Temporary Pacemaker Research Articles

Acute myocarditis presentation and intra-hospital prognosis: results of the multicenter prospective MYOCARDITIRM study

Abstract Background Acute myocarditis (AM) usually presents as chest pain with rising troponin and normal coronary arteries. Despite frequent favorable evolution at the acute phase, it is associated with heart failure and ventricular rhythm disorders and is considered the leading cause of sudden cardiac death in young apparently healthy adults. There is no recommendation for AM, only expert consensus, given the lack of important databases for a strong level of confidence. Methods We performed a multicenter prospective observational study of patients admitted for AM acknowledged by cardiac MRI to describe baseline characteristics, management, in-hospital and long-term outcomes of AM patients in France. Secondary objectives were to investigate determinants of prognosis, modalities of treatment and follow-up, and to identify gaps between expert consensus and real-life management. Results We enrolled 805 consecutive patients hospitalized for AM in 49 participating centers between May 2016 and February 2019. Median age was 31 (IQR 23-41) with 19% of female. Chest pain was the most frequent symptom (93%) and 112 (14%) had severity criteria upon admission (LVEF<50% or severe ventricular arrythmia or high-grade AV block or cardiogenic shock). ST elevation was observed in 49% of patients. One 26-years old patient died during initial hospital stay. Overall, 62 patients (8%) experienced intra-hospital complication of their AM, defined as a combined endpoint of death, LVEF<40% (MRI), sustained ventricular or supraventricular arrythmia, acute renal failure, cardiogenic shock, need for ventricular assistance device, need for inotropic drugs, temporary cardiac pacing, pace-maker or cardiac defibrillator implantation. Patients with initial severity criteria were 10 times more likely to present intra-hospital complication (33% vs 3.6%, p<0.001). Conclusion This prospective cohort represents the largest database on AM worldwide. Here we report baseline characteristics and in hospital events. Most patients had typical presentation with favorable outcomes but as much as 8% of patients did exhibit intra-hospital complication. The prospective follow up will provide valuable data to better identify subset of patients with poor prognosis that may be of interest to develop new therapeutic strategies.Acute myocarditis on cardiac MRI

Electrical performance of a novel extravascular temporary pacing lead system

Abstract Background An investigational extravascular (EV) cardiac temporary pacing system has been developed that includes a parasternally-positioned temporary pacing lead within the anterior mediastinum. The pacing lead is inserted using a custom delivery tool through a parasternal skin incision. This novel system may provide clinical advantages over existing device alternatives that require intravascular, endocardial, or epicardial contact. Objective The purpose of this study was to evaluate electrical performance of an EV temporary pacing lead over 48 hours. Methods In this single-center study, patients who underwent a transvenous (TV) permanent pacemaker implant or replacement were simultaneously implanted with the investigational EV temporary pacing lead. Electrical performance was evaluated through analysis of capture thresholds, impedance, and R-wave amplitudes during multiple times on the day of the procedure and on the subsequent 2 days of follow-up. Results Lead insertions with acute capture were successful in all 8 patients (40% female, 71 ± 8 years, BMI 27 ± 3 kg/m2). Mean acute measurements for pacing capture threshold at 1.5 ms, impedance and R-wave amplitude were 6.2 mA, 1396 Ω, 5.4 mV, respectively. Pacing capture was maintained in 100% of assessments conducted over 3 days (Figure 1). There were no serious complications during insertion, removal or chronic use of the lead. Conclusions Results support that the investigational EV temporary pacing lead is capable of safely providing temporary pacing with thresholds typically well below the maximum output of temporary pacemakers.

Effects of remimazolam versus dexmedetomidine on recovery after transcatheter aortic valve replacement under monitored anesthesia care: a propensity score-matched, non-inferiority study.

Minimalist transcatheter aortic valve replacement (TAVR) under monitored anesthesia care (MAC) emphasizes early recovery. Remimazolam is a novel benzodiazepine with a short recovery time. This study hypothesized that remimazolam is non-inferior to dexmedetomidine in terms of recovery after TAVR. In this retrospective observational study, remimazolam was compared to dexmedetomidine in patients who underwent TAVR under MAC at a tertiary academic hospital between July 2020 and July 2022. The primary outcome was timely recovery after TAVR, defined as discharge from the intensive care unit within the first day following the procedure. Propensity score matching was used to compare timely recovery between remimazolam and dexmedetomidine, applying a non-inferiority margin of -10%. The study included 464 patients, of whom 218 received remimazolam and 246 received dexmedetomidine. After propensity score matching, 164 patients in each group were included in the analysis. Regarding timely recovery after TAVR, remimazolam was non-inferior to dexmedetomidine (152 of 164 [92.7%] in the remimazolam group versus 153 of 164 [93.3%] in the dexmedetomidine group, risk difference [95% CI]: -0.6% [-6.7%, 5.5%]). The use of remimazolam was associated with fewer postoperative vasopressors/inotropes (21 of 164 [12.8%] vs. 39 of 164 [23.8%]) and temporary pacemakers (TPMs) (76 of 164 [46.3%] vs. 108 of 164 [65.9%]) compared to dexmedetomidine. In patients undergoing TAVR under MAC, remimazolam was non-inferior to dexmedetomidine in terms of timely recovery. Remimazolam may be associated with better postoperative recovery profiles, including a lesser need for vasopressors/inotropes and TPMs.

Failure of pacemaker therapy in a pediatric patient with neurally mediated complete heart block and syncope: A case report.

Neurally mediated syncope (NMS) is a well-known condition that can be subdivided into three subgroups: vasopressor type, cardioinhibitory type, and mixed type. While different degrees of sinus bradycardia occur at the time of syncope in all types, complete heart block is a rare event that can lead to pulselessness during syncope. We present a case of a 14-year-old girl with documented NMS before and after temporary pacemaker implantation, who had complete heart block during syncope. The patient's temporary pacemaker placement was ineffective in preventing syncope during a repeat head-up tilt test, indicating that permanent pacing may not be effective in this patient. Midodrine, an alpha-adrenergic agonist, was started, and the patient experienced complete control of syncope episodes without recurrence during a 2-month follow-up.

Management of complete heart block detected during labor: A case report

Complete heart block in women of childbearing age is rare, and incidental diagnosis during pregnancy is more uncommon. Hence, there remain no well-established guidelines on the management of patients with complete heart block presenting in labor. Here, we present a 26-year-old full-term primigravida, with no known previous cardiac history, in active labor with asymptomatic bradycardia in the 30–40s unresponsive to atropine augmentation. After multidisciplinary consultation, the decision was to proceed with delivery as planned without indication for a temporary pacemaker. The patient successfully delivered a full-term infant via operative vaginal delivery, with an ensuing cardiac workup completed postpartum.

Study on Unguided Temporary Pacing Via the Jugular Vein at the Mohamed VI University Hospital of Marrakech: Safety, Effectiveness and Practicability

This study evaluates the safety, effectiveness, and feasibility of unguided temporary pacemaker insertion in 348 patients at the Mohamed VI University Hospital of Marrakech. The procedure was performed by cardiology residents and showed a high success rate of 99.71%, with successful access to the right internal jugular vein in 89.66% of cases. The majority of patients (66.38%) achieved venous access on the first attempt, with an average procedure time of 11.5 ± 2.1 minutes. Minor complications were observed in 10.63% of patients, including local hematomas (3.45%), accidental arterial punctures (2.30%), pneumothorax (1.15%), and other issues such as local infections and non-sustained ventricular tachycardia. No deaths attributable to the procedure were reported. The clinical significance of this study lies in its demonstration that unguided temporary pacemaker insertion is a safe and effective alternative in resource-limited settings, reducing treatment delays and potentially lowering mortality among patients requiring temporary cardiac pacing. Based on these results, it is recommended to encourage clinicians in primary and secondary healthcare settings to adopt this approach to improve access to urgent cardiac care in under-resourced regions.

REVERSIBILITY OF COMPLETE HEART BLOCK AFTER ACUTE ANTERIOR WALL MI

Acute myocardial infarction (MI) can result in varying degrees of heart block, most commonly in inferior wall MI. Identifying the reversibility of complete heart block (CHB) is crucial for guiding clinical management, particularly in determining the need for temporary or permanent pacemaker implantation. Objective: To determine the frequency of reversibility of complete heart block in patients presenting with acute myocardial infarction at Bolan Medical Complex, Quetta. Methods: This cross-sectional study was conducted at Bolan Medical Complex, Quetta, from March 2022 to June 2023. A total of 100 patients aged 18–65 years presenting with syncope and atypical chest pain were included. All patients underwent coronary angiography to identify ischemic causes of bradyarrhythmias. Temporary pacemaker dependency was monitored for two weeks, and permanent pacemaker implantation was performed if necessary. Data on demographic and clinical characteristics were collected and analyzed using SPSS version 22.0. Descriptive statistics were calculated, and the association between heart block reversibility and clinical variables was assessed using the Chi-square test, with p ≤ 0.05 considered significant. Results: The mean age of the patients was 52.5 ± 14.8 years, with 60% male and 40% female patients. The prevalence of diabetes, hypertension, and smoking was 40%, 55%, and 43%, respectively. CHB occurred in 7% of patients aged 16-35 years and 8% in those aged 36-65 years. The overall reversibility rate of CHB was 48%. A statistically significant association (p < 0.05) was found between second-degree atrioventricular (AV) block and CHB in relation to reversibility. Conclusion: Complete heart block in patients with acute myocardial infarction is often reversible, particularly in those with mild coronary artery disease. Temporary pacemaker use should be considered before deciding on permanent pacemaker implantation to allow time for potential spontaneous recovery.

Standardized Temporary Atrial Epicardial Wire Locations Lead to Enhanced Atrial Signal Identification.

Background: Arrhythmias, common after pediatric cardiac surgery, are associated with increased morbidity and mortality. Atrial epicardial wires (AEW) improve diagnostic accuracy but have variable pacing and sensing properties based on their location. Even so, there are no longitudinal prospective pediatric studies examining ideal placement of AEW. Methods: This multicenter study compared atrial amplitudes, pacing sensitivities and thresholds via AEW placed at Bachmann's Bundle (BB) and the interatrial groove near the right pulmonary veins (IGRPV) versus the surgeons' standard locations. An AtriAmp system was used to obtain an atrial ECG to calculate atrial and ventricular amplitude from atrial electrograms on the bedside monitor. Sensitivities and thresholds via a temporary pacemaker were documented. ANOVA tests with repeated measures and post-hoc pairwise comparisons were performed to compare variables within the first 24-h postoperative hours. Mixed effects linear regression models were employed to examine daily trends. Results: In the first 24-h following cardiac surgery, AEW at BB and IGRPV showed significantly larger atrial amplitudes than the surgeons' standard locations. In addition, there was a negative trend in atrial ECG amplitude in all AEW from postoperative days 0 to 1; however, subsequent days showed a positive mean change in atrial amplitude with largest increase seen at BB. Atrial sensing as measured by the temporary pacemaker had statistically greater atrial signal amplitude from the BB-IGRPV set in both polarities (ie, with the BB as the - or + electrode pair) as compared to the surgeons' standard locations. No difference in atrial thresholds (mA) were noted in the immediate postoperative period or over time, with a relatively low atrial threshold at all sites. Conclusion: Standardization of AEW at Bachmann's Bundle can yield largest atrial amplitudes by atrial ECG and highest atrial sensing parameters without compromising atrial thresholds.

Microbial growth on temporary pacemaker leads post-TAVR: pathogen spectrum and clinical implications.

Transcatheter aortic valve replacement (TAVR) is an established treatment option for patients with symptomatic severe aortic stenosis across all stages of surgical risk. Rapid pacing during the procedure and the risk for the occurrence of conduction disturbances after TAVR requires the pre-interventional insertion of a temporary pacemaker (TP). However, this approach poses risks, including the risk of infection. For this reason, the following study aimed to investigate microbial growth on temporary pacemaker leads and its association with outcome post-TAVR and to identify associated pathogens and related risk factors. A prospective study was conducted including 344 patients undergoing TAVR at the Heart Centre Bonn. Of these, 97 patients did not require TP leads as they already had permanent pacemakers; this group was considered as comparison group. The TP leads of the remaining 247 patients were removed, sonicated, and cultured to investigate bacterial growth over a period of 14days. Finally, we compared patients without microbial growth (n = 184) and patients with microbial growth (n = 63). The primary endpoint of the study was 30-day all-cause mortality, secondary endpoints were periprocedural infections, the length of the postprocedural hospital stay, 30-day major vascular complications and the 30-day stroke rate. The majority of cases (74.5%) showed no bacterial growth. In the remaining cases (25.5%), diverse microorganisms were identified, mostly non-pathogenic bacteria. The statistical analysis revealed no significant differences between groups according to microbial growth in terms of 30-day mortality (p = 0.446), postprocedural hospital stay (p = 0.401), periprocedural infections (p = 0.434), 30-day major vascular complications (p = 1.0), and 30-day stroke rate (p = 1.0). Notably, the timing of sheath insertion was significantly associated with microbial growth; sheath placement more than 2days prior to the procedure was associated with a significantly higher risk of microbial growth (OR: 2.1; 95% CI 1.1-4.3) (p = 0.030). The presence of temporary leads does not significantly impact clinical outcomes, irrespective of bacterial growth on the lead. However, the timing and duration of sheath placement plays a crucial role in contamination incidence. Thus, temporary leads/sheaths should be placed shortly before the procedure and removed promptly to reduce the risk of contamination/infection.

Immune checkpoint inhibitor-associated sick sinus syndrome and cardiogenic shock.

Immune checkpoint inhibitors (ICI) represent a major advance in the treatment of cancer. Most studies of ICI have underestimated their cardiotoxicity; however, an increasing number of cases of cardiotoxicity are being reported. Herein we discussed a 67-year-old, male, Japanese patient who presented with cardiogenic shock accompanied by sick sinus syndrome 4days into his second course of ipilimumab plus nivolumab combination therapy. A temporary transvenous pacemaker was subsequently placed, and a permanent pacemaker was implanted for persistent, symptomatic, intermittent bradycardia. The permanent implantation of the pacemaker improved his symptoms and allowed him to continue his ICI therapy.

Understanding the role of temporary epicardial pacemakers after heart transplantation in the cardiac intensive care unit

The International Society of Heart and Lung Transplantation (ISHLT) guidelines for the care of heart transplant recipients recommend the placement of temporary epicardial pacing wires at the time of surgery. However, there is little data regarding optimal postoperative pacing modality and its implication on ICU length of stay (LOS).We conducted a single-center retrospective cohort study of 187 patients who underwent heart transplantation from January 1, 2019 to February 28, 2023 and had postoperative epicardial pacemaker wires placed. The study's primary outcome was to observe the association between pacing modalities and prolonged ICU LOS (greater than 5 days). The secondary outcome was to observe the association between pacing modalities and prolonged hospital LOS (greater than 15 days), readmission within 30 days of discharge, days on inotropic and pressor support, death, high-grade rejection on biopsy, coronary artery vasculopathy at 1 year, primary graft dysfunction, mediastinitis, and development of a malignancy.22 patients (12%) had their pacing mode turned off at the time of arrival to the ICU, 36 patients (19%) had their pacing mode set to AAI, 101 patients (54%) had theirs set to DDD, and 28 (15%) had theirs set to VVI. No mode of epicardial pacing was associated with an increased ICU LOS, hospital LOS, increased readmission rates, increased short-term adverse effects (STAEs), increased long-term adverse effects (LTAEs), or increased duration of support with vasoactive medications.Our study demonstrated no significant association between the mode of temporary pacing and LOS or adverse effects after heart transplantation.

An unusual cause of cardiac arrest in a young infant

BackgroundAnomalous aortic origin of a coronary artery from the inappropriate sinus of Valsalva (AAOCA) is a rare congenital heart lesion. It is uncommon for patients with AAOCA to present with severe symptoms at a very young age.Case presentationWe describe a very rare but critical presentation in a young infant with AAOCA that requires surgical repair and pacemaker placement. A three-month-old infant was referred because of syncope. Cardiac arrest occurred shortly after admission. The electrocardiogram indicated a complete atrioventricular block and a transvenous temporary pacemaker was implanted. A further coronary computed tomographic angiography (CTA) showed the anomalous origin of the right coronary artery from the left sinus of Valsalva. Coronary artery unroofing was performed due to an interarterial course with the intramural component, and a permanent epicardial pacemaker was implanted. The postoperative recovery was uneventful, and this patient was thriving and asymptomatic at the nine-month follow-up. However, the electrocardiogram still indicated a complete pacing rhythm.ConclusionsBy timely diagnosis and treatment, this patient is successfully rescued. Although rare, AAOCA may be fatal even in infants.

Malposition of the Aortic Valve After TAVI with Consequent Severe Aortic Regurgitation

Male, 63 years old, with a long-term history of ischemic heart disease. After an myocardial infarction 20 years ago, a surgical evascularization was performed with left interior mammary artery (LIMA) – left anterior descending (LAD) bypass. Elective percutaneous coronary intervention (PCI) with the implantation of one bare metal stent in the circumfl ex artery was done 4 years ago. During this procedure, an indication for transcatheter aortic valve implantation (TAVI) was set due to the progression of stenosis gradient in the bicuspid aortic valve. Immediately after the TAVI procedure, the patient developed symptoms and signs of acute heart failure due to the malposition of the aortic valve and consequent severe aortic regurgitation (AR)(1). The images depict a transesophageal echocardiographic examination after TAVI (Figure 1-4). Severe AR with paravalvular jets is the result of the malposition of the biological valve after TAVI, where the valve partially occupies the left ventricular outfl ow tract. The inadequately positioned aortic val-ve was surgically removed, followed by the implantation of a mechanical aortic valve. Subsequently, as the patient was dependent on a temporary pacemaker, a permanent dual-chamber pacemaker was implanted. Following the surgical treatment, the patient recovered successfully (2,3).

Usefulness of temporary pacemaker during acetylcholine provocation testing

Usefulness of temporary pacemaker during acetylcholine provocation testing

The Role of Alcohol Ablation Therapy in Hypertrophic Obstructive Cardiomyopathy Management

Objectives: The following study aims to investigate alcohol septal ablation’s (ASA) role in hypertrophic obstructive cardiomyopathy (HOCM) management, focusing on in-hospital outcomes, efficacy in reducing left ventricular outflow tract (LVOT) obstruction, and safety profiles. Methods: The study, conducted at the Institute of Cardiology, National Hospital of Sri Lanka, included a total of nine HOCM patients. Participants with exercise-induced symptoms, dyspnea/angina, and specific ventricular gradients were included; unidentified septal branches led to exclusion. Diagnostic assessments, including electrocardiogram, contrast echocardiography, and cardiac catheterization, confirmed HOCM. ASA procedures involved careful target septal branch selection, alcohol injection, and post-procedure care with temporary pacemaker monitoring. Results: The study population (N=9) comprised seven males and two females, with a mean age of 40. Pre- and post-ablation measurements showed 78% reduction in LVOT gradient. Immediate complications included chest pain (100%), while 22.2% developed complete heart block. Notably, no mortality occurred during the study. Conclusion: ASA proved safe and effective in managing HOCM, with significant mean reduction in post-ablation LVOT gradient (78%). Complications were generally minor, emphasizing ASA’s viability for symptomatic HOCM patients. While acknowledging the absence of randomized controlled trials comparing ASA with alternative techniques, this study contributes valuable insights to guide collaborative treatment decisions by specialists.

Optimal timing of of cardiac implantable electronic device reoperation

Abstract Background Early re-intervention may increase the risk of infection of cardiac implantable electronic devices (CIED). Some operators therefore delay lead repositioning in case of dislocation by weeks, however there is no evidence to support this practice. The aim of our study was to evaluate the impact of the timing of re-operation on infection risk. Methods Data from consecutive patients (n=249) receiving lead/generator repositioning in one Hungarian and one German tertiary centre between January 1995 and August 2022 were retrospectively analysed. Relative risk of CIED infection in the first year was compared among patients undergoing early (≤1 week) vs. delayed (from 1 week to 1 year) re-operation. Results Out of 249 patients (mean age 70 ± 13 years, 54% male) requiring CIED re-intervention (30% single-chamber, 48% dual-chamber, and 22% CRT devices), 55 patients underwent right atrial (22%), 145 patients underwent right ventricular (59%), 20 patients underwent coronary sinus (8%), and 28 patients underwent multiple lead (11%) repositioning. Eighty-five patients (34%) went through an early (median 2, interquartile range (IQ): 1-4.5) and 164 (66%) patients had a delayed lead/pocket revision (median 53, IQ 36-209 days). A total of 9 (3,6%) wound/device infections were identified during the first year of follow-up, 1 (1,2%) vs. 8 (4,9%) in the in the early vs delayed groups. The risk of infection was numerically lower in the early vs. the delayed intervention groups yielding no statistically significant difference (OR=0.232; 95% CI 0.029-1.888; p=0.172). After adjustment for typical risk factors for CIED infection (i.e., number of implanted leads, diabetes, heart failure, fever prior to implant, therapy with corticosteroids, anticoagulation or antiplatelet therapy, temporary pacemaker) this difference remained non-significant (adjusted OR=0.266, 95% CI 0.032-2.246, p=0.224). System explantation/extraction was necessary in 7 cases (2,8 %), all being revised in the delayed group (OR early vs. delayed 0.128, 95% CI 0.01-2.273, p=0.161). Conclusion In this bicentric study, delayed re-intervention did not reduce the risk of CIED infection compared to patients undergoing an early (<1 week) re-operation.

In-hospital outcomes of anterior versus non-anterior st elevation myocardial infarction complicated with complete atrioventricular block

Abstract Background Complete atrioventricular block (CAVB) is an infrequent complication of acute ST-elevation myocardial infarction (STEMI), and information on its outcomes is scarce. We aimed to address the characteristics and in-hospital outcomes of patients with anterior versus non-anterior STEMI complicated with CAVB in a contemporary, nationwide, all-comer registry, in the U.S. Methods Using the National Inpatient Sample (NIS) database, we identified patients who were hospitalized with STEMI, complicated with CAVB between 2016- 2019. Patients with any cardiac implantable electronic device (CIED) in-situ were excluded. Baseline characteristics, in-hospital procedures and outcomes including time to temporary or permanent pacemaker (PPM)/implantable cardioverter defibrillator (ICD) implantation, length of stay and mortality were collected. Results A total of 17470 patients, were hospitalized with a primary diagnosis of STEMI and concomitant diagnosis of CAVB, 2755(15.8%) with Anterior and 14715(84.2%) with non-anterior STEMI. Non-anterior STEMI patients included more women, had higher prevalence of hypertension, dyslipidemia, smoking history and chronic pulmonary disease, while anterior STEMI patients had higher prevalence of chronic kidney disease and ischemic cardiomyopathy. Anterior STEMI patient had significantly higher rate of in hospital death [955 (35%) vs 2220 (15%), p<0.001], CPR, VT/VF, cardiac arrest, acute heart failure, respiratory failure, mechanical ventilation >96 hours and acute kidney injury. In both groups 40% received temporary pacemaker, but mean time to implantation was longer in anterior STEMI patients [1.1±3.3 vs 0.3±1.2 days, p<0.001]. Rate of any permanent CIED implantation was also significantly higher in the anterior STEMI patients with longer time to PPM implantation, [3.3±3.5 vs 2.8±2.8 days, p<0.001]. Use of mechanical circulatory support devices was significantly higher in anterior STEMI patients. Conclusion In STEMI patients complicated with CAVB, in-hospital outcomes of anterior STEMI were worse comparing to non-anterior STEMI, with significantly higher rates of in-hospital death, in-hospital complications and CIED implantations.

Clinical analysis of temporary pacemaker implantation in 6 children with fulminant myocarditis.

There is little literature on the use of temporary pacemakers in children with fulminant myocarditis. Therefore, we summarized the use of temporary cardiac pacemakers in children with fulminant myocarditis in our hospital. The clinical data of children with fulminant myocarditis treated with temporary pacemakers in Wuhan Children's Hospital from January 2017 to May 2022 were retrospectively analyzed. A total of 6 children were enrolled in the study, including 4 boys and 2 girls, with a median age of 50 months and a median weight of 15kg. The average time from admission to pacemaker placement was 2.75 ± 0.4h. The electrocardiogram showed that all 6 children had third-degree atrioventricular block (III°AVB). The initial pacing voltage, the sensory sensitivity of the ventricle and the pacing frequency were set to 5-10 mV, 5V and 100-120bpm respectively. The sinus rhythm was recovered in 5 patients within 61h (17-134) h, and the median time of using temporary pacemaker was 132h (63-445) h. One of the children had persistent III°AVB after the temporary pacemaker. With parental consent, the child was fitted with a permanent pacemaker on the 12th day of his illness. When fulminant myocarditis leads to severe bradycardia or atrioventricular block in children, temporary pacemakers have the characteristics of high safety to improve the heart function.

A CASE OF DUAL–SITE LEFT VENTRICULAR PACING PERFORMED VIA A PERSISTENT LEFT SUPERIOR VENA CAVA IN A PATIENT WITH COMPLETE ATRIO–VENTRICULAR BLOCK AND RIGHT SUPERIOR VENA CAVA OCCLUSION

Abstract Patient A 64 year old male admitted for syncope. EKG presented 3rd degree AV block. Attempting to place temporary pacemaker was unsuccessful due to occlusion of the right femoral vein and the presence of a catheter for hemodialysis in the left femoral vein. He also has complete thrombosis of the right internal jugular vein, proximal superior vena cava and right femoral vein. He was referred to ICCU for monitoring, asymptomatic with no signs of congestion or hypoperfusion. Dopamine was started at 4 mcg/kg/min and then isoprenaline 0.06 mcg/kg/min. Initial work up Echocardiography showed depressed LV ejection fraction (LVEF 40%). Chest and abdomen angio–CT showed persistence of a superior left vena cava (PSLVC), which drained in the coronary sinus (CS). Right axillary and subclavian veins were occluded, and also right superior vena cava and right jugular vein. Left jugular, axillary and subclavian veins were pervious. Left femoral and right iliac–femoral veins showed significantly narrowing of the vessel lumen. Diagnosis and Management Our indication for this patient was CRT rather than RV pacing. The implant of a leadless AV pacemaker was also considered, but it was considered unfeasible due to limited access from the femoral veins. The presence of a PSLVC cava draining into CS was confirmed with angiography in the EP Lab. At the beginning of the procedure two episodes of asystole occurred. A first bipolar lead was rapidly placed in a postero–lateral branch of the CS, to obtain a stable temporary pacing. We then placed a quadripolar, active fixation, left ventricular pacing lead via the PSLVC into an antero–lateral branch of the CS. Finally, we placed a right atrium active fixation pacing lead in the right atrium again through the PSLVC. Vascular accesses were cephalic left vein and axillary vein. Acceptable sensing and pacing parameters were achieved. The bipolar LV lead was connected to the IS–1 RV port for sensing and the quadripolar lead was connected to the IS–4 LV port for pacing. Programming was DDDR 60–130 with active LV pacing only. Total procedural time was 180 minutes. No complications occurred. At discharge electric parameters were stable. Echocardiography showed an improvement in LVEF (45% vs 40%) and ECG showed atrio–ventricular LV pacing. Conclusion As far as we know this is the first reported case of a CRT delivered by two left ventricle pacing leads both placed via a PLSVC, with no need to place a pacing lead in the right ventricle.

LYME AND DENGUE FEVER: FROM BANGLADESH TO ITALY

Abstract Background Dengue fever (Flavivirus) and Lyme disease (Borrelia burgdorferi) are rare tropical infectious diseases transmitted by hematophagous vectors (Aedes mosquitoes and ticks, respectively), and they are extremely uncommon in Italy. In European countries, both represent a public health concern as they manifest as imported diseases. Case Report A 54–year–old man from Bangladesh was admitted with symptoms of fever, dyspnea, and pericarditic chest pain. Laboratory and imaging examinations revealed severe acute respiratory failure secondary to left lower lobe pneumonia and pleuropericardial effusion. Broad–spectrum antibiotic therapy and anti–inflammatory treatment were initiated, suspecting para–pneumonic pleuropericarditis. During hospitalization, there was a gradual improvement with a reduction in inflammatory indices and resolution of lung consolidation. The patient was discharged after 14 days with anti–inflammatory therapy (ibuprofen and colchicine). Approximately 7 days later, the patient returned to the emergency department complaining of a recurrence of symptoms and fatigue. The EKG showed phases of 2:1 AV block, EAS and EPS, complete de novo left bundle branch block (LBBB), alternating with an escape atrial rhythm, not evident in previous EKG. During hospitalization, complete AV block emerged with prolonged asystolic phases, requiring urgent placement of a temporary pacemaker. Concurrently, blood tests revealed anemia and increased levels of inflammatory markers, troponin, creatinine, transaminases, cholestatic indices, LDH, and lipase, indicative of multiple organ failure (MOF). Acute pathologies or active bleeding were ruled out by total body CT with contrast. Blood cultures and serological tests were performed to exclude infections by Trichinella, Mycoplasma, Borrelia, Dengue, and other rare infectious diseases. Due to progressive deterioration, the patient was transferred to a tertiary care hospital. In the following days, laboratory results showed positive IgG and IgM for Dengue (without serological evidence of viral RNA) and positive IgG and IgM antibodies for Borrelia burgdorferi. Conclusion In Italy, the incidence of these diseases is low, and their coexistence in the same host is even rarer (if not anecdotal). However, coinfection cannot be excluded in patients from areas where these diseases are endemic, such as Bangladesh.