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Lakartidningen Jun 2024Ventricular tachycardia (VT) in patients with structural heart disease is potentially life threatening, and most patients have an indication for an implantable... (Review)
Review
Ventricular tachycardia (VT) in patients with structural heart disease is potentially life threatening, and most patients have an indication for an implantable cardioverter-defibrillator (ICD). Catheter ablation is an effective therapeutic strategy to reduce the risk of VT recurrence and subsequent ICD therapies. However, VT ablation is a technically complex procedure with significant risks and should be performed in experienced centers with appropriate resources. While several reports on outcome and procedural risks have been published, there is currently no data from Sweden. In addition to this literature review, we have analyzed VT ablation outcome data from our center. In 2021 and 2022, 68 VT ablations were performed in 60 patients with structural heart disease. After a median follow-up of 20 months, 18 percent had recurrent VT and there were 2 major adverse events (stroke and complete atrioventricular block). Seven patients died from non-arrhythmia related causes during follow-up. A large proportion (68 percent) were subacute procedures which are associated with a higher periprocedural risk. Referral for VT ablation earlier in the course of disease progression may likely further improve outcomes.
Topics: Humans; Catheter Ablation; Tachycardia, Ventricular; Defibrillators, Implantable; Treatment Outcome; Recurrence; Male; Female; Aged; Sweden; Middle Aged; Postoperative Complications
PubMed: 38832571
DOI: No ID Found -
BMJ Open Jun 2024Intraoperative opioids have been used for decades to reduce negative responses to nociception. However, opioids may have several, and sometimes serious, adverse effects....
Opioid-free anaesthesia with dexmedetomidine and lidocaine versus remifentanil-based anaesthesia in cardiac surgery: study protocol of a French randomised, multicentre and single-blinded OFACS trial.
INTRODUCTION
Intraoperative opioids have been used for decades to reduce negative responses to nociception. However, opioids may have several, and sometimes serious, adverse effects. Cardiac surgery exposes patients to a high risk of postoperative complications, some of which are common to those caused by opioids: acute respiratory failure, postoperative cognitive dysfunction, postoperative ileus (POI) or death. An opioid-free anaesthesia (OFA) strategy, based on the use of dexmedetomidine and lidocaine, may limit these adverse effects, but no randomised trials on this issue have been published in cardiac surgery.We hypothesised that OFA versus opioid-based anaesthesia (OBA) may reduce the incidence of major opioid-related complications after cardiac surgery.
METHODS AND ANALYSIS
Multicentre, randomised, parallel and single-blinded clinical trial in four cardiac surgical centres in France, including 268 patients scheduled for coronary artery bypass grafting under cardiac bypass, with or without aortic valve replacement. Patients will be randomised to either a control OBA protocol using remifentanil or an OFA protocol using dexmedetomidine/lidocaine. The primary composite endpoint is the occurrence of at least one of the following: (1) postoperative cognitive disorder evaluated by the Confusion Assessment Method for the Intensive Care Unit test, (2) POI, (3) acute respiratory distress or (4) death within the first 48 postoperative hours. Secondary endpoints are postoperative pain, morphine consumption, nausea-vomiting, shock, acute kidney injury, atrioventricular block, pneumonia and length of hospital stay.
ETHICS AND DISSEMINATION
This trial has been approved by an independent ethics committee ( on 23 February 2021). Results will be submitted in international journals for peer reviewing.
TRIAL REGISTRATION NUMBER
NCT04940689, EudraCT 2020-002126-90.
Topics: Humans; Dexmedetomidine; Lidocaine; Remifentanil; Cardiac Surgical Procedures; Single-Blind Method; Analgesics, Opioid; France; Postoperative Complications; Randomized Controlled Trials as Topic; Multicenter Studies as Topic; Pain, Postoperative
PubMed: 38830745
DOI: 10.1136/bmjopen-2023-079984 -
International Journal of Cardiology.... Jun 2024Third-degree atrioventricular (AV) blocks are rare but cause significant symptoms and require immediate intervention. Coronary artery disease (CAD) is felt to be the...
BACKGROUND
Third-degree atrioventricular (AV) blocks are rare but cause significant symptoms and require immediate intervention. Coronary artery disease (CAD) is felt to be the most common etiology. Although smoking is a prominent risk factor for CAD, there is a paucity of data assessing the direct effect of smoking on third-degree AV block.
METHODS
We performed a retrospective cohort study on adult-weighted admissions in 2019-2020 with a primary diagnosis of third-degree AV block and a history of smoking using the National Inpatient Sample (NIS) database. In-hospital mortality, rates of pacemaker insertion, cardiogenic shock, cardiac arrest, acute kidney injury (AKI), stroke, tracheal intubation, mechanical ventilation, mechanical circulatory support, vasopressor use, length of stay (LOS), and total hospitalization costs were analyzed using regression analysis. We performed a secondary analysis using propensity score matching to confirm the results.
RESULTS
A total of 77,650 admissions met inclusion criteria (33,625 females [43.3 %], 58,315. Caucasians [75 %], 7030 African American [9 %], 6155 Hispanic [7.9 %]; mean [SD] age 75.4.[10.2] years) before propensity matching. A total of 29,380 (37.8 %) patients with AV block were smokers.A total of 5560 patients with and without a history of smoking were matched for the analysis. Smokers had.decreased odds of mortality (aOR, 0.59; CI, 0.44-0.78; p < 0.001), cardiogenic shock, cardiac arrest, tracheal intubation, mechanical ventilation, shorter LOS, and lower total hospital costs in both the multivariable regression and propensity-matched analyses.
CONCLUSION
Third-degree AV block had lower in-hospital mortality, cardiogenic shock, cardiac arrest, LOS, and total hospitalization cost in patients with smoking history.
PubMed: 38828463
DOI: 10.1016/j.ijcrp.2024.200289 -
Journal of Cardiology Cases Jun 2024Patients with congenitally corrected transposition of the great arteries (ccTGA) often develop complete atrioventricular block and heart failure due to the abnormal...
UNLABELLED
Patients with congenitally corrected transposition of the great arteries (ccTGA) often develop complete atrioventricular block and heart failure due to the abnormal disposition of atrioventricular node and disadvantage of systemic right ventricle. These issues are managed with a pacing system and a ventricular assist device (VAD), respectively. While technological advances offer new treatment strategies, the simultaneous deployment of a leadless pacemaker and a VAD in cases of ccTGA remains unexplored. Here, we present a case of leadless pacemaker implantation for a VAD-supported ccTGA patient. The safety of a leadless pacemaker for a subpulmonary left ventricle and electromagnetic interference between devices are major concerns when implanting a leadless pacemaker; however, the current case overcomes these obstacles. There were no perioperative complications, and both devices were functioning without problems during a one-year follow up. We expect that, even in patients with cardiac complexity such as systemic right ventricle under VAD support, a leadless pacemaker could become the treatment of choice if the indication is appropriate, although careful and close follow up is needed.
LEARNING OBJECTIVE
Technological advances expand treatment strategies and provide significant benefits to patients with adult congenital heart disease (ACHD). However, discussion of the combination of a leadless pacemaker and a ventricular assist device (VAD) is rare. We demonstrated the efficacy of a leadless pacemaker for a subpulmonary left ventricle in a patient with systemic right ventricle on VAD. This approach could be an option even for ACHD patients.
PubMed: 38826767
DOI: 10.1016/j.jccase.2024.02.004 -
Journal of Cardiovascular Echography 2024Bradycardia caused by total atrioventricular block (TAVB) is treated by implantation of permanent pacemakers (PPMs) in either dual-chamber (DDD) versus ventricular (VVI)...
CONTEXT
Bradycardia caused by total atrioventricular block (TAVB) is treated by implantation of permanent pacemakers (PPMs) in either dual-chamber (DDD) versus ventricular (VVI) pacing modes. DDD is considered a more physiological pacing mode than VVI as it avoids atrioventricular dyssynchrony. However, previous trials have failed to demonstrate the superiority of DDD in improving quality of life and morbidity.
AIMS
This study aims to provide postpacemaker function of the left ventricle (LV) measured with global longitudinal strain (GLS), in TAVB patients.
SETTINGS AND DESIGN
This is a comparative study; samples included in the study are adult TAVB patients undergoing PPM implantation, without significant heart function, and structural abnormality. Echocardiographic parameters are obtained before, after 1 month, and after 3 months post-PPM.
SUBJECTS AND METHODS
A total of 98 TAVB patients undergoes PPM implantation during the study period, 55 patients were excluded, and in the end, only 43 patients fulfill the inclusion criteria.
STATISTICAL ANALYSIS USED
Baseline data between DDD and VVI are compared using unpaired -test. Statistical significance 1 month post-PPM and 3 months post-PPM is analyzed using paired -test.
RESULTS
There were no significant differences between both groups at baseline. However, significant GLS changes are observed 1 month after PPM in the VVI group ( = 0.002), but no significant change was observed in the DDD group even after 3 months ( = 0.055).
CONCLUSIONS
In our study, we conclude that DDD is superior in maintaining LV function in the short term in TAVB patients after PPM implantation.
PubMed: 38818320
DOI: 10.4103/jcecho.jcecho_78_23 -
Alternative Therapies in Health and... May 2024Right ventricular pacing (RVP) therapy is the conventional approach for atrioventricular block despite its propensity to cause electrical and mechanical dyssynchrony....
BACKGROUND
Right ventricular pacing (RVP) therapy is the conventional approach for atrioventricular block despite its propensity to cause electrical and mechanical dyssynchrony. This dyssynchrony increases the risk of atrial fibrillation and heart failure, eventually leading to left ventricular dysfunction. Left bundle branch pacing (LBBP) has recently emerged as a novel physiological pacing method. This study utilizes conventional ultrasound cardiography (UCG), two-dimensional speckle tracking imaging (2D-STI), and tissue Doppler imaging (TDI) to investigate the disparities in electrical and mechanical cardiac synchrony between LBBP and RVP patients.
METHODS
The retrospective analysis includes data from patients who underwent LBBP (n=50) and RVP (n=50) in Zhangjiagang First People's Hospital between January 2019 and June 2020, meeting the stipulated inclusion criteria. The study compares pacing parameters, UCG metrics, cardiac electrical and mechanical synchrony, pacing success rates, and safety events both pre-operation and at 3, 6, 12, and 24 months post-operation.
RESULTS
Implantation success rates for both RVP and LBBP groups were 100%, with 92% and 100% pacing success rates, respectively [P = .001 RR (95% CI) : 2.5 (1.5, 3.5)]. The LBBP group exhibited significant advantages over the RVP group throughout the follow-up period. LBBP patients displayed shortened QRS duration, reduced pacing thresholds and impedance, improved sensory function, lower serum NT-proBNP levels, and an increased proportion of NYHA class I patients [P = .003 RR (95% CI) : 1.6 (1.1, 2.3)]. Furthermore, left ventricular ejection fraction increased significantly, while left ventricular diastolic and end-systolic diameters decreased in the LBBP group compared to the RVP group [P = .004 RR (95% CI) : 1.7 (1.3, 2.2)]. The LBBP group also demonstrated shorter ventricular systolic synchrony parameters, including Tls-Dif, PSD, Trs-SD, Tas-SD, Tas-post, Ts-SD, and Ts-DIf, compared to the RVP group [P = .005 RR (95% CI) : 1.5 (1.2, 2.0)]. Notably, no postoperative complications occurred in either group, such as electrode displacement, lead thrombus attachment, incision bleeding, pocket hemorrhage, or infection. However, the readmission rates for heart failure were 16% in the RVP group and 2% in the LBBP group.
CONCLUSION
LBBP achieves physiological cardiac pacing, leading to significant improvements in serum NT-proBNP levels and cardiac function and enhanced ventricular contraction synchrony. Utilizing UCG, 2D-STI, and TDI for quantitative evaluation of cardiac electrical and mechanical synchrony proves to be a valuable clinical approach.
PubMed: 38814612
DOI: No ID Found -
Turkish Journal of Medical Sciences 2023Despite advancements in valve technology and increased clinical experience, complications related to conduction defects after transcatheter aortic valve implantation...
BACKGROUND/AIM
Despite advancements in valve technology and increased clinical experience, complications related to conduction defects after transcatheter aortic valve implantation (TAVR) have not improved as rapidly as expected. In this study, we aimed to predict the development of complete atrioventricular (AV) block and bundle branch block during and after the TAVR procedure and to investigate any changes in the cardiac conduction system before and after the procedure using electrophysiological study.
MATERIALS AND METHODS
A total of 30 patients who were scheduled for TAVR at our cardiovascular council were planned to be included in the study. TAVR was performed on patients at Erciyes University Medical Faculty Hospital as a single center between May 2019 and August 2020 Diagnostic electrophysiological study was performed before the TAVR procedure and after its completion. Changes in the cardiac conduction system during the preprocedure, intra-procedure, and postprocedure periods were recorded.
RESULTS
Significant increases in baseline cycle length, atrial-His (AH) interval, his-ventricular (HV) interval and atrioventricular (AV) distance were observed before and after the TAVR procedure (p = 0.039, p < 0.001, p = 0.018, p < 0.001, respectively). During the TAVR procedure, the preprocedural HV interval was longer in patients who developed AV block and bundle branch block compared to those who did not and this difference was statistically significant (p = 0.024). ROC curve analysis revealed that a TAVR preprocedure HV value >59.5 ms had 86% specificity and 75% sensitivity in detecting AV block and bundle branch block (AUC = 0.83, 95% CI: 0.664-0.996, p = 0.013). The preprocedure HV distance was 98 ± 10.55ms in the group with permanent pacemaker implantation and the mean value in the group without permanent pacemaker implantation was 66.27 ± 15.55 ms, showing a borderline significant difference (p = 0.049).
CONCLUSION
The prolongation of HV interval in patients with AV block and bundle branch block suggests that the block predominantly occurs at the infra-hisian level. Patients with longer preprocedural HV intervals should be closely monitored for the need for permanent pacemaker implantation after the TAVR procedure.
Topics: Humans; Transcatheter Aortic Valve Replacement; Male; Female; Pacemaker, Artificial; Aged; Aged, 80 and over; Atrioventricular Block; Bundle-Branch Block; Aortic Valve Stenosis; Electrocardiography; Postoperative Complications; Heart Conduction System
PubMed: 38813482
DOI: 10.55730/1300-0144.5750 -
The Journal of Innovations in Cardiac... May 2024A 78-year-old male patient with complete atrioventricular block underwent an uncomplicated pacemaker implantation. After 24 h, he presented acute chest pain, dyspnea,...
A 78-year-old male patient with complete atrioventricular block underwent an uncomplicated pacemaker implantation. After 24 h, he presented acute chest pain, dyspnea, ST-segment-elevation in the anterior leads, left ventricular apical ballooning, and an ejection fraction of 35%. His coronary angiogram was normal. Within 2 days, his symptoms and electrocardiogram (ECG) abnormalities disappeared, while wall motion abnormalities recovered after 6 weeks. A diagnosis of takotsubo syndrome (TTS) was made. Pacemaker implantation has been described as a potential trigger for TTS. The clinical picture exhibits some peculiarities, including a higher percentage of men and asymptomatic patients and challenging ST-segment interpretation of paced ECGs. It is unclear whether pathophysiologic mechanisms are different compared to other forms of TTS and whether the acute initiation of ventricular pacing plays a role.
PubMed: 38808172
DOI: 10.19102/icrm.2024.15051 -
European Heart Journal. Case Reports May 2024Differentiation of syncope from seizure is challenging and has therapeutic implications. Cardioinhibitory reflex syncope typically affects young patients where permanent...
BACKGROUND
Differentiation of syncope from seizure is challenging and has therapeutic implications. Cardioinhibitory reflex syncope typically affects young patients where permanent pacing should be avoided whenever possible. Cardioneuroablation may obviate the need for a pacemaker in well-selected patients.
CASE SUMMARY
A previously healthy 24-year-old woman was referred to the emergency department after recurrent episodes of transient loss of consciousness (TLOC). The electrocardiogram (ECG) and the echocardiogram were normal. An electroencephalogram (EEG) showed intermittent, generalized pathological activity. During EEG under photostimulation, the patient developed a short-term TLOC followed by brachial myocloni, while the concurrent ECG registered a progressive bradycardia, which turned into a complete atrioventricular block and sinus arrest with asystole for 14 s. Immediately after, the patient regained consciousness without sequelae. The episode was interpreted as cardioinhibitory convulsive syncope. However, due to the pathological EEG findings, an underlying epilepsy with ictal asystole could not be fully excluded. Therefore, an antiseizure therapy was also started. After discussing the consequences of pacemaker implantation, the patient agreed to undergo a cardioneuroablation and after 72 h without complications, she was discharged home. At 10 months, the patient autonomously discontinued the antiepileptics. The follow-up EEG displayed unspecific activities without clinical correlations. An implantable loop recorder didn't show any relevant bradyarrhythmia. At 1-year follow-up, the patient remained asymptomatic and without syncopal episodes.
DISCUSSION
Reflex syncope must be considered in the differential diagnosis of seizures. The cardioneuroablation obviated the need for a pacemaker and allowed for the withdrawal of anticonvulsants, originally started on the premise of seizure.
PubMed: 38807945
DOI: 10.1093/ehjcr/ytae256