Pulse generator failure due to blunt trauma

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators

This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.

Seat belts-related behaviors in car drivers with cardiac implantable electronic devices

BACKGROUND

Seat belt use is the single most effective means of reducing fatal injuries in road traffic accidents. The presence of a cardiac implantable electronic device (CIED) might influence seat belt-related behaviors due to the physical proximity of the seat belt and left subclavian area in which the device is usually implanted. Understanding the underlying mechanisms of improper seat belt use may improve safety of these patients.

METHODS

We performed a prospective study using a structured questionnaire with 120 CIED recipients (age, 63.9 ± 10.9 years) attending a pacing outpatient clinic. All study participants were active drivers and predominantly male. The majority of patients (79%) had undergone high-energy device implantation.

RESULTS

We found that 18% of study participants do not fasten seat belts on a regular basis or use the seat belt in an atypical fashion (such as under the armpit). Moderate or high level of discomfort from the interaction between seat belt and CIED was present in 27%, while more than half (51%) were afraid of seat belt-induced CIED damage. In multifactorial analysis, we found the following independent predictors of improper seat belt use: (1) at least moderate level of discomfort at the CIED site (P = 0.02); (2) fear of CIED damage (P = 0.009); and (3) irregular seat belt use prior to CIED implantation (P = 0.037).

CONCLUSIONS

Improper seat belt-related behaviors are common in CIED recipients. They arise from previous habits and from CIED-related physical and psychological factors. Patients' education regarding the importance and safety of proper seat belt use is a priority.

Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions Part I: Supraventricular arrhythmias and pacemakers

This document by the Study Group on Sports Cardiology of the European Society of Cardiology extends on previous recommendations for sports participation for competitive athletes by also incorporating guidelines for those who want to perform recreational physical activity. For different supraventricular arrhythmias and arrhythmogenic conditions, a description of the relationship between the condition and physical activity is given, stressing how arrhythmias can be influenced by exertion or can be a reflection of the (patho)physiological cardiac adaptation to sports participation itself. The following topics are covered in this text: sinus bradycardia; atrioventricular nodal conduction disturbances; pacemakers; atrial premature beats; paroxysmal supraventricular tachycardia without pre-excitation; pre-excitation, asymptomatic or with associated arrhythmias (i.e. Wolff-Parkinson-White syndrome); atrial fibrillation; and atrial flutter. A related document discusses ventricular arrhythmias, channelopathies and implantable cardioverter defibrillators.

[Sport for pacemaker patients]

Sport activity is an important issue in many patients with a pacemaker either because they performed sport activities before pacemaker implantation to reduce the cardiovascular risk or to improve the course of an underlying cardiovascular disease (e.g. coronary artery disease, heart failure) by sports. Compared to patients with an implantable cardioverter defibrillator (ICD) the risks from underlying cardiovascular disease (e.g. ischemia, heart failure), arrhythmia, lead dysfunction or inappropriate therapy are less important or absent. Sport is contraindicated in dyspnea at rest, acute heart failure, new complex arrhythmia, acute myocarditis and acute myocardial infarction, valvular disease with indications for intervention and surgery and comorbidities which prevent physical activity. Patients with underlying cardiovascular disease (including hypertension) should preferably perform types and levels of physical activity that are aerobic (with dynamic exercise) such as running, swimming, cycling instead of sport with high anaerobic demands and high muscular workload. In heart failure, studies demonstrated advantages of isometric sport that increases the amount of muscle, thereby preventing cardiac cachexia. Sport with a risk of blows to the chest or physical contact (e.g. boxing, rugby, martial arts) should be avoided. Implantation, programming and follow-up should respect specific precautions to allow optimal physical activity with a pacemaker including implantation of bipolar leads on the side contralateral to the dominant hand, individual programming of the upper sensor and tracking rate and regular exercise testing.

Fracture of Epicardial Resynchronization Lead Caused by Deceleration Injury

A 50-year-old man with heart failure, systolic dysfunction, and abnormal septal motion underwent ventricular resynchronization. Postoperative clinical and echocardiographic improvement was observed. Several months later, he complained of worsening functional class after a traffic accident. Pacing lead fracture was diagnosed. After replacing the lead, improvement of clinical condition and ventricular parameters was achieved. The role of seat belts in causing dysfunction of pacemakers and resynchronization devices after deceleration injury is discussed.

Permanent cardiac pacemakers: issues relevant to the emergency physician, part II

Many people benefit from the implantation of cardiac pacemakers for management of certain cardiac dysrhythmias. These patients are seen regularly in the Emergency Department with a variety of pacemaker complications and malfunctions. The presence of a pacemaker may also affect management of unrelated medical problems. This, the second of a two-part series, covers the causes, diagnosis, and management of pacemaker malfunction; the pacemaker syndrome; the pacemaker Twiddler's syndrome; and other considerations in the paced patient including diagnosis of acute myocardial infarction, ACLS protocols, trauma, and sources of interference.

Intraoperative pacemaker dysfunction caused by the use of electrocautery during a total hip arthroplasty

Pacemaker dysfunction encountered during orthopedic procedures is a rare but potentially life-threatening complication. With an increasing number of orthopedic procedures performed on the aging population, it is not uncommon to encounter patients with pacemakers requiring major orthopedic intervention. Most, if not all, major orthopedic procedures performed today require the use of electrocautery for hemostasis. In this article we review the literature for pacemaker complications and report a case of pacemaker failure after a single use of the unipolar electrocautery on a patient undergoing a total hip replacement.

Ventricular output failure in a DDD permanent pacemaker associated with increased atrial output

Previous reports have described the occurrence of ventricular output failure in a permanent DDD pacemaker system related to an increase in the atrial output in the presence of low atrial lead impedance (Medtronic Synergyst/Synergyst II). This phenomenon is seen exclusively following atrial paced events and may potentially lead to significant bradyarrhythmia or ventricular asystole in a pacemaker dependent patient. We describe the occurrence of analogous behavior in a Medtronic Symbios 7006 generator.

Ventricular output failure in a DDD permanent pacemaker associated with increased atrial output

Previous reports have described the occurrence of ventricular output failure in a permanent DDD pacemaker system related to an increase in the atrial output in the presence of low atrial lead impedance (Medtronic Synergyst/Synergyst II). This phenomenon is seen exclusively following atrial paced events, and may potentially lead to significant bradyarrhythmia or ventricular asystole in a pacemaker dependent patient. We describe the occurrence of analogous behavior in a Medtronic Symbios 7006 generator.

Blunt trauma-induced pacemaker failure

A 54-year-old man with an artificial pacemaker sustained blunt trauma to his chest when he was struck with a baseball bat. Within 15 minutes after the injury, the patient experienced cardiovascular collapse. His pacemaker failed, and he required insertion of a temporary transvenous pacemaker. At surgery, the defect was traced to failure of the pulse generator, a rare cause of pacemaker failure. Emergency department evaluation should include prompt and continuous ECG monitoring, an overpenetrated chest radiograph, and telemetry evaluation after discharge.

Function of ventricular pacemakers during resuscitation

The reciprocal effects of resuscitation and permanent, ventricular-inhibited pacemakers were examined in four, well-documented cases of witnessed out-of-hospital arrest. The resulting observations provide useful insight in the treatment of cardiac arrest in the large number of patients with permanent pacemakers. Transient sensing malfunctions occurred in the two patients in whom direct current countershocks were not required and were probably related to the severely deranged state of the myocardium. In spite of periods of asynchronous pacing in this critically unstable setting, no arrhythmias were precipitated. In the two patients who required defibrillation, transient malfunctions of pacing, capture and sensing occurred in spite of protective electronics in the pacing system, the left-sided location of the generator and, in one patient, the bipolar configuration. The pacemaker appeared to intermittently sense coarse ventricular fibrillatory waves. The malfunctions in the two latter cases were probably the result of the combined effects of the countershock and the abnormal state of the myocardium. All four patients succumbed, three in the emergency room and one on the eighth hospital day. Outcome was predominantly determined by the patient's response to therapeutic interventions. The observed pacemaker malfunctions, although potentially life-threatening, had no obvious, adverse effect on outcome in these four cases, mainly because of the transient nature of the abnormalities. Indeed, in one case, the presence of pacemaker activity was pivotal in identifying the native rhythm, illustrating the diagnostic potential of this analytical approach.