A retrospective survey comparing suture techniques regarding the risk of permanent epicardial pacemaker implantation after ventricular septal defect closure

Abstract Objective: The aim of this study is to compare the continuous and combined suturing techniques in regards to the needing epicardial pacing at the time of weaning from cardiopulmonary bypass (EP-CPB) and to evaluate permanent epicardial pacemaker (PEP) implantation in patients who had undergone surgical ventricular septal defect (VSD) closure. Methods: This single-centre retrospective survey includes 365 patients who had consecutively undergone VSD closure between January 2006 and October 2015. Results: The median age and weight of the patients were 15 months (range 27 days - 56.9 years) and 10 kg (range 3.5 - 100 kg), respectively. Continuous and combined suturing techniques were utilised in 302 (82.7%) and 63 (17.3%) patients, respectively. While 25 (6.8%) patients required EP-CPB, PEP was implanted in eight (2.2%) patients. Comparison of the continuous and combined suturing techniques regarding the need for EP-CPB (72% vs. 28%, P=0.231) and PEP implantation (87.5% vs. 12.5%, P=1.0) were not statistically significant. The rate of PEP implantation in patients with perimembraneous VSD without extension and perimembraneous VSD with inlet extension did not reveal significant difference between the suture techniques (P=1.0 and P=0.16, respectively). In both univariate and multivariate analyses, large VSD (P=0.001; OR 8.63; P=0.011) and perimembraneous VSD with inlet extension (P<0.001; OR 9.02; P=0.005) had a significant influence on PEP implantation. Conclusion: Both suturing techniques were comparable regarding the need for EP-CPB or PEP implantation. Caution should be exercised when closing a large perimembraneous VSD with inlet extension.

Minitoracotomia direita para implante de marcapasso epicárdico definitivo dupla-câmara / Dual chamber epicardial pacing through right minithoracotomy

A cirurgia minimamente invasiva é segura e eficaz no tratamento de diversas afecções cardíacas, com evolução intra-hospitalar bastante positiva. Descrevemos aqui o caso de paciente do sexo masculino, com 72 anos de idade, portador de comunicação interatrial com shunt bidirecional e bloqueio atrioventricular avançado com síncope. Foi contraindicado o fechamento da comunicação interatrial e indicado marcapasso dupla-câmara com cabos-eletrodos epicárdicos em decorrência da presença do shunt. O procedimento foi realizado por meio de minitoracotomia direita, com implante de cabos-eletrodos atrial e ventricular direitos bipolares, com gerador implantado em loja subcutânea na região infraclavicular direita. O paciente apresentou boa evolução, recebendo alta no quarto dia de pós-operatório em boas condições

Minimally invasive cardiac surgery is safe and effective in the treatment of a wide range of cardiac diseases, with very positive in-hospital outcomes. We describe the case of a 72-year-old male patient, with atrial septal defect, bidirectional shunt and advanced atrioventricular block with syncope. The atrial septal defect closure was contraindicated and he was referred for a dual-chamber pacemaker and epicardial leads implantation due to the presence of shunt. The patient underwent a right minithoracotomy with the implantation of bipolar atrial and ventricular leads and placement of a pacemaker generator in a subcutaneous envelope in the right infraclavicular region. The patient evolved well and was discharged on the fourth postoperative day in good conditions

Diretrizes Brasileiras de Dispositivos Cardíacos Eletrônicos Implantáveis (DCEI): parte II / Brazillian guidelines of implanted eletronic cardiac devices (ECD): part. II

A padronização das indicações para implantes de marcapassos é preocupação constante em todas as sociedades científicas relacionadas à área...

Bloqueo atrioventricular completo y reversible en un paciente con corazón estructuralmente sano

Se presenta el caso de un paciente joven, deportista, quien presentó un episodio de síncope con pródromo breve, durante ejercicio físico. Se encontró el corazón estructuralmente normal y que durante la prueba de inclinación presentó bloqueo atrioventricular completo, que revirtió rápidamente con la posición de decúbito dorsal.

Agenesia de cava superior associada a bloqueio atrioventricular de 3º grau / Agenesis of the right superior vena cava associated with total heart block

A persistência de veia cava superior esquerda com ausência da veia cava superior é uma anomalia rara, principalmente quando associada a bloqueio atrioventricular de 3º grau. Relatamos o caso de uma paciente, na qual durante implante de marca-passo definitivo, para a correção de bloqueio atrioventricular total, foi detectada presença de veia cava superior esquerda com suspeição de ausência de veia cava superior, o que levou ao emprego de técnica diferenciada para fixação do eletrodo ventricular. Para confirmação da provável agenesia, foram realizados diversos exames complementares de imagem, demonstrando-se a dificuldade no diagnóstico da síndrome aqui descrita.

The superior left vena cava with the absent superior vena cava is a rare abnormality, especially when associated with total heart block. We report a case of a patient in which the presence of superior left vena cava and the absence of the superior vena cava was detected during the implantation of a pacemaker for the correction of a total heart block, which led us to use a different technique for the fixation of the ventricular electrode. To confirm the supposed absence, several image exams were made showing the difficulty on the diagnosis of the described syndrome.

Cardiac Pacemaker Treatment of in Enugu a 5-Year. Review

Background: Symptomatic heart block is a treatable cardiac cause of death which occurs globally. In Nigeria it is increasingly diagnosed and treated with permanent artificial cardiac pacemaker insertion and pulse generator implantation; sometimes after a period of misdiagnosis and inappropriate treatment. Methods: Twenty-three patients who were diagnosed with symptomatic heart block and surgically treated with permanent artificial cardiac pacemaker in National Cardiothoracic Centre; Enugu; between April 2001 and March 2006 had their case notes retrospectively reviewed and information entered into a proforma. This was analyzed. Patients diagnosed with symptomatic heart block but not treated with artificial cardiac pacemaker insertion were excluded from the study. There were eight such patients who could not afford the cost of surgical treatment during the period under review. Results: The mean age of the patients was 70 years and the commonest presentation was shortness of breath (100). Hypertensive heart disease was present in 65of the patients and a history of chronic chloroquine usage was positive in 73of the patients. Predominant pre-treatment pulse rate was in the range of 30-40 per minute (43) while 21of the patients had pulse rate below 30 per minute. These categories of patients commonly had Stoke-Adams syndrome. Sixty-seven per cent of the patients had predominantly systolic hypertension on admission and 16had hypotension. Third degree heart block was present in 65of the patients and 89of all patients needed pre-pacing haemodynamic stabilization with positive inotropic / chronotropic drug(s). Treatment consisted of permanent endocardial pacing in 65and epicardial pacing in 35of the patients with equally good response in symptoms; haemodynamic parameters and electrocardiographic features. Conclusion: Permanent artificial cardiac pacing is the reliable treatment of symptomatic heart block and should be included in the National Health Insurance Scheme list

Mudança do modo VVI para DDD ("upgrade") na troca eletiva do gerador de pulsos: análise comparativa clínico-funcional / Upgrading from VVI to DDD pacing Mode during elective replacement of pulse generator: a comparative clinical-functional analysis

OBJETIVO: Comparar o comportamento clínico e funcional dos modos de estimulação ventricular e atrioventricular na troca eletiva do gerador de pulsos em pacientes com cardiopatia chagásica e bloqueio atrioventricular. MÉTODOS: Foram estudados comparativamente sob estimulação ventricular e atrioventricular 27 pacientes, inicialmente na inclusão do estudo e alternadamente no modo ventricular e atrioventricular em duas fases com duração de 90 dias, considerando: o comportamento clínico, avaliado pela qualidade de vida e classe funcional, e o comportamento funcional, avaliado pela ecocardiografia transtorácica e pelo teste de caminhada de seis minutos. A análise estatística foi realizada na condição basal, modo ventricular e modo atrioventricular, utilizando-se o teste qui-quadrado e a análise de variância para medidas repetidas, considerando-se nível de significância de 0,05. RESULTADOS: A média das medidas avaliadas na qualidade de vida foram: capacidade funcional (VVI 71,3+/-18,2 , DDD 69,3+/-20,4), estado geral (VVI 68,1+/-21,8 , DDD 69,4+/-19,4) e vitalidade (VVI 64,8+/-24,6 , DDD 67,6+/-25,5); na ecocardiografia: FEVE (VVI 52,5+/-12,8 , DDD 51,8+/-14,9), DDFVE (VVI 53,0+/-7,7 , DDD 42,4+/-7,8), AE (VVI 38,6+/-5,4 DDD 38,5+/-5,1) e no teste de caminhada de seis minutos: distância percorrida (VVI 463,4+/-84,7 , DDD 462,6+/-63,4). Houve quatro casos de complicações: três associadas à mudança de modo de estimulação. CONCLUSÃO: Não houve diferença entre os dois modos de estimulação, no comportamento clínico, avaliado pela qualidade de vida e classe funcional e no comportamento funcional, avaliado pela ecocardiografia e pelo teste de caminhada de seis minutos.

OBJECTIVE: Evaluate the clinical and functional behavior of the ventricular and atrioventricular stimulation modes in the elective replacement of pulse generator in patients with chagasic cardiopathy and atrioventricular block. METHODS: Twenty-seven patients under ventricular and atrioventricular stimulation were comparatively evaluated at the beginning of the study, and alternately in ventricular and atrioventricular modes in two 90-day phases, with regard to: the clinical behavior evaluated according to quality of life and functional class, and the functional behavior evaluated by transthoracic echocardiography and the six-minute walk test. The statistical analysis was performed with patients at baseline, and under ventricular and atrioventricular modes, using the chi-square test and the repeated measures analysis of variance, and taking into consideration a 0.05 level of significance. RESULTS: The mean quality-of-life scores were: functional capacity (VVI 71.3+/-18.2 , DDD 69.3+/-20.4); overall health status (VVI 68.1+/-21.8, DDD 69.4+/-19.4) and vitality (VVI 64.8+/-24.6 , DDD 67.6+/-25.5); on echocardiography: LVEF (VVI 52.5+/-12.8 , DDD 51.8+/-14.9), LVDD (VVI 53.0+/-7.7 , DDD 42.4+/-7.8), LA (VVI 38.6+/-5.4 DDD 38.5+/-5.1), and in the six-minute walk test: distance walked (VVI 463.4+/-84.7, DDD 462.6+/-63.4). There were four cases of complications, three of them associated with the change in stimulation mode. CONCLUSION: This study showed no differences between the two stimulation modes in the clinical behavior assessed by quality of life and functional class, and in the functional behavior, evaluated according to the ecochardiographic findings and the six-minute walk test.

Acute results of permanent pacemaker implantation in Cipto Mangunkusumo General Hospital, Jakarta.

AIM: To investigate the acute results (parameters at implant and clinical parameters) of permanent pacemaker implantation at our institution. METHODS: Twenty five patients undergoing pacemaker implantation were included in this study. Subjects underwent medical history and functional class was assessed using New York Heart Association (NYHA) classification. All technical parameters (pacing threshold, sensing, and pacing impedance) and clinical parameters (complication and procedure time) were measured during and post implant. RESULTS: Majority (80%) of patients were in NYHA functional class II. The commonest indication for pacemaker implant was the complete heart block (56%). The most frequent pacemaker type was single chamber (80%) with the commonest pacing mode of VVIR (72%). Average optimal parameters achieved were pacing threshold of 0.5 volt, sensing of 12.6 mV, and impedance of 829 Ohm. Average procedure time was 1.6 hour. Major complication (pocket infection) was noted in only one patient. CONCLUSION: It is confirmed from this study that permanent pacemaker implantation could be carried out safely and effectively with low complication rate in a general hospital. Optimal pacing parameters could be achieved in the acute phase. Most patients still could not afford appropriate pacing devices due to limited financial support. Government insurance coverage for the poor should be encouraged to cover more people.

Pérdida de resincronización biventricular: Causa inhabitual. Caso clínico / Loss of biventricular resynchronization due to an uncommon cause: Report of one case

Cardiac resynchronization therapy is a non-pharmacological treatment for patients with dilated cardiomyophaty and congestive heart failure. The success of this therapy depends of permanent biventricular stimulation. We report an 84 year-old man, with intermittent loss of biventricular pacemaker stimulation despite having adequate sensing and stimulation thresholds in the right atrium and both ventricles. The problem was solved after correcting some programming parameters.

Bloqueo atrioventricular: manejo perinatal y seguimiento / Atrioventricular block: perinatal management and follow-up

Presentamos una revisión de 8 casos de bloqueo atrioventricular (BAV) congénito diagnosticados prenatalmente, controlados en el Centro de Referencia Perinatal Oriente (CERPO) entre 2003-2006. Entre las 8 gestantes portadoras de fetos con BAV encontramos tres casos asociados a malformación cardíaca y cinco casos aislados. Las cardiopatías estructurales corresponden a un caso de síndrome de hipoplasia ventricular izquierdo (SHVI) y dos casos a transposición de grandes arterias corregida (L-TGA). Entre los bloqueos aislados hubo un único caso con estudio serológico positivo para autoanticuerpos maternos anti-Ro y anti-La. Se diagnosticaron seis BAV completos y dos BAV de 2º grado (tipo Mobitz II). Un caso recibió terapia fetal transplacentaria con dexametasona, manteniéndose en bloqueo de 2º grado hasta el parto. Seis de las ocho pacientes fueron derivadas desde otras regiones al CERPO. El resultado perinatal fue satisfactorio, salvo una muerte fetal ocurrida en un BAV completo asociado a SHVI y presencia de hidrops fetal. Todos los casos necesitaron implantación de marcapasos, entre el primer día y hasta los 10 meses de vida. Hubo un caso de mortalidad postneonatal por sepsis, posterior a la corrección quirúrgica de una comunicación interventricular. El seguimiento postnatal fluctúa entre los 3 meses y 1 año 8 meses de vida. Todos los pacientes asisten a control periódico en cardiología infantil, se encuentran en buenas condiciones y sin secuelas.

RVoutflow tract pacing versus RV Apical pathophysiologic Effects and prognostic implications

Right ventricular apical pacing has been reported to be associated with adverse haemodynamic effects and alternative sites of pacing have been recommended. On the other hand RV septal pacing was claimed to be more physiological. The present work is intended to compare the classic right ventricular apical DDD pacing to RV outflow tract [RVOT] pacing in both normal and diseased hearts. We studied 30 patients [pts] with complete heart block [CHB]. Fourteen pts [Group I] had no underlying heart disease [8M and 6F with mean age 64.1 +/- 6.4, range 54-76 years] and 16 [Group II] had heart disease [10M, 6F, with mean age 67.5 +/- 8.9, range 58-86 years] including DCM in 12, 1HD in 3 and RHD in Ipt. Right ventricular apical pacing was conducted in 7pts from group I and 8pts from group II. RVA was conducted in 7pts of group I and 8pts of group II. Besides clinical evaluation, all pts were subjected to 2D echo before, and 6 months after pacing. Echo parameters studied included LVEDD, LVESD, EF% and CO with effects expressed in terms of% changes in various parameters. Compared to RVA pacing RVOT pacing in group I [pts with normal heart] induced insignificant% decrease in LVEDD [2.4 +/- 4.8vs 8.6 +/- 9.3, p value =0.146] or LVESD [4.6 +/- 7.8vs 8.3 +/- 6.0,p value =0.113] and insignificant increase in EF [2.4 +/- 4.6vs 0.42.6, p value =0.113] and CO [2.8 +/- 8.0vs 3.3 +/- 3.5, p value =0.08]. However in RVOT pacing in group II [pts with disease heart] induced significantly greater% decrease in LVEDD [3.0 +/- 2.8vs 1.2 +/- 2.3, p=0.005] in LVESD [3.7 +/- 0.9vs 2.5 +/- 2.3, p=0.000], and significantly greater% increase in EF [8.9 +/- 3.3vs I.7 +/- 1.2,p=0.001] and CO [5.8 +/- 9.6vs 10.7 +/- 18.3, p=0.04] in comparison to RVA pacing in group II In the presence of underlying cardiac dysfunction, DDD pacing by RVOT lead is hemodynamically more advantageous to classic RV apical pacing in terms of improving dimensions and enhancing systolic function. We recommend RVOT pacing in the presence of underlying HD to avoid the so called pacing-induced cardiomyopathy.

Marca-passo cardíaco definitivo em criancas com bradicardia pós-operatória: resultados tardios / Permanent cardiac pacing in children with postoperative bradycardia: long-term follow-up

OBJETIVO: Avaliar a evolucão tardia de criancas com marca-passo definitivo por bradicardia pós-operatória, e identificar fatores de risco para a mortalidade. MÉTODO: De 1980 a 2004, 120 criancas receberam implante de marca-passo definitivo por bradicardia pós-operatória. O intervalo médio entre a correcão do defeito e o implante foi de 1,2 n 2,8 anos, com mediana de 21 dias. Bloqueio atrioventricular esteve presente em 94,2 por cento dos pacientes. A via de acesso transvenosa (78,3 por cento) e marca-passos (MP) definitivos ventriculares (79,2 por cento) foram os mais utilizados. Empregou-se o método de Kaplan-Meier e o teste de Log-Rank para a análise de sobrevivência. RESULTADOS: Após 5,7 n 5,9 anos de seguimento (máximo= 22,5 anos), 97 pacientes estavam vivos e 11 haviam sido perdidos para o seguimento. As principais causas de morte foram insuficiência cardíaca (10), infeccão não relacionada ao marca-passo (seis) e morte súbita (três). A expectativa de sobrevida aos cinco, 10 e 15 anos de seguimento mostrou, respectivamente, índices de 80,9 n 4,1 por cento, 75,4 n 5,5 por cento e 67,2 n 7,4 por cento. A persistência de problemas hemodinâmicos após a correcão (correcões paliativas, uso de próteses valvares ou defeitos residuais) foi identificada como única variável preditora independente de risco para mortalidade, alterando significativamente as curvas de sobrevivência (p = 0,0123). CONCLUSÕES: O implante de marca-passo em casos de bradicardia pós-operatória possibilitou boa expectativa de sobrevida. A realizacão de correcões paliativas, assim como a presenca de defeitos residuais ou de próteses valvares, foram os únicos fatores preditores de mau prognóstico para essas criancas.

Pacemaker Lead Endocarditis Caused by Achromobacter xylosoxidans

We report the case of a 35-yr-old patient who presented with high fever and chills. He had undergone a patch closure of the ventricular septal defect 18 yr before. One year later, a VVI pacemaker was implanted via the right subclavian vein because of complete heart block. Nine years after that, a new VVI pacemaker with another right ventricular electrode was inserted controlaterally and the old pacing lead was abandoned. Trans-thoracic and trans-esophageal echocardiogram identified the pacemaker lead in the right ventricle (RV) attaching hyperechoic materials and also a fluttering round hyperechoic mass with a stalk in the RV outflow tract. Cultures in blood and pus from pacemaker lead grew Achromobacter xylosoxidans. A diagnosis of pacemaker lead endocarditis due to Achromobacter xylosoxidans was made. In this regards, the best treatment is an immediate removal of the entire pacing system and antimicrobial therapy.

Alternativas de estimulación cardiaca crónica en pacientes con prótesis mecßnica tricuspÝdea y bloqueo atrioventricular / Alternatives to chronic cardiac stimulation in patients with mechanical tricuspid prosthesis and atrioventricular block

One of the complications of tricuspid valve replacement (TVR) is the complete heart block (CHB). In these patients an epicardial permanent pacemaker is frequently used but its insertion is another major operation and higher thresholds are needed. Two patients are reported, both women, with rheumatic heart disease and TVR who required a permanent pacemaker because they developed CHB. The first patient underwent mitral valve replacement with a disc valve seventeen years before and TVR recently. A single chamber pacemaker was implanted. Left ventricular pacing was achieved through the great cardiac vein. The acute and chronic pacing thresholds were adequate. The second patient underwent tricuspid and mitral replacement with a Starr-Edwards (SE) valve. Eighteen years later this patient had atrial fibrillation with slow ventricular response and heart failure. The pacemaker lead had to be inserted across the tricuspid SE valve because ventricle pacing through the coronary veins was unsuccessful. The endocardial pacing resulted in mild tricuspid regurgitation and has continued the same way for four years. To conclude, ventricle pacing through the coronary veins is safe, produces excellent results and fewer complications. On the other hand, ventricle pacing across a prosthetic tricuspid valve remains questionable because of possible damage to the prosthesis itself leading to valve insufficiency and because of damage to the pacing lead.

Left ventricular pacing through coronary sinus tributaries: initial experience.

BACKGROUND: Left ventricular pacing is increasingly being used as a part of biventricular pacing in congestive heart failure but data on safety, feasibility, reliability and lead maturation are sparse. METHODS AND RESULTS: Seventeen patients (13 males and 4 females) with persistent symptomatic degenerative complete heart block underwent temporary left ventricular pacing by a left subclavian puncture through the coronary sinus to its tributaries using a unipolar permanent pacing lead connected to an external pulse generator. The left ventricular pacing was done for two weeks. Permanent right ventricular apical pacing was also done at the same time through a right cephalic vein cut-down or subclavian puncture and the pacing rate was kept below that of the initial left ventricular pacing rate. Pacing parameters of the left and right ventricles were assessed at the time of implantation and at two weeks. Out of 17 patients, left ventricular pacing was successful in 11 (67.7%) patients. The time taken for the total procedure was 56+/-18.1 min. Lead displacement was noted in one patient without loss of pacing. At the time of implant and after two weeks, left ventricular pacing threshold, impedance, R wave height and slew rate were not different as compared to right ventricular pacing. Holter recording for 24 hours revealed regular left ventricular pacing at the end of two weeks in all patients. CONCLUSIONS: The present study shows that left ventricular pacing through coronary sinus tributaries is feasible and reliable. Acute and subacute maturation of left ventricular pacing are similar to right ventricular apical pacing.

Cardiac pathology of permanent pacemaker implementation.

The cardiac findings in five cases of permanent pacemaker implantation seen at autopsy in a three-year period is reported. Implantation was done for complete heart block in four patients and sick sinus syndrome in one. The periods of implantation ranged from seven days to four years. The common findings were right sided valvar and mural bland thrombus formation. Additional findings included superior vena caval thrombosis, endocardial 'tunnel' formation for the pacing wires, perforation of the tricuspid leaflet and a gross morphology similar to that seen in right sided endomyocardial fibrosis.

Bloqueo auriculoventricular familiar. Presentación de un caso clínico / Familial atrioventricular heart block. A case report

Se presenta una familia con antecedentes de síncope y trastornos de conducción. Dos de sus miembros, de 18 años varón y 20 años mujer padecieron cuadros sincopales. Tenían examen físico, electrocardiograma, radiografía de tórax, ecocardiograma transtorácico y laboratorio normales. En ambos, sendos registros Holter pusieron en evidencias episodio de bloqueo auriculoventricular paroxístico de alto grado en un caso y Mobitz II en otro, sin trastornos de conducción en las ramas del haz de His. G.S. recibió el implante de un marcapasos hace 18 meses, luego continuó asintomático. R.S. padeció síncope hace 5 años pero luego continuó asintomática. Se revisa la literatura