Transvenous Pacemaker Insertion Research Articles

Double left brachiocephalic vein in a paediatric patient with CHD: a case report

AbstractAnomalous brachiocephalic vein (ABCV) is a rare entity of head and neck venous channel variations and malformations. Amongst the five subtypes of ABVC, double left brachiocephalic vein (DLBCV) is the rarest. We present the case of a 1-year-11-month-old syndromic child, who had global developmental delay (GDD) with Sprengel deformity and failure to thrive (suspected Klippel Feil phenotype), who presented to us for the cardiac evaluation. Her 2D echocardiography revealed unobstructed total anomalous supra-cardiac pulmonary venous connection. However, for the delineation of individual pulmonary venous course, CT-pulmonary angiography was advised. CTPA revealed supra-cardiac total anomalous pulmonary venous connection (TAPVC) with incidentally noted DLBCV. Importance of recognition of DLBCV enables us to prevent accidental venous injury during cardiac surgery and to avoid intraoperative technical issues during transvenous pacemaker insertion.

Immune checkpoint inhibitor myocarditis with complete heart block: a case series

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Immune checkpoint inhibitor (ICI) myocarditis is a life-threatening condition characterized by lymphocytic myocardial infiltration[1]. Complete heart block (CHB) occurs in 15% of cases and is often fatal[2-4]. The nature and optimal management of this often-malignant condition is poorly understood[5]. Purpose This case series assesses prognostic factors associated with survival at 90 days among people with ICI myocarditis and CHB. Methods The electronic patient record system was used to identify patients admitted with ICI myocarditis. A two-physician review was used to assess the presence of ICI-associated CHB. Wilcoxon rank sum and Spearman’s rank correlation were used for categorical and quantitative variables respectively. Data was analysed using STATA/IC 16.1. The primary outcome was person-day survival 90 days after presenting symptom onset. Results Six patients were included in the final analysis. Mean survival was 47 person days. All had metastatic disease and presented 15 to 32 days after the first ICI infusion. All had muscle weakness. Other common self-symptoms were shortness of breath (4), blurred vision (4), double vision (3), collapse (3), and leg swelling (1). Proximal myopathy (2), fatigable myopathy (1), ptosis (3), and peripheral oedema (1) were present on examination. Raised troponin T and white blood cell count (WBC) were associated with 90-day survival (see Table 1). Nt-pro BNP, AST, and CK levels were raised in all patients. Two patients were tested for anti-striated muscle antibody titres, and both were strongly positive. Increase in QRS duration compared to baseline ECG was associated with lower survival at 90 days. Only one patient had CHB on admission. Steroid dose, IVIG, and plasmapheresis weren’t associated with survival. One patient declined device therapy. One declined permanent pacemaker (PPM) after insertion of transvenous pacemaker (TVP). Both died within 2 weeks. Three people underwent insertion of a transvenous pacemaker (TVP) followed by PPM insertion (table 2). All three eventually died within 100 days. One person received isoproterenol and immunosuppression as a bridge to PPM and survived. One patient was managed initially with TVP but subsequently declined PPM insertion. TVP removal resulted in CHB recurrence, and they died shortly after discharge. One person declined device therapy and died while receiving comfort care. Lead malfunction was frequent. One patient experienced bradycardia arrest with failure of a TVP lead to capture, while another experienced lead dislodgement. Conclusion CHB secondary to ICI is often fatal. It should be considered in patients presenting with symptoms of myositis, raised troponin and increased QRS duration. Despite a small sample size, this study identifies several prognostic factors which can guide both patients and physicians with decision-making. Larger studies are needed to better understand the role of device therapy in this population.

Rapid Cycle Deliberate Practice in Virtual Reality: Teaching Transvenous Pacemaker Insertion to Emergency Medicine Residents.

IntroductionTransvenous pacemaker insertion is a critical life-saving procedure that is infrequently performed. Traditional mannequin-based training paradigms are resource intensive and sometimes inadequate due to time constraints. Rapid Cycle Deliberate Practice (RCDP) is an effective teaching modality for highly scripted procedures. We propose using a simulation-based technique of RCDP in virtual reality (VR) to teach this procedure.MethodsSixteen emergency medicine residents were recruited. A pre-survey was administered at the start of the session, followed by a baseline task trainer checklist-based assessment. This checklist was created based on expert consensus. Participants then underwent the RCDP VR intervention with a subsequent repeat checklist-based assessment as well as a post-survey. ResultsPost-test scores were found to be significantly higher than pre-test scores after residents completed VR deliberate practice simulation (19.5±3.5 vs 24.1±2.0; p<0.001). Subanalysis did not reveal any significant difference based on post-graduate year, previous performance of procedure on a live patient, or previous VR experience. The experience increased participant feelings of preparedness and comfort in performing the procedure (2-disagree vs 4-agree) based on a 5-point Likert scale. ConclusionsVirtual reality using RCDP to teach transvenous pacemaker insertion demonstrated an improvement in task trainer performance. Further investigation into whether this translates into better patient outcomes or can be generalized to other procedures needs to be considered.

Intrapleural Pocket for Pediatric Epicardial Pacemaker Through Right Axillary Incision

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

Alternative cardiac intensive care unit locations during the COVID-19 pandemic at an academic medical center

Alternative cardiac intensive care unit locations during the COVID-19 pandemic at an academic medical center

Bedside Temporary Transvenous Pacemaker Insertion in the Emergency Department: A Single-Center Experience.

Objectives:Insertion of a temporary transvenous pacemaker (TTPM) is one of the life-saving interventions performed in the emergency department (ED). The aim of the study was to determine demographic, clinical characteristics, and in-hospital outcomes of patients who underwent TTPM insertion due to hemodynamically unstable bradyarrhythmia in the ED.Methods:In our study, 234 consecutive patients who underwent TTPM insertion at the bedside in the ED between January 2014 and October 2019 were included in the study. Etiological characteristics, electrocardiographic (ECG) findings, requirements for permanent pacemaker (PPM), and in-hospital mortality of the patients were analyzed retrospectively.Results:Extrinsic causes were the most common etiology of unstable bradyarrhythmia (57.6%). Most extrinsic causes were drug therapy-related factors (60.7%). Bradyarrhythmia persisted in 60% of patients after extrinsic causes were eliminated. The most common ECG finding was a high-degree atrioventricular block (62%). PPM was implanted in 44% of patients. In-hospital mortality rate was 19.7%. In the multivariate regression analysis, the left ventricular ejection fraction (LVEF) and diastolic blood pressure (DBP) measured at admission (p<0.001 and p<0.001, respectively) were determined to be independent predictors for in-hospital mortality.Conclusion:First diagnosis and intervention in the ED are of great importance for patients with unstable bradyarrhythmia. The fastest possible TTPM insertion in the ED can reduce mortality by reducing the exposure time to hypoperfusion of vital organs, especially in patients with reduced LVEF and low DBP. Furthermore, it should be kept in mind that an underlying latent conduction system disease can also be present in bradyarrhythmias thought to occur potentially due to extrinsic factors.

Clinical Profile of Patients Undergoing Temporary Transvenous Pacing in a Tertiary Cardiac Care Centre in Nepal

Introduction Temporary transvenous pacemaker insertion is an emergency lifesaving procedure for patients with hemodynamically unstable and life-threatening bradyarrythmias. The aim of this study was to analyze demographics, indications, route of insertion and complications in patients undergoing temporary transvenous pacemaker implantation.&#x0D; MethodsThis was a retrospective observational study conducted at a tertiary-care center in Nepal. The hospital records of patients who had undergone temporary transvenous pacemaker implantation between July 2015 and June 2019 were reviewed.&#x0D; ResultsA total of 343 patients with mean age of 65.52±16.09 years received temporary transvenous pacing. Out of these 205 (59.8%) were males. Greater proportion of patients were between the age group of 70-80 years (n=76, 22.2%). Hypertension (n=97, 28.3%) was the most common comorbidity noted. The most common indication for temporary pacing was symptomatic complete heart block 165 (59.6%). Total of 288 (84%) patients received permanent pacemakers while 55(16%) had reversible cause so TPI was removed. Right Femoral vein was the most common (99%) venous access site. Among the 343 patients, complications were observed in 29 (8.4%) of cases during and after the temporary transvenous pacemaker insertion. The overall mortality stood low at 2% (n=7).&#x0D; ConclusionTemporary transvenous pacemaker insertion is required in elderly population presenting with bradyarrythmias and occasionally in acute myocardial infarction presenting with bradyarrythmias as complication. Temporary pacemaker insertion was overall a safe procedure with infrequent serious complications; however, strategies to avoid and alleviate such complications (RV perforation) should be sought and implemented.

Clinical Profile of Patients Undergoing Temporary Transvenous Pacing in a Tertiary Cardiac Care Centre in Nepal

Introduction: Temporary transvenous pacemaker insertion is an emergency lifesaving procedure for patients with hemodynamically unstable and life-threatening bradyarrythmias. The aim of this study was to analyze demographics, indications, route of insertion and complications in patients undergoing temporary transvenous pacemaker implantation. Methods: This was a retrospective observational study conducted at a tertiary-care center in Nepal. The hospital records of patients who had undergone temporary transvenous pacemaker implantation between July 2015 and June 2019 were reviewed. Results: A total of 343 patients with mean age of 65.52±16.09 years received temporary transvenous pacing. Out of these 205 (59.8%) were males. Greater proportion of patients were between the age group of 70-80 years (n=76, 22.2%). Hypertension (n=97, 28.3%) was the most common comorbidity noted. The most common indication for temporary pacing was symptomatic complete heart block 165 (59.6%). Total of 288 (84%) patients received permanent pacemakers while 55(16%) had reversible cause so TPI was removed. Right Femoral vein was the most common (99%) venous access site. Among the 343 patients, complications were observed in 29 (8.4%) of cases during and after the temporary transvenous pacemaker insertion. The overall mortality stood low at 2% (n=7). Conclusion: Temporary transvenous pacemaker insertion is required in elderly population presenting with bradyarrythmias and occasionally in acute myocardial infarction presenting with bradyarrythmias as complication. Temporary pacemaker insertion was overall a safe procedure with infrequent serious complications; however, strategies to avoid and alleviate such complications (RV perforation) should be sought and implemented.

Acute oleander poisoning: A study of clinical profile from a tertiary care center in South India.

Introduction:Yellow oleander (Thevetia peruviana), which belongs to the Apocyanaceae family, is a common shrub seen throughout the tropics. All parts of the plant contain high concentrations of cardiac glycosides which are toxic to cardiac muscle and the autonomic nervous system. Here, we describe the clinical profile of patients with oleander poisoning and their outcomes.Methods and Materials:This retrospective study was conducted over a period of 12 months (March 2016 to February 2017). The data was extracted from the inpatient electronic medical records. Adult patients with a diagnosis of acute yellow oleander poisoning were included in the study. Descriptive statistics were obtained for all variables in the study and appropriate statistical tests were employed to ascertain their significance.Results:The study comprised 30 patients aged 30.77 ± 12.31 (mean ± SD) who presented at 12.29 ± 8.48 hours after consumption of yellow oleander. Vomiting (80%) was the most common presenting symptom. Metabolic abnormalities at presentation included hyperchloremia in 22 patients and metabolic acidosis (bicarbonate <24 mmol/L) in 29 patients. Fifteen (50%) patients had abnormal ECG, of which second-degree AV block was the commonest ECG abnormality seen in 4 (13.3%). Fifteen (50%) patients had transvenous temporary pacemaker insertion (TPI). Having a TPI significantly prolonged the duration of hospital stay (OR 1.85, 95% CI 1.06–3.21, P 0.03). The mortality in the cohort was 2 (6.7%).Conclusion:In patients with yellow oleander poisoning, dyselectrolytemia with ECG abnormalities was common. TPI prolonged the duration of hospital stay. Further studies are required to know the indication for and to ascertain the effect of temporary pacing on survival.

Left atrial tumor, complete heart block, and triple-vessel coronary artery disease: A very rare case report

Primary cardiac tumor (PCT) is a very rare clinical presentation, with myxoma representing the most common type. Majority of the myxomas are found in the left atrium along with a female dominance. This report describes a very rare case of a 67-year-old woman presenting with PCT, complete heart block, and triple-vessel coronary artery disease. The patient was planned to undergo a coronary artery bypass grafting (CABG) along with concomitant tumor excision and epicardial pacemaker insertion. Since the patient and her family did not consent for the CABG, transvenous permanent pacemaker insertion was performed with an advice to follow-up for CABG and tumor excision.

P015: Staff skills: a procedural skills curriculum for emergency medicine attending physicians in Calgary

Introduction: Emergency medicine attending physicians perform many essential procedures but some infrequently. Skill proficiency and familiarity declines over time. We intended to identify skills where colleagues felt deficient and create an opportunity to demonstrate and practice in a safe environment. Methods: Sessions began from a review of ultrasound guided central line and pacemaker insertion. Other procedures have been added as a result of critical incidents, needs assessments by attending physicians, acquisition of new technology/equipment and expert consensus. An evaluation and needs assessment is performed after each session to adjust curricula. Results: Since 2011, we have held 2-3 skill sessions per year at the Advanced Trauma Surgical Skills Laboratory at the University of Calgary. Sessions are taught by attending emergency physicians, employ task trainers, simulators, animal and human cadaveric models, ultrasound, and procedural equipment stocked in our local hospitals. We are able to accommodate ~30 participants per session for 3 hours of rotating 7-8 participants through various stations. Every session has been fully attended with a wait list. Physicians register by email with preference given to new participants and those identified during clinical practice review of requiring remediation. Costs of sessions are covered by voluntary contribution to an emergency department physician support fund. Procedures practiced have included airway (basic, adjuncts, bronchoscopy, video laryngoscopy, surgical airway, chest tube), vascular access (ultrasound guided central venous insertion, transvenous pacemaker insertion, nerve blocks, IO insertion), surgical skills (thoracotomy, chest tube, canthotomy, surgical airway) and other percutaneous procedures (paracentesis, thoracentesis, nerve block, lumbar puncture). High fidelity skills videos were created to augment the sessions, available on the department website. Four point scale evaluations from our most recent session yielded 100% excellent rating for overall workshop and relevance to practice. The 6 facilitators performance received 100% excellent or good ratings. Conclusion: We have developed a fun, nonthreatening opportunity for attending physicians to practice infrequent but important ED procedures. The sessions are well received, well attended, foster collegiality, confidence and competence in performance of infrequent ED skills. Our model could be generalized to other centres.

Procedural Skills of a General Internist - Informed by the Front Line.

Procedural Skills of a General Internist - Informed by the Front Line.

A case of pacemaker implantation in the patient with duplication of the left innominate vein: a case report.

Introduction Duplication of the left innominate vein is a rare systemic venous anomaly defined as the coexistence of a retroaortic innominate vein and a normally positioned left innominate vein. We describe a successful case of pacemaker implantation in a patient with duplication of the left innominate vein via a retroaortic innominate vein.Case descriptionA 70-year-old mentally challenged man was admitted to our hospital because of bradycardia and an altered state of consciousness. Electrocardiogram indicated sinus arrest and junctional escape rhythm with a heart rate of 40 beats/min; hence, a pacemaker was implanted. Left subclavian venography showed two vessels that were connected to the superior vena cava: a narrow, normal positioned left innominate vein and a tortuous vein. The normally positioned left innominate vein was too narrow to pass through with a guide wire. Therefore, we chose the tortuous vein for implantation. However, the procedure was difficult because of the vein’s tortuosity. Finally, leads at the right atrium and ventricle were successfully implanted using a steerable stylet. After the procedure, computed tomography showed two innominate veins: a retroaortic innominate vein and narrow left innominate vein that was a duplication of the left innominate vein.Discussion and evaluationThe exact embryogenesis of retroaortic innominate vein remains unknown and incidence of retroaortic innominate vein is very rare. But for cardiologists performing transvenous pacemaker insertion, the anomalous brachiocephalic vein may cause technical difficulty during a left arm approach.ConclusionsIn cases in which subclavian venography shows a tortuous vein, cardiologists should consider the presence of a retroaortic innominate vein.

Post-cardiac injury syndrome following transvenous pacemaker insertion: A case report and review of the literature

Post-cardiac injury syndrome is an inflammatory process involving the pleura and pericardium secondary to cardiac injury and can develop following transvenous pacemaker insertion. We now report a patient who developed this syndrome following dual-chamber pacemaker insertion with active fixation of the atrial and ventricular leads. The pericardial fluid was bloody and had a neutrophilic predominance. The pericardial biopsy revealed fibrinous pericarditis with a mixed inflammatory cell infiltrate. The pleural effusion was exudative and had a neutrophilic predominance. Nine similar cases were identified in the English literature dating back to 1975. These patients usually present within one month after pacemaker insertion. They have exudative pericardial and pleural effusions. The pericardial effusions can cause tamponade and may require treatment with either catheter drainage or a surgical window. Some of these patients respond well to anti-inflammatory medications, including prednisone. Therefore, early identification of these patients could allow medical treatment and might help avoid the need for a surgical procedure. Cardiologists should remember that this uncommon syndrome can occur after routine endovascular procedures.

Recanalization of systemic venous baffles by radiofrequency perforation and stent implantation

Complete transposition of the great arteries has been historically managed by the Mustard (atrial switch) operation. This procedure is associated with longterm complications such as baffle occlusion, which also precludes the insertion of a permanent transvenous pacemaker. Transcatheter techniques have allowed the successful angioplasty and stenting of stenotic baffles but complete occlusions continue to pose a therapeutic challenge. We report the use of a novel technique, a radiofrequency perforation wire for the management of complete occlusion of systemic venous baffles post-Mustard operation.

Delayed isolated hemothorax caused by temporary pacemaker: A case report

An 81-year-old male was admitted to our hospital with dysarthria. Electrocardiogram revealed complete atrioventricular conduction block and then temporary pacemaker was performed. Nine days later, massive hemothorax was presented, but not pericardial effusion existed by echocardiography and chest computer tomography findings. Being a rare complication of transvenous temporary pacemaker insertion, we discussed the delayed hemothorax without associated pericardial effusion.

Characteristics of Patients With Cervical Spinal Injury Requiring Permanent Pacemaker Implantation

Acute cervical spinal cord injury frequently results in bradydysrhythmia, which may lead to hypotension and asystole. Such symptoms are more common in the first 2 weeks after the injury. Treatment modalities include atropine, epinephrine, aminophylline, and pacemaker insertion. The criteria for pacemaker use in this population are not well defined. We describe characteristics of 3 patients who required permanent, transvenous pacemaker implantation for recurrent symptoms. In 2 of the 3 patients, transcutaneous pacing failed to provide adequate protection. Transcutaneous pacemakers are not reliable, as was the case of these patients, and early consideration for transvenous pacemaker insertion may be indicated, especially in hemodynamically unstable patients. In this report, all 3 patients required permanent pacemaker implantation.

Trypanosoma cruzi myocardial infection reactivation presenting as complete atrioventricular block in a Chagas' heart transplant recipient

A 56-year-old man underwent orthotopic heart transplantation because of end-stage Chagas' cardiomyopathy. One hundred and ten days following heart transplantation, an electrocardiogram tracing showed complete atrioventricular block, which was treated with temporary transvenous pacemaker insertion. An underlying endomyocardial biopsy was graded 3A. The patient was treated with pulse steroid therapy. One week later, the patient died of multiorgan failure secondary to septicemia. A careful review of the endomyocardial biopsy showed nests of parasites in the myocardial tissue accompanied by mononuclear cell infiltrate similar to that found in acute graft rejection. Thus, complete atrioventricular block may be another clinical manifestation of Trypanosoma cruzi infection reactivation in Chagas' heart transplant recipients.

Reevaluation of temporary transvenous cardiac pacemaker usage during carotid angioplasty and stenting: a safe and valuable adjunct.

Although many current series document the safety of carotid angioplasty and stenting procedures (CAS), several acknowledge clinically significant hemodynamic disturbances in 25-71% of patients. We report herein the safety and efficacy of prophylactic percutaneous temporary transvenous cardiac pacemaker insertion during CAS for the prevention of hemodynamic changes. At a community-based institution, 48 patients undergoing 51 attempted CAS procedures from March 1999 to August 2002 for carotid artery occlusive disease were retrospectively reviewed. Thirty-one percent of patients had procedures performed for either recurrent disease or a history of neck radiation; 62.5% had significant coronary disease. Temporary transvenous pacemakers were inserted as an adjunctive procedure in the authors' CAS protocol. The pacers were set to capture a heart rate decrease below 60 beats per minute. Demographics, cardiac risk, and outcomes were analyzed. CAS was successfully performed in 96% (49 lesions). In the intent-to-treat group, the patients had a mean age of 71 +/-9 years and angiographic stenoses of 88 +/-8%, with 29% having symptomatic lesions. Significant bradycardia or asystole to trigger ventricular pacing occurred in 11 (22%) procedures, thus, triggering ventricular pacing. Pharmacologic support for concomitant hypotension was temporarily necessary in only 4 (8%) cases. No patient required prolonged pacing or medication therapy following CAS. Neither presence of carotid-related symptoms nor disease etiology was related to need for intraprocedural pacing. Furthermore, there was no occurrence of pacemaker failure or other complication secondary to venous catheterization. Hemodynamic changes may occur during mechanical dilation of the carotid artery and bulb, with reports in the literature of the need for prolonged pharmacologic support. In selected patients, the prophylactic placement of a transvenous pacemaker is a safe, feasible, and expeditious method to treat periprocedural hemodynamic changes with a decrease in additional pharmacologic support during CAS.

Emergency medicine–trained physicians are proficient in the insertion of transvenous pacemakers

Study objective The insertion and management of a temporary transvenous pacemaker can be a lifesaving procedure in the emergency department setting. We compare the success and complication rates associated with temporary transvenous pacemaker insertion between physicians trained in either emergency medicine or cardiology. Methods This was a retrospective medical record review of all patients with a billing code for temporary transvenous pacemaker insertion at our institution between July 1999 and December 2002. Patients were excluded if the temporary transvenous pacemaker was not supervised by an attending physician or was placed under fluoroscopy or if the indication for pacing was asystole. Cases were reviewed by 2 physicians certified in emergency medicine and categorized by the specialty training of the attending physician providing direct supervision. Results During the review period, 10 emergency medicine faculty and 8 cardiologists directly supervised 141 of the 158 temporary transvenous pacemaker insertions in 154 patients. Twenty-four were placed for asystole, 4 were placed under fluoroscopy, and 13 were placed without direct attending supervision, leaving a total of 117 cases (30 emergency medicine, 87 cardiology) for review. The procedure was successful 97% (95% confidence interval [CI] 90% to 100%) of the time for emergency medicine faculty and 95% (95% CI 91% to 100%) of the time for cardiology faculty. Complications were seen in 23% (95% CI 7% to 39%) of the temporary transvenous pacemakers inserted by emergency medicine attending physicians and 20% (95% CI 11% to 28%) of the temporary transvenous pacemakers inserted by cardiologists. There was no statistical difference in errors between the specialties, and no complication resulted in death or prolonged disability. Conclusion Physicians trained in emergency medicine perform temporary transvenous pacemaker insertions in the acute care setting with a proficiency similar to that of their counterparts in cardiology.