Refractory coronary vasospasm complicated by complete atrio-ventricular block during neck surgery: is there an indication for pacing?

Vasospastic angina is a clinical condition characterized by coronary artery spasm in angiographically normal coronary arteries. Vasospastic angina can often lead to ventricular arrhythmias, sudden cardiac death, or life-threatening bradyarrhythmias, such as high-degree atrioventricular block or asystole. We present the unusual case of a woman with depressive syndrome who underwent emergency surgery for hemostasis of a neck lesion that caused hemorrhagic shock after a suicide attempt. During surgery, the electrocardiogram revealed inferior and posterior ST-segment elevation, total atrioventricular block and torsades de pointes; the patient also suffered 4 minutes of cardiac arrest. A temporary pacemaker was placed. Coronary angiography showed right coronary artery vasospasm. Following a second similar episode after tracheostomy, a permanent pacemaker was implanted. The indication for definitive electrostimulation in such a context and the stimulation mechanisms of the carotid sinus underlying vasospasm constitute the interesting points of this clinical case. LEARNING OBJECTIVE: The indication for definitive electrostimulation in a context of recurrent episodes of high-degree atrioventricular block during vasospastic angina and the stimulation mechanisms of the carotid sinus underlying vasospasm constitute the interesting points of this clinical case.

Ultrasound-guided Axillary Vein Puncture for Cardiac Device Implantation: A Safe and Effective Approach.

Ultrasound-guided axillary vein access is an effective alternative to conventional subclavian and cephalic access for cardiac implantable electronic device implantation. The aim of this study was to compare the safety, efficacy, and radiation exposure data of the ultrasound-guided axillary approach with other conventional access techniques. The study population included 130 consecutive patients, stratified as 65 (64% male; median age, 79 years) in the study group and 65 (66% male; median age, 81 years) in the control group. We performed a retrospective not-randomized analysis by comparing ultrasound-guided axillary vein puncture with subclavian and cephalic approaches in order to test the effect on X-ray exposure, total procedure time, and complications. Significant differences were observed in terms of radiation exposure, including fluoroscopy time (median, 95 s [study group] vs. 193 s [control group]; P < .001), air kerma (median, 29 mGy [study group] vs. 55.7 mGy [control group]; P < .001), and dose-area product (median, 8219 mGy·cm2 [study group] vs. 16736 mGy·cm2 [control group]; P < .001). The median procedure time was 45 min in the study group but 50 min in the control group (P < .05). Complications occurred in 6 control group patients (1 urticaria contrast medium-related, 3 pneumothorax, 2 subclavian artery puncture) and 2 study group patients (2 axillary artery puncture). We conclude that the ultrasound-guided axillary venous approach is a fast, feasible, and safe technique for cardiac lead implantation. It allows a significant reduction in fluoroscopy time without prolonging the procedural time. This approach offers direct visualization of the vessel during the puncture, so it can be useful in patients who cannot receive contrast medium, those who require "difficult" thoracic approaches (emphysema, too much or too little fat tissue), or those on anticoagulant therapy.

A challenging pacemaker implantation in the presence of a giant right coronary aneurysm compressing the right atrium.

Giant coronary artery aneurysm is an uncommon disease, treated with surgical intervention or percutaneous coil embolization. A thrombosed aneurysm can cause extrinsic compression on the cardiac chambers, with potential hemodynamic effects and may cause problems when we need to implant a cardiac device. We present a case of difficult pacemaker implantation in a patient with 3 syncopes, first-degree AV block and complete left bundle branch block on electrocardiogram. The patient presented a giant aneurysm of the right coronary artery (85 x 90 mm), thrombosed, with right atrial compression. The pacemaker implantation was hampered by the difficulty of passing the lead through the compressed right atrium; indeed, only with simultaneous echocardiographic and fluoroscopic guidance, was it possible to complete the procedure. This case demonstrates the utility of echocardiogram, in particular settings, in cardiac stimulation procedures.

Takotsubo syndrome and pheochromocytoma: an insidious combination.

Pheochromocytoma is a rare adrenal tumor characterized by the secretion of catecholamines and vasoactive peptides. It can cause a catecholaminergic storm and lead to acute coronary syndromes. We present the case of a 53-year-old man, without any medical history, who arrived to the hospital following a spinal trauma due a fall. He presents back and retrosternal pain, with a clinical status of acute pulmonary edema, sinus tachycardia with left bundle branch block, left ventricular apical ballooning with depressed systolic function. Blood tests show a very important increase of Troponin and transaminases. A contrast chest-abdomen CT highlighted a right adrenal solid mass, with a diameter of 78mm, partial capsular laceration, compression of the inferior vena cava and the hepatic parenchyma. The clinical condition of the patient rapidly worsens from a respiratory and hemodynamic point of view, with cardiogenic shock, anuria and sepsis, refractory to all the medical treatments, until the patient died. The autopsy confirmed that the abdominal mass was a pheochromocytoma, broken after the trauma suffered. The resulting catecholaminergic storm caused a myocardial ischemia with Takotsubo syndrome, with cardiogenic shock. This unfortunate case confirms the pheochromocytoma as important risk factor for the onset of Takotsubo syndrome, and the how dramatic and severe a catecholaminergic storm can be.

Therapeutic management of ventricular arrhythmias in Andersen-Tawil syndrome.

Andersen-Tawil Syndrome (ATS) is a rare periodic paralysis with typical skeletal and neuromuscular features. Cardiac involvement may range from asymptomatic ventricular arrhythmias to sudden death. Its management remains challenging and the choice between antiarrhythmic drug therapy and implantable cardioverter defibrillator (ICD) is not simple. We present a case of ATS patient with episodes of bidirectional ventricular tachycardia, well controlled by flecainide therapy initially, which in particular conditions of fever and hypokaliemia had a cardiac arrest with ventricular fibrillation, with neurological sequelae and need of an ICD implant. A review of the therapeutic management of this disease is presented.

Acute contractile recovery extent during biventricular pacing is not associated with follow-up in patients undergoing resynchronization.

BACKGROUND: It has been reported that contractility, as assessed using dobutamine infusion, is independently associated with reverse remodeling after CRT. Controversy, however, exists about the capacity of this approach to predict a long-term clinical response. This study's purpose was to assess whether long-term CRT clinical effects can be predicted according to acute inotropic response induced by biventricular stimulation (CRT on), as compared with AAI-VVI right stimulation pacing mode (CRT off), quantified at the time of implantation. METHODS: In 98 patients (ejection fraction 29 ± 10%), acute changes in left ventricular (LV) elastance (Ees), arterial elastance (Ea), and Ees/Ea, as assessed from slope changes of the force-frequency relation obtained when the heart rate increased, and also assessed while measuring triplane LV volumes and continuous noninvasive blood pressure, were related to death or rehospitalization during a 3-year follow-up. Other covariances tested were age, gender, disease etiology, QRS duration, amount of mitral regurgitation, LV diastolic volume, ejection fraction, and the degree of asynchrony and longitudinal strain at baseline. RESULTS: There was a marked increment in the Ees slope with CRT (interaction P = 0.004), no Ea change, and modest Ees/Ea increase (interaction P < 0.05). In Cox analysis, however, neither slope changes nor baseline values of Ees, Ea, and Ees/Ea were associated with long-term follow-up. Only ventricular diastolic volume (direct relation P = 0.002) and QRS duration (inverse relation P = 0.009) predicted death/rehospitalization. CONCLUSIONS: Acute contractile recovery in CRT patients is not associated with 3 years prognosis. Instead, death or rehospitalization can be predicted from QRS duration and LV diastolic volume at baseline.

Right ventricular septal pacing: Safety and efficacy in a long term follow up.

AIM: To evaluate the safety and efficacy of the permanent high interventricular septal pacing in a long term follow up, as alternative to right ventricular apical pacing. METHODS: We retrospectively evaluated: (1) 244 patients (74 ± 8 years; 169 men, 75 women) implanted with a single (132 pts) or dual chamber (112 pts) pacemaker (PM) with ventricular screw-in lead placed at the right ventricular high septal parahisian site (SEPTAL pacing); (2) 22 patients with permanent pacemaker and low percentage of pacing (< 20%) (NO pacing); (3) 33 patients with high percentage (> 80%) right ventricular apical pacing (RVA). All patients had a narrow spontaneous QRS (101 ± 14 ms). We evaluated New York Heart Association (NYHA) class, quality of life (QoL), 6 min walking test (6MWT) and left ventricular function (end-diastolic volume, LV-EDV; end-systolic volume, LV-ESV; ejection fraction, LV-EF) with 2D-echocardiography. RESULTS: Pacing parameters were stable during follow up (21 mo/patient). In SEPTAL pacing group we observed an improvement in NYHA class, QoL score and 6MWT. While LV-EDV didn't significantly increase (104 ± 40 mL vs 100 ± 37 mL; P = 0.35), LV-ESV slightly increased (55 ± 31 mL vs 49 ± 27 mL; P = 0.05) and LV-EF slightly decreased (49% ± 11% vs 53% ± 11%; P = 0.001) but never falling < 45%. In the RVA pacing control group we observed a worsening of NYHA class and an important reduction of LV-EF (from 56% ± 6% to 43% ± 9%, P < 0.0001). CONCLUSION: Right ventricular permanent high septal pacing is safe and effective in a long term follow up evaluation; it could be a good alternative to the conventional RVA pacing in order to avoid its deleterious effects.

Beta-Blockers and Nitrates: Pharmacotherapy and Indications.

Many clinically important differences exist between beta blockers. B1-selectivity is of clinical interest because at clinically used doses, b1- selective agents block cardiac b-receptors while having minor effects on bronchial and vascular b-receptors. Beta-adrenergic blocking agents significantly decrease the frequency and duration of angina pectoris, instead the prognostic benefit of beta-blockers in stable angina has been extrapolated from studies of post myocardial infarction but has not yet been documented without left ventricular disfunction or previous myocardial infarction. Organic nitrates are among the oldest drugs, but they still remain a widely used adjuvant in the treatment of symptomatic coronary artery disease. While their efficacy in relieving angina pectoris symptoms in acute settings and in preventing angina before physical or emotional stress is undisputed, the chronic use of nitrates has been associated with potentially important side effects such as tolerance and endothelial dysfunction. B-blockers are the firstline anti-anginal therapy in stable stable angina patients without contraindications, while nitrates are the secondline anti-anginal therapy. Despite 150 years of clinical practice, they remain fascinating drugs, which in a chronic setting still deserve investigation. This review evaluated pharmacotherapy and indications of Beta-blockers and nitrates in stable angina.

Lack of interference of electromagnetic navigation bronchoscopy to implanted cardioverter-defibrillator: in-vivo study.

AIMS: Electromagnetic navigation bronchoscopy (ENB) (Superdimension) is a diagnostic and therapeutic tool in patients with lung lesions. Very small data are available about potential interference of ENB magnetic field to implanted cardioverter-defibrillators (ICDs) and any documentation of ICD behaviour if a ventricular tachyarrhythmia occurs during ENB is lacking. We tested a number of selected ICDs to assess if any interference occurs by ENB magnetic field on detection of clinical ventricular fibrillation and shock delivery. METHODS AND RESULTS: Thirteen patients undergoing an ICD implantation or elective replacement with a clinical indication to assess the efficacy of defibrillation underwent: (i) real-time telemetric recording from ICD during ENB activation to detect possible noise; (ii) defibrillation test during exposure to ENB board-generated magnetic field. All tested ICDs showed no noise detection at maximum sensitivity level. Induced ventricular fibrillation was correctly detected and cured by implanted device. No change in programmed ICD parameters was induced by exposure to ENB magnetic field. CONCLUSION: All tested ICDs correctly operated and rescued the patients from induced ventricular fibrillation during ENB. Electromagnetic navigation bronchoscopy appears to be safe in heart patients with an ICD; however, close cardiac monitoring of these patients during ENB must be ensured as correct behaviour of all existing ICDs can only be presumed from compliance of the manufacturer to International Standards which establish procedures for electromagnetic interference checking on implantable devices on different ranges of frequency.

Left atrium function in patients with coronary artery disease.

PURPOSE OF REVIEW: The left atrial cavity has recently been identified as a potential biomarker for cardiac and cerebrovascular accidents. This review examines the potential of left atrial size and function in predicting cardiovascular disease in the general population and outcomes in coronary artery disease (CAD) patients. RECENT FINDINGS: The atrium is perfused primarily by branches of the proximal left circumflex coronary artery (LCx), and depression of the cavity mechanical performance has been demonstrated in experimental studies during LCx occlusion. Thus, left atrial volume and function assessment may have prognostic relevance, particularly in CAD patients. Such a line of thinking, however, is challenged by the widespread notion that the contribution by left atrial chamber morphology and functional quantitation to the risk stratification process after a first cardiovascular event is not adequately considered. However, a number of studies have shown that left atrial volume predicts survival and major adverse events after an acute myocardial infarction. Left atrial remodeling also provides an important overall prognostic information and correlates with brain natriuretic peptide after primary percutaneous coronary interventions. SUMMARY: Evaluation of left atrial size and function is currently of great interest and it will be more so in the very near future, given its potential for insights into the pathophysiology of the ischemic heart, which makes it an important clinical risk identifier in CAD patients.

Systolic heart failure and cardiac resynchronization therapy: a focus on diastole.

Conflicting data exist about the effects of cardiac resynchronization therapy (CRT) on diastolic function (DF). Aim of the study was to assess if and how CRT affects DF in systolic heart failure patients. We also investigated potential relations between CRT-induced left ventricular changes and the composite clinical endpoint of progressive heart failure and cardiac death over 3 years follow-up. 119 CRT patients underwent clinical evaluation and echocardiography before CRT and 4 months later. DF was quantified by transmitral velocities [E/A waves, deceleration time (DT), E/DT], early diastolic mitral annulus velocity (E'), E/E' ratio and 2-D speckle tracking strain rate during isovolumetric relaxation (IVR, SRivr). End-diastolic pressure-volume relationship (EDPVR) was also assessed noninvasively using a single-beat method. Overall stiffness was quantified by ventricular stiffness (Klv) normalized to end-diastolic volume (EDV). New York Heart Association class improved at 4 months (from 2.7 ± 0.7 to 1.9 ± 0.6, p < 0.001) as did ventricular filling (E/DT from 0.48 ± 0.29 to 0.39 ± 0.31 cm/s(2), p = 0.01). In contrast, relaxation (E', SRivr) and filling pressures (E/E', E/SRivr) did not change. Slope of EDPVR did not change with CRT. Such finding, together with an unmodified Klv/EDV and a 7 ± 18 % reduction in EDV (p = 0.001), suggested reverse remodelling towards a smaller equilibrium volume. Finally, end-systolic LV volume decreased from 147 ± 59 to 125 ± 52 ml and ejection fraction increased from 0.26 ± 0.07 to 0.32 ± 0.09 (both p < 0.001). Using a Cox regression model we found that only changes (Δ) in diastolic, but not systolic indexes, correlated with the composite clinical endpoint, with increments in ΔEDV20 and ΔE/DT, single or combined, greatly increasing risk of heart failure and/or cardiac death (p = 0.003). Ventricular reverse remodelling, together with improvement in ventricular filling, rather than improvements of systolic function, predict clinical prognosis long-term post-CRT.

Low--molecular weight heparins and unfractionated heparins during primary coronary intervention.

Coronary artery diseases continue to be the most common causes of mortality and morbidity in the industrialized world, especially in the setting of acute myocardial infarction. Anticoagulation during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) has traditionally been supported by anticoagulant unfractionated heparin (UFH). Recently, alternative anticoagulants such as low molecular weight heparin (LMWH) were included in the management of STEMI. The aim of the present review is to compare efficacy and safety outcomes among patients receiving low molecular weight heparins (LMWH) or unfractionated heparin (UFH) while undergoing PCI for STEMI.