Implantation of cardioverter defibrillators with minimal fluoroscopy using a three-dimensional navigation system: a feasibility study.

AIMS: Fluoroscopy is necessary to implant cardioverter defibrillators using the conventional approach. Modern electroanatomic navigation systems allow the visualization of multiple catheters and, as they are capable of rendering precise geometrical reconstructions of cardiac chambers, have been used for fluoroscopy-free electrophysiological procedures. The aim of our study was to assess the feasibility of non-fluoroscopic implants using a three-dimensional navigation system. METHODS AND RESULTS: The NavX system was used to create the virtual anatomies of heart chambers and thoracic veins. Defibrillator leads were placed at stable positions using exclusively the electrical and anatomical information provided by the navigator. A single fluoroscopy shot confirmed final lead positions. Thirty-five consecutive patients had 30 single-chamber and 5 dual-chamber defibrillators implanted. Cardiac chambers geometries were developed in 10 ± 4.3 min. Ventricular and atrial leads were implanted, with suitable positions and electrical parameters being achieved, in 18 ± 22 and 16 ± 9 min, respectively. The final confirmatory shot was the only fluoroscopy needed in 31 (89%) cases. Two patients needed fluoroscopy-guided relocation of the ventricular lead due to high defibrillation threshold and a breakdown of the active-fixation mechanism, respectively. In one patient the ventricular lead was totally extracted and reimplanted because a loop has formed in the vena cava, and one patient required fluoroscopy-guided subclavian puncture. In five cases (16%), the position of the proximal defibrillation coil was minimally modified with fluoroscopy due to incomplete geometric reconstruction of the superior vena cava. CONCLUSION: Fluoroscopy-free defibrillators implantation is feasible using a navigation system. Suitable placement of the proximal coil is a critical stage and requires a reliable and complete reconstruction of the superior vena cava.

A randomized pilot study of optimization of cardiac resynchronization therapy in sinus rhythm patients using a peak endocardial acceleration sensor vs. standard methods.

AIMS: Non-response rate to cardiac resynchronization therapy (CRT) might be decreased by optimizing device programming. The Clinical Evaluation on Advanced Resynchronization (CLEAR) study aimed to assess the effects of CRT with automatically optimized atrioventricular (AV) and interventricular (VV) delays, based on a Peak Endocardial Acceleration (PEA) signal system. METHODS AND RESULTS: This multicentre, single-blind study randomized patients in a 1 : 1 ratio to CRT optimized either automatically by the PEA-based system, or according to centres' usual practices, mostly by echocardiography. Patients had heart failure (HF) New York Heart Association (NYHA) functional class III/IV, left ventricular ejection fraction (LVEF) <35%, QRS duration >150 or >120 ms with mechanical dyssynchrony. Follow-up was 1 year. The primary endpoint was the proportion of patients who improved their condition at 1 year, based on a composite of all-cause death, HF hospitalizations, NYHA class, and quality of life. In all, 268 patients in sinus rhythm (63% men; mean age: 73.1 ± 9.9 years; mean NYHA: 3.0 ± 0.3; mean LVEF: 27.1 ± 8.1%; and mean QRS duration: 160.1 ± 22.0 ms) were included and 238 patients were randomized, 123 to PEA and 115 to the control group. At 1 year, 76% of patients assigned to PEA were classified as improved, vs. 62% in the control group (P= 0.0285). The percentage of patients with improved NYHA class was significantly (P= 0.0020) higher in the PEA group than in controls. Fatal and non-fatal adverse events were evenly distributed between the groups. CONCLUSION: PEA-based optimization of CRT in HF patients significantly increased the proportion of patients who improved with therapy, mainly through improved NYHA class, after 1 year of follow-up.

Dual-chamber implantable cardioverter defibrillator implantation guided by non-fluoroscopic electro-anatomical navigation.

A dual-chamber implantable cardioverter defibrillator was implanted in a 37-year-old pregnant woman with dilated cardiomyopathy, symptomatic sinus bradycardia, and a family history of sudden death. Two leads were connected to a three-dimensional navigation system and placed at the right atrium and right ventricle, respectively, without fluoroscopy.

Cardioverter defibrillator implantation in a pregnant woman guided with transesophageal echocardiography.

This report describes a 28-year-old pregnant woman with mitral valve prolapse and sudden cardiac death due to a ventricular fibrillation who underwent an ICD implantation guided by tranesophageal echocardiography.

[Approach to the elderly in family health programs]. / Abordagem do idoso em programas de saúde da família.

This article discusses the role of the Brazilian National Policy for Senior Citizens' Health in the promotion of healthy aging, preservation and improvement of functional capacity in the elderly, disease prevention, recovery of those who fall ill, and rehabilitation of those with limited functional capacity, will the goal of ensuring that senior citizens can remain in their surroundings and independently exercise their functions in society. Care for the elderly should be based primarily on the family, with support from primary health care services, under the family health strategy, representing a link between the elderly and the health system. The article goes on to list some health problems among the elderly in which family health programs can have a major impact. The Family Health Strategy in Brazil is analyzed in relation to health care for the elderly, along with the responsibilities, skills, and attributions required by the health care team.

Abordagem do idoso em programas de saúde da família / Approach to the elderly in family health programs

Discorre-se sobre a Política Nacional de Saúde do Idoso cujo propósito basilar reside na promoçäo do envelhecimento saudável, na manutençäo e melhoria, ao máximo, da capacidade funcional dos idosos, na prevençäo de doenças, na recuperaçäo da saúde dos que adoecem e na reabilitaçäo daqueles que venham a ter a sua capacidade funcional restringida, de modo a garantir-lhes permanência no meio em que vivem, exercendo de forma independente suas funções na sociedade. O cuidado do idoso deve basear-se, fundamentalmente, na família com o apoio das Unidades Básicas de Saúde sob a Estratégia de Saúde da Família, as quais devem representar para o idoso, o vínculo com o sistema de saúde. Após, säo listados alguns dos problemas de saúde do idoso em que os programas de saúde da família podem causar um impacto importante. Se analisa a Estratégia de Saúde da Família no Brasil em relaçäo à atençäo ao idoso, além das competências, habilidades e atribuições necessárias da equipe

[Tricuspid stenosis after pacemaker implantation without evidence of bacterial endocarditis. A case report]. / Estenosis tricúspide tras la implantación de marcapasos intracavitario sin evidenica de endocarditis. a propósito de un caso.

Tricuspid stenosis related to endocardial pacemaker leads is uncommon. We report the case of a patient with severe tricuspid stenosis documented 15 years after the implantation of a permanent DDD pacemaker for symptomatic congenital heart block. The atrial and ventricular leads both had a loop at the level of the tricuspid valve that may have caused endothelial damage and, eventually, tricuspid stenosis.

Estenosis tricúspide tras la implantación de marcapasos intracavitario sin evidencia de endocarditis. A propósito de un caso / Tricuspid stenosis after pacemaker implantation without evidence of bacterial endocarditis. A case report

La estenosis tricúspide relacionada con la presencia de un electrodo de marcapasos es poco frecuente. Describimos el caso de una paciente que presentaba una estenosis tricúspide severa diagnosticada 15 años tras implantarse un marcapasos intracavitario DDD. Ambos electrodos auricular y ventricular presentaban un bucle que se apoyaba sobre el plano valvular tricúspide (AU)

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Desafios a serem enfrentados no terceiro milênio pelo setor saúde na atençäo integral ao idoso / Challenges to be tackled in the third millennium for the health sector in the full attention to aged people

Texto redigido por um grupo de profissionais de vários estados com inserção nas Instituições de Ensino Superior e por técnicos do Ministério da Saúde, convocados através da Secretaria de Políticas de Saúde do Ministério da Saúde (Portaria no. 19, de 30 de setembro de 1998, publicada no Diário Oficial da União no.189 de 2 de outubro de 1998), a elaborarem a Política Nacional de Saúde do Idoso (PNSI)... O objetivo dessa política é permitir um envelhecimento saudável, o que significa preservar a sua capacidade funcional, a sua autonomia e manter o nível de qualidade de vida... A Política Nacional de Saúde do Idoso foi promulgada pelo Sr. Ministro da Saúde, Dr. José Serra (aprovada pela portaria no. 1.395, de 9 de dezembro de 1999, pelo Ministro da Saúde e publicada no DOU no. 237-E, seção 1, páginas 20 a 24 de 13 de dezembro de 1999)...O texto apresenta a síntese do documento oficial. Enfatizamos, também, os aspectos teóricos e conceituais e as novas terminologias. A relevância e as inovações apresentadas pela nova diretriz política merecem uma ampla divulgação no meio acadêmico, nos serviços de saúde e na sociedade em geral, para que sua implementação se efetive o mais breve possível.