Safety and Efficacy of the Subcutaneous Implantable Defibrillator.

Multiple randomized, multicenter trials have established the role of the implantable cardioverter-defibrillator (ICD) in the treatment and prevention of sudden cardiac death. However, transvenous ICD leads have significant short- and long-term complications, offsetting some of the benefit of this therapy. This has led to the development of the entirely subcutaneous ICD. This system is safe and effective, avoiding the need for intravascular leads. It is best suited for patients at low risk for pacing and increased risk for transvenous lead complications. Ongoing randomized and long-term registries will help identify the optimal role of this device in clinical practice.

Natural History and Implantable Cardioverter-Defibrillator Implantation After Revascularization for Stable Coronary Artery Disease With Depressed Ejection Fraction.

BACKGROUND: Following revascularization, most payors require 3 months of medical therapy, followed by left ventricular ejection fraction (LVEF) reassessment, before implantable cardioverter-defibrillator (ICD) implantation possibly contributing to incomplete follow-up and suboptimal utilization of ICD therapy. The natural history of these patients, and their fate regarding ICD implantation, is unknown. HYPOTHESIS: We hypothesized that a waiting period after revascularization for stable CAD results in missed opportunities to provide care with regard to ICD implantation. METHODS: We followed patients with LVEF ≤ 35% and no ICD who underwent revascularization (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]) for stable CAD. Follow-up used chart review and scripted telephone interviews. RESULTS: Among 3164 revascularized patients (2198 [69%] PCI, 966 [31%] CABG), only 62 (2%; 33 [53%] male, age 67 ± 12 y, LVEF 28% ± 6%) had stable CAD, depressed LVEF, and no ICD. Over 35 ± 19 months, 35 (56%) of these 62 patients were no longer candidates for ICD based on improved LVEF, 14 (23%) received an ICD, 5 (8%) declined ICD despite physician recommendation, 3 (5%) were not offered ICD despite continued eligibility, 2 (3%) died, 1 (2%) was not a candidate due to substance abuse, and 1 (2%) had ICD implantation temporarily deferred. Only 1 (2%) was lost to follow-up. CONCLUSIONS: Following revascularization for stable CAD with depressed LVEF, ≥50% of patients' ventricular function improved enough to make ICD implantation unnecessary. A waiting period after revascularization prior to ICD implantation appears appropriate and does not significantly negatively impact follow-up or the rate of appropriate ICD implantation.

Clinical experience with subcutaneous implantable cardioverter-defibrillators.

The subcutaneous implantable cardioverter-defibrillator (S-ICD) is a novel technology for the treatment of sudden cardiac death. The system consists of a pulse generator implanted in the left axillary position and a single subcutaneous lead for detection and delivery of therapy. Initial clinical trials of S-ICDs demonstrated improved safety and efficacy when compared to transvenous ICD systems, leading to their widespread approval. The main advantage of the S-ICD is the avoidance of vascular access and the complications associated with transvenous leads. Owing to limitations of S-ICDs, patients who require pacing support or antitachycardia pacing are not candidates for the device; instead, this system is currently used most commonly in young patients with previous lead malfunction, limited vascular access, or low risk for subsequent bradycardia or antitachycardia pacing. Findings from device trials support S-ICDs as a viable alternative to transvenous ICDs in certain patients, and the current limitations associated with S-ICDs are likely to be addressed in future iterations of the device, extending its indications and target patient populations.

Developments in Cardiac Resynchronisation Therapy.

Cardiac resynchronisation therapy (CRT) is an important therapy for patients with heart failure with a reduced ejection fraction and interventricular conduction delay. Large trials have established the role of CRT in reducing heart failure hospitalisations and improving symptoms, left ventricular (LV) function and mortality. Guidelines from major medical societies are consistent in support of CRT for patients with New York Health Association (NYHA) class II, III and ambulatory class IV heart failure, reduced LV ejection fraction and QRS prolongation, particularly left bundle branch block. The current challenge facing practitioners is to maximise the rate of patients who respond to CRT and the magnitude of that response. Current areas of interest for achieving these goals include tailoring patient selection, individualising LV lead placement and application of new technologies and techniques for CRT delivery.

Superexchange contributions to distance dependence of electron transfer/transport: exchange and electronic coupling in oligo(para-phenylene)- and oligo(2,5-thiophene)-bridged donor-bridge-acceptor biradical complexes.

The preparation and characterization of three new donor-bridge-acceptor biradical complexes are described. Using variable-temperature magnetic susceptibility, EPR hyperfine coupling constants, and the results of X-ray crystal structures, we evaluate both exchange and electronic couplings as a function of bridge length for two quintessential molecular bridges: oligo(para-phenylene), ß = 0.39 Å(-1) and oligo(2,5-thiophene), ß = 0.22 Å(-1). This report represents the first direct comparison of exchange/electronic couplings and distance attenuation parameters (ß) for these bridges. The work provides a direct measurement of superexchange contributions to ß, with no contribution from incoherent hopping. The different ß values determined for oligo(para-phenylene) and oligo(2,5-thiophene) are due primarily to the D-B energy gap, Δ, rather than bridge-bridge electronic couplings, H(BB). This is supported by the fact that the H(BB) values extracted from the experimental data for oligo(para-phenylene) (H(BB) = 11,400 cm(-1)) and oligo(2,5-thiophene) (12,300 cm(-1)) differ by <10%. The results presented here offer unique insight into the intrinsic molecular factors that govern H(DA) and ß, which are important for understanding the electronic origin of electron transfer and electron transport mediated by molecular bridges.

Modification of molecular spin crossover in ultrathin films.

Scanning tunneling microscopy and local conductance mapping show spin-state coexistence in bilayer films of Fe[(H2Bpz2)2bpy] on Au(111) that is independent of temperature between 131 and 300 K. This modification of bulk behavior is attributed in part to the unique packing constraints of the bilayer film that promote deviations from bulk behavior. The local density of states measured for different spin states shows that high-spin molecules have a smaller transport gap than low-spin molecules and are in agreement with density functional theory calculations.

Complex materials for molecular spintronics applications: cobalt bis(dioxolene) valence tautomers, from molecules to polymers.

Using first principles calculations, we predict a complex multifunctional behavior in cobalt bis(dioxolene) valence tautomeric compounds. Molecular spin-state switching is shown to dramatically alter electronic properties and corresponding transport properties. This spin state dependence has been demonstrated for technologically relevant coordination polymers of valence tautomers as well as for novel conjugated polymers with valence tautomeric functionalization. As a result, these materials are proposed as promising candidates for spintronic devices that can couple magnetic bistability with novel electrical and spin conduction properties. Our findings pave the way to the fundamental understanding and future design of active multifunctional organic materials for spintronics applications.

Takotsubo cardiomyopathy in a patient with previously undiagnosed hypertrophic cardiomyopathy with obstruction.

Takotsubo cardiomyopathy (TCM) is usually characterized by left ventricular anteroapical dysfunction in the absence of significant coronary disease commonly precipitated by an emotional or stressful trigger. Hypertrophic cardiomyopathy (HCM) is usually diagnosed on the basis of symptoms, family history, echocardiography, or by the presence of a characteristic murmur. We report a unique case of TCM occurring in a patient with previously undiagnosed HCM with left ventricular outflow tract (LVOT) obstruction who presented with an acute coronary syndrome and ultimately underwent successful alcohol septal ablation. The potential pathophysiologic correlations are discussed.