Management of exposed pacemaker caused by burns.

Annual implants of cardiovascular implantable devices (CIEDs) are increasing, thus increasing the risk of device exposure. This case presents CIED management issues following traumatic thermal injury. A 59-year-old female presented to intensive care with 42% total body surface area burn involving tissue over her pacemaker generator. Electrophysiologists interrogated and reprogrammed the pacer and observed the patient over 72 hours without pacing. Serratia bacteremia developed and cardiology recommended device removal. The pacemaker generator and leads were removed by cardiothoracic and burn surgery. Postoperatively, asystole required emergency transvenous pacing wire placement. During bacteremia treatment, cardiology planned to pace with an active-fixation screw-in lead with long-term plans to place a single right ventricular chamber leadless pacemaker because of the extensive burns. The patient developed fungemia and the family opted for comfort care. This case report discusses the management of a CIED exposed after a traumatic thermal burn, including device extraction.

Iatrogenic Ventricular Fibrillation after Direct-Current Cardioversion of Preexcited Atrial Fibrillation Caused by Inadvertent T-Wave Synchronization.

Direct-current cardioversion is an important means of managing arrhythmias. During treatment, carefully synchronizing energy delivery to the QRS complex is necessary to avoid ventricular fibrillation caused by a shock during the vulnerable period of ventricular repolarization, that is, a shock on the T wave. The presence of an accessory pathway and ventricular preexcitation can lead to difficulty in distinguishing the QRS complex from the T wave because of bizarre, wide, irregular QRS complexes and prominent repolarization. We present the cases of 2 patients who had iatrogenic ventricular fibrillation from inappropriate T-wave synchronization during direct-current cardioversion of preexcited atrial fibrillation. Our experience shows that rapidly recognizing the iatrogenic cause of VF and immediate treatment with unsynchronized defibrillation can prevent adverse clinical outcomes.

Impact of a Pharmacy-Cardiology Collaborative Practice on Dofetilide Safety Monitoring.

BACKGROUND: Limited studies have been published examining dofetilide's postmarketing use and its recommended monitoring. OBJECTIVE: To evaluate the impact of a collaborative pharmacy-cardiology antiarrhythmic drug (AAD) monitoring program on dofetilide monitoring. METHODS: This retrospective cohort study was performed to assess if a novel monitoring program improved compliance with dofetilide-specific monitoring parameters based on the Food and Drug Administration's Risk Evaluation and Mitigation Strategy. RESULTS: A total of 30 patients were included in the analysis. The monitoring parameters evaluated included electrocardiogram, serum potassium, serum magnesium, and kidney function. The primary outcome evaluated was the composite of these dofetilide monitoring parameters obtained in each cohort. In the standard cohort, 245 of 352 (69.6%) monitoring parameters were completed versus 134 of 136 (98.5%) in the intervention group ( P < 0.05). CONCLUSION: A collaborative pharmacy-cardiology AAD monitoring program was associated with a significant improvement in dofetilide monitoring. This improvement could potentially translate into enhanced patient safety outcomes, such as prevention of adverse drug reactions and decreased hospitalizations.

Right ventricular morphology and the onset of dyspnea: the MESA-right ventricle study.

BACKGROUND: The association of right ventricular (RV) structure and function with symptoms in individuals without cardiopulmonary disease is unknown. We hypothesized that greater RV mass and RV end-diastolic volume (RVEDV), smaller RV stroke volume (RVSV), and lower RV ejection fraction (RVEF) measured by cardiac magnetic resonance imaging (MRI) in participants free of clinical cardiovascular disease at baseline would be associated with a greater risk of self-reported dyspnea. METHODS: The Multi-Ethnic Study of Atherosclerosis (MESA) performed cardiac MRIs on participants without clinical cardiovascular disease between 2000 and 2002. We excluded subjects who reported "prevalent" dyspnea at the first assessment (24 months). The presence of dyspnea was assessed at 24 months, 42 months, and 60 months from baseline. Cox proportional hazards models were used to examine the relationship between RV measures and incident dyspnea. RESULTS: In the final study sample (N = 2763), there were significant interactions between RV measures and sex in terms of the risk of dyspnea (p<0.05). Among men (N = 1453), lower RV mass (p = 0.003), smaller RVEDV (p<0.001), smaller RV end-systolic volume (RVESV) (p = 0.03) and decreased RVSV (p<0.001) were associated with an increased risk of developing dyspnea after adjusting for covariates. Associations remained after adjusting for left ventricular function and lung function. However, there were no significant associations between RV measures and the risk of dyspnea in women. CONCLUSIONS: Lower RV mass and smaller RV volumes were associated with an increased risk of dyspnea in men, but not in women.