Temporary Pacemaker Research Articles

Short and midterm outcome of intraprocedural sinus node dysfunction requiring stimulation during ablation of persistent atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Ablation within the superior, antero-lateral portions of the right atrium has been described as a risk for sinus node dysfunction (SND) because of direct damage to the sinus node. The sinoatrial nodal artery arises from the right coronary artery in the majority of people and courses close to the superior posterior aspect of the interatrial septum. Rare cases of SND were observed periprocedurally during atrial fibrillation/flutter ablation. We sought to report on clinical characteristics, ablation set and acute and midterm rhythm outcome of patients who develop acute SND during/immediately after exclusively left atrial ablation. Methods We performed a retrospective analysis of AF/Aflutter ablation patients between January 2017 and December 2019 to characterize those who required temporary pacemaker (TPM) implantation due to acute sinus node dysfunction (sinus arrest, sinus bradycardia <35 beats/min with hemodynamic compromise) following atrial ablation. Results Of 1,072 patients, at nine patients [0,8%] intraprocedural temporary pacemaker implantation was necessary due to severe SND and hemodynamic compromise. The reasons for implantation were identified as sinus arrest (n=6) or severe sinus bradycardia (n=3). Eight of nine patients were male [89%], age 73 +11.2, 6/9 [67%] persistent AF, 2/9 [22%] Aflutter. The ablation set consisted of: pulmonary vein (PV) isolation in all patient (n = 9), left atrium(LA)-substrate modification in 8. In detail: roof line ablation (n = 3), mitral annulus-right superior PV line ablation ( n=8), mitral annulus-left superior PV line (n = 3). No patient had an ablation within the the right atrium. Four of nine [22%] pts. received permanent PM before discharge, performed 5 days postablation (range 3-7 days). At 3-month device interrogation, all patients were atrially paced, with a pacing proportion of >40% in 3/4 [0,3%] patients. Conclusion Acute sinus node dysfunction is a rare complication of sole left atrial ablation outside the pulmonary veins. However, a relevant fraction of these patients requires permanent implantation with substantial pacing proportion during midterm follow up.

Predictors of pacemaker implantation within three months after catheter ablation of atrial fibrillation.

It is inevitable for patients to have a temporary or permanent pacemaker implanted during or after radiofrequency catheter ablation (RFCA) for treatment of atrial fibrillation (AF) in some cases. The aim of our study was to evaluate the incidence of pacemaker implantation (PMI) during or within 3 months of RFCA for AF and to identify the risk factors that were associated with PMI. We performed a retrospective analysis of consecutive AF patients who underwent RFCA between August 2018 and October 2020 at our center. The incidence of PMI within 3 months during or after RFCA were assessed. A multivariate logistic regression model was performed to identify predictors of PMI. One thousand and five patients (mean age, 60.2±10.3 years; 37.6% women) were included in this analysis. PVI was performed in all patients. A total of 23 (2.3%) patients had a pacemaker implanted within 3 months during or after ablation. Multivariable logistic regression analysis revealed that older age (OR: 1.08 [95% CI 1.03-1.13], p=.003), female sex (OR: 3.08 [95% CI 1.28-7.45], p=.012), paroxysmal AF (OR: 4.71 [95% CI 1.09-20.45], p=.038) and repeated ablation (OR: 2.78 [95% CI 1.04-7.40], p=.041) were the independent predictors for PMI. Older age, female sex, paroxysmal AF and repeated ablation were identified as predictive risk factors for PMI after RFCA in patients with AF. A "watch and wait" strategy could be taken for patients with temporary PMI after ablation, especially for those with prolonged sinus pause after AF termination.

P231 CORONARY VASOSPASM REFRACTORY TO MEDICAL THERAPY AND COMPLICATED BY ASYSTOLE, HOW TO MANAGE IT?

Abstract Vasospastic angina is a form of angina caused by coronary artery spasm. This usually determines rest chest pain and electrocardiogram changes. In some patients severe ventricular tachyarrhythmias or bradyarrhythmias may develop during myocardial ischemia. Vasospastic angina attacks can be prevented by calcium antagonists and nitrates but artery spasm may be refractory to optimal medical therapy. A 66–year–old woman, affected by Hailey–Hailey disease was brought to the emergency department for hemorrhagic shock after anti–conservative purposes. She underwent emergency surgery for haemostasis of the neck lesion, reinsertion of the subhyoid muscles and right parotidectomy. After surgery an electrocardiogram (ECG) showed inferior and posterior ST–segment elevation, total atrioventricular block (AVB) and torsades de pointes (FIG 1), then evolved in asystole and cardiac arrest . ROSC occurred in 4 minutes. Temporary pacemaker (PM) was placed. Coronary angiography showed right coronary artery and left anteriori descending artery vasospasm, slightly reduced after nitroglycein infusion (FIG 2). Transdermal nitrates and calcium channel blocker were started. Hospitalization has been prolonged due to infectious/psychiatric problems, with necessity of percutaneous endoscopic gastrostomy and tracheostomy, A new episode of vasospastic angina developed during hospitalization with recurrence of total AVB and torsades de pointes. Temporary PM was placed but after 24 hours perforated the right ventricle free wall. Echocardiogram showed small circumferential pericardial effusion. The patient underwent transvenous removal of the right ventricular catheter and two lead DDD PM was implanted. She was discharged with nitrate and calcium channel blocker therapy. No recurrence of angina was documented at 6–months follow–up. The management of this clinical case was complex because it was a form of vasospastic angina complicated by 2 cardiac arrests, unresponsive to medical therapy and with temporary PM that perforated the right ventricle. We therefore opted for a definitive PM implant for protection. Few case report describes definitive PM implantation in fatal bradyarrhythmias during vasospastic angina. To date, the best treatment of coronary vasospasm refractory to medical therapy is debated, pecutaneous revascularization and sympathectomy are considered, treatment methods that we will consider at follow–up in case of (probable) anginal recurrences.

P40 LIGHTS AND SHADOWS OF THE MICROCOAXIAL PUMP DEVICE IN A UNIQUE SETTING: CARDIOGENIC SHOCK DUE TO ACUTE MYOCARDIAL INFARCTION IN PATIENT WITH UNKNOWN HYPERTROPHIC CARDIOMYOPATHY

Abstract Cardiogenic shock remains the leading cause of death in patients with acute myocardial infarction (AMICS). The IntraAortic Balloon Pump (IABP) has been the device of first choice for these patients for years, but it has not shown a mortality benefit over optimal medical therapy. The Impella (AbioMed, Danvers, Massachusetts) is an alternative circulatory support system that produces cardiac output appropriate for the needs of the patient. A 59–year–old mailman suddenly lost consciousness during his work. Basic life support was administered, and ROSC was achieved after a single effective defibrillator discharge. When the ambulance arrived, the patient presented conscious but complained of oppressive chest pain, with soreness in his left arm and head. EKG showed an ST elevation in aVR and aVL and a right bandle branch block (Fig 1). Aspirin, Heparin, and opioids were administered. During the transport, hemodynamic parameters appeared to deteriorate towards cardiogenic shock. Coronary angiography showed a total occlusion of the left main. Cangrelor was started promptly. Hemodynamic conditions dictated the application of a mechanical circulatory support device (MCSD), so IABP was applied. Primary angioplasty was performed with restoration of TIMI 3 flow. A 3.50 x 23 mm everolimus–eluting stent was implanted with a good result. Norepinephrine was ineffective in achieving satisfactory hemodynamic status with systemic arterial pressure below 50 mmHg. After volemic restoration, neither IABP nor the vasopressor could interrupt the spiral of cardiogenic shock. A coaxial pump, i.e. the Impella CP, was applied via left arterial femoral access. Despite the precise placement of this device, the parameters suggested a poor suction capacity from the pump–inlet into the left ventricle (LV) to systemic circulation in aorta. Meanwhile, echocardiogram revealed an unknown and severe hypertrophic cardiomyopathy that did not allow a proper functioning of the Impella CP device (Fig. 2). When a temporary pacemaker was applied due to reperfusion bradycardia, there were a better LV diastolic filling and Impella functioning due to right pacing. The patient was transferred to the intensive care unit, Impella was removed after 3 days, he was extubated within two weeks, no brain damage was reported but he is still hospitalised after a concomitant urinary infection, with predictable low ejection fraction (around 30%). We‘ll see: luckily, slow improvement, it is still an improvement!

P298 TRANS–AXILLARY ACCESS AS AN ALTERNATIVE ROUTE IN TRANSCATHETER AORTIC VALVE IMPLANTATION

Abstract Background Transcatheter aortic valve replacement (TAVR) is the main procedure for treating severe aortic stenosis in patients considered at high surgical risk. Generally, this procedure is performed through percutaneous femoral arterial access. The presence of anatomical variants or peripheral atherosclerotic pathology sometimes necessitates the use of alternative vascular accesses, including access through the axillary artery. Data from a meta–analysis involving 1793 patients who underwent TAVR through trans axillary or transapical access showed a statistically significant reduction in 30–day mortality in the former group. We wait for future randomized trials to confirm the consistency of these data. Clinical case 71–year–old man, smoker, hypertensive and dyslipidaemic. In 2018, he underwent bilateral aorta–iliac–femoral bypass surgery for severe lower limb arteriopathy. Due to the onset of angina and dyspnea at rest, he went to the ER where a diagnosis of NSTEMI was made. On echocardiogram, there was evidence of severe high–gradient aortic stenosis while coronary angiography showed 80% RCA stenosis in the middle tract. Because of the high surgical risk (EUROSCORE II: 12%) and the evidence of bilateral femoral artery occlusion on CT–angiography, the Heart Team concluded to perform TAVR through percutaneous left trans–axillary access with concomitant percutaneous coronary revascularization. Obtained the backup access on the left radial artery, PTCA+DES was performed on RCA through the right radial access with subsequent placement of a pigtail catheter in the non–coronary sinus of Valsalva. Once the temporary pacemaker had been placed through the right femoral vein, an angio–guided puncture of the left axillary artery was performed with placement of the 14 Fr introducer for implantation of the Medtronic Evolut R 26 mm aortic biological prosthesis. Post–procedure ultrasound examination showed a residual mean aortic valve gradient of 17 mmHg with evidence of a small periprosthetic leak. Seven days after the procedure, the patient was discharged, asymptomatic and in good hemodynamic compensation without vascular complications. Conclusions Trans–axillary arterial access should be considered a viable alternative to transfemoral access for the performance of TAVR.

P131 ACUTE RIGHT HEART FAILURE: MASSIVE PULMONARY EMBOLISM OR RIGHT INFARCTION?

Abstract Right ventricular infarction is often unrecognized. Rarely isolated, it complicates up to 50% of inferior infarction, conditioning morbidity and mortality. Clinical presentation, characterized by hypotension, and echocardiografic features, with right ventricular involvement, can often mimic high risk pulmonary embolism. This case report focuses on an 85–years–old woman who called 118 for chest pain and asthenia. The patient is in shock, when accepted into the emergency room. ECG reveals a third–degree AV block with escape rhythm at rate of 35bpm and ST segment elevation in inferior leads, requiring temporary transvenous pacemaker placement. Bedside echo shows a borderline LV systolic function (EF 50%) with inferior wall akinesis and a dilated and hypokinetic right ventricle (TAPSE 15mm). In emergency we perform a coronary angiogram, that reveals a total occlusion of the ostial right coronary artery, treated by PCI 2 DES. During clinical course, no complications occur. At hospital discharge, the patient is hemodynamically compensated, without neurological sequelae and with cardiac enzymes in decrease (Trp I HS peak 94 000pg/ml). The aim of this case report is to focus cardiologist’s attention on right ventricular infarction, knowing its clinical presentation and its laboratory, electrocardiographic and echocardiographic features.

P242 CARDIOGENIC SHOCK WITH ISCHEMIC PHENOTYPE SECONDARY TO INCESSANT VENTRICULAR TACHYCARDIA: A CALL FOR IMPLEMENTATION OF HUB–AND–SPOKE MODEL

Abstract A 55–years–old patient presents to emergency room with extensive anterior STEMI, complicated by acute pulmonary edema. The ECG showed sinusal tachycardia, Q waves in V1–V3, ST elevation >2mm V2–V6. The echocardiogram showed akinesia of the apex and anterolateral wall with severe reduction of contractile function (LVEF 30%). The patient was treated with CPAP, dual antiplatelet therapy and diuretics; the urgent coronary angiography showed three–vessel disease with occlusion of the proximal LAD, treated with PCI and two drug–eluting stents implantation. 48 after admission to ICU, the patient developed "combined" shock (IC↓ RVS↓ WP↑), sustained by both severe cardiac dysfunction and a septic complication, requiring inotropes and targeted antibiotic therapy (noradrenaline 0.02 gamma/Kg/min and piperacillin/tazobactam i.v). At 96 hours there was a recovery of contractile function and haemodynamics (CI from 1.8 to 2.7). Weaned from inotropes, he began therapy with low doses of ACE inhibitor, beta blocker, antialdosteronic. On the 7th day of hospitalization, without ischemic and/or electrolyte "triggers", the patient developed "arrhythmic storm" with incessant sustained ventricular tachycardias. Arrhythmias persisted despite antiarrhythmics (magnesium sulfate, amiodarone, lidocaine), IOT, sedation, mechanical ventilation. The temporary pacemaker for overdrive pacing was placed in. After placement of IABP, the patient underwent revascularization of residual coronary artery stenosis. Despite 1 hour of assistance (ABLS), incessant ventricular tachycardia persisted; a third–level center for VA–ECMO inside support was called. After positioning VA–ECMO there was progressive clinical stabilization and –concomitantly– a progressive reduction of ventricular tachycardias. ECMO support was needed for over 7 days due to persistence of arrhythmic storm; it was slowly weaned with stabilization of the patient; an AICD was implanted. Residual function of the left ventricle was mild reduced (LVEF40%) despite protracted CPR. There wasn’t residual cognitive impairment. Implementation of multidisciplinary teams in the spoke centers would improve protocols and early treatments in patients with cardiogenic shock; spoke centers would provide early access to life–saving therapies and safe transfer to hub centers.

P21 INFECTIVE ENDOCARDITIS COMPLICATED BY BLOCKED ATRIAL FIBRILLATION AND AORTIC VALVE RUPTURE: A CASE REPORT

Abstract A 63–year–old male patient with a mechanical mitral prosthesis and permanent atrial fibrillation in TAO was hospitalized for heart failure during a SARS CoV–2 infection in April 2022; the transthoracic echocardiogram performed during the hospitalization showed an ejection fraction of 38% The patient was rehospitalized in September 2022 due to worsening general conditions during suspected pneumonia. The hospitalization was complicated by brady AF with heart rate < 30 b.p.m. symptomatic for asthenia and dyspnoea despite the suspension of beta–blocker and digitalis therapy. Therefore, we decided on the implantation of a temporary pacemaker in urgency and subsequently a definitive pacemaker (Essentio MRI – Boston Scientific). During the hospitalization, the clinical conditions continued to be precarious; a transthoracic echocardiogram revealed suspicious formation of endocardic nature at the aortic valve with consensual severe regurgitation. This datum was confirmed with the TEE echo. At this point, in the suspicion of infective endocarditis, antibiotic therapy was set up and the patient was taken to our reference cardiac surgery where he underwent aortic valve replacement with a mechanical prosthesis, reconstruction of the coronary sinus and of the outflow tract of the left ventricle with heterologous pericardial patch. Currently, the patient performs regular clinical follow up at our Center and is in good general condition.

C1 COMPLETE HEART BLOCK AS A RARE MANIFESTATION OF GRANULOMATOSIS WITH POLYANGITIS: A CASE REPORT

Abstract A 42–year–old male with prior smoking habit presented at our emergency department after atraumatic syncope preceded by severe pain in the left lower limb. One month prior to presentation, due to persistence of nonproductive cough he underwent a chest computed tomography (CT), which showed 2 pulmonary nodules with hypercaptation at PET performed later (figure 1). The 12–lead electrocardiogram showed sinus rhythm with complete atrioventricular block and ventricular escape rhythm at 40 bpm (figura 1). Ecofast revealed a mildly impaired left ventricular systolic function (left ventricular ejection fraction [LVEF] 45%) with basal septal hypokinesis. Laboratory assessment showed leukocytosis (marked neutrophilia and eosinophilia), thrombocytosis anemia, elevated C–reactive protein (193 mg/dl), troponin I (18483 ng/L), NTproBNP (14627 ng/l) and creatinine (2.27 mg/dL) levels. The patient was transported to the catheterization laboratory for temporary pacemaker insertion and coronary angiography, which depicted distal occlusion of the first septal branch (Figure 2A), the first diagonal branch (Figure 2B) and the obtuse marginal branch (Figure 2C). After the procedure due to persistent ischemia of the left lower limb, several unsuccessful procedures to restore limb vascularization by means of locoregional thrombolysis and percutaneous angioplasty were attempted, but a leg amputation above the knee was eventually performed after few days. Neoplastic markers, blood cultures and urine cultures resulted negative, urine sediment examination showed cylinders, leucocytes and microhematuria. A brain/facial bones CT scan was performed, showing left maxillary sinusitis (figure 1). A rheumatologic screening was also performed, showing high titer of cANCA(125 UI/ml) hinting at a systemic vasculitis. The histopathological results of the amputated limb depicted marked necrotizing vasculitis with extensive involvement of small–medium caliber and larger caliber arterial vessels (figure 2). Based on these clinical and laboratory findings, a diagnosis of granulomatosis with polyangiitis (GPA) was made. The patients was treated with ev methylprednisolone and rituximab. After the induction therapy, chest CT scan showed a marked reduction of the size of the pulmonary nodule (Figure 3); renal function progressively improved and physiological atrioventricular conduction being restored

P139 RETURN TO THE ORIGINS: WHEN THE THROMBOLYSIS SAVES THE ANGIOPLASTY

Abstract A 62 year old man arrived in PS for typical chest pain radiating to the jugular and associated with sweating for about three hours. History of arterial hypertension and untreated dyslipidemia, family history of CVD. ECG: sinus rithm at rate of 50 bpm with first degree AVB. Inferior ST elevation in inferior leads and ST depression in V2–V3. Echocardiogram: depressed systolic function (EF 48%) in relation to hypo–akinesia of the mid–basal segments of the inferior–posterior–lateral wall. Diagnosed with STEMI inferior–posterior, was sent to the cath lab to undergo to emergency coronary angiography, with findings of non–significant atheromas on IVA and Cx. Multiple unsuccessful attempts to search for the right coronary artery and failure to visualize the aortography in two complementary projections. During the procedure hemodynamic and electrical instability, worsening angor, marked hypotension and extreme bradycardia up to complete AVB with asystole phases. Inotropics and atropine were started, which proved ineffective, and it was therefore decided to proceed with the implantation of a temporary pacemaker. During the placement, the patient presented cardiac arrest from VF (likely an irritating effect from the passage of the lead through the tricuspid) treated with effective DC–shock. Given the technical difficulties in proceeding with mechanical revascularization and given the patient‘s instability, the decision was made to postpone PCI by attempting systemic thrombolysis. Early efficacy of thrombolysis with disappearance of precordial pain, improvement of echo motion and reduction > 50% of the ST–segment elevation to the rare spontaneous QRS displayed at the transient shutdown of the temporary PM. Subsequent emergence of AF at rate of 116 bpm. Approximately 12 hours after thrombolysis: complete ST resolution in absence of Q waves. AngioTC of the coronaries was performed which showed regularl origin of Cdx from the right coronary sinus but higher up and lateralized to the left, with severe lesion in the first segment. So the patient underwent falicitated PCI with detection of ostio–proximal Cdx thrombotic lesion effectively treated with PTCA and drug–eluting stent placement with good final angiographic result. Control echo: preserved global left ventricular motion (FE 55%), hypokinesia of the basal segment of the inferior wall. The remaining stay decurred without any complications and the patient was discharged with indications for a close follow–up.

Rate of various access sites for temporary transvenous pacing and different outcomes at Lady Reading Hospital, Peshawar Pakistan.

To evaluate the various temporary transvenous pacemaker (TPM) access sites, its indications, procedural complications, and outcomes of patients. This prospective study conducted in a tertiary care hospital of Peshawar, included 100 patients, who underwent TPM for any reasons, via the trans jugular, subclavian, or trans-femoral route. The duration of the study was from October 1st, 2021 to March 31st, 2022. The demographic, procedure -related complications, causes of complete heart block and in hospital outcomes were recorded. Of the 100 patients who underwent temporary transvenous pacing, 56%were males and 44% were females, with an age range of 46-80 years. In majority of the patients, (N =54) internal jugular vein was used as the venous access site followed by the subclavian vein. (N=24). Coronary artery disease was prevalent in 42% of the patients. 50% had complete AV block, 19% had symptomatic second-degree block, and 10% had sinus nodal diseases. Seventy three percent of the patients needed TPM implantation on an emergency basis, which is statistically significant (p=0.009). Almost 40% of the patient ultimately underwent a permanent pacemaker. Out of 100 patients, 16 patients expired. The major procedure related complications were bleeding 16% overall at the puncture site and 14.8% in the internal jugular group. Other complications were local infection 13% at the insertion site followed by hemopericardium 3%, in the internal jugular group. Atrioventricular block is the commonest indication for temporary pacing in our study. The average time the TPM remained in place was significantly higher in the trans jugular approach group along with a higher complication rate in this group.

Prophylactic Intravenous Aminophylline for Preventing Bradyarrhythmias During Coronary Atherectomy: A 10-Year Single-Center Experience.

Aminophylline, an adenosine antagonist, can be used to prevent adenosine-mediated bradyarrhythmias. Retrospective, observational, descriptive analysis of patients undergoing rotational atherectomy with intravenous (IV) aminophylline pretreatment during a 10-year period (2010-2020). The primary composite outcome was the occurrence of a documented bradyarrhythmia requiring pharmacologic intervention and/or temporary pacemaker (TPM) implantation. A total of 296 patients received IV aminophylline pretreatment. The primary composite outcome occurred in 1.7% (n = 5) of patients. None of the patients required rescue TPM. Bradyarrhythmias were documented in 2.4% (n = 7) of patients. Pharmacologic interventions, typically with IV atropine, were used in 15% (n = 43) of patients. Per-vessel analyses demonstrated that patients undergoing atherectomy to the circumflex and right coronary arteries were more likely than those undergoing atherectomy to other vessels to have bradyarrhythmias requiring pharmacologic intervention (3.4% vs 0%, P = .01). In this 10-year single-center experience using IV aminophylline pretreatment to prevent major bradyarrhythmias in patients undergoing coronary atherectomy, none of the patients required rescue TPM implantation. These data demonstrate that coronary atherectomy can be performed safely without prophylactic TPM, with aminophylline pretreatment and selective use of atropine representing an effective noninvasive approach.

PO-04-043 ALTERNATING PR AND RP INTERVALS PRIOR TO COMPLETE AV BLOCK: THE CHICKEN OR THE EGG?

The incidence of permanent pacemaker implantation for high-degree AV block after transcatheter aortic valve replacement (TAVR) is approximately 6%, because of mechanical damage to the conduction system. We report a novel ECG marker, i.e. inverse decremental conduction (IDC), that heralds paroxysmal AV block. Case report and exploration of the electrophysiological mechanism. N/A A 73-year-old male with severe symptomatic aortic stenosis underwent TAVR with a balloon-expandable valve. On day 1 post-TAVR, his 12-lead ECG revealed sinus rhythm with a normal PR interval and unchanged RBBB with a left anterior fascicular block (LAFB). The patient was discharged with mobile cardiac outpatient telemetry. Although the patient was asymptomatic, he was asked to come to the emergency department (ED) after his monitor detected a 3.5-second pause during sleep. Shortly after a 12-lead ECG was obtained in the ED, he experienced two sudden cardiac arrests due to complete AV block and asystole requiring CPR and transcutaneous pacing. He underwent emergent implantation of a dual-chamber pacemaker. His ECG in the ED reveals alternating PR intervals (Figure). The first impression of the alternating PR intervals is a dual AV nodal physiology with a 2:1 block in the fast pathway, a relatively benign ECG sign. However, paroxysmal AV block and recent history of TAVR suggested a His-Purkinje injury with block at the subnodal level. More specifically, TAVR-related IDC in the left posterior fascicle (LPF) underlies alternating PR intervals in the setting of RBBB and LAFB. In other words, the PR length is proportional to the preceding RP length, i.e. a longer RP leads to a longer subsequent PR and vice versa due to IDC in LPF. The injured His-Purkinje fibers may lose their all-or-none conduction property and display IDC post-TAVR. This manifests as LBBB with a duration proportional to the preceding RP or RR interval or as prolongation of the PR interval with lengthening of the preceding RP interval in presence of RBBB. IDC in the His-Purkinje may be masked by decremental conduction in the AV node and is often under-recognized. Once the PR interval prolongs with lengthening of the preceding RP interval post-TAVR, unrelated to vagal stimulation, insertion of a temporary or permanent pacemaker is urgently indicated. Alternating PR intervals can be a benign finding, but in this case were linked with paroxysmal AV block secondary to IDC, with resultant cardiac arrest post-TAVR.

Screening of Influencing Factors for AKI Based on Lasso Regression

Background: Acute kidney injury (AKI) is one of the common critical diseases in hospitalized patients. There are many factors affecting acute kidney injury, difficult to obtain disease data, and short treatment time window. Early detection of AKI is critical to reducing mortality. Methods: MIMIC-IV data were used to establish the prediction model of AKI in critical patients after operation. 1585 intensive care unit (ICU) patients were randomly divided into a training set (n=1109) and a prediction set (n=476) on a 7:3 basis. LASSO regression analysis was performed on the data, area under the operating characteristic curve (AUROC) was used to evaluate the model, and Hosmer-Lemeshow (HL) was used to test the degree of fit. Results: Spinal injury, implantation of temporary cardiac pacemaker, esophageal disease, contrast media, diuretic, epinephrine, aminoglycoside antibiotics, tumor chemotherapy drugs, age, gender and red blood cells were determined to be independent risk factors for acute kidney injury. The AUROC of the model in the train set was 0.901 (95% confidence interval: 0.856~0.946). In the validation set, AUROC was 0.851 (95% confidence interval: 0.808~0.894). AUROC of the above two groups indicated that the model had a good degree of differentiation, which was greater than 70% in both groups. Hosmer-Lemeshow (HL) test showed P>0.05, indicating a good fit of the model. Conclusion: This prediction model can be used for the identification of post-operative AKI patients and provide a basis for clinicians or inpatients to more quickly self-measure the risk.

Potential use of prophylactic intracoronary atropine in reducing reperfusion vagal reflex-related events in ST-elevation myocardial infarction

In this study, we evaluated the potential use of atropine in reducing reperfusion vagal reflex-related events during emergency percutaneous coronary intervention (PCI) for acute inferior ST-elevation myocardial infarction (STEMI). Retrospectively, we included 142 patients with inferior wall STEMI, who were treated between October 2015 and October 2020, in this study. The patients were divided into an experimental group (n = 70) and a control group (n = 72) depending on whether they received prophylactic intracoronary atropine. The experimental group was then subdivided into a low-dose group (0.5 – 1 mg atropine, n = 40) and a high-dose group (2 mg atropine, n = 30). We compared the incidence of reperfusion vagal reflex-related events and the application of temporary pacemakers between these groups. The results showed that the incidence of bradycardia (24.3% vs. 45.8%, P = 0.007), hypotension (18.6% vs. 40.3%, P = 0.005), ventricular tachycardia (4.3% vs. 19.4%, P = 0.005), and ventricular fibrillation (8.6% vs. 20.8%, P = 0.040) as well as the application of temporary pacemakers (14.3% vs. 29.2%, P = 0.032) were all much lower (all P < 0.05) in the experimental group than in the control group. In addition, the incidence of bradycardia (10% vs. 35%, P = 0.016), hypotension (6.7% vs. 27.5%, P = 0.027), ventricular tachycardia (6.7% vs. 25%, P = 0.044), and ventricular fibrillation (0 vs. 15%, P = 0.034) as well as the application of temporary pacemakers (3.3% vs. 22.5%, P = 0.036) were all much lower (all P < 0.05) in the high-dose group than the low-dose group. Our findings demonstrate that atropine pretreatment could prevent reperfusion vagal reflex-related events and reduce the application of temporary pacemakers during emergency PCI for acute inferior STEMI. These effects can be significantly enhanced by high-dose (2 mg) atropine pretreatment.

Carotid Sinus Syndrome - Case Report

Abstract Syncope caused by carotid sinus syndrome due to malignancy of the head and neck is rare. The aim of this paper is an inspection into current knowledge of this syndrome, its clinical characteristics, differential diagnosis and current treatment modalities. We present a case of recurrent syncope resulting from extreme bradycardia based on a malignant process in the neck area that compresses the carotid sinus. To discover the cause of syncope, an extensive diagnosis was made including electrocardiography, 24h holter electrocardiography, computed tomography of the neck, biopsy of the lump on the right side of the neck. In order to perform the biopsy, the patient was implanted with a temporary pacemaker. Pathohistological processing of biopsy showed the existence of squamous cell carcinoma of the neck region. Due to localization of the malignant change, surgical resection was contraindicated, so the patient was treated with radiotherapy. Syncope based on carotid sinus hypersensitivity caused by a malignant process of the neck region is a significant diagnostic challenge for any clinician. Neck tumor is rarely thought of, since its frequency is rare in the general population. The disease is mostly recognized in the advanced stages when episodes of syncope are more frequent.

A Degradable and Biocompatible Supercapacitor Implant Based on Functional Sericin Hydrogel Electrode

AbstractImplantable power sources face great challenges in balancing multiple factors including high performance, biocompatibility, mechanical properties for soft tissue fit, and biodegradability. Toward this goal, a simple and feasible method is proposed to prepare implantable a hydrogel‐based supercapacitor (SC). Specially, a multinetwork conductive electrode is in situ formed by aminated‐reduced‐graphene‐oxide‐and‐methacrylic‐anhydride‐comodified sericin (SrMA/A‐rGO) sequentially cross‐linking with four‐arm polyethylene glycol succinimide carbonate and polyethylene glycol acrylate. The conductive multinetwork endows the SrMA/A‐rGO‐based SC implant an equivalent series resistance of 21 Ω cm−2, a volumetric energy density of 26.0 µW cm−2, and a high specific capacitance retention (over 76.4%) after long‐term charging/discharging. Two SCs connected in tandem are able to light up a light‐emitting diode for both in vitro and in vivo studies. Moreover, they can work as a direct output power source to electrically stimulate a stopped heart to start beating again. Additionally, the SC exhibits superior biocompatibility and biodegradability in vivo, and holds the value of specific capacitance above 30% 2 weeks after implantation. Thus, this work demonstrates the SrMA/A‐rGO‐based SC's potential to serve as a power storage unit for medical implants (such as a temporary pacemaker).

Reversible Complete Heart Block in a Pregnant Woman Responding to Steroids: A rare Case Report

Background: Complete heart block (CHB) is the total absence of conduction from atria to ventricles with an escape rhythm most commonly arising from the AVN or His bundle. CHB in pregnancy is very rare, and most reported cases are due to congenital variety, where the pre-existing CHB from birth is either detected incidentally or presented with symptoms during pregnancy. Pregnancy is associated with various physiological changes, such as a pro-inflammatory, hypercoagulable state with possible oedema of the heart's conduction system, which may rarely give rise to CHB. There are no clear guidelines to manage CHB complicating pregnancy. Case Presentation:: An asymptomatic 27-year-old lady with G2P1L1, 39 weeks of gestation with breech presentation, was referred for delivery given the low maternal heart rate of 40 bpm. Per abdominal examination revealed a term size uterus with active contractions and a fetal heart rate of 140bpm. An ECG revealed a CHB with an escape rate of 40 bpm. Other routine investigations were normal, with negative serological evaluation for hepatitis B, C, and HIV. ANA and Anti-Ro ⁄ SSA antibodies. She underwent an emergency LSCS under spinal anaesthesia with a backup temporary pacemaker (TPM). She received a short course of empirical steroid therapy for three days as there were no obvious secondary causes for CHB, which reverted to sinus rhythm after 48 hours. Discussion: CHB complicating pregnancy with or without symptoms may require definitive therapy in the form of permanent pacemaker implantation. However, the insertion of a TPM for managing pregnancy is controversial as opinion in the literature is divided. There are no reports of CHB occurring in pregnancy without congenital or other known acquired causes. In the reported case, the CHB reverted to sinus rhythm with a short course of IV steroid therapy without any subsequent need for a PPM implantation. Conclusion: Congenital CHB remains the most common cause of rarely seen CHB complicating pregnancy. Through the conduction system oedema and inflammation, physiological changes in gestation may rarely cause CHB during pregnancy. In the absence of congenital CHB and other demonstrable acquired causes, a short course of steroid therapy may reverse the CHB avoiding PPM implantation as shown in the reported case.

An Ambulatory Approach to Atrioventricular Block in Lyme Carditis Using Temporary Permanent Pacemakers.

An Ambulatory Approach to Atrioventricular Block in Lyme Carditis Using Temporary Permanent Pacemakers.

Nurses' Performance Regarding Care of Temporary Pacemaker among Critically Ill Patient

Nurses' Performance Regarding Care of Temporary Pacemaker among Critically Ill Patient