ABSTRACT
Association of atrial septal aneurysm (ASA) with patent foramen ovale (PFO) is considered an important risk factor for cardioembolism frequently forwarding paradoxical embolism in patients with cryptogenic or unexplained cerebral ischemic events. We herein describe the case of a 69-year-old male patient reporting uncontrolled movements of the right arm due to a muscle weakness, slurred speech, and paresthesia in the oral region some seconds after he had blown his nose. These neurological symptoms had improved dramatically within a few minutes and were completely regressive at admission to our hospital about two hours later. On transesophageal echocardiography (TEE) a huge ASA associated with PFO was detected. Diagnosis of the large-sized ASA was also confirmed by cardiac magnetic resonance imaging. Due to the early complete recovery from his neurological symptoms, the patient was diagnosed with a transient ischemic attack (TIA). After nine days he was discharged in a good clinical condition under the treatment with oral anticoagulation. It is concluded that in cryptogenic or unexplained stroke or TIA TEE should always be performed to rule out ASA and PFO as potential sources for paradoxical embolism in those inconclusive clinical situations.
ABSTRACT
Important goals, when implanting a cardiac resynchronization therapy (CRT) system, are to reach a stable LV lead position in a suitable coronary sinus (CS) tributary associated with a low capture threshold and no extracardiac stimulation. The aim of this study was to assess the 2-year performance of a new preshaped lead designed for LV stimulation. The study enrolled 102 patients with heart failure and bundle branch block who underwent implantation of a CRT system, including a sheath-guided, unipolar, S-shaped LV lead placed in a CS tributary. At each follow-up the electrical parameters and CRT system related adverse events were recorded. Eight patients who underwent LV stimulation alone, versus 88 patients who received biventricular CRT systems, were analyzed separately. Access to the CS was reached in 98 patients, and the lead was permanently implanted in 96 (94%) patients. The overall procedural time was 98 +/- 28 minutes. During follow-up, three patients underwent reinterventions for phrenic nerve stimulation (n = 2) and hematoma (n = 1). The capture threshold at implantation was 1.4 +/- 0.9 V with LV versus 1.7 +/- 0.5 V with biventricular stimulation, and after a transient increase, remained between 1.6 and 1.9 V in both configurations. The device measured impedance was significantly higher with LV than with biventricular stimulation at the time of CRT system implantation (698 +/- 296 Omega vs 380 +/- 67 Omega, P < 0.05) and during follow-up. The initial R wave amplitude was 14.3 +/- 5.9 mV in LV versus 8.9 +/- 3.2 V in the biventricular configuration (NS) and 13.8 +/- 7 mV in LV versus 12.8 +/- 4.8 mV in the biventricular configuration at 24 months (NS). Implantation of the S-shaped LV lead for CRT was safe, expeditious, and associated with a high success rate and reliable long-term performance.
