Case report: State-of-the-art risk-modifying treatment of sudden cardiac death in an asymptomatic patient with a mutation in the SCN5A gene and a review of the literature

Brugada syndrome is a rare hereditary disorder characterized by distinct ECG findings, complex genetics, and a high risk of sudden cardiac death. Recognition of the syndrome is crucial as it represents a paradigm of sudden death tragedy in individuals at the peak of their lives. Notably, Brugada syndrome accounts for more than 20% of sudden cardiac deaths in individuals with structurally normal hearts. Although this syndrome follows an autosomal dominant inheritance pattern, it is more prevalent and severe in males. Diagnosis is primarily based on the characteristic ECG pattern observed in the right precordial leads. Mutations in the SCN5A gene, resulting in loss of function, are the most common genetic cause. We presented a 36-year-old proband with a family history of sudden cardiac death. Although the patient was asymptomatic for Brugada syndrome, his father had experienced sudden death at the age of 36. The proband was admitted to St. Catherine's Specialty Hospital where blood was taken and subjected to next-generation sequencing (NGS) using a "Sudden cardiac death" panel. The analysis identified a pathogenic variant in the SCN5A gene [c.4222G > A(p.Gly1408Arg)], which is associated with autosomal dominant Brugada syndrome. Based on the positive genetic test result, the patient was referred for further examination. ECG with modified precordial lead positioning confirmed the presence of the Brugada phenotype, displaying the type-2 and type-1 ECG patterns. Therefore, we made the diagnosis and decided to implant an implantable cardioverter-defibrillator (ICD) based on the results of broad genetic NGS testing, diagnostic criteria (ECG), and considering the high burden of sudden cardiac death in the patient's family, as well as his concerns that limited his everyday activities. This case shows that genetics and personalized medicine hold immense potential in the primary prevention, diagnosis, and treatment of Brugada syndrome and sudden cardiac death.

Enterobacter cloacae septicemia in a triple-cannula extracorporeal membrane oxygenation circulatory support treated with Seraph-100 Microbind affinity blood filter

Bloodstream infections (BSI) are frequently encountered during extracorporeal membrane oxygenation (ECMO) support. Once septicemia is observed, treatment should be rapid, adequate, and multifaceted, particularly in advanced ECMO configurations. We report on a case of a 60-year-old male patient with acute-on-chronic heart failure due to ischemic cardiomyopathy. The treatment was complicated by cardiogenic shock requiring veno-arterial ECMO support, and, due to persistent pulmonary congestion, an upgrade with an additional left-atrial drainage cannula. After seven days of ECMO support, septicemia with shock ensued. Ex iuvantibus antibiotic treatment was started promptly. We wanted to minimize the likelihood of bacterial biofilm build-up requiring an exchange of the ECMO circuit and cannula, which was expected to be challenging. Therefore, we added a Seraph-100 Microbind affinity blood filter (providing blood purification with the potential for rapid bacterial clearance) to the ECMO circuit. Initial blood cultures tested positive for Enterobacter cloacae. Following a course of Seraph-100 treatment, bacteremia, septicemia, and shock resolved. There was no need for a circuit or cannula exchange. The additional eleven days of ECMO support were uneventful. The patient was successfully bridged to long-term mechanical circulatory support. We believe that the synergistic effect of early implementation of both broad-spectrum antibiotic treatment and blood purification with the potential for rapid bacterial clearance (such as the one provided with the Seraph-100 Microbind affinity blood filter) is crucial in BSI in patients receiving advanced ECMO.

Novel protocol for optimal utilization of HPSD approach for pulmonary vein isolation

BACKGROUND

The efficiency of pulmonary vein isolation (PVI) depends on the durability of RF lesions. Recent studies documented sustained continuity of ablation lines, improvements in durability, and expected clinical outcomes through altered settings in duration and power. However, the ablation strategy has not been adapted to this new approach and different biophysics of lesion formation.

PURPOSE

The aim of this study was to demonstrate that by adjusting the ablation approach to the broader geometry of lesions by increasing the minimal spacing between adjacent RF, a further significant reduction of procedural time while maintaining sufficient long-term outcomes is achievable.

METHODS

The presented study was a prospective, observational multi-center trial. The periprocedural data were compared with data from a consecutively collected historical cohort.

RESULTS

In total, 196 patients were included (mean age 62 ± 11 years, male 64.3%). Procedural duration, RF time, and LA dwelling time were significantly shorter in the HPSD group compared with the standard group (73 ± 26 min vs. 98 ± 36 min, p < .001; 14 ± 7 min vs. 33 ± 12 min, p < .001; and 59 ± 21 min vs. 77 ± 32 min, p < .001, respectively). Mean AF-free survival in the first year of follow-up was 304 ± 14 days in the HPSD group versus 340 ± 10 days in the standard group (log-rank p = .403). There were no statistically significant differences in the complication rates between the groups.

CONCLUSION

Increasing the minimal distance between individual application points simplifies AF ablation and further reduces procedure time without negative effects on efficacy and safety. Larger studies are needed to optimally utilize this approach.

Ablation of residual potentials along the circumferential line reduces acute pulmonary vein reconnection

INTRODUCTION

Acute pulmonary vein (PV) reconnection is frequently encountered in patients undergoing PV isolation (PVI) procedure for the treatment of atrial fibrillation. In this study, we investigated whether the identification and ablation of residual potentials (RPs), after the initial achievement of PVI, reduces acute PV reconnection rate.

METHODS

Following PVI in 160 patients, mapping along the ablation line was performed to identify RPs, defined as bipolar amplitude ≥0.2 mV or 0.1-0.19 mV combined with a negative component of the unipolar electrogram. Ipsilateral PV sets with RPs were randomized to either no further ablation (Group B) or to additional ablation of the identified RPs (Group C). The primary study endpoint was spontaneous or adenosine-mediated acute PV reconnection after a 30-min waiting period and was also evaluated in ipsilateral PV sets without RPs (Group A).

RESULTS

After isolation of 287 PV pairs, 135 had no RPs (Group A), whereas the remaining PV pairs were randomized to either Group B (n = 75) or Group C (n = 77). Ablation of RPs resulted in a reduction of spontaneous or adenosine-mediated PV reconnection rate (16.9% in Group C vs 48.0% in Group B; p < 0.001). Group A was associated with a significantly lower percentage of acute PV reconnection as compared to Group B (5.9% vs 48.0%; p < 0.001) and Group C (5.9% vs 16.9%; p = 0.016).

CONCLUSION

After PVI achievement, the absence of RPs along the circumferential line is associated with a low likelihood of acute PV reconnection rate. Ablation of RPs significantly reduces spontaneous or adenosine-mediated acute PV reconnection rate.

Antihyperlipidemic potential of dietary supplementation with carnosine in high-fat diet-fed rats

OBJECTIVE

The aim of this study was to investigate the hypolipidemic effects of carnosine and a commercial carnosine supplement on lipid status, liver and kidney function, and inflammation associated with dyslipidemia in rats with high-fat diet-induced hyperlipidemia.

MATERIALS AND METHODS

The study was conducted on adult male Wistar rats, divided into control and experimental groups. Animals were kept in standard laboratory conditions and according to groups were treated with saline, carnosine, carnosine dietary supplement, simvastatin, and their combinations. All substances were prepared fresh every day and used by oral gavage.

RESULTS

Treatment with a carnosine-based supplement significantly improved total and LDL cholesterol levels in serum, especially in the combination with simvastatin as a conventional drug in dyslipidemia treatment. The effect of carnosine on the metabolism of triglycerides was not as evident as in the case of cholesterol. Nevertheless, the values of the atherogenic index showed that the combinations of carnosine and carnosine supplement with simvastatin were the most effective in lowering this comprehensive lipid index. Dietary carnosine supplementation resulted also in anti-inflammatory effects, as demonstrated by immunohistochemical analyses. Besides, the good safety profile of carnosine in terms of its effect on liver and kidney functions was also confirmed.

CONCLUSIONS

The use of carnosine supplements in preventing and/or treatment of metabolic disorders requires further investigations into the mechanisms of action and potential interactions with conventional therapy.

Clinical effectiveness of primary prevention implantable cardioverter-defibrillators: results of the EU-CERT-ICD controlled multicentre cohort study

Aims

The EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter-Defibrillators (EU-CERT-ICD), a prospective investigator-initiated, controlled cohort study, was conducted in 44 centres and 15 European countries. It aimed to assess current clinical effectiveness of primary prevention ICD therapy.

Methods and results

We recruited 2327 patients with ischaemic cardiomyopathy (ICM) or dilated cardiomyopathy (DCM) and guideline indications for prophylactic ICD implantation. Primary endpoint was all-cause mortality. Clinical characteristics, medications, resting, and 12-lead Holter electrocardiograms (ECGs) were documented at enrolment baseline. Baseline and follow-up (FU) data from 2247 patients were analysable, 1516 patients before first ICD implantation (ICD group) and 731 patients without ICD serving as controls. Multivariable models and propensity scoring for adjustment were used to compare the two groups for mortality. During mean FU of 2.4 ± 1.1 years, 342 deaths occurred (6.3%/years annualized mortality, 5.6%/years in the ICD group vs. 9.2%/years in controls), favouring ICD treatment [unadjusted hazard ratio (HR) 0.682, 95% confidence interval (CI) 0.537–0.865, P = 0.0016]. Multivariable mortality predictors included age, left ventricular ejection fraction (LVEF), New York Heart Association class <III, and chronic obstructive pulmonary disease. Adjusted mortality associated with ICD vs. control was 27% lower (HR 0.731, 95% CI 0.569–0.938, P = 0.0140). Subgroup analyses indicated no ICD benefit in diabetics (adjusted HR = 0.945, P = 0.7797, P for interaction = 0.0887) or those aged ≥75 years (adjusted HR 1.063, P = 0.8206, P for interaction = 0.0902).

Conclusion

In contemporary ICM/DCM patients (LVEF ≤35%, narrow QRS), primary prophylactic ICD treatment was associated with a 27% lower mortality after adjustment. There appear to be patients with less survival advantage, such as older patients or diabetics.

Delayed radiofrequency ablation efficacy in slow pathway ablation: a case report

BACKGROUND

The delayed effect of radiofrequency (RF) ablation was described in cases of accessory pathway and premature ventricular contraction ablation, as well as delayed atrioventricular (AV) block after slow pathway ablation.

CASE SUMMARY

We report a case of a female patient with AV nodal re-entry tachycardia (AVNRT), in whom the first electrophysiology study ended with acute failure of slow pathway ablation, despite using long steerable sheath, both right and left-sided ablation with >15 min of RF energy application and repeatedly achieving junctional rhythm. Six weeks afterwards, during scheduled three-dimensional electroanatomical mapping procedure, there was no proof of dual AV nodal conduction nor could the tachycardia be induced. Also, the patient did not have palpitations between the two procedures nor during the 12-month follow-up period.

DISCUSSION

This case illustrates that watchful waiting for delayed RF ablation efficacy in some cases of AVNRT ablation could be reasonable, in order to reduce the risk of complications associated with slow pathway ablation.

Atrial appendages’ mechanics assessed by 3D transoesophageal echocardiography as predictors of atrial fibrillation recurrence after pulmonary vein isolation

•

Data on atrial appendages' mechanics as predictors of AF recurrence after PVI is scarce.

•

3D and 2D-TEE have potential to provide additional data on LAA function.

•

Patients with AFR had significantly lower LAA tissue velocity and ostium surface area.

•

RAA tissue velocity and SVC ostium surface area were not correlated to AF recurrence.

Background

Although there are numerous studies reflecting predictors of atrial fibrillation (AF) recurrence (AFR) after pulmonary vein isolation (PVI), data on atrial appendages' mechanics is scarce. This study aimed to assess atrial appendages' mechanics by 2-dimensional (2D) and 3-dimenssional (3D) transoesphageal echocardiography (TEE) and to explore its value to predict AFR after PVI.

Methods

Consecutive patients with paroxysmal AF undergoing first PVIwere analysed. 3D and 2D-TEE with tissue Doppler imaging (TDI) and strain analysis was obtained prior to the PVI, including: left atrial appendage (LAA) TDI and strain analysis, LAA ostium surface area, right atrial appendage’s TDI velocity and superior vena cava (SVC) ostium surface area. The primary end-point was freedom from any documented recurrence of atrial arrhythmia lasting > 30 s.

Results

This single-centre, prospective study included 74 patients with paroxysmal AF (median age 59 years; 36% female; BMI 27.4 ± 4.1 kg/m², LA volume index 32 ± 11 mL/m²). After a median follow-up of 14 (IQR 10–22) months, 21 (28%) patients had AFR. In a univariate and multivariate Cox-regression analysis LAA TDI velocity (HR 1.48, 95%CI 1.28–1.62, p < 0.001) and LAA ostium surface area(HR 1.58, 95%CI 1.06–1.81, p = 0.033) both independently predicted AFR after single PVI. RAA TDI velocity and SVC ostium surface area were not correlated to AFR.

Conclusion

Paroxysmal AF patients with lower LAA TDI tissue velocity and LAA ostium surface area have higher risk of developing AFR after PVI. To our knowledge, this is the first study assessing atrial appendages’ mechanics in predicting AFR after PVI.

Clinical trial registration: www.drks.de(Identifier: DRKS00010495)

Fluoroscopy usage in contemporary interventional electrophysiology: Insights from a European registry

Background

Fluoroscopy has been an essential part of every electrophysiological procedure since its inception. However, till now no clear standards regarding acceptable x‐ray exposure nor recommendation how to achieve them have been proposed.

Hypothesis

Current norms and quality markers required for optimal clinical routine can be identified.

Methods

Centers participating in this Europe‐wide multicenter, prospective registry were requested to provide characteristics of the center, operators, technical equipment as well as procedural settings of consecutive cases.

Results

Twenty‐five centers (72% university clinics, with a mean volume of 526 ± 348 procedures yearly) from 14 European countries provided data on 1788 cases [9% diagnostic procedures (DP), 38% atrial fibrillation (AF) ablations, 44% other supraventricular (SVT) ablations, and 9% ventricular ablations (VT)] conducted by 95 operators (89% male, 41 ± 7 years old).

Mean dose area product (DAP) and time was 304 ± 608 cGy*cm², 3.6 ± 4.8 minutes, 1937 ± 608 cGy*cm², 15.3 ± 15.5 minutes, 805 ± 1442 cGy*cm², 10.6 ± 10.7 minutes, and 1277 ± 1931 cGy*cm², 10.4 ± 12.3 minutes for DP, AF, SVT, and VT ablations, respectively. Seven percent of all procedures were conducted without any use of fluoroscopy.

Procedures in the lower quartile of DAP were performed more frequently by female operators (OR 1.707, 95%CI 1.257‐2.318, P = .001), in higher‐volume center (OR 1.001 per one additional procedure, 95%CI 1.000‐1.001, P = .002), with the use of 3D‐mapping system (OR 2.622, 95%CI 2.053‐3.347, P < .001) and monoplane x‐ray system (OR 2.945, 95%CI 2.149‐4.037, P < .001).

Conclusion

Exposure to ionizing radiation varies widely in daily practice for all procedure. Significant opportunities for harmonization of exposure toward the lower range has been identified.

Analysis of business systems and automation; the application of the original web platform for start-up entrepreneurial endeavors

Ensuring a good position on the market is risked in start-up entrepreneurial endeavors, in which there is an evident funding problem and which have a small amount of the initial capital at their disposal. For that reason, with the help of knowledge and information technologies, entrepreneurial endeavors oriented towards the provision of consulting services for other companies and institutions, or for the personal needs of business decision-making, can ensure a good competitive position by conducting the automation of their services with the help of the original web platform presented in the paper. Thanks to the said automation and web platform, start-up entrepreneurial firms are provided with a strong tool within the framework of their field of work, at a low price, which enables them to be cost-competitive. As the young are increasingly involved in the field of information technologies irrespective of the job they do and as learning programming is increasingly more available within the framework of formal education, non-formal education, i.e. courses, as well as free of charge, via the content on the Internet through diverse tutorials and programs, start-up companies are enabled to utilize their employees’ skills in multiple ways with minimal investments in order to establish the platform, whereas when the professional segment within the field of management and economics, i.e. the managerial segment, are concerned, they may utilize the available knowledge funds and consultants.

MANAGEMENT OF PATIENTS WITH CARDIAC IMPLANTABLE ELECTRONIC DEVICES UNDERGOING MAGNETIC RESONANCE IMAGING - PROPOSAL FOR UNIFIED HOSPITAL PROTOCOL: CROATIAN WORKING GROUP ON ARRHYTHMIAS AND CARDIAC PACING

For many years, magnetic resonance imaging (MRI) was contraindicated in patients with cardiac implantable electronic devices (CIED). Today, there is a growing amount of evidence that MRI can be performed safely in the majority of patients with CIEDs. Firstly, there are devices considered MRI conditional by manufacturers that are available on the market and secondly, there is clear evidence that even patients with MRI non-conditional devices can also undergo MRI safely. Protocols have been developed and recommendations from different cardiac and radiologic societies have been published in recent years. However, the majority of physicians are still reluctant to refer these patients to MRI. Therefore, this document is published as a joint statement of the Croatian Working Group on Arrhythmias and Cardiac Pacing and Department of Radiology, Sestre milosrdnice University Hospital Centre to guide and ease the management of patients with CIED undergoing MRI. Also, we propose a unified protocol and checklist that could be used in Croatian hospitals.

Chromogenic anti-FXa assay calibrated with low molecular weight heparin in patients treated with rivaroxaban and apixaban: possibilities and limitations

Introduction

Clinical application of rivaroxaban and apixaban does not require therapeutic monitoring. Commercial anti-activated factor X (anti-FXa) inhibition methods for all anti-FXa drugs are based on the same principle, so there are attempts to evaluate potential clinical application of heparin-calibrated anti-FXa assay as an alternative method for direct FXa inhibitors. We aimed to evaluate relationship between anti-FXa methods calibrated with low molecular weight heparin (LMWH) and with drug specific calibrators, and to determine whether commercial LMWH anti-FXa assay can be used to exclude the presence of clinically relevant concentrations of rivaroxaban and apixaban.

Materials and methods

Low molecular weight heparin calibrated reagent (Siemens Healthineers, Marburg, Germany) was used for anti-FXa activity measurement. Innovance heparin (Siemens Healthineers, Marburg, Germany) calibrated with rivaroxaban and apixaban calibrators (Hyphen BioMed, Neuville-sur-Oise, France) was used for quantitative determination of FXa inhibitors.

Results

Analysis showed good agreement between LMWH calibrated and rivaroxaban calibrated activity (κ = 0.76) and very good agreement with apixaban calibrated anti-Xa activity (κ = 0.82), respectively. Low molecular weight heparin anti-FXa activity cut-off values of 0.05 IU/mL and 0.1 IU/mL are suitable for excluding the presence of clinically relevant concentrations (< 30 ng/mL) of rivaroxaban and apixaban, respectively. Concentrations above 300 ng/mL exceeded upper measurement range for LMWH anti-FXa assay and cannot be determined by this method.

Conclusion

Low molecular weight heparin anti-FXa assay can be used in emergency clinical conditions for ruling out the presence of clinically relevant concentrations of rivaroxaban and apixaban. However, use of LMWH anti-FXa assay is not appropriate for their quantitative determination as an interchangeable method.

THE INFLUENCE OF LIQUID CALCIUM SOURCE ON EGGSHELL QUALITY

It is estimated that the world’s population will enlarge by 25% by the middle of this century, resulting in the food production increase by at least 60%. Intensifying egg production is one of the most affordable solutions to provide animal protein. Among many other efforts to improve the quality of eggs, special attention is paid to attempts to provide a better endurance and strength of eggshell, due to the fact that the production of eggs with broken, cracked or soft shells incurs significant economic losses. One of the most important factors to achieve this goal is careful adjustment of calcium in the diet of laying hens, but the nutritional role of calcium is closely linked to that of phosphorus and the effect of vitamin D. The aim of the experiment was to determine whether two different nutritional supplements of calcium, applied in drinking water of laying hens for two weeks have any significant influence on the shell egg quality. Statistically very significant difference in egg production was observed in the treatment with the product containing calcium and phosphorus. On the other hand, the product consisting of calcium and vitamin D3 had no beneficial impact on the egg parameters.  Based on the obtained results and literature data, it can be concluded that the amount and source of calcium in the diet of laying hens is a very complex and not fully solved issue. Therefore, especially keeping in mind the duration of the experiment, additional research is needed on this subject.

Present criteria for prophylactic ICD implantation: Insights from the EU-CERT-ICD (Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators in EUrope) project

BACKGROUND

The clinical effectiveness of primary prevention implantable cardioverter defibrillator (ICD) therapy is under debate. It is urgently needed to better identify patients who benefit from prophylactic ICD therapy. The EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators (EU-CERT-ICD) completed in 2019 will assess this issue.

SUMMARY

The EU-CERT-ICD is a prospective investigator-initiated non-randomized, controlled, multicenter observational cohort study done in 44 centers across 15 European countries. A total of 2327 patients with heart failure due to ischemic heart disease or dilated cardiomyopathy indicated for primary prophylactic ICD implantation were recruited between 2014 and 2018 (>1500 patients at first ICD implantation, >750 patients non-randomized non-ICD control group). The primary endpoint was all-cause mortality, and first appropriate shock was co-primary endpoint. At baseline, all patients underwent 12‑lead ECG and Holter-ECG analysis using multiple advanced methods for risk stratification as well as documentation of clinical characteristics and laboratory values. The EU-CERT-ICD data will provide much needed information on the survival benefit of preventive ICD therapy and expand on previous prospective risk stratification studies which showed very good applicability of clinical parameters and advanced risk stratifiers in order to define patient subgroups with above or below average ICD benefit.

CONCLUSION

The EU-CERT-ICD study will provide new and current data about effectiveness of primary prophylactic ICD implantation. The study also aims for improved risk stratification and patient selection using clinical risk markers in general, and advanced ECG risk markers in particular.

LEFT VENTRICULAR LEAD PLACEMENT FOR PACING AND SENSING IN A PATIENT WITH ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY UNDERGOING ICD IMPLANTATION

We present a case of a 64-year-old female patient scheduled for implantable cardioverter defibrillator (ICD) implantation due to arrhythmogenic right ventricular cardiomyopathy (ARVC). Dual coil, active fixation ICD lead was introduced through the axillary vein. More than 20 positions were changed in the right ventricle (RV) (outflow tract, high, mid and apical septum, infero-basal, apical and lateral wall). Maximum R wave amplitude was 2 mV with pacing threshold of 0.5 V. Since the sensing was inappropriate, we decided to place the pace/sense lead of the ICD in the coronary sinus. The lead was placed in the basal part of the lateral vein. The pacing threshold was 1.0 V/0.40 ms and R wave was 9 mV. The lead was connected to the ICD sense-pace port and high voltage coils were connected in the usual way. The RV sense-pace lead was capped off. The device sensed an R wave of 7.0 mV 48 hours later. The purpose of this report is to show a possible solution of sensing problems during an ICD implantation in a patient with ARVC.

ROUTINELY AVAILABLE BIOMARKERS AS LONG-TERM PREDICTORS OF DEVELOPING SYSTOLIC DYSFUNCTION IN COMPLETELY REVASCULARIZED PATIENTS WITH ACUTE ST ELEVATION MYOCARDIAL INFARCTION

The aim of this study was to assess the efficacy of high-sensitivity C-reactive protein (hsCRP), cardiac troponin T (cTnT) and creatine kinase (CK) as long-term predictors of reduced systolic function in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with complete revascularization. This prospective study evaluated consecutive patients with acute STEMI who had normal left ventricular ejection fraction (LVEF ≥50%) at admission with single-vessel disease and underwent complete revascularization. Blood samples were collected from admission to day 7. The primary endpoint was reduction of LVEF <50% after 12 months. The study included 47 patients, median age 59±10 years, 74.5% of them men. Patients who developed systolic dysfunction (LVEF <50%) had significantly higher mean values of cTnT after 24 hours (5.11 vs. 2.82 µg/L, p=0.010) and peak values of CK (3375.5 vs. 1865 U/L, p=0.008). There was no significant relation between hsCRP and development of reduced LVEF (p=0.541). In conclusion, cTnT and CK could serve as long-term predictors of reduced left ventricular systolic function (<50%) in acute STEMI patients with normal systolic function at admission, single-vessel coronary disease and complete revascularization during primary PCI.

Recommendations for Perioperative Management of Patients with Cardiac Implantable Electronic Devices

SUMMARY – Four thousand cardiac implantable electronic devices (CIED) are implanted yearly in Croatia with constant increase. General anesthesia and surgery carry some specific risk for the patients with implanted CIEDs. Since most of the surgical procedures are performed in institutions without reprogramming devices available, or in the periods when they are unavailable, these guidelines aim to standardize the protocol for perioperative management of these patients. With this protocol, most of the procedures can be performed easily and, more importantly, safely in the majority of surgical patients.

Rationale and design of the EU-CERT-ICD prospective study: comparative effectiveness of prophylactic ICD implantation

Aims

The clinical effectiveness of primary prevention implantable cardioverter defibrillator (ICD) therapy is under debate. The EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators (EU‐CERT‐ICD) aims to assess its current clinical value.

Methods and results

The EU‐CERT‐ICD is a prospective investigator‐initiated non‐randomized, controlled, multicentre observational cohort study performed in 44 centres across 15 European Union countries. We will recruit 2250 patients with ischaemic or dilated cardiomyopathy and a guideline indication for primary prophylactic ICD implantation. This sample will include 1500 patients at their first ICD implantation and 750 patients who did not receive a primary prevention ICD despite having an indication for it (non‐randomized control group). The primary endpoint is all‐cause mortality; the co‐primary endpoint in ICD patients is time to first appropriate shock. Secondary endpoints include sudden cardiac death, first inappropriate shock, any ICD shock, arrhythmogenic syncope, revision procedures, quality of life, and cost‐effectiveness. At baseline (and prior to ICD implantation if applicable), all patients undergo 12‐lead electrocardiogram (ECG) and Holter ECG analysis using multiple advanced methods for risk stratification as well as detailed documentation of clinical characteristics and laboratory values. Genetic biobanking is also organized. As of August 2018, baseline data of 2265 patients are complete. All subjects will be followed for up to 4.5 years.

Conclusions

The EU‐CERT‐ICD study will provide a necessary update about clinical effectiveness of primary prophylactic ICD implantation. This study also aims for improved risk stratification and patient selection using clinical and ECG risk markers.

An uncommon case of spontaneous conversion from AV re-entry tachycardia to AV nodal re-entry tachycardia in a patient with dual tachycardia

We report the case of a 46-year old patient in whom an electrophysiology study (EP) was performed due to paroxysmal supraventricular tachycardia documented in 12-lead ECG. During the EP study, supraventricular tachycardia was induced easily and it corresponded to orthodromic AV reentry tachycardia (AVRT) using a concealed left free wall accessory pathway. However, during the study AVRT spontaneously and repeatedly converted to the typical slow-fast AV node reentry tachycardia (AVNRT). Both accessory and AV nodal slow pathways were ablated, due to the finding that both AVRT and AVNRT were independently inducible during the EP study.

Transcatheter patent foramen ovale closure and radiofrequency ablation of right atrial tachycardia

Patent foramen ovale (PFO) can be found in approximately 25% of adult population. Transcatheter closure of PFO is a potential option in selected patients with PFO. We report a case of a female patient that underwent mapping and catheter ablation of atrial tachycardia and PFO closure in the same procedure.

Consensus statement on screening, diagnosis, classification and treatment of endemic (Balkan) nephropathy

Currently used diagnostic criteria in different endemic (Balkan) nephropathy (EN) centers involve different combinations of parameters, various cut-off values and many of them are not in agreement with proposed international guidelines. Leaders of EN centers began to address these problems at scientific meetings, and this paper is the outgrowth of those discussions. The main aim is to provide recommendations for clinical work on current knowledge and expertise. This document is developed for use by general physicians, nephrologists, urologist, public health experts and epidemiologist, and it is hoped that it will be adopted by responsible institutions in countries harboring EN. National medical providers should cover costs of screening and diagnostic procedures and treatment of EN patients with or without upper urothelial cancers.

Comparison between piezoelectric material properties obtained by using low-voltage magnitude frequency sweeping and high-level short impulse signals

Determination of electromechanical piezoceramic material parameters is usually done by fitting the measured input electrical impedance of the piezoceramic sample to the theoretical modelling equation for the input electrical impedance of the unloaded free piezoceramic resonator. The input electrical impedance of the sample is usually measured by using low voltage or current magnitude frequency sweeping signals. In this work, the complex material parameters of piezoceramic samples are determined in the real operating conditions by using the high voltage short impulse excitation signals. The input electrical impedance determined in the impulse mode around thickness extensional vibration mode (TE) and calculated piezoceramic parameters (clamped dielectric permittivity, electromechanical coupling factor, elastic stiffness and piezoelectric constant) are compared to the results obtained by using the low voltage magnitude frequency sweeping signals. When impulse excitation is used, the series resonance frequency is decreased and the input electrical impedance magnitude at series resonance is increased, which means that overall losses included in the piezoceramic parameters are increased. The complex material parameters obtained from the input electrical impedances determined by using the low voltage magnitude sweeping signal and high level short impulse signals are included in the KLM theoretical model describing the piezoceramic sample behaviour around TE mode. Better agreement between measured and theoretically determined current magnitude response around TE mode has been obtained, in the KLM model, when piezoceramic parameters determined by using the impulse signal excitations are included in the modelling. The physical reason for increase of the losses in piezoceramic material could lie in the fact that the ferroelectric domains in the piezoceramic respond harder on very short impulse excitation signals than on continuous frequency sweeping signals which are usually used in determination of piezoelectric material parameters.

Electrophysiological predictors of propafenone efficacy in prevention of atrioventricular nodal re-entrant and atrioventricular re-entrant tachycardia

Aim

To assess the efficacy of propafenone in prevention of atrioventricular nodal reentrant tachycardia (AVNRT) and orthodromic atrioventricular tachycardia (AVRT) based on the clinical results of arrhythmia recurrence and find the electrophysiological predictor of propafenone effectiveness.

Methods

This retrospective study included 44 participants in a 12-month period, who were divided in two groups: group A – in which propafenone caused complete ventriculo-atrial block and group B – in which propafenone did not cause complete ventriculo-atrial block.

Results

Group A had significantly lower incidence of tachycardia than group B (95% vs 70.8%, P = 0.038), and complete ventriculo-atrial block predicted the efficacy of propafenone oral therapy in the prevention of tachycardia (sensitivity 87.5%, specificity 52.8%, positive predictive value 95%, negative predictive value 29.2%). Patients with AVNRT in group B who did not experience the recurrences of tachycardia had significantly shorter echo zone before intravenous administration of propafenone than the patients who experienced episodes of sustained tachycardia (median 40 ms [range 15-60 ms] vs 79 ms [range 50-180 ms], P = 0.008).

Conclusion

In patients with non-inducible tachycardia, complete ventriculo-atrial block can be used as an electrophysiological predictor of the efficacy of propafenone oral therapy in the prevention of tachycardia. In patients with non-inducible AVNRT, but without complete ventriculo-atrial block, propafenone was more effective in patients with shorter echo zone of tachycardia.

Persistent atrial fibrillation is associated with a poor prognosis in patients with atrioventricular block and dual-chamber pacemaker

BACKGROUND

The prognostic significance of development of persistent atrial fibrillation (AF) in patients with atrioventricular (AV) block and dual chamber (DDD) pacemakers has not been separately investigated. We sought to determine whether persistent AF influences clinical outcome in these patients.

METHODS

Three hundred-eight consecutive patients with second- or third-degree AV block and implanted a DDD pacemaker were followed for 36 ± 20 months and retrospectively divided into two groups. Thirty-four patients who developed persistent AF formed persistent AF group, and 278 patients who remained free of this arrhythmia control group. Clinical and outcome data of the two groups were compared. The primary outcome was cardiovascular death.

RESULTS

The primary outcome occurred more often among the patients in the persistent AF group (6.8% per year) than among those in the control group (2.9% per year; P = 0.028). This difference was primarily because of higher rate of heart failure-related deaths in the persistent AF group (P = 0.009). Secondary outcomes, hospitalization for heart failure and paroxysmal AF episode ≥5 minutes, occurred also more often among the patients in the persistent AF group (P = 0.008 and P < 0.001, respectively), although the risk of nonfatal stroke was similar in both groups (P = 0.628).

CONCLUSION

In patients with second- or third-degree AV block and DDD pacemaker, the development of persistent AF is associated with an increased risk of cardiovascular death and heart failure.

Repetitive stent fractures with diffuse coronary artery microaneurysm formation--sirolimus eluting stent hypersensitivity?

While drug eluting stents (DES) are being more widely used in ever more patients receiving DES each day, some new complications may be emerging. Stent fractures and hypersensitivity reactions to stents are among recognized complications that can lead to therapeutic dead end from the interventional cardiologist's point of view. We present a case in which we reached therapeutic dead end with a sirolimus eluting stent, i.e. repetitive stent fractures with diffuse microaneurysms along the implanted DES, possibly due to hypersensitivity reaction to parts of the stent.

Incidence and predictors of asymptomatic atrial fibrillation in patients older than 70 years with complete atrioventricular block and dual chamber pacemaker implantation

AIM

To evaluate predictors of asymptomatic atrial fibrillation in patients older than 70 years with complete atrioventricular (AV) block, normal left ventricular systolic function, and implanted dual chamber (DDD) pacemaker.

METHODS

Hundred and eighty six patients with complete AV block were admitted over one year to the Sisters of Mercy University Hospital. The study recruited patients older than 70 years, with no history of atrial fibrillation, heart failure, or reduced left ventricular systolic function. All the patients were implanted with the same pacemaker. Out of 103 patients who were eligible for the study, 81 (78%) were evaluated. Among those 81 (78%) were evaluated. Eighty one (78%) patients were evaluated. Follow-up time ranged from 12 to 33 months (average ±standard deviation 23 ± 5 months). Primary end-point was asymptomatic atrial fibrillation occurrence recorded by the pacemaker. Atrial fibrillation occurrence was defined as atrial high rate episodes (AHRE) lasting >5 minutes. Binary logistic regression was used to identify the predictors of development of asymptomatic atrial fibrillation. Results. The 81 patients were stratified into two groups depending on the presence of AHRE lasting >5 minutes (group 1 had AHRE>5 minutes and group 2 AHRE<5 minutes). AHRE lasting >5 minutes were detected in 49 (60%) patients after 3 months and in 53 (65%) patients after 18 moths. After 3 months, only hypertension (odds ratio [OR], 17.63; P = 0.020) was identified as a predictor of asymptomatic atrial fibrillation. After 18 months, hypertension (OR, 14.0; P = 0.036), P wave duration >100 ms in 12 lead ECG (OR, 16.5; P = 0.001), and intracardial atrial electrogram signal amplitude >4 mV (OR, 4.27; P = 0.045) were identified as predictors of atrial fibrillation.

CONCLUSION

In our study population, hypertension was the most robust and constant predictor of asymptomatic atrial fibrillation after 3 months, while P wave duration >100 ms in 12-lead ECG and intracardial atrial signal amplitude were predictors after 18 months.

Electrophysiological effects, efficacy and safety of intravenous propafenone in termination of atrioventricular nodal reentrant tachycardia and atrioventricular reentrant tachycardia: a prospective non-randomized interventional study

The aim of this prospective, non-randomized interventional study was to assess electrophysiological effects, efficacy and safety of intravenous propafenone in termination of atrioventricular nodal reentrant tachycardia (AVNRT) and orthodromic atrioventricular reentrant tachycardia (AVRT). This single-center study was carried out at Department of Cardiology, Sestre milosrdnice University Hospital in Zagreb, Croatia, between January 1, 2005 and December 31, 2006. Eligibility requirements were fulfilled by a total of 70 patients with AVNRT (n=37) and AVRT (n=33). The intervention consisted of the electrophysiological study aimed at inducing tachycardia, followed by intravenous administration of 2 mg/kg propafenone in both groups. The main outcome measures were safety and efficacy of 2 mg/kg intravenous propafenone in tachycardia termination and re-induction. Out of 37 patients with AVNRT, propafenone managed to terminate it in 28 (75.7%) patients, while tachycardia was not inducible in 25 (67.56%) patients. Out of 33 patients with AVRT, propafenone managed to terminate AVRT in 29 (87.9%) patients, while tachycardia was not inducible in 22 (66.66%) patients. The overall propafenone efficacy in tachycardia termination was 81.42%. No propafenone-related adverse effects were recorded during the study period. Propafenone was found to be a safe and effective anti-arrhythmic drug and can be justifiably administered for AVNRT and AVRT termination. It could be considered as an alternative to adenosine and verapamil.

Wellens' syndrome in a female patient presenting to emergency room after resolving exercise-induced chest pain

Wellens' syndrome, also known as the left anterior descending (LAD) coronary T wave syndrome, is a potentially under-recognized syndrome in emergency room, which can have potentially fatal consequences. It usually consists of typical electrocardiography (ECG) finding in precordial leads that represents significant stenosis of the proximal LAD. Although the syndrome is not included in indications for primary percutaneous coronary intervention (patients with typical ECG findings are usually pain free at the time of recording), every patient with suspicion of typical Wellens' syndrome should be seen by interventional cardiologist and considered for emergency cardiac catheterization. A case is reported of a patient with no previous medical history of coronary disease and with only one risk factor for cardiovascular disease that presented to emergency room with typical Wellens' syndrome.

B-type natriuretic peptide as predictor of heart failure in patients with acute ST elevation myocardial infarction, single-vessel disease, and complete revascularization: follow-up study

AIM

To assess the concentration of B-type natriuretic peptide (BNP) as a predictor of heart failure in patients with acute ST elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI) with successful and complete revascularization.

METHODS

Out of a total of 220 patients with acute STEMI admitted to the Sisters of Mercy University Hospital in the period January 1 to December 31, 2007, only patients with acute STEMI undergoing primary PCI who had single vessel disease and were successfully revascularized were included in the study. Selected patients had no history of myocardial infarction or heart failure and a normal or near-normal left ventricular ejection fraction (> or =50%) assessed by left ventriculography at admission. Only 58 patients met the inclusion criteria for the study. Out of those, 6 patients refused to participate in the study, and another 5 could not be followed up, so a total of 47 patients were evaluated. Blood samples were taken for measurement of BNP levels at admission, 24 hours later, and 7 days later. Patients were followed up for 1 year. The primary outcome was reduction in left ventricular ejection fraction (LVEF) to <50% after 1 year.

RESULTS

Patients who developed echocardiographic signs of reduced systolic function defined as LVEF<50% had significantly higher values of BNP (> or =80 pg/mL) at 24 hours (P=0.001) and 7 days (P=0.020) after STEMI and successful reperfusion. Patients who had BNP levels > or =80 pg/mL after 7 days were 21 times more likely to develop LVEF<50 (odds ratio, 20.8; 95% confidence interval, 2.2-195.2; P=0.008).

CONCLUSION

BNP can be used as a predictor of reduced systolic function in patients with STEMI who underwent successful reperfusion and had normal ejection fraction at admission.

[Arterial hypertension in patients on long-term haemodialysis]

Arterial hypertension is one of the most frequent causes of chronic kidney failure but also one of most frequent complications in patients on long-term haemodialysis. The aim of this work is to investigate the prevalence of arterial hypertension in long-term haemodialysis patients, and methods for treating it. A total of 168 patients (86 women and 82 men average age 62.9 +/- 12.9 years) from three dialysis centers were included in this study. Arterial hypertension was defined as blood pressure immediately before hemodialysis > 140/90 mmHg or less if the patient has been on anti-hypertensive therapy. Before the beginning of a long-term hemodialysis program arterial hypertension was registered in 139 (81%) patients. The patients were on haemodialysis 52.5 +/- 45.17 months. All patients were dialyzed three times per week, an average of 11.7 hours per week (9 to 13.5 hours). Body weight of the patients was 68.4 +/- 15.8 kg, and weight gain between dialysis treatments was 2.9 +/- 1.1 kg. Arterial hypertension was recorded in 141 patients (84%), i.e. average blood pressure before haemodialysis in all patients was 157.3 +/- 17.3/85.2 +/- 8 mmHg. The average blood pressure of the remaining patients was 132.6 +/- 8.2/ 78.3 +/- 10.3 mmHg. The patients were treated with a variety of anti-hypertensive drugs. Thirty-seven patients were on monotherapy, while the others were on combined treatment (2-4 antihypertensive drugs). The most frequently used antihypertensive drugs were calcium channel blockers (95 patients, or 67%), ACE inhibitors (47 patients, or 33%), beta-blockers (29 patients, or 20%), angiotensin II receptor blockers and alpha-blockers (25 patients, or 17%), diuretics (11 patients, or seven percent), and nine patients (6%) received central agents or drugs wich acted like an alpha+beta blocker. Prevention and treatment of arterial hypertension is a special problem for haemodialysis patients. Unfortunately, there are still no guidelines for the optimal method of measuring blood pressure in these patients, or optimal values of arterial blood pressure, the first drug of choice or optimal combination of therapies. Perhaps because of this cardiovascular morbidity and mortality among these patients is high.