Small bowel capsule endoscopy in patients with cardiac pacemakers and implantable cardioverter defibrillators:Outcome analysis using telemetry review

AIM:To determine if there were any interactions between cardiac devices and small bowel capsules secondary to electromagnetic interference (EMI) in patients who have undergone small bowel capsule endoscopy (SBCE).METHODS:Authors conducted a chart review of 20 patients with a cardiac pacemaker (CP) or implantable cardioverter defibrillator (ICD) who underwent continuous electrocardiographic monitoring during their SBCE from 2003-2008.authors searched for unexplained electrocardiogram (ECG) findings,changes in CP andICD set parameters,any abnormality in transmitted capsule data,and adverse clinical events.RESULTS:There were no adverse events or hemodynamically significant arrhythmias reported.CP and ICD set parameters were preserved.The majority of ECG abnormalities were also found in pre-or post-SBCE ECG tracings and the CP behavior during arrhythmias appeared appropriate.Two patients seemed to have episodes of undersensing by the CP.However,similar findings were documented in ECGs taken outside the time frame of the SBCE.One patient was observed to have a low signal encountered from the capsule resulting in lack of localization,but no images were lost.CONCLUSION:Capsule-induced EMI remains a possibility but is unlikely to be clinically important.CPinduced interference of SBCE is also possible,but is infrequent and does not result in loss of images transmitted by the capsule.

Single lead catheter of implantable cardioverterdefibrillator with floating atrial sensing dipole implanted via persistent left superior vena cava

Persistent left superior vena cava(LSVC) is a congenital anomaly with 0.3%-1% prevalence in the general population. It is usually asymptomatic but in case of transvenous lead positioning, i.e., for pacemaker or implantable cardioverter defibrillator(ICD), may be a cause for significant complications or unsuccessful implantation. Single lead ICD with atrial sensing dipole(ICD DX) is a safe and functional technology in patients without congenital abnormalities. We provide a review of the literature and a case report of successful implantation of an ICD DX in a patient with LSVC and its efficacy in treating ventricular arrhythmias.

Interference between pacemakers/implantable cardioverter defibrillators and video capsule endoscopy

Our Letter to the Editor, related to the article "Small bowel capsule endoscopy in patients with cardiac pacemakers and implantable cardioverter defibrillators: Outcome analysis using telemetry" by Cuschieri et al , comments on some small errors, that slipped into the authors discussions. The given informations concerning the pacemakerand implantable cardioverter defibrillators modes were inaccurate and differ between the text and the table. Moreover, as 8 of 20 patient's pacemakers were programmed to VOO or DOO ("interference mode") and one patient was not monitored by telemetry during capsule endoscopy, 9 of 20 patients (45%) lack the informations of possible interference between capsule endoscopy their implanted device. Another objection refers to the interpretation of an electrocardiogram (figure 1, trace B) presented: in contrast to the author's opinion the marked spike should be interpreted as an artefact and not as "undersensing of a fibrillatory wave". Finally, three comments to cited reviews were not complete respectively not quoted correctly.

Implantable cardioverter defibrillator lead-related methicillin resistant Staphylococcus aureus endocarditis:Importance of heightened awareness

Methicillin resistant Staphylococcus aureus(MRSA) septicemia is associated with high morbidity and mortality especially in patients with immunosuppression,diabetes,renal disease and endocarditis.There has been an increase in implantation of cardiac implantable electronic devices(CIED) with more cases of devicelead associated endocarditis been seen.A high index of suspicion is required to ensure patient outcomes are optimized.The excimer laser has been very efficient in helping to ensure successful lead extractions in patients with CIED infections.We present an unusual case report and literature review of MRSA septicemia from device-lead endocarditis and the importance of early recognition and prompt treatment.

Antitachycardia pacing programming in implantable cardioverter defibrillator:A systematic review

Implantable cardioverter defibrillator(ICD) programminginvolves several parameters. In recent years antitachycardia pacing(ATP) has gained an increasing importance in the treatment of ventricular arrhythmias, whether slow or fast. It reduces the number of unnecessary and inappropriate shocks and improves both patient's quality of life and device longevity. There is no clear indication regarding the type of ATP to be used, except for the treatment of fast ventricular tachycardias(188 bpm-250 bpm) where it has been shown a greater efficacy and safety of burst compared to ramp; 8 impulses in each sequence of ATP appears to be the best programming option in this setting. Beyond ATP use, excellent clinical results were obtained with programming standardization following these principles: extended detection time in ventricular fibrillation(VF) zone; supraventricular discrimination criteria up to 200 bpm; first shock in VF zone at the maximum energy in order to reduce the risk of multiple shocks. The MADIT-RIT trial and some observational registries have also recently demonstrated that programming with a widespread use of ATP, higher cut-off rates or delayed intervention reduces the number of inappropriate and unnecessary therapies and improves the survival of patients during mid-term follow-up.

Induced atrial fibrillation during defibrillation test on implantation of subcutaneous implantable cardioverter defibrillator

The subcutaneous implantable cardioverter defibrillator(S-ICD)has become an alternative to the transvenous ICD in indicated patients.However,inappropriate shock or failed ventricular tachycardia/fibrillation conversion is the most alarming complication of S-ICD.Therefore,defibrillation test(DFT)is recommended for the S-ICD implantation.

Critical analysis of ineffective post implantation implantable cardioverter-defibrillator-testing

AIM To test of the implantable-cardioverter-defibrillator is done at the time of implantation. We investigate if any testing should be performed.METHODS All consecutive patients between January 2006 and December 2008 undergoing implantable cardioverterdefibrillator(ICD) implantation/replacement(a total of 634 patients) were included in the retrospective study.RESULTS Sixteen patients(2.5%) were not tested(9 with LA/LVthrombus, 7 due to operator's decision). Analyzed were 618 patients [76% men, 66.4 + 11 years, 24% secondary prevention(SP), 46% with left ventricular ejection fraction(LVEF) < 20%, 56% had coronary artery disease(CAD)] undergoing defibrillation safety testing(SMT) with an energy of 21 + 2.3 J. In 22/618 patients(3.6%) induced ventricular fibrillation(VF) could not be terminated with maximum energy of the ICD. Six of those(27%) had successful SMT after system modification or shock lead repositioning, 14 patients(64%) received a subcutaneous electrode array. Younger age(P = 0.0003), non-CAD(P = 0.007) and VF as index event for SP(P = 0.05) were associated with a higher incidence of ineffective SMT. LVEF < 20% and incomplete revascularisation in patients with CAD had no impact on SMT.CONCLUSION Defibrillation testing is well-tolerated. An ineffective SMT occurred in 4% and two third of those needed implantation of a subcutaneous electrode array to passa SMT > 10 J.

Wearable cardioverter defibrillator:Bridge or alternative to implantation?

The implantable cardioverter-defibrillator(ICD) is effective to prevent sudden cardiac death(SCD) in selected patients with heart disease known to be at high risk for ventricular arrhythmia. Nevertheless, this invasive and definitive therapy is not indicated in patients with potentially transient or reversible causes of sudden death, or in patients with temporary contraindication for ICD placement. The wearable cardioverter defibrillator(WCD) is increasingly used for SCD prevention both in patients awaiting ICD implantation or with an estimated high risk of ventricular arrhythmia though to be transient. We conducted a review of current clinical uses and benefits of the WCD, and described its technical aspects, limitations and perspectives.

Outcomes after asystole events occurring during wearable defibrillator-cardioverter use

AIM To examine whether wearable cardioverter defibrillator(WCD) alarms for asystole improve patient outcomes and survival.METHODS All asystole episodes recorded by the WCD in 2013 were retrospectively analyzed from a database of device and medical record documentation and customer call reports. Events were classified as asystole episodes if initial presenting arrhythmia was asystole(< 10 beats/minor ≥ 5 s pause). Survival was defined as recovery at the scene or arrival to a medical facility alive, or not requiring immediate medical attention. Episodes occurring in hospitals, nursing homes, or ambulances were considered to be under medical care. Serious asystole episodes were defined as resulting in unconsciousness, hospital transfer, or death.RESULTS Of the total 51933 patients having worn the WCD in 2013, there were 257 patients(0.5%) who had asystole episodes and comprised the study cohort. Among the 257 patients(74% male, median age 69 years), there were 264 asystole episodes. Overall patient survival was 42%. Most asystoles were considered "serious"(n = 201 in 201 patients, 76%), with a 26% survival rate. All 56 patients with "non-serious" asystole episodes survived. Being under medical care was associated with worse survival of serious asystoles. Among acute survivors, 20% later died during WCD use(a median 4 days post asystole episode). Of the 86 living patients at the end of WCD use period, 48(56%) received ICD/pacemaker and 17(20%) improved their condition.CONCLUSION Survival rates after asystole in patients with WCD are higher than historically reported survival rates. Those under medical care at time of asystole exhibited lower survival.

Experience on application of transveneous implantable MINI Ⅱ cardioverterdefibrillator for ventricular tachycardia due to right ventricular dysplasia:a report of a case

Objectics: Implantable cardioverter-defibrillator (ICI)is an important mean for treating ventricular tachycardia (VT ) in patients with structural heart diseases .This report deals with our primary experiences in cliical application of transveneous implantable cardioverter defibrillator.Metgids: A 13- year-old male patient with right ventricular dysplasia (ARVD) ). who lhad a failed result from antiarrhythmic drug therapy was implanted with ICD transveneously. Results: During follow. up. the antitachycardia pacing (ATP) did not terminate the first 2 episodes of VT. The episodes of VT were reverted into sinus rhythm by 4 J shock. The patient had a strong uncomfortable sensation :After resettin ATP program . VTs of patient were automaticallly terminated by ICD with ATP therapy many times. Conclusion: ICD implantation is an effective approach for treating VT and reasonable resetting of ATP is needed.

Anesthetic management of patient with hypertrophic cardiomyopathy and automatic implantable cardioverter defibrillator with a hand fracture

A 26-year-old male with a history of hypertrophic cardiomyopathy(HCM) and ventricular arrhythmias s/p automatic implantable cardioverter defibrillator(AICD) placement presented for open reduction and internal fixation of an open third metacarpal fracture and extensor tendon repair. He underwent successful surgery after placement of an ultrasound-guided infraclavicular brachial plexus block with ropivacaine 0.5% as the main anesthetic. This case report discusses the anesthetic management of patients with HCM and AICD, different approaches available for brachial plexus blockade, and potential complications of anesthesia and surgery in this group of patients.

Electrochemotherapy and heart function:Treatment in a patient with implantable cardioverter defibrillator/pacemaker

Electrochemotherapy(ECT) is a recently described therapy that relies on the permeation of cancer cell membranes by electrical pulses to enhance cytotoxic drug penetration. It has been successfully used in the treatment of primary and metastatic skin cancer. Systemic chemotherapy is the most commonly used therapeutic strategy, and the prevailing orientation calls for the administration of the maximum tolerated dose; however, considerable limitations exist including toxicities to healthy tissues and low achievable drug concentrations at tumor sites. We reported a case of an 83-years-old patient with a laterocervical metastasis of a squamous epidermoidal lip cancer. The patient had a complex medical history and an implantable cardioverter defibrillator(ICD)/pace-maker. The lesion was localized in the supraclavicular right side with a distance from the pace-maker/ICD about 5 cm, but the nodule was not deeply located. The ECT was performed un-der general anesthesia and particular attention we put on the interference with the functioning of the heart. The synchronization algorithm currently implemented in Clinoporator Vitae device coupled with the external triggering device Accu Sync proved to be effective in preventing external stimulation of the heart during the so-called vulnerable period of the ventricles. As a result all electroporation pulses in our study were delivered outside the vulnerable period and no heart arrhythmias or any other pathological morphological changes were observed. The safety of treatment was demonstrated also by absence of side effects during and after ECT.

NYHA Class II or III Heart Failure: Who Will Need an Implantable Cardioverter Defibrillator (ICD)?

Sudden cardiac death (SCD) is one of the most debilitating and life-threatening complications of heart failure (HF) which has challenged medical care for long. Current guidelines suggest the use of Implantable Cardioverter Defibrillator (ICD) in primary prevention of SCD in both New York Heart Association (NYHA) class II and class III heart failure. This paper critically evaluated the evidence underlying the guideline recommendation. In contrast to recent guidelines, the majority of the intervention trials conducted on the topic till date found a promising role of ICD only in the prevention of SCD in NYHA class II HF. One of the trials which found a significant role of ICD in type III heart failure was underpowered. Thus, further trials are needed to validate the use of ICD in the prevention of SCD in type III HF.

A MEDIAN FOLLOW-UP OF TWENTY-TWO MONTHS FOR CARDIOVERTER DEFIBRILLATOR IMPLANTATION IN SYMPTOMATIC OR ASYMPTOMATIC PATIENTS WITH BRUGADA SYNDROME

Objective To explore the outcome of patients with Brugada syndrome by remedial or prophylactic implantable cardioverter defibrillator （ ICD ） for ventricular tachyarrhythmia. Methods Sixteen single chamber ICDs and 5 double chamber ICDs in 21 consecutive patients [ 17 males, 4 females; mean age, （ 36 ± 11） years ] with Brugada syndrome were involved. Fifteen patients with spontaneous or induced ventricular tachycardia/ventricular fibrillation （VT/VF） received the remedial and prophylactic ICD implantation. Six patients only with positive family history or syncope accepted the ICD implantation for prophylaxis. Results After a median follow-up of （22.3 ± 13. 4） months, all patients were alive. One patient was suspected with febrile syndrome due to endocarditis on the auricular face of the lead of defibrillator 18 months after 1CD implantation and disappearance of vegetation was found after receiving one-month antibiotic treatment. Nine appropriate ICD interventions took place in 3 individuals with documented spontaneous ventricular arrhythmias. Multivariable analysis suggested that occurrence of appropriate interventions was related to the spontaneous ventricular arrhythmias （ P 〈 0. 0001 ）. Eleven inappropriate ICD interventions occurred in 3 patients for atrial fibrillation or atrial flutter with rapid ventricular rate. Multivariable analysis suggested that occurrence of inappropriate interventions was related to documented spontaneous supraventricular arrhythmias （P 〈 O. 0062 ）. All appropriate interventions and inappropriate interventions occurred within six months after ICD implantation. Conclusion Appropriate interventions may associate to spontaneous ventricular arrhythmias before 1CD implantation in patients with Brugada syndrome. Patients may suffer from inappropriate ICD intervention for supraventricular arrhythmias with rapid ventricular rate when they had a history of supraventricular arrhythmias.

Effect of a low-cost instruction card for automated external defibrillator operation in lay rescuers: a randomized simulation study

BACKGROUND:To evaluate whether a simplified self-instruction card can help potential rescue providers use automated external defibrillators(AEDs)more accurately and quickly.METHODS:From June 1,2018,to November 30,2019,a prospective longitudinal randomized controlled simulation study was conducted among 165 laypeople(18–65 years old)without prior AED training.A self-instruction card was designed to illuminate key AED operation procedures.Subjects were randomly divided into the card(n=83)and control(n=82)groups with age stratification.They were then individually evaluated in the same simulated scenario to use AED with(card group)or without the self-instruction card(control group)at baseline,posttraining,and at the 3-month follow-up.RESULTS:At baseline,the card group reached a significantly higher proportion of successful defibrillation(31.1%vs.15.9%,P=0.03),fully baring the chest(88.9%vs.63.4%,P<0.001),correct electrode placement(32.5%vs.17.1%,P=0.03),and resuming cardiopulmonary resuscitation(CPR)(72.3%vs.9.8%,P<0.001).At post-training and follow-up,there were no significant differences in key behaviors,except for resuming CPR.Time to shock and time to resume CPR were shorter in the card group,while time to power-on AED was not different in each phase of tests.In the 55–65 years group,the card group achieved more skill improvements over the control group compared to the other age groups.CONCLUSION:The self-instruction card could serve as a direction for first-time AED users and as a reminder for trained subjects.This could be a practical,cost-effective way to improve the AED skills of potential rescue providers among different age groups,including seniors.

Mismatch between Sites of Incidence of Out-of-Hospital Cardiac Arrest and Locations of Installed Automated External Defibrillator in the Tokyo Metropolitan Area

Background: Since 2004, the number of installed Automated External Defibrillator (AED) has been increased in Japan annually, the cumulative number of sold AED more than 600,000 units by 2016. Despite there have been about 130,000 out of hospital cardiac arrest annually, there have only 1302 cases delivered defibrillation by bystanders at the scene. Therefore, we investigate that number of AED installation and usage rate for Out of Hospital Cardiac Arrest (OHCA) patients. Methods: Retrospective metropolitan wide cohort study. Subject: Total 13,364 OHCA patients in the Tokyo Metropolitan area from Jan. 1 through Dec. 31 in 2012 were eligible for theses analyses. Also, OHCA occurrence place and AED usage rate were studied. Results: 82.8% of OHCA occurred at residences, 10% at outdoors, 6.4% at indoors, only 0.7% at schools. In the other hand, highest bystander’s CPR rates were found in sports facilities and schools (71.4%). The installation rate of AEDs in residences was 9.6%, instead of highest incidence for OHCA patients, school and sports institute made up 21.4% of AED installations, but only 1.0% of the incidences of cardiac arrest. We found that there is a mismatch between incidence sites of cardiac arrest and locations of installed AED. Discussion: It is essential to increase the number of AED installations. Furthermore, it is desirable to install AEDs in locations where cardiac arrest is liable to occur following guidelines for the proper placement of AEDs, and important to further spread BLS education among the general citizens.

Transvenous defibrillator implantation in a patient with persistent left superior vena cava

Persistent left superior vena cava(LSVC) can be incidentally detected during pacemaker implantation through left pectoral side.There is technical difficulty of optimal site pacing and lead stability for right ventricle lead in such situation.We hereby report a case of successful single-chamber implantable cardioverter defibrillator(ICD) implantation in a 50 years-old male with LSVC.The practical issues related with right ventricle lead implantation and pacing/defibrillation parameters for ICD device are discussed.

Remote monitoring of implantable defibrillators is associated with fewer inappropriate shocks and reduced time to medical assessment in a remote and rural area

BACKGROUND Implantable cardioverter defibrillators(ICDs)and cardiac resynchronisation therapy with defibrillators(CRT-D)reduce mortality in certain cardiac patient populations.However,inappropriate shocks pose a problem,having both adverse physical and psychological effects on the patient.The advances in device technology now allow remote monitoring(RM)of devices to replace clinic follow up appointments.This allows real time data to be analysed and actioned and this may improve patient care.AIM To determine if RM in patients with an ICD is associated with fewer inappropriate shocks and reduced time to medical assessment.METHODS This was a single centre,retrospective observational study,involving 156 patients implanted with an ICD or CRT-D,followed up for 2 years post implant.Both appropriate and inappropriate shocks were recorded along with cause for inappropriate shocks and time to medical assessment.RESULTS RM was associated with fewer inappropriate shocks(13.6%clinic vs 3.9%RM;P=0.030)and a reduced time to medical assessment(15.1±6.8 vs 1.0±0.0 d;P<0.001).CONCLUSION RM in patients with an ICD is associated with improved patient outcomes.

Risk factors for sudden cardiac death to determine high risk patients in specific patient populations that may benefit from a wearable defibrillator

BACKGROUND There is a high risk for sudden cardiac death(SCD) in certain patient groups that would not meet criteria for implantable cardioverter defibrillator(ICD) therapy.In conditions such as hypertrophic cardiomyopathy(HCM) there are clear risk scores that help define patients who are high risk for SCD and would benefit from ICD therapy. There are however many areas of uncertainty such as certain patients post myocardial infarction(MI). These patients are high risk for SCD but there is no clear tool for risk stratifying such patients.AIM To assess risk factors for sudden cardiac death in major cardiac disorders and to help select patients who might benefit from Wearable cardiac defibrillators(WCD).METHODS A literature search was performed looking for risk factors for SCD in patients post-MI, patients with left ventricular systolic dysfunction(LVSD), HCM, long QT syndrome(LQTS). There were 41 studies included and risk factors and the relative risks for SCD were compiled in table form.RESULTS We extracted data on relative risk for SCD of specific variables such as age,gender, ejection fraction. The greatest risk factors for SCD in post MI patients was the presence of diabetes [Hazard ratio(HR) 1.90-3.80], in patient with LVSD was ventricular tachycardia(Relative risk 3.50), in LQTS was a prolonged QTc(HR36.53) and in patients with HCM was LVH greater than 20 mm(HR 3.10). A proportion of patients currently not suitable for ICD might benefit from a WCDCONCLUSION There is a very high risk of SCD post MI, in patients with LVSD, HCM and LQTS even in those who do not meet criteria for ICD implantation. These patients may be candidates for a WCD. The development of more sensitive risk calculators to predict SCD is necessary in these patients to help guide treatment.

Subcutaneous implantable defibrillator: State-of-the art 2013

The subcutaneous implantable cardioverter-defibrillator(S-ICD)has recently been approved for commercial use in Europe,New Zealand and the United States.It is comprised of a pulse generator,placed subcutaneously in a left lateral position,and a parasternal subcutaneous lead-electrode with two sensing electrodes separated by a shocking coil.Being an entirely subcutaneous system it avoids important periprocedural and long-term complications associated with transvenous implantable cardioverter-defibrillator(TV-ICD)systems as well as the need for fluoroscopy during implant surgery.Suitable candidates include pediatric patients with congenital heart disease that limits intracavitary lead placements,those with obstructed venous access,chronic indwelling catheters or high infection risk,as well as young patients with electrical heart disease(e.g.,Brugada Syndrome,long QT syndrome,and hypertrophic cardiomyopathy).Nevertheless,given the absence of intracavitary leads,the S-ICD is unable to offer pacing(apart from shortterm post-shock pacing).It is therefore not suitable in patients with an indication for antibradycardia pacing or cardiac resynchronization therapy,or with a history of repetitive monomorphic ventricular tachycardia that would benefit from antitachycardia pacing.Current data from initial clinical studies and post-commercialization"real-life"case series,including over 700 patients,have so far been promising and shown that the S-ICD successfully converts induced and spontaneous ventricular tachycardia/ventricular fibrillation episodes with associated complication and inappropriate shock rates similar to that of TV-ICDs.Furthermore,by using far-field electrograms better tachyarrhythmia discrimination when compared to TV-ICDs has been reported.Future results from ongoing clinical studies will determine the S-ICD system’s long-term performance,and better define suitable patient profiles.