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Deaths Following Cardiac Surgery and Invasive Interventions
Published in Mary N. Sheppard, Practical Cardiovascular Pathology, 2022
Complications from pacemaker implantation can be divided into immediate, intermediate and late-term complications. The rates of complications range from <1% to 6%. Immediate complications include pneumothorax, pericarditis, haemothorax, cardiac perforation, air embolism and lead dislodgement. Intermediate complications include haematomas around the pacer and infection with erosion through the skin, venous thrombosis or stenosis, pain or discomfort at the pocket site and mechanical disruption of the tricuspid valve with tricuspid regurgitation. Late complications include lead fracture or insulation breaks due to mechanical stresses, increases in pacing threshold or impedances due to tissue ingrowth, and device infections, often with systemic bloodstream infection. Treatment of the late-term complications of device implantation is often complicated, requiring lead extraction, which can be technically challenging and carries a risk of central venous or cardiac perforation, haemothorax and death. As already stated, old leads will often be left in situ.
Arrhythmias in Hypertrophic Cardiomyopathy and Their Management
Published in Srilakshmi M. Adhyapak, V. Rao Parachuri, Hypertrophic Cardiomyopathy, 2020
Tom Kai Ming Wang, Milind Y. Desai
It is important to reduce or remove pharmacological agents that slow the heart rate if HCM patients present with bradycardias and/or AVB. Also, extra care needs to be taken when managing patients who have had invasive interventions to relieve LVOT obstruction because of their elevated risk of AVB [11]. Otherwise, the indications for pacing should follow contemporary guidelines [55]. Pacemaker implantation is also necessary if atrioventricular nodal ablation is performed for drug-refractory AF rate control (dual-chamber if paroxysmal AF, single-chamber if permanent) [2]. Furthermore, cardiac resynchronization therapy should be considered in those with reduced ejection fraction, along with other conventional criteria of left bundle branch block, QRS > 120 ms and heart failure symptoms despite optimal medical therapy [55]. Such devices often incorporate defibrillating functions in HCM patients to offer protection from bradycardias, ventricular arrhythmias, SCD, and heart failure.
Syncope Management and Diagnostic Testing
Published in Andrea Natale, Oussama M. Wazni, Kalyanam Shivkumar, Francis E. Marchlinski, Handbook of Cardiac Electrophysiology, 2020
Subramanya Prasad, Oussama M. Wazni, Robert Schweikert, Kenneth Mayuga, Mina K. Chung
The minimum testing required during an EPS for syncope diagnosis per ESC guidelines is: Measurement of sinus node recovery time and corrected sinus node recovery time by repeated sequences of atrial pacing for 30–60 s with at least one low (10–20 beats/min higher than sinus rate) and two higher pacing rates.Assessment of the His Purkinje system includes measurement of the HV interval at baseline and His Purkinje conduction with stress by incremental atrial pacing. If the baseline study is inconclusive, pharmacologic provocation with slow infusion of ajmaline (1 mg/kg iv), procainamide (10 mg/kg iv), or disopyramide (2 mg/kg iv) is added unless contraindicated.Assessment of ventricular arrhythmia inducibility by ventricular program-med stimulation at two right ventricular sites (apex and outflow tract), at two basic drive cycle lengths (100 or 120 beats/min), with up to 2 extra stimuli. Use of a third extra stimulus can increase sensitivity but decreases specificity.Assessment of supraventricular arrhythmia inducibility by any atrial stimulation protocol.
Management of congenitally corrected transposition from fetal diagnosis to adulthood
Published in Expert Review of Cardiovascular Therapy, 2023
Due to abnormal position of the atrioventricular node and its connection to the atrioventricular bundle in ccTGA, cardiac conduction disorders are common and permanent pacemaker therapy is frequently required [27]. Unless contraindicated (patient’s size, unrepaired associated lesions), the transvenous system can be implanted. Subpulmonary univentricular pacing was shown to be associated with deterioration of sRV and exacerbation of tricuspid valve regurgitation [59,60]. Study on 53 patients with dual-chamber univentricular pacemakers revealed an improvement after upgrading to biventricular pacing [60]. However, some observations provided different results [61]. Transvenous implantation of an sRV lead is possible in ccTGA patients with suitable anatomy assessed by advanced cardiac imaging [62]. Alternatively, surgical placement of ventricular pacing leads or a hybrid approach can be performed. According to Pediatric and Congenital Electrophysiology Society (PACES) and Heart Rhythm Society guidelines, cardiac resynchronization therapy (CRT) can be useful for adults with sRV function ≤35%, sinus rhythm, complete right bundle branch block with QRS ≥150 ms (spontaneous or paced) and NYHA class II-IV [63]. The benefit of CRT in patients with sRV dysfunction without conduction disturbances is unclear.
Recurrent syncope in patients with a pacemaker and bradyarrhythmia
Published in Scandinavian Cardiovascular Journal, 2023
Julie Majormoen Davidsen, Regitze Skals, Frederik Dalgaard, Bhupendar Tayal, Christian Torp-Pedersen, Peter Søgaard, Christina Ji-Young Lee
Compared to AV block, a higher risk of recurrent syncope was seen for patients with sinus node dysfunction and unspecified bradyarrhythmias. Pacing in symptomatic sinus node dysfunction is based on evidence level class I by European Society of Cardiology (ESC) guidelines; however, patients with sinus node dysfunction are generally old and frequently have concomitant heart disease, which could potentially explain the observed higher risk. While the patients with unspecified bradyarrhythmias in our study was likely a heterogeneous group, they all had a clinical presentation adjudicated severe enough to indicate pacing without having a well-defined bradyarrhythmia diagnosis, which is not always possible to achieve in a clinical setting. Furthermore, the importance of a clear cause-effect relationship of syncope and bradyarrhythmia for recurrent syncope has recently been emphasized in a study, where patients with a presumed bradyarrhythmic origin of the syncope had the highest risk compared to patients with a definite bradyarrhythmia diagnosis [16].
Guidelines and new directions in the therapy and monitoring of ATTRv amyloidosis
Published in Amyloid, 2022
Yukio Ando, David Adams, Merrill D. Benson, John L. Berk, Violaine Planté-Bordeneuve, Teresa Coelho, Isabel Conceição, Bo-Göran Ericzon, Laura Obici, Claudio Rapezzi, Yoshiki Sekijima, Mitsuharu Ueda, Giovanni Palladini, Giampaolo Merlini
The supportive care in patients with heart failure can be done with low doses of loop diuretics (i.e. furosemide) or mineralocorticoid receptor antagonists (i.e. spironolactone or eplerenone) in case of loop diuretics fail [15]. Beta blockers, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, might be considered in the absence of clear contraindications, starting from low doses, with slow up-titration and close monitoring. Anticoagulation with either warfarin or the novel oral anticoagulants can be used in cases of rhythm disturbances [16]. Pacing is primarily used for significant bradycardia and certain types of atrial-ventricular blocks, as a result of myocardial tissue infiltration. Implantable cardioverter defibrillator (ICD) is not indicated as sudden cardiac death in ATTR cardiomyopathy may result from electromechanical dissociation or arrhythmias not amenable to ICD.