Interventions in the diagnosis and adoption of pacemaker therapy in sinus node dysfunction patients: Results from the IMPROVE Brady study

Aims: IMPROVE Brady assessed whether a process improvement intervention could increase adoption of guideline-based therapy in sinus node dysfunction (SND) patients. Methods: /Results: IMPROVE Brady was a sequential, prospective, quality improvement initiative conducted in India and Bangladesh. Patients with symptomatic bradycardia were enrolled. In Phase I, physicians assessed and treated patients per standard care. Phase II began after implementing educational materials for physicians and patients. Primary objectives were to evaluate the impact of the intervention on SND diagnosis and pacemaker (PPM) implant. SF-12 quality of life (QoL) and Zarit burden surveys were collected pre- and post-PPM implant. A total of 978 patients were enrolled (57.7 ± 14.8 years, 75% male), 508 in Phase I and 470 in Phase II. The diagnosis of SND and implantation of PPM increased significantly from Phase I to Phase II (72% vs. 87%, P < 0.001 and 17% vs. 32%, P < 0.001, respectively). Pacemaker implantation was not feasible in 41% of patients due to insurance/cost barriers which was unaltered by the intervention. Both patient QoL and caregiver burden improved at 6-months post-PPM implant (P < 0.001). Conclusions: A process improvement initiative conducted at centers across India and Bangladesh significantly increased the diagnosis of SND and subsequent treatment with PPM therapy despite the socio-economic constraints.

Prevention of no flow/slow reflow phenomenon in primary PCI by Nicorandil.

AIM: To investigate the efficacy of Nicorandil in preventing no-flow/slow reflow phenomenon in patients with acute myocardial infarction undergoing primary PCI. MATERIALS AND METHODS: From September 2004 to October 2005, 29 patients underwent a primary percutaneous coronary intervention and stenting with nicor-andil as a protocol drug at a dose of 1 mg/hour - this drug was titrated upwards to maximum tolerated dose, with a 2 mg intracoronary bolus given after balloon inflation during PCI. LAD was the infarct related artery in 62% of cases. 72.4% of them had a TIMI thrombus grade of 5. The corrected TIMI frame count following primary percutaneous intervention in the Nicorandil arm was 19.54 + 8.7. None of the patients had a no flow or slow reflow phenomenon with this protocol. One patient developed a subacute stent thrombosis necessitating a revascularization. At a mean follow up of 251 +/- 96.7% days, MACE was not reported in the other patients. Thirty four patients underwent a primary percutaneous coronary intervention and stenting without nicorandil as an adjuvant drug. Some of these patients were retrospectively assessed. They have been followed up for 285.4 +/- 264.6 days. LAD was the infarct related artery in 61.8% of cases while 79.5% of them had a TIMI thrombus grade of 5. The corrected TIMI frame count in this group was 23.9 +/- 17.5 (p <0.56). MACE was reported in 5 of these patients. The mean TIMI frame count for these 5 patients was 40.5 +/- 29.2. Glycoprotein IIb/IIIa receptor inhibitors were given to all patients in both groups. The choice of the agent used was left to the discretion of the operator. CONCLUSION: Nicorandil prevents no-flow/slow reflow phenomenon in patients undergoing primary PCI for acute myocardial infarction. This is shown by a lower corrected TIMI frame count in the nicorandil arm (p < 0.56). Reduction in the incidence of no-flow/slow reflow phenomenon translates into a lower MACE. The drug is safe and does not require intensive monitoring. It must be started early and electively in patients undergoing a primary PCI as a strategy to prevent no-flow rather than to treat this phenomenon.

Carotid artery stenting prior to coronary artery bypass graft surgery inpatients with left-main-coronary-artery disease.

Patients with concomitant carotid and left main or left main equivalent coronary artery disease are at high risk of both cardiac and cerebrovascular complications when they undergo revascularization procedures. Here, we present case reports of three patients who successfully underwent elective carotid stenting prior to coronary artery bypass surgery. Any sort of intervention in these patients is fraught with high risk due to the severity of their carotid and coronary artery disease.

Long-term results of radiofrequency ablation of slow pathway in patients with atrioventricular nodal reentrant tachycardia: single-center experience.

BACKGROUND: This study sought to evaluate the long-term recurrence rate of atrioventricular nodal reentrant tachycardia (AVNRT) after radiofrequency catheter ablation. The clinical and electrophysiological features of patients with AVNRT and their immediate outcomes after undergoing slow pathway ablation/modification were also studied. METHODS AND RESULTS: The study included 264 consecutive patients with AVNRT (mean age 46 -/+ 15 years, 143 women, 121 men) who underwent slow pathway ablation/modification using a combined electrophysiological and anatomical approach. The primary endpoint of ablation procedure was non- inducibility of the arrhythmia. The primary endpoint of the study was the recurrence of AVNRT on follow-up. Acute success was achieved in 262 (99.6%) patients. Complication rate of the ablation procedure was 2.6% and the average fluoroscopy time was 18.3 -/+ 11 minutes. The patients were followed up for a mean duration of 20 -/+ 9 months during which there was only one case of recurrence. CONCLUSION: Radiofrequency ablation or modification of slow pathway is highly effective in the treatment of AVNRT. The technique has a high initial success rate and a low complication rate. The recurrence rates are extremely low (0.3%) on long-term follow-up.

Temporary endoepicardial atrioventricular sequential pacing for complete heart block following complex surgery for congenital heart disease.

Complete heart block following intracardiac surgical repair for complex congenital heart disease is not uncommon. In the presence of ventricular dysfunction, ventricular pacing alone may not improve the cardiac output. We report the feasibility and efficacy of endoepicardial atrioventricular sequential pacing in a case of postoperative complete heart block.