[Cardiac perforation following pacemaker implantation - a case series from Iceland]. / Rof á hjarta eftir gangráðsísetningu - íslensk tilfellaröð.

INTRODUCTION: Perforation of the heart is a serious complication following pacemaker implantation that can cause life threatening bleeding and cardiac tamponade. Here we describe five cases that were diagnosed in Iceland during a four year period. MATERIALS AND METHODS: This population-based case series includes five patients diagnosed with cardiac perforation following pacemaker insertion at Landspítali and Akureyri Hospital from January 1, 2007 to December 31, 2010. The mode of detection, treatment given and outcome were studied. RESULTS: Altogether five patients (mean age 71 years, three females) were diagnosed with cardiac perforation in Iceland during the study period, one in 2008 and four in 2009. Chest pain was the most common presenting symptom (n=4) and no patient had acute cardiac tamponade. In all five cases the diagnosis was obtained with computed tomography scan or echocardiography. No perforation was detected intraoperatively but four of the cases were diagnosed within three weeks of the operation. Three patients were treated with surgical evacuation of blood via sternotomy and suture of the perforation. In the other two cases the pacemaker leads were removed in the operating room with trans-oesophageal echocardiographic guidance. Four patients survived the treatment and were discharged but one died of pneumonia in the intensive care unit. CONCLUSION: Cardiac perforation is a serious complication and should be kept in mind in patients with chest pain following pacemaker insertion.

Plasma n-3 and n-6 fatty acids and the incidence of atrial fibrillation following coronary artery bypass graft surgery.

BACKGROUND: The anti-inflammatory or anti-arrhythmic effects of n-3 long-chain polyunsaturated fatty acids (LC-PUFA) may decrease the risk of postoperative atrial fibrillation (POAF), but interventional studies have yielded conflicting results. We examined the association between n-3 LC-PUFA and n-6 LC-PUFA in plasma phospholipids (PL) and POAF in patients undergoing coronary artery bypass grafting (CABG). METHODS: A total of 125 patients undergoing CABG were enrolled in the study. The levels of fatty acids in PL were measured preoperatively and on the third postoperative day. The endpoint was defined as POAF lasting ≥5 min. The incidence of POAF was compared between quartiles of the level of each fatty acid in plasma PL by univariate and multivariable analysis. RESULTS: The incidence of POAF was 49·6%. By univariate analysis, the incidence of POAF increased significantly with each higher quartile of pre- and postoperative docosahexaenoic acid (DHA) and diminished significantly with each higher quartile of pre- and postoperative arachidonic acid (AA). For postoperative total n-3 LC-PUFA, there was a significant U-curve relationship where the second quartile had the lowest incidence of POAF or 25·8%. In multivariable analysis, this U-curve relationship between n-3 LC-PUFA levels and POAF risk was not significant, whereas the association between POAF and DHA or AA remained statistically significant. CONCLUSIONS: This study suggests that n-3 LC-PUFA supplements might prevent POAF in CABG patients with low baseline levels of these fatty acids in plasma PL, but may be harmful in those with high levels. AA may play an important role in electrophysiological processes.

Does treatment with n-3 polyunsaturated fatty acids prevent atrial fibrillation after open heart surgery?

AIMS: To examine the effect of n-3 polyunsaturated fatty acid (PUFA) treatment on the incidence of post-operative atrial fibrillation (POAF). METHODS AND RESULTS: A prospective, randomized, double-blinded, placebo-controlled trial was conducted in patients admitted for coronary artery bypass grafting and/or valvular repair surgery. The patients received either n-3 PUFA capsules, containing a daily dose of 1240 mg eicosapentaenoic acid and 1000 mg docosahexaenoic acid, or olive oil capsules for 5-7 days prior to surgery and post-operatively until hospital discharge. The endpoint was POAF, defined as an episode detected by continuous electrocardiographic monitoring, lasting >5 min. A total of 170 patients were enrolled in the study, and 168 patients underwent surgery. Their median age was 67 (range 43-82) years, and 79.2% were males. There was no difference in baseline characteristics between the n-3 PUFA group (n = 83) and the placebo group (n = 85), and the incidence of POAF was 54.2 and 54.1% (P = 0.99), respectively. Factors associated with POAF included advanced age, peak post-operative C-reactive protein level, valvular surgery, lower body mass index, and non-smoking, but n-3 PUFA concentration in plasma lipids was not associated with POAF. CONCLUSION: There is no evidence for a beneficial effect of treatment with n-3 PUFA on the occurrence of POAF in patients undergoing open heart surgery.

The use of implantable cardioverter defibrillators in Iceland: a retrospective population based study.

BACKGROUND: Indications for implantable cardioverter defibrillator (ICD) implantation have expanded considerably in recent years, resulting in steadily growing numbers of ICD recipients worldwide. The aim of this study was to review the overall experience with ICDs in Iceland. METHODS: This was a retrospective single centre study set at the University Hospital in Iceland. Data on all ICD implantations in Iceland from the first implantation in 1992 till the end of 2002 was reviewed. RESULTS: Sixty-two patients (71% male) received an ICD during this period. There was an increase in the number of implants by year and the number of new implants in 2001 and 2002 amounted to 56 and 38 per million, respectively. The mean age at implantation was 58 (+/-14) years. Forty patients (65%) had coronary artery disease. The most common indications for ICD implantation were cardiac arrest, 32 (52%) and another 26 (42%) had experienced ventricular tachycardia without cardiac arrest. The most common adverse event was inappropriate shocks. Twenty-eight patients (45%) received therapy from their ICDs, with the majority receiving appropriate therapy. Of the thirteen patients deceased before or during the study period, no case of sudden arrhythmic death was observed. CONCLUSION: This study shows that the experience with ICDs in Iceland is in most respects similar to other Western countries.

Health-related quality of life of patients with implantable cardioverter defibrillators compared with that of pacemaker recipients.

AIMS: Studies indicate a poorer quality of life (QoL) for implantable cardioverter defibrillator (ICD) patients than for the general population. However, studies comparing the QoL of ICD patients with that of patients with other implantable cardiac devices are scarce. We hypothesized that ICD patients had a poorer QoL than pacemaker patients. METHODS AND RESULTS: All ICD patients living in Iceland at the beginning of 2002 (44 subjects), and a comparison group of 81 randomly selected patients with pacemakers were invited to participate. The Icelandic Quality of Life Questionnaire (IQL), the General Health Questionnaire (GHQ), the Beck Anxiety Inventory (BAI), and the Beck Depression Inventory (BDI) were submitted to measure QoL, psychiatric distress, and symptoms of anxiety and depression. The ICD and pacemaker groups did not differ on IQL, BAI, BDI, or GHQ scores. ICD patients were as a group more fearful of death (P = 0.056) and showed more concerns about returning to work (P = 0.072), although these items fell just short of statistical significance. CONCLUSION: Contrary to our expectations, ICD patients had a comparable QoL with pacemaker recipients and were not more likely to suffer from anxiety, depression, or general psychiatric distress. These findings are encouraging in view of expanding ICD indications.

[Cryoablation for cardiac arrhythmias]. / Frysting á aukaleiethsluböndum -- nýjung í meethfereth hjartsláttartruflana.

The development of radiofrequency ablation has revolutionized the treatment of certain arrhythmias such as supraventricular tachycardia. Radiofrequency ablation has now become first line therapy for arrhythmias such a atrioventricular nodal reentrant tachycardia and Wolf Parkinson White syndrome. A major drawback of these procedures, especially those that necessitate ablation close to the atriocentricular node, is the risk of inadvertent atrioventricular block. In the last few years a new technique, cryoablation, has been developed to treat supraventricular arrhythmias. One of the main advantages of this new energy source for ablation is the extremely low risk of atrioventricular block. This technique is therefore especially beneficial if ablation is planned in the vicinity of the atrioventricular node. This paper describes this new procedure along with the experience with the first cases of cryoablation in Iceland.

Effects of a 5-lipoxygenase-activating protein inhibitor on biomarkers associated with risk of myocardial infarction: a randomized trial.

CONTEXT: Myocardial infarction (MI) is the leading cause of death in the world. Variants in the 5-lipoxygenase-activating protein (FLAP) gene are associated with risk of MI. OBJECTIVE: To determine the effect of an inhibitor of FLAP on levels of biomarkers associated with MI risk. DESIGN, SETTING, AND PATIENTS: A randomized, prospective, placebo-controlled, crossover trial of an inhibitor of FLAP (DG-031) in MI patients who carry at-risk variants in the FLAP gene or in the leukotriene A4 hydrolase gene. Of 268 patients screened, 191 were carriers of at-risk variants in FLAP (87%) or leukotriene A4 hydrolase (13%). Individuals were enrolled in April 2004 and were followed up by designated cardiologists from a university hospital in Iceland until September 2004. INTERVENTIONS: Patients were first randomized to receive 250 mg/d of DG-031, 500 mg/d of DG-031, 750 mg/d of DG-031, or placebo. After a 2-week washout period, patients received DG-031 if they had received placebo first or placebo if they had received DG-031 first. Treatment periods lasted for 4 weeks. MAIN OUTCOME MEASURES: Changes in levels of biomarkers associated with risk of MI. RESULTS: In response to 750 mg/d of DG-031, production of leukotriene B4 was significantly reduced by 26% (95% confidence interval [CI], 10%-39%; P = .003) and myeloperoxidase was significantly reduced by 12% (95% CI, 2%-21%; P = .02). The higher 2 doses of DG-031 produced a nonsignificant reduction in C-reactive protein (16%; 95% CI, -2% to 31%; P = .07) at 2 weeks. However, there was a more pronounced reduction (25%; 95% CI, 5%-40%; P = .02) in C-reactive protein at the end of the washout period that persisted for another 4 weeks thereafter. The FLAP inhibitor DG-031 was well tolerated and was not associated with any serious adverse events. CONCLUSION: In patients with specific at-risk variants of 2 genes in the leukotriene pathway, DG-031 led to significant and dose-dependent suppression of biomarkers that are associated with increased risk of MI events.

[Pulmonary arterial hypertension: new treatments and case report.].

Pulmonary arterial hypertension is a rare disease with substantial morbidity and mortality. In the last few years significant progress has been made in the understanding of the pathogenesis and course of the disease. New classification and drug treatment have emerged. The new drugs are expensive but can improve quality of life significantly. Given here is a brief review and two cases presented.

[Pulmonary vein ablation as a therapy for atrial fibrillation.].

Atrial fibrillation is a common arrhythmia and frequently difficult to treat. Despite therapeutic options, such as antiarrhythmic drugs and electrical cardioversion, many patients with this arrhythmia have recurrences. Radiofrequency catheter ablation has been a developing therapeutic option for patients with atrial fibrillation. Pulmonary vein ablation, where atrial tissue in the pulmonary veins is targeted, has been the most promising ablation strategy. This atrial tissue is a frequent source of ectopic beats which can induce atrial fibrillation. Recently, this was utilised for the first time on Icelandic patients. These two case reports and a description of the procedure are the focus of this paper.

[Radiofrequency catheter ablations of supraventricular tachycardias in Iceland.].

OBJECTIVE: During the last decade a new and successful treatment of supraventricular tachycardia - radiofrequency catheter ablations - gained ground. In Iceland this method was first used in 1993, seldom during the first year but with increasing frequency the following year. The aim of this study is to evaluate its success rate during the first five years of its use and compare it to that of other centres. MATERIAL AND METHODS: During the five year period 1994-1988 seventy-five ablations were performed on 68 patients, 39 men and 29 women. The patients chosen had to have considerable symptoms of tachycardia and/or unsatisfactory results or significant side-effects from medication. Also, they had to show signs of conceivable benefit from ablation on a 12-lead electrocardiogram or on non-invasive electrophysiologic testing. Electrophysiological criteria were used to evaluate success at the end of each ablation and clinical results deemed satisfactory when the patient was free of tachycardia and medication. To further guarantee results non-invasive electrophysiologic testing was repeated at least three months after the ablation to ensure that the mechanism of arrhythmia was broken. RESULTS: Twenty-six patients of the 68 in the study were diagnosed with atrioventricular reentry tachycardia. The first ablation was successful in 21 patient, but two needed re-ablation (91% success rate). Eighteen patients turned out to have concealed bypass tracts. The first ablation resulted in 83% success rate and when repeated reached a 94% success. Sixteen patients had Wolff-Parkinson-White syndrome. In their case 80% were sucessfully ablated the first time, but three needed re-ablation with transseptal puncture. Final success rate was 93%. Radiofrequency ablations of atrial flutter were started near the end of the study period. Three patients who all had considerable symptoms as well as episodes with atrial fibrillation were treated. Two relapsed, both getting atrial flutter as well as atrial fibrillation, one four weeks after the ablation and the other after 12 months. CONCLUSIONS: Radiofrequency ablations on patients with supraventricular tachycardia have greatly improved their treatment. If successful, it is a permanent cure for this condition whereas medication only holds symptoms at bay. This study shows a success rate quite comparable to that of other centres.