implantation.

To describe the postprocedural and 1-year follow-up incidence of heart conduction disturbances in patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Ninety-five patients were enrolled from 2008 to 2011 (mean age 81.8 ± 7.2 years, 63.1% women). Clinical and ECG data were recorded at admission, discharge, and 3, 6 and 12 months following TAVI. Fifty-seven Edwards SAPIEN (31 transapical, 26 transfemoral) and 38 transfemoral CoreValve implants were used. Two (2.1%) patients died during the procedure and 11 (11.6%) patients received a pacemaker prior to discharge (7 CoreValve, 3 transapical, 1 transfemoral SAPIEN; P = 0.18). Among the surviving patients not receiving a pacemaker, TAVI increased the PQ interval (176 ± 29 vs. 188 ± 36 ms; P = 0.001), QRS width (90 ± 15 vs. 108 ± 26 ms; P < 0.001), and first-grade atrioventricular block (17 vs. 29%; P < 0.001). Postprocedural complete left bundle branch block was reported most in transapical (from 10 to 36%; P = 0.01) and CoreValve (from 8 to 64%; P < 0.001) recipients compared to the transfemoral SAPIEN group. At the 12-month follow-up, 24 (25.3%) patients had died [two (2.1%) sudden deaths] and four (4.2%) required pacemaker implantation. Among the survivors not receiving a pacemaker at the 1-year follow-up, the PQ interval (178 ± 27 vs. 188 ± 36 ms; P = 0.39) remained unchanged in the ECG, whereas the QRS width (100 ± 22 vs. 108 ± 26 ms; P = 0.008) decreased compared to measurements taken at discharge. Conduction disturbances following TAVI primarily develop during hospitalization and subsequently stabilize. However, the small percentage of patients suffering sudden death or pacemaker implantation requires attention.

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Severe Aortic Valve Stenosis: 1-Year Results From the All-Comers NOTION Randomized Clinical Trial

BackgroundTranscatheter aortic valve replacement (TAVR) is an option in certain high-risk surgical patients with severe aortic valve stenosis. It is unknown whether TAVR can be safely introduced to lower-risk patients. ObjectivesThe NOTION (Nordic Aortic Valve Intervention Trial) randomized clinical trial compared TAVR with surgical aortic valve replacement (SAVR) in an all-comers patient cohort. MethodsPatients ≥70 years old with severe aortic valve stenosis and no significant coronary artery disease were randomized 1:1 to TAVR using a self-expanding bioprosthesis versus SAVR. The primary outcome was the composite rate of death from any cause, stroke, or myocardial infarction (MI) at 1 year. ResultsA total of 280 patients were randomized at 3 Nordic centers. Mean age was 79.1 years, and 81.8% were considered low-risk patients. In the intention-to-treat population, no significant difference in the primary endpoint was found (13.1% vs. 16.3%; p = 0.43 for superiority). The result did not change in the as-treated population. No difference in the rate of cardiovascular death or prosthesis reintervention was found. Compared with SAVR-treated patients, TAVR-treated patients had more conduction abnormalities requiring pacemaker implantation, larger improvement in effective orifice area, more total aortic valve regurgitation, and higher New York Heart Association functional class at 1 year. SAVR-treated patients had more major or life-threatening bleeding, cardiogenic shock, acute kidney injury (stage II or III), and new-onset or worsening atrial fibrillation at 30 days than did TAVR-treated patients. ConclusionsIn the NOTION trial, no significant difference between TAVR and SAVR was found for the composite rate of death from any cause, stroke, or MI after 1 year. (Nordic Aortic Valve Intervention Trial [NOTION]; NCT01057173)

New conduction disturbances and pacemaker indications after CoreValve® transcatheter aortic valve replacement. Incidence and follow up in a single center experience

Transcatheter aortic valve implantation (TAVI) is currently reserved for patients with symptomatic aortic stenosis and high surgical risk. One major limiting factor related to TAVI procedural complications is conduction abnormalities and the need for permanent pacemaker implantation. Evaluate the incidence of new conduction disturbances and pacemaker indications in patients with TAVI CoreValve® prosthesis (Medtronic Inc. Minneapolis, Minnesota, United States). We included 28 patients, mean age 80 years. ECG parameters were evaluated previous and after implantation. All patients were monitorized during TAVI. Follow up Holter monitoring was performed at one, 6 and 12 months after the procedure and we also evaluated telemetry of implanted pacemaker. In previous ECG we found 7 patients had right bundle branch block and 7 patients had left bundle brunch block (LBBB). The post implant ECG showed 7 new LBBB: 3 during valvuloplasty and 4 on the end of it. Six patients required pacemaker implantation for permanent or paroxysmal complete AV block (CAVB). At one year follow up, 3 patients with LBBB during valvuloplasty had a normal ECG, one still had LBBB and one an asymptomatic CAVB found in Holter monitoring. Conduction abnormalities are frequent after CoreValve® aortic valve prosthesis implantation. The incidence of new LBBB was 25%. CAVB during or post TAVI require PM implantation. New LBBB may need a closer follow up because in a 3% of the cases it may progress to CAVB.

FREQUENCY AND PREDICTORS OF PACEMAKER IMPLANTATION AFTER CATHETER ABLATION OR CARDIOVERSION FOR ATRIAL FIBRILLATION

Sinus node dysfunction requiring pacemaker implantation is commonly associated with atrial fibrillation (AF) but may not be clinically apparent until restoration of sinus rhythm with ablation or cardioversion. We sought to determine frequency, time course and predictors for pacemaker implantation

Association of temporary complete AV block and junctional ectopic tachycardia after surgery for congenital heart disease.

Aim:Junctional ectopic tachycardia (JET) is a postoperative complication with a mortality rate of up to 14% after surgery for congenital heart disease. This study evaluated the risk factors of JET and explored the association of postoperative temporary third degree atrioventricular (AV) block and the occurrence of JET.Materials and Methods:Data were collected retrospectively from 1158 patients who underwent surgery for congenital heart disease.Results:The overall incidence of JET was 2.8%. Temporary third degree AV block occurred in 1.6% of cases. Permanent third degree AV block requiring pacemaker implantation occurred in 1% of cases. In all, 56% of patients with JET had temporary AV block (P < 0.001), whereas no case of postoperative JET was reported in patients with permanent AV block (P = 0.56). temporary third degree AV block did not suffer from JET.Conclusions:A correlation between temporary third degree AV block and postoperative JET could be observed. The risk factors identified for JET include younger age groups at the time of surgery, longer aortic cross clamping time and surgical procedures in proximity to the AV node.

Treatment of arrhythmias in children without heart disease

In children, arrhythmias have an etiology, evolution and treatment strategy that often differs from that of adults. Ectopic beats are very common, but rarely need to be treated. Macroreentrant supraventricular tachycardia is the arrhythmia that usually requires a treatment intervention. Adenosine for tachycardia interruption and 1C anti-arrhythmic drugs for prevention of recurrences are the first-line treatment. Automatic supraventricular tachycardias are infrequent but are typical of the pediatric age; treatment should be targeted at rate control in addition to tachycardia interruption. Beta-blockers and calcium antagonists are the most useful drugs for tachycardia control. Ventricular tachycardia is a very uncommon arrhythmia in children usually related to channelopathies; in this setting beta-blockers are often the first-choice treatment, but in many selected patients implantation of a cardioverter-defibrillator is required. Other types of ventricular tachycardia include fascicular and infundibular tachycardias that are usually well controlled by medical and/or ablation therapy. Ablation procedures are very effective in curing many tachyarrhythmias also in the pediatric age; the main indication for ablation is the need for continuing medical therapy after the age of 10-12 years. Hypokinetic arrhythmias are very rare and usually require pacemaker implantation.

Uma década de transplantação cardíaca em Coimbra. O valor da experiência

Introduction and ObjectivesTo analyze the experience gained in 10 years of the heart transplantation program of the University Hospital of Coimbra. MethodsBetween November 2003 and December 2013, 258 patients with a mean age of 53.0±12.7 years (3‐72 years) and predominantly male (78%) were transplanted. Over a third of patients had ischemic (37.2%) and 36.4% idiopathic cardiomyopathy. The mean age of donors was 34.4±1.3 years and 195 were male (76%), with gender difference between donor and recipient in 32% of cases and ABO disparity (non‐identical groups but compatible) in 18%. Harvest was distant in 59% of cases. In all cases total heart transplantation with bicaval anastomoses, modified at this center, was used. Mean ischemia time was 89.7±35.4 minutes. All patients received induction therapy. ResultsEarly mortality was 4.7% (12 patients) from graft failure and stroke in five patients each, and hyperacute rejection in two. Thirteen patients (5%) required prolonged ventilation, 25 (11.8%) required inotropic support for more than 48 hours, and seven required pacemaker implantation. Mean hospital stay was 15.8±15.3 days (median 12 days). Ninety percent of patients were maintained on triple immunosuppressive therapy including cyclosporine, the remainder receiving tacrolimus. In 23 patients it was necessary to change the immunosuppression protocol due to renal and/or neoplastic complications and humoral rejection. All but two patients have been followed in the Surgical Center. Fifty patients (19.4%) subsequently died from infection (18), cancer (10), vascular (eight), neuropsychiatric (four), cardiac (two) or other causes (eight). Forty‐six patients (17.8%) had episodes of cellular rejection (>2 R on the ISHLT classification), eight had humoral rejection (3.1%), and 22 have evidence of graft vascular disease (8.5%). Actuarial survival at 1, 5, and 8 years was 87±2%, 78±3% and 69±4%, respectively. ConclusionThis 10‐year series yielded results equivalent or superior to those of centers with wider and longer experience, and have progressively improved following the introduction of changes prompted by experience. This program has made it possible to raise and maintain the rate of heart transplantation to values above the European average.

A decade of cardiac transplantation in Coimbra: The value of experience

Introduction and ObjectivesTo analyze the experience gained in 10 years of the heart transplantation program of the University Hospital of Coimbra. MethodsBetween November 2003 and December 2013, 258 patients with a mean age of 53.0±12.7 years (3–72 years) and predominantly male (78%) were transplanted. Over a third of patients had ischemic (37.2%) and 36.4% idiopathic cardiomyopathy. The mean age of donors was 34.4±1.3 years and 195 were male (76%), with gender difference between donor and recipient in 32% of cases and ABO disparity (non-identical groups but compatible) in 18%. Harvest was distant in 59% of cases. In all cases total heart transplantation with bicaval anastomoses, modified at this center, was used. Mean ischemia time was 89.7±35.4 minutes. All patients received induction therapy. ResultsEarly mortality was 4.7% (12 patients) from graft failure and stroke in five patients each, and hyperacute rejection in two. Thirteen patients (5%) required prolonged ventilation, 25 (11.8%) required inotropic support for more than 48 hours, and seven required pacemaker implantation. Mean hospital stay was 15.8±15.3 days (median 12 days). Ninety percent of patients were maintained on triple immunosuppressive therapy including cyclosporine, the remainder receiving tacrolimus. In 23 patients it was necessary to change the immunosuppression protocol due to renal and/or neoplastic complications and humoral rejection. All but two patients have been followed in the Surgical Center. Fifty patients (19.4%) subsequently died from infection (18), cancer (10), vascular (eight), neuropsychiatric (four), cardiac (two) or other causes (eight). Forty-six patients (17.8%) had episodes of cellular rejection (>2 R on the ISHLT classification), eight had humoral rejection (3.1%), and 22 have evidence of graft vascular disease (8.5%). Actuarial survival at 1, 5, and 8 years was 87±2%, 78±3% and 69±4%, respectively. ConclusionThis 10-year series yielded results equivalent or superior to those of centers with wider and longer experience, and have progressively improved following the introduction of changes prompted by experience. This program has made it possible to raise and maintain the rate of heart transplantation to values above the European average.

Permanent His-bundle pacing is feasible, safe, and superior to right ventricular pacing in routine clinical practice.

Right ventricular pacing (RVP) has been associated with heart failure and increased mortality. His-bundle pacing (HBP) is more physiological but requires a mapping catheter or a backup right ventricular lead and is technically challenging. We sought to assess the feasibility, safety, and clinical outcomes of permanent HBP in an unselected population as compared to RVP. All patients requiring pacemaker implantation routinely underwent attempt at permanent HBP using the Select Secure (model 3830) pacing lead in the year 2011 delivered through a fixed-shaped catheter (C315 HIS) at one hospital and RVP at the second hospital. Patients were followed from implantation, 2 weeks, 2 months, 1 year, and 2 years. Fluoroscopy time (FT), pacing threshold (PTh), complications, heart failure hospitalization, and mortality were compared. HBP was attempted in 94 consecutive patients, while 98 patients underwent RVP. HBP was successful in 75 patients (80%). FT was similar (12.7 ± 8 minutes vs 10 ± 14 minutes; median 9.1 vs 6.4 minutes; P = .14) and PTh was higher in the HBP group than in the RVP group (1.35 ± 0.9 V vs 0.6 ± 0.5 V at 0.5 ms; P < .001) and remained stable over a 2-year follow-up period. In patients with >40% ventricular pacing (>60% of patients), heart failure hospitalization was significantly reduced in the HBP group than in the RVP group (2% vs 15%; P = .02). There was no difference in mortality between the 2 groups (13% in the HBP group vs 18% in the RVP group; P = .45). Permanent HBP without a mapping catheter or a backup right ventricular lead was successfully achieved in 80% of patients. PTh was higher and FT was comparable to those of the RVP group. Clinical outcomes were better in the HBP group than in the RVP group.

Impact of Pre-Procedural Cardiopulmonary Instability in Patients With Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention (from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction Trial)

Rapid reperfusion with primary percutaneous coronary intervention improves survival in patients with ST-segment elevation myocardial infarction. Preprocedural cardiopulmonary instability and adverse events (IAE) may delay reperfusion time and worsen prognosis. The aim of this study was to evaluate the relation between preprocedural cardiopulmonary IAE, door-to-balloon time (DBT), and outcomes in the Harmonizing Outcomes With Revascularization and Stents in AMI (HORIZONS-AMI) trial. Preprocedural cardiopulmonary IAE included sustained ventricular or supraventricular tachycardia or fibrillation requiring cardioversion or defibrillation, heart block or bradycardia requiring pacemaker implantation, severe hypotension requiring vasopressors or intra-aortic balloon counterpulsation, respiratory failure requiring mechanical ventilation, and cardiopulmonary resuscitation. Three-year outcomes of patients with and without IAE according to DBT were compared. Among 3,602 patients, 159 (4.4%) had ≥1 IAE. DBT did not differ significantly in patients with and without IAE; however, patients with IAE were less likely to have Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow after percutaneous coronary intervention. Mortality at 3 years was significantly higher in patients with versus those without IAE (17.0% vs 6.3%, p<0.0001), and IAE was an independent predictor of mortality, whereas DBT was not. However, a significant interaction was present such that 3-year mortality was reduced in patients with DBT<99 minutes (the median) versus ≥99 minutes to a greater extent in patients with IAE (9.9% vs 20.7%, hazard ratio 0.43, 95% confidence interval 0.16 to 1.16) compared with those without IAE (5.0% vs 7.2%, hazard ratio 0.69, 95% confidence interval 0.50 to 0.95) (p for interaction=0.004). In conclusion, IAE before PCI is an independent predictor of death and identifies a high-risk group in whom faster reperfusion may be particularly important to improve survival.

Perinatal arrhythmias.

Cardiac arrhythmias are very frequent in fetuses and newborns. The prognosis depends on the nature of the arrhythmias but is most often either spontaneously benign or following short-term medication administration. A correct diagnosis is essential for both management and prognosis. It is based on echocardiography during the fetal period and mainly on history, physical exam, and electrocardiogram after birth, but other modalities are available to record transient arrhythmic events. Irregular rhythms are mostly benign and rarely require therapy. In most fetuses and infants, tachyarrhythmias resolve spontaneously or require short-term administration of antiarrhythmics. Approximately one third of these may recur later on, especially during adolescence. Persistent bradyarrhythmias might require pacemaker implantation when associated with failure to thrive or with risk of sudden death. Arrhythmias in fetuses and infants are very common and mostly benign. History, physical exam, and recording of the arrhythmia are essential to make a correct diagnosis and establish an appropriate management for the rare potentially harmful arrhythmias.