Exploring Trauma Patterns and Contributing Factors With Slim Straight Electrode Array After Cochlear Implantation.

OBJECTIVE: To assess trauma patterns associated with the insertion of lateral wall electrode arrays. The study focused on 3 categories-scala tympani (ST), intermediate, and scala vestibuli (SV)-to identify traumatic patterns and contributing factors. STUDY DESIGN: Retrospective study. SETTING: Data from 106 cochlear implant recipients at a tertiary otologic center. METHODS: Demographic and surgical data were collected from recipients who underwent cochlear implantation manually and with RobOtol®. Measurements included cochlear dimensions, angular depth of insertion, and position of the first electrode. Three-dimensional reconstructions were used to analyze the electrode array location relative to the basilar membrane, categorized into ST, intermediate, and SV electrodes. Nontraumatic insertion was defined as all electrodes in the ST, while traumatic insertions had 1 or more electrodes in intermediate or SV locations. RESULTS: Out of 106 cases, 44% had nontraumatic and 56% had traumatic insertions. Demographic and surgical characteristics showed no association with traumatic insertions. A deeper position of the first electrode, relative to the round window, was associated with traumatic insertions (P = .03). Three trauma patterns were observed: distal (facing the apical electrodes), proximal (facing the middle electrodes around 180°), and distal/proximal. CONCLUSION: This study considers the intermediate position which could be associated with basilar membrane lesions. Risk zones for intracochlear trauma with lateral wall arrays were identified distally and proximally. Traumatic insertions were independently linked to deeper array placement. Future studies should explore whether gentler insertion, without insisting on further electrode array insertion depth, could reduce the trauma during cochlear implantation.

Transnasal endoscopy-guided percutaneous access to the sphenopalatine ganglion for neurostimulation in the treatment of primary headache: operative technique and feasibility

Abstract Objectives: Cluster headache is considered a trigeminal autonomic cephalalgia and may present with characteristic symptoms of sympathetic/parasympathetic activation on the affected side of the face, such as nasal discharge, tearing, and conjunctival injection. Invasive therapies targeting the sphenopalatine ganglion have been performed in these headache syndromes and can have a medication-sparing effect, especially in refractory, difficult-to-manage cases. The gate control theory of pain suggests that electric pulses delivered to nerve tissues can modulate neuronal activity, thus aiding in management of nociceptive or neuropathic pain, and studies have demonstrated the efficacy and safety of sphenopalatine ganglion neurostimulation. Within this context, we sought to assess the feasibility of a new surgical technique for neurostimulation of the sphenopalatine ganglion in a cadaver dissection model. Methods: The technique was developed through dissection of two cadaver heads. We divided the procedure into two stages: an endonasal endoscopic approach to expose the sphenopalatine ganglion and confirm electrode placement, and a cervicofacial approach to introduce the electrode array and position the internal pulse-generator unit. Computed tomography was performed to confirm implant placement at the end of the procedure. Results: The pulse-generator unit was successfully placed through a retroauricular incision, as is already standard for cochlear implant placement. This should reduce the incidence of perioperative sequelae, especially pain and swelling in the oral region, which are a common complication of previous approaches used for this purpose. Control imaging confirmed proper electrode placement. The device used in this study allows the patient to modulate the intensity of the stimulus, reducing or even obviating the need for drug therapy. Conclusion: The novel technique described herein, based on percutaneous access guided by transmaxillary endoscopy, can provide great precision in electrode array positioning and decreased perioperative morbidity, combining the advantages of endoscopic approaches with those of the retroauricular route. Level of evidence: 3.

Reducing cardiac implantable electronic device-induced artefacts in cardiac magnetic resonance imaging.

OBJECTIVES: Cardiac implantable electronic device (CIED)-induced metal artefacts possibly significantly diminish the diagnostic value of magnetic resonance imaging (MRI), particularly cardiac MR (CMR). Right-sided generator implantation, wideband late-gadolinium enhancement (LGE) technique and raising the ipsilateral arm to the generator during CMR scanning may reduce the CIED-induced image artefacts. We assessed the impact of generator location and the arm-raised imaging position on the CIED-induced artefacts in CMR. METHODS: We included all clinically indicated CMRs performed on patients with normal cardiac anatomy and a permanent CIED with endocardial pacing leads between November 2011 and October 2019 in our institution (n = 171). We analysed cine and LGE sequences using the American Heart Association 17-segment model for the presence of artefacts. RESULTS: Right-sided generator implantation and arm-raised imaging associated with a significantly increased number of artefact-free segments. In patients with a right-sided pacemaker, the median percentage of artefact-free segments in short-axis balanced steady-state free precession LGE was 93.8% (IQR 9.4%, n = 53) compared with 78.1% (IQR 20.3%, n = 58) for left-sided pacemaker (p < 0.001). In patients with a left-sided implantable cardioverter-defibrillator, the median percentage of artefact-free segments reached 87.5% (IQR 6.3%, n = 9) using arm-raised imaging, which fell to 62.5% (IQR 34.4%, n = 9) using arm-down imaging in spoiled gradient echo short-axis cine (p = 0.02). CONCLUSIONS: Arm-raised imaging represents a straightforward method to reduce CMR artefacts in patients with left-sided generators and can be used alongside other image quality improvement methods. Right-sided generator implantation could be considered in CIED patients requiring subsequent CMR imaging to ensure sufficient image quality. KEY POINTS: • Cardiac implantable electronic device (CIED)-induced metal artefacts may significantly diminish the diagnostic value of an MRI, particularly in cardiac MRIs. • Raising the ipsilateral arm relative to the CIED generator is a cost-free, straightforward method to significantly reduce CIED-induced artefacts on cardiac MRIs in patients with a left-sided generator. • Right-sided generator implantation reduces artefacts compared with left-sided implantation and could be considered in CIED patients requiring subsequent cardiac MRIs to ensure adequate image quality in the future.

Transnasal endoscopy-guided percutaneous access to the sphenopalatine ganglion for neurostimulation in the treatment of primary headache: operative technique and feasibility.

OBJECTIVES: Cluster headache is considered a trigeminal autonomic cephalalgia and may present with characteristic symptoms of sympathetic/parasympathetic activation on the affected side of the face, such as nasal discharge, tearing, and conjunctival injection. Invasive therapies targeting the sphenopalatine ganglion have been performed in these headache syndromes and can have a medication-sparing effect, especially in refractory, difficult-to-manage cases. The gate control theory of pain suggests that electric pulses delivered to nerve tissues can modulate neuronal activity, thus aiding in management of nociceptive or neuropathic pain, and studies have demonstrated the efficacy and safety of sphenopalatine ganglion neurostimulation. Within this context, we sought to assess the feasibility of a new surgical technique for neurostimulation of the sphenopalatine ganglion in a cadaver dissection model. METHODS: The technique was developed through dissection of two cadaver heads. We divided the procedure into two stages: an endonasal endoscopic approach to expose the sphenopalatine ganglion and confirm electrode placement, and a cervicofacial approach to introduce the electrode array and position the internal pulse-generator unit. Computed tomography was performed to confirm implant placement at the end of the procedure. RESULTS: The pulse-generator unit was successfully placed through a retroauricular incision, as is already standard for cochlear implant placement. This should reduce the incidence of perioperative sequelae, especially pain and swelling in the oral region, which are a common complication of previous approaches used for this purpose. Control imaging confirmed proper electrode placement. The device used in this study allows the patient to modulate the intensity of the stimulus, reducing or even obviating the need for drug therapy. CONCLUSION: The novel technique described herein, based on percutaneous access guided by transmaxillary endoscopy, can provide great precision in electrode array positioning and decreased perioperative morbidity, combining the advantages of endoscopic approaches with those of the retroauricular route.

Lumbar Level Peripheral Nerve Stimulation for Low Back Pain.

Background: Low back pain affects the lives of millions of people in the United States and the world. Not only does low back pain affect the quality of life for the individual patient, but it also accounts for many emergency department and health care visits. For a subset of patients, conservative measures such as medications and physical therapy, nonsurgical interventions, and surgery are not effective. Peripheral nerve stimulation is an emerging treatment option for patients with chronic low back pain. This case series assesses 6 patients' experiences with lumbar level peripheral nerve stimulation. Case Report: Three male and 3 female patients underwent lumbar level peripheral nerve stimulation as a treatment for chronic low back pain. The average age of the patients was 63.5 years, and they demonstrated an average pain reduction of 64.8%. Conclusion: This series provides evidence that lumbar level peripheral nerve stimulation may be an efficacious treatment for chronic low back pain that is refractory to conservative measures. Large studies are needed to assess the outcomes and durations of improvement associated with this treatment.

Magnetic resonance imaging safety in patients with abandoned or functioning epicardial pacing leads.

OBJECTIVES: The European Society of Cardiology Guidelines on cardiac pacing from 2021 allow magnetic resonance imaging (MRI) in patients with cardiac implantable electronic devices (CIEDs) but do not recommend MRI in patients with epicardial pacing leads. The clinical dilemma remains whether performing an MRI in patients with CIED and epicardial leads is safe. We aimed to evaluate the safety of performing an MRI in patients with CIED and abandoned or functioning epicardial pacing leads. METHODS: We included all adult patients who underwent clinically indicated MRIs with CIED and functioning or abandoned epicardial leads in a single tertiary hospital between November 2011 and October 2019. The data were retrospectively collected. RESULTS: Twenty-six MRIs were performed on 17 patients with functioning or abandoned epicardial pacing leads. Sixty-nine percent of the MRI scans (18/26) were conducted on patients with functioning epicardial pacing leads. A definite adverse event occurred in one MRI scan. This was a transient elevation of the pacing threshold in a patient with a functioning epicardial ventricular pacing lead implanted 29 years previously. An irreversible atrial pacing lead impedance elevation was detected 6 months after the MRI in another patient; the association with the previous MRI remained unclear. No adverse events were detected in MRIs performed on patients with modern (implanted in 2000 or later) functioning epicardial leads. CONCLUSIONS: MRIs in patients with CIED and modern functioning epicardial pacing leads were performed without detectable adverse events. Further large-scale studies are necessary to confirm MRI safety in patients with epicardial pacing leads. KEY POINTS: • Currently, MRI in patients with cardiac implantable electronic devices (CIEDs) and functioning or abandoned epicardial pacing leads is not recommended. • MRIs in patients with CIED and modern functioning epicardial leads (implanted in 2000 or later) were performed without detectable adverse events in our patient cohort. • Allowing MRI in patients with epicardial pacing leads may significantly improve the diagnostic work-up, especially in specific patient groups, such as patients with congenital heart disease.

CT imaging-based approaches to cochlear duct length estimation-a human temporal bone study.

OBJECTIVES: Knowledge about cochlear duct length (CDL) may assist electrode choice in cochlear implantation (CI). However, no gold standard for clinical applicable estimation of CDL exists. The aim of this study is (1) to determine the most reliable radiological imaging method and imaging processing software for measuring CDL from clinical routine imaging and (2) to accurately predict the insertion depth of the CI electrode. METHODS: Twenty human temporal bones were examined using different sectional imaging techniques (high-resolution computed tomography [HRCT] and cone beam computed tomography [CBCT]). CDL was measured using three methods: length estimation using (1) a dedicated preclinical 3D reconstruction software, (2) the established A-value method, and (3) a clinically approved otosurgical planning software. Temporal bones were implanted with a 31.5-mm CI electrode and measurements were compared to a reference based on the CI electrode insertion angle measured by radiographs in Stenvers projection (CDLreference). RESULTS: A mean cochlear coverage of 74% (SD 7.4%) was found. The CDLreference showed significant differences to each other method (p < 0.001). The strongest correlation to the CDLreference was found for the otosurgical planning software-based method obtained from HRCT (CDLSW-HRCT; r = 0.87, p < 0.001) and from CBCT (CDLSW-CBCT; r = 0.76, p < 0.001). Overall, CDL was underestimated by each applied method. The inter-rater reliability was fair for the CDL estimation based on 3D reconstruction from CBCT (CDL3D-CBCT; intra-class correlation coefficient [ICC] = 0.43), good for CDL estimation based on 3D reconstruction from HRCT (CDL3D-HRCT; ICC = 0.71), poor for CDL estimation based on the A-value method from HRCT (CDLA-HRCT; ICC = 0.29), and excellent for CDL estimation based on the A-value method from CBCT (CDLA-CBCT; ICC = 0.87) as well as for the CDLSW-HRCT (ICC = 0.94), CDLSW-CBCT (ICC = 0.94) and CDLreference (ICC = 0.87). CONCLUSIONS: All approaches would have led to an electrode choice of rather too short electrodes. Concerning treatment decisions based on CDL measurements, the otosurgical planning software-based method has to be recommended. The best inter-rater reliability was found for CDLA-CBCT, for CDLSW-HRCT, for CDLSW-CBCT, and for CDLreference. KEY POINTS: • Clinically applicable calculations using high-resolution CT and cone beam CT underestimate the cochlear size. • Ten percent of cochlear duct length need to be added to current calculations in order to predict the postoperative CI electrode position. • The clinically approved otosurgical planning software-based method software is the most suitable to estimate the cochlear duct length and shows an excellent inter-rater reliability.

Efetividade e Segurança da Remoção de Cabos-Eletrodos Transvenosos de Marca-Passos e Desfibriladores Implantáveis no Cenário da Prática Clínica Real / Effectiveness and Safety of Transvenous Removal of Cardiac Pacing and Implantable Cardioverter-defibrillator Leads in the Real Clinical Scenario

Resumo Fundamento Remoção de cabos-eletrodos de dispositivos cardíacos eletrônicos implantáveis (DCEI) é procedimento pouco frequente e sua realização exige longo treinamento profissional e infraestrutura adequada. Objetivos Avaliar a efetividade e a segurança da remoção de cabos-eletrodos de DCEI e determinar fatores de risco para complicações cirúrgicas e mortalidade em 30 dias. Métodos Estudo prospectivo com dados derivados da prática clínica. De janeiro/2014 a abril/2020, foram incluídos, consecutivamente, 365 pacientes submetidos à remoção de cabos-eletrodos, independentemente da indicação e técnica cirúrgica utilizada. Os desfechos primários foram: taxa de sucesso do procedimento, taxa combinada de complicações maiores e morte intraoperatória. Os desfechos secundários foram: fatores de risco para complicações intraoperatórias maiores e morte em 30 dias. Empregou-se análise univariada e multivariada, com nível de significância de 5%. Resultados A taxa de sucesso do procedimento foi de 96,7%, sendo 90,1% de sucesso completo e 6,6% de sucesso clínico. Complicações maiores intraoperatórias ocorreram em 15 (4,1%) pacientes. Fatores preditores de complicações maiores foram: tempo de implante dos cabos-eletrodos ≥ 7 anos (OR= 3,78, p= 0,046) e mudança de estratégia cirúrgica (OR= 5,30, p= 0,023). Classe funcional III-IV (OR= 6,98, p<0,001), insuficiência renal (OR= 5,75, p=0,001), infecção no DCEI (OR= 13,30, p<0,001), número de procedimentos realizados (OR= 77,32, p<0,001) e complicações maiores intraoperatórias (OR= 38,84, p<0,001) foram fatores preditores para mortalidade em 30 dias. Conclusões Os resultados desse estudo, que é o maior registro prospectivo de remoção de cabos-eletrodos da América Latina, confirmam a segurança e a efetividade desse procedimento no cenário da prática clínica real. (Arq Bras Cardiol. 2020; 115(6):1114-1124)

Abstract Background Transvenous lead extraction (TLE) of cardiac implantable electronic devices (CIED) is an uncommon procedure and requires specialized personnel and adequate facilities. Objectives To evaluate the effectiveness and safety of the removal of CIED leads and to determine risk factors for surgical complications and mortality in 30 days. Methods Prospective study with data derived from clinical practice. From January 2014 to April 2020, we included 365 consecutive patients who underwent TLE, regardless of the indication and surgical technique used. The primary outcomes were: success rate of the procedure, combined rate of major complications and intraoperative death. Secondary outcomes were: risk factors for major intraoperative complications and death within 30 days. Univariate and multivariate analysis were used, with a significance level of 5%. Results Procedure success rate was 96.7%, with 90.1% of complete success and 6.6% of clinical success. Major intraoperative complications occurred in 15 (4.1%) patients. Predictors of major complications were: lead dwelling time ≥ 7 years (OR = 3.78, p = 0.046) and change in surgical strategy (OR = 5.30, p = 0.023). Functional class III-IV (OR = 6.98, p <0.001), renal failure (OR = 5.75, p = 0.001), CIED infection (OR = 13.30, p <0.001), number of procedures performed (OR = 77.32, p <0.001) and major intraoperative complications (OR = 38.84, p <0.001) were predictors of 30-day mortality. Conclusions The results of this study, which is the largest prospective registry of consecutive TLE procedures in Latin America, confirm the safety and effectiveness of this procedure in the context of real clinical practice. (Arq Bras Cardiol. 2020; 115(6):1114-1124)

A study on modelling cochlear duct mid-scalar length based on high-resolution computed tomography, and its effect on peri-modiolar and mid-scalar implant selection.

OBJECTIVE: To determine cochlear duct mid-scalar length in normal cochleae and its role in selecting the correct peri-modiolar and mid-scalar implant length. METHODS: The study included 40 patients with chronic otitis media who underwent high-resolution computed tomography of the temporal bone. The length and height of the basal turn, mid-modiolar height of the cochlea, mid-scalar and lateral wall length of the cochlear duct, and the 'X' line (the largest distance from mid-point of the round window to the mid-scalar point of the cochlear canal) were measured. RESULTS: Cochlear duct lateral wall length (28.88 mm) was higher than cochlear duct mid-scalar length (20.08 mm) (p < 0.001). The simple linear regression equation for estimating complete cochlear duct length was: cochlear duct length = 0.2 + 2.85 × X line. CONCLUSION: Using the mid-scalar point as the reference point (rather than the lateral wall) for measuring cochlear duct mid-scalar length, when deciding on the length of mid-scalar or peri-modiolar electrode, increases measurement accuracy. Mean cochlear duct mid-scalar length was compatible with peri-modiolar and mid-scalar implant lengths. The measurement method described herein may be useful for pre-operative peri-modiolar or mid-scalar implant selection.

The application of sacral neuromodulation in the treatment of female neurogenic lower urinary tract dysfunction / 中国医师杂志

Trauma,iatrogenic injury,and neurological disorders can lead to neurogenic lower urinary tract dysfunction (NLUTD).However,there are some special causes in women,including radical hysterectomy,mid-urethral suspension,pelvic organ prolapse repair,Fowler syndrome,interstitial cystitis etc.Traditional behavioral therapy,drug treatment and surgeries may work less well in patients with NLUTD and may even lead to progression and deterioration of the diseases.A review of current literatures revealed that there is an increasing evidence on the application of sacral neuromodulation (SNM) in the treatment of NLUTD in female.This review will provide a summary of the known mechanisms of female NLUTD and the effectiveness of SNM.

Application of sacral neuromodulation in lower urinary tract diseases related to pelvic floor dysfunction / 中国医师杂志

Pelvic floor dysfunction associated with lower urinary tract diseases,is a common disease in women.Sacral neuromodulation is a safe and effective new technique with small trauma,which has significant advantages for patients with refractory pelvic floor dysfunction-related lower urinary tract diseases and has good clinical application prospects.

La colocación de los electrodos para el registro electronistagmográfico

Fundamento: la calidad de un registro nistagmográfico durante los estudios del sistema vestibular, depende de la adecuada selección y colocación de los electrodos, los cuáles suelen ser ubicados en puntos específicos de la órbita ocular para permitir la recolección de la variación de potencial eléctrico generado entre la córnea y la retina causada por las sacudidas del nistagmo inducido o natural. Objetivo: presentar los resultados experimentales que demuestran esta influencia al cuantificar el efecto sobre los registros. Desarrollo: se empleó la técnica de estimulación visual con blanco móvil a diferentes frecuencias de movimiento, y los registros se realizaron en las condiciones de iluminación establecidas para electrooculografía, se utilizó un amplificador biomédico (electronistagmógrafo) de dos canales con frecuencia de muestreo de 1 kHz. Los Resultados obtenidos reflejan el cambio de las tensiones en los registros de acuerdo a la zona de colocación de los electrodos, al existir una zona óptima para el adecuado registro electronistagmográfico. Conclusiones: se demostró la afectación por zonas en los registros en el dominio temporal y de la frecuencia, y su influencia en la generación de errores en el diagnóstico topográfico de enfermedades que afectan el Sistema Vestibular.

Background: quality of record of electronystagmography during the studies of the vestibular system depends on the proper selection and placement of the electrodes, which are usually located at specific points in the eye socket to allow the collection of the variation of electric potential generated between the cornea and the retina caused by the jerking of the induced or natural nystagmus. Objective: to present the experimental results that demonstrate this influence by quantifying the effect on the records. Development: it was used the technique of visual stimulation with moving target at different frequencies of movement, and the records were made under the lighting conditions established in the published standard for electrooculography, using a two-channel amplifier with a sampling frequency of 1 kHz. The results obtained reflect the change in the tensions in the records according to the electrode placement zone, there being an optimal zone for the adequate record of electronystagmography. Conclusions: the affectation by zones in the records in the temporal domain and the frequency was demonstrated, and its influence in the generation of errors in the topographic diagnosis of diseases that affect the Vestibular System.

Precision implantation with positional confirmation of fine-wire EMG electrodes in the deep posterior neck muscles.

Precise electrode placement is essential for obtaining useful electromyographic (EMG) recordings. Our aim was to develop a protocol for computerized-tomography (CT) guided fine-wire (FW) electrode placement that permits confirmation of the final electrode position in the deep posterior cervical multifidus (CM). FW-EMG electrodes were custom-made from three 50-µm diameter Teflon-insulated platinum/iridium wires. The electrodes were inserted bilaterally in the CM in 15 healthy adult subjects through a 45-mm cannula under CT guidance. The final position of the electrode placement was confirmed in reconstructed 2D and 3D images. Electrode placement was within the fascial boundaries of the CM for 21 of the 25 successfully inserted FW-EMG electrodes. The distance from the electrode to the middle of the CM did not increase significantly with target depth until a breakpoint at 63.2 mm (95%CI 59.1-65.3), from where it increased by an additional 2.9 mm per mm increase in target depth (95%CI 1.3-6.6). Viable EMG was obtained from 21 electrodes. CT guided implantation provided excellent visual documentation in three dimensions of the final placement of the tip of the electrode bundle. The technique affords confidence in studies of motoneuron activity in CM.

A lost cable: «reel¼ syndrome / Un cable suelto: síndrome del «carrete¼

Abstract: Lead dislodgement syndromes (twiddler, ratchet or reel syndromes) are rare causes of cardiac stimulation device malfunction that can occur most commonly early after device implantation. In most cases, lead replacement (due to extensive damage) or reposition (due to displacement) is needed. We present a case of reel syndrome involving the left ventricular lead of a (AU)

Resumen: Los síndromes de desprendimiento de los cables (síndrome de "tweedler", trinquete o carrete) son causas raras de disfunción del dispositivo de estimulación cardiaca, que generalmente ocurren en el periodo temprano después del implante. En la mayoría de los casos, se requiere el reemplazo del cable (debido a daños extensos) o el reposicionamiento (debido al desplazamiento). Presentamos un caso de síndrome del carrete que involucra de manera exclusiva el cable ventricular izquierdo de un dispositivo de resincronización-desfibrilador cardiaco.(AU)

Comparison between left ventricular quadripolar leads and traditional left ventricular bipolar leads / 心血管康复医学杂志

While receiving cardiac resynchronization therapy (CRT) ,traditional left ventricular lead implantation may fail due to anatomical abnormality of heart vein ,poor left ventricular pacing threshold ,lead dislocation and ra-dial nerve stimulation etc .So left ventricular quadripolar leads rise in response to the proper time and condition .The present article made a brief review on research progress of application of left ventricular quadripolar leads in clinic .

[Clinical application of one-stage operation of epicardial permanent pacemaker implantation and cardiac surgery].

Objective: To summarize the results and clinical application experience of one-stage operation of epicardial permanent pacemaker implantation and cardiac surgery. Methods: From November 2014 to July 2016, 15 patients (9 males and 6 females) with ages ranging from 50 to 73 (63.5±6.2) years requiring cardiac surgery with bradycardia underwent one-stage operation of epicardial permanent pacemaker implantation and cardiac surgery. All operations were performed under general anesthesia with chest median incision approach. Among them, single chamber pacemaker (n=10) and dual chamber pacemaker (n=5) permanent epicardial pacing leads were implanted. Simultaneous procedures included valve replacement in 7 cases, valve replacement combined with atrial fibrillation ablation in 3 cases, coronary artery bypass grafting in 2 cases, aortic root replacement in 2 cases, and valve replacement combined with coronary artery bypass surgery in 1 case. Their parameters of pacemaker including sensitivity, pacing threshold, pacing impedance were measured during surgery and closely followed up at 1 week and 3, 6 months after surgery. Results: All 15 patients with epicardial permanent pacemaker implantation in the same period of cardiac surgery were successfully cured and discharged, without any surgical complications. A total of 20 epicardial electrodes were implanted for them including 5 right atrial electrodes and 15 right ventricular electrodes. The postoperative follow-up period ranged from 3 to 22 months. No electrode fracture and surgical wound infection occurred in those patients, and their impedance, sensing and stimulation thresholds were all in normal ranges during follow-up. Conclusions: For patients with bradycardia who required cardiac surgery, one-stage operation of epicardial permanent pacemaker implantation and cardiac surgery is safe and effective, and the results in the short-term and medium-term are satisfactory, avoiding the risk of staged surgery.

Marcapasos permanente: a propósito del diagnóstico tardío del desplazamiento del electrodo / Permanent pacemaker: report of a late diagnosis of displacement of the electrode

Fundamento: en los últimos años el implante de marcapasos permanente se ha convertido en un procedimiento seguro con bajo índice de complicaciones pero cuando estas se presentan, pueden ocasionar un desenlace fatal en la vida del paciente debido a la disfunción del dispositivo. Objetivo: analizar el diagnóstico tardío del desplazamiento del electrodo de marcapasos permanente en una paciente. Caso clínico: paciente de 68 años de edad, con historia de hipertensión arterial de alrededor de 25 años de evolución, con tratamiento diario de amlodipino e hidroclorotiazida de 10 y 25 mg, respectivamente. Hacía cinco años se le había implantado un marcapasos permanente, por bloqueo auriculoventricular de tercer grado y síncope, con buena evolución y sin complicaciones al alta hospitalaria. A los cuatro meses de operada presentó otro síncope y acudió a consulta de programación de marcapasos, sin problemas con la estimulación del dispositivo. Continuó con mareos y pérdida del conocimiento, por lo que recurrió a las consultas programadas de seguimiento especializado. Finalmente se le diagnostica el desplazamiento del electrodo, se reinterviene y se coloca un nuevo cable. En el seguimiento posterior no presento más síncope ni mareos. Conclusiones: el método clínico constituye el elemento principal para el diagnóstico de complicaciones en el seguimiento de pacientes con marcapasos permanentes, aun así un solo medio diagnóstico no es suficiente para descartar la misma, por lo que se deben utilizar otros medios diagnósticos.

Background: in the last years, the placement of permanent pacemakers has become a safe procedure with low rates of complications; however, when these complications present they can cause a fatal end for patients due to the dysfunction of the device. Objective: to analyze the late diagnosis of displacement of the electrode in the permanent pacemaker of a patient. Clinical case: a sixty-six-year-old female patient with a history of high blood pressure of 25 years of evolution. The patient was under a daily treatment with amlodipine and hydrochlorothiazide, 10 and 25 mg respectively. Five years ago, because of third-degree atrioventricular block and syncope, she underwent the implantation of a permanent pacemaker. The patient had a good progress and no complications when discharged from the hospital. Four months after the operation she presented syncope and went to the pacemaker program consultation; there were no problems with the stimulation of the device. She continued presenting dizziness and loss of consciousness so she went to the specialized programmed follow-up consultations. Finally, the patient is diagnosed with displacement of the electrode. She underwent another procedure to place a new lead. She did not present dizziness or syncope in the follow-up. Conclusions: the clinical method is the main element for the diagnosis of complications in the follow-up of patients with permanent pacemakers; still, only one diagnosis element is not enough to discard the problem so is necessary to use other diagnostic means.

Chest pain associated with moderator band pacing.

A 65-year-old man was evaluated for chronic chest pain that had been present for 8 years after placement of a dual-chamber implantable cardioverter-defibrillator to treat inducible ventricular tachycardia. Previous coronary angiography had revealed nonobstructive coronary artery disease and a left ventricular ejection fraction of 0.45 to 0.50, consistent with mild idiopathic nonischemic cardiomyopathy. Evaluation with chest radiography and transthoracic echocardiography showed the implantable cardioverter-defibrillator lead to be embedded within the right ventricle at the moderator band, which had mild calcification. Treatment included extraction of the dual-coil lead and placement of a new single-coil right ventricular lead at the mid septum. The patient had complete relief of symptoms after the procedure. This case shows that chest pain can be associated with the placement of a right ventricular implantable cardioverter-defibrillator lead in the moderator band and that symptomatic relief can occur after percutaneous lead extraction and the implantation of a new right ventricular lead to the mid septal region.

Implanted neuroprosthesis for restoring arm and hand function in people with high level tetraplegia.

OBJECTIVE: To develop and apply an implanted neuroprosthesis to restore arm and hand function to individuals with high level tetraplegia. DESIGN: Case study. SETTING: Clinical research laboratory. PARTICIPANTS: Individuals with spinal cord injuries (N=2) at or above the C4 motor level. INTERVENTIONS: The individuals were each implanted with 2 stimulators (24 stimulation channels and 4 myoelectric recording channels total). Stimulating electrodes were placed in the shoulder and arm, being, to our knowledge, the first long-term application of spiral nerve cuff electrodes to activate a human limb. Myoelectric recording electrodes were placed in the head and neck areas. MAIN OUTCOME MEASURES: Successful installation and operation of the neuroprosthesis and electrode performance, range of motion, grasp strength, joint moments, and performance in activities of daily living. RESULTS: The neuroprosthesis system was successfully implanted in both individuals. Spiral nerve cuff electrodes were placed around upper extremity nerves and activated the intended muscles. In both individuals, the neuroprosthesis has functioned properly for at least 2.5 years postimplant. Hand, wrist, forearm, elbow, and shoulder movements were achieved. A mobile arm support was needed to support the mass of the arm during functional activities. One individual was able to perform several activities of daily living with some limitations as a result of spasticity. The second individual was able to partially complete 2 activities of daily living. CONCLUSIONS: Functional electrical stimulation is a feasible intervention for restoring arm and hand functions to individuals with high tetraplegia. Forces and movements were generated at the hand, wrist, elbow, and shoulder that allowed the performance of activities of daily living, with some limitations requiring the use of a mobile arm support to assist the stimulated shoulder forces.