Home monitoring after ambulatory implanted primary cardiac implantable electronic devices: The home ambulance pilot study.

BACKGROUND: The Home Monitoring (HM) system of cardiac implantable electronic devices (CIEDs) permits early detection of arrhythmias or device system failures. The aim of this pilot study was to examine how the safety and efficacy of the HM system in patients after ambulatory implanted primary CIEDs compare to patients with a standard procedure and hospitalization. HYPOTHESIS: We hypothesized that HM and their modifications would be a useful extension of the present concepts for ambulatory implanted CIEDs. METHODS: This retrospective analysis evaluates telemetric data obtained from 364 patients in an ambulatory single center over 6 years. Patients were assigned to an active group (n = 217), consisting of those who were discharged early on the day of implantation of the primary CIED, or to a control group (n = 147), consisting of those discharged and followed up with the HM system according to usual medical practices. RESULTS: The mean duration of hospitalization was 73.2% shorter in the active group than in the control group, corresponding to 20.5 ± 13 fewer hours (95% confidence interval [CI]: 6.3-29.5; P < 0.01) spent in the hospital (7.5 ± 1.5 vs 28 ± 4.5 h). This shorter mean hospital stay was attributable to a 78.8% shorter postoperative period in the active group. The proportion of patients with treatment-related adverse events was 11% (n = 23) in the active group and 17% (n = 25) in the control group (95% CI: 5.5-8.3; P = 0.061). This 6% absolute risk reduction (95% CI: 3.3-9.1; P = 0.789) confirmed the noninferiority of the ambulatory implanted CIED when compared with standard management of these patients. CONCLUSIONS: Early discharge with the HM system after ambulatory CIED implantation was safe and not inferior to the classic medical procedure. Thus, together with lower costs, HM and its modifications would be a useful extension of the present concepts for ambulatory implanted CIEDs.

Failure of Femoral Access to Electrophysiological Evaluation Due to Aplasia of the Inferior Vena Cava.

We report an interesting case of a man with a persistent left superior vena cava (PLSVC) with left azygos vein who underwent electrophysiological evaluation. Further evaluation revealed congenital dilated azygos vein, while a segment connecting the inferior vena cava (IVC) to the hepatic vein and right atrium was missing. The azygos vein drained into the superior vena cava, and the hepatic veins drained directly into the right atrium. The patient did not have congenital anomalies of the remaining thoracoabdominal vasculature.

Acute left main coronary artery occlusion.

The treatment of an acute left main coronary artery occlusion still poses a challenge. In this case report we present a 50-year-old patient with an acute occlusion of the left main artery. After a successful angioplasty without "stenting" due to the complexity of the stenosis the patient underwent a successful bypass surgery. We discuss the therapeutic options of acute left main occlusion regarding medical, interventional and surgical options.

Reduced capacity of heart rate regulation in response to mild hypoglycemia induced by glibenclamide and physical exercise in type 2 diabetes.

OBJECTIVE: Decreased heart rate variability (HRV) is associated with enhanced mortality due to abnormal cardiac rhythm. While hypoglycemic events are increasingly common in the treatment of type 2 diabetes, HRV is part of the counter-regulation against low blood glucose levels. We hypothesized that HRV was impaired in mild hypoglycemia in diabetic individuals. MATERIALS/METHODS: Hyperinsulinemic-hypoglycemic clamps were performed in twelve type 2 diabetic patients without cardiovascular disease and in non-diabetic subjects matched for age, sex, and weight. In an additional study, hypoglycemic events, induced by either a single morning dose of glibenclamide or physical exercise, were recorded for the subsequent 24h. Blood glucose concentrations and electrocardiograms were continuously monitored. Serum hormone levels, hypoglycemic symptoms, and forearm blood flow were measured at defined time points. RESULTS: Occurrence of a symptomatic hypoglycemic episode (mean blood glucose 3.1±0.4 mmol/l) attenuated most of the time and frequency domain measurements in both healthy and diabetic individuals. The magnitude of reduction of HRV parameters was significantly lower in diabetic compared to healthy subjects. Glibenclamide taken in the morning enhanced the daily number of mild hypoglycemic events compared with placebo or moderate exercise. Concordantly, 24-h mean HRV measurements were decreased. CONCLUSION: HRV response to hypoglycemia is impaired in type 2 diabetic subjects resulting in a higher than expected risk for sudden arrhythmia following mild hypoglycemic episodes.

Transcatheter aortic valve implantation: our experience and review of the literature.

Transcatheter Aortic Valve Implantation [TAVI] is widespread worldwide as an alternative therapy procedure to the patients suffering from severe aortic valve stenosis. However, we shouldn't forget that the conventional surgical aortic valve replacement is still the gold standard therapy for severe aortic valve stenosis. For the patients who cannot be treated conventionally because of high risk comorbid diseases and older age, TAVI is an effective alternative therapy method. The indications should be limited, concerning the high mortality rate, 10% within 30 days of intervention. Long term efficacy data are still inadequate. Although the indications are restricted to older patients with a STS score >10 or log-Euro Score >20, age is not a definite indication for this treatment. The patients should be assessed by a heart team including a non-interventional cardiologist, interventional cardiologist, cardiac anesthesiologist and cardiac surgeon according to their general status, frailty and STS- Euro score. In other words, assessment and treatment of the patient by a heart team is the main factor besides the limited power of the scoring systems. The treatment should be applied to the patients with an aortic annulus diameter between 18-27 mm and a life expectancy of at least over 1 year. The currently ongoing investigations are focused on parameters like safety, efficiency and long term reliability of TAVI. The scientific and technical developments lead to new definitions and parameters regarding the treatment indications of severe aortic valve stenosis. In this review, we present the actual data about TAVI and also our own experiences.

Left Atrial Appendage (LAA) Closure-Device Disengagement as a Serious Complication and How it Can Be Easily Removed.

A stroke attack in the brainstem area as a serious complication of atrial fibrillation (AF) in a 51 year old woman with known paroxysmal AF (CHADS(2) score 3) was treated with LAA occlusion procedure after the complication of arterial bleeding secondary to anticoagulation therapy. LAA closure device embolisation was developed following the LAA occlusion procedure. The device was located and removed successfully from the systemic circulation.

Quadripolar Left Ventricular Lead in a Patient with CRT-D Does Not Overcome Phrenic Nerve Stimulation.

Effective cardiac resynchronization therapy (CRT) requires an accurate atrio-biventricular pacing system. The innovative Quartet lead is a quadripolar, over-the-wire left ventricular lead with four electrodes and has recently been designed to provide more options and greater control in pacing vector selection. A lead with multiple pacing electrodes is a potential alternative to physical adjustment of the lead and may help to overcome high thresholds and phrenic nerve stimulation (PNS).

Randomized comparison of multipolar, duty-cycled, bipolar-unipolar radiofrequency versus conventional catheter ablation for treatment of common atrial flutter.

INTRODUCTION: Radiofrequency (RF) catheter ablation has been established as an effective and curative treatment for atrial flutter (AFL). Approved methods include a drag-and-drop method, as well as a point-by-point ablation technique. The aim of this study was to compare the acute efficacy and procedural efficiency of a multipolar linear ablation catheter with simultaneous energy delivery to multiple catheter electrodes against conventional RF for treatment of AFL. METHODS: Patients presenting to our department with symptomatic, typical AFL were enrolled consecutively and randomized to conventional RF ablation with an 8-mm tip catheter (ConvRF) or a duty-cycled, bipolar-unipolar RF generator delivering power to a hexapolar tip-versatile ablation catheter (T-VAC) group. For both groups, the procedural endpoint was bidirectional cavotricuspid isthmus block. RESULTS: Sixty patients were enrolled, 30 patients each assigned to ConvRF and T-VAC groups. Total procedure time (40.2 ± 15.8 min vs 60.5 ± 12.7 min), energy delivery time (8.5 ± 3.7 min vs 14.7 ± 5.2 min), radiation dose (14.5 ± 3.5 cGy/cm² vs 31.7 ± 12.1 cGy/cm²), and the minimum number of RF applications needed to achieve block (4.2 ± 2.4 vs 8.9 ± 7.2) were significantly lower in the T-VAC group. In 7 patients treated with the T-VAC catheter, bidirectional block was achieved with less than 3 RF applications, versus no patients with conventional RF energy delivery. CONCLUSION: The treatment of typical AFL using a hexapolar catheter with a multipolar, duty-cycled, bipolar-unipolar RF generator offers comparable effectiveness relative to conventional RF while providing improved procedural efficiency.

Culture and healthcare in medical education: migrants' health and beyond.

One of the main challenges for teaching programs on immigration, ethnic diversity and health is to transform the commonplace notion of "culture" into a helpful tool for medical training and practice. This paper presents the teaching approach of an interdisciplinary course on "migrants' health" established at the University of Giessen since 2004, which has recently been complemented by a thematically related collaboration with two universities in Latin America (Ecuador, Peru). The overall goal is to translate the abstract philosophy of "think global and teach local" into medical practice, and to provide students with the insights, attitudes and skills needed for a fruitful use of concepts like "culture", "ethnicity" and "migration background". A key feature of the course is the strong commitment to ethnography as an important means for looking under the surface of superficial attributions to culture, and for grasping the interplay of medicine and health with cultural, social, religious, economic and legal aspects in its particular local and/or individual shape. Three elements of the course are presented to illustrate this approach: First, a unit on Islam and Medicine, as important parts of the local immigrant community are Muslims. The second one deals with psychosomatic aspects, because in case of immigrants, complex symptoms and disease representations like somatisation are easily misinterpreted as "cultural". The third element consists of a unit with specialized social workers form outside the university, who provide direct insights into the living conditions and health problems of local immigrant communities.

Magnetic resonance imaging in pancreas transplantation.

Magnetic resonance imaging (MRI) plays an important role in the evaluation of pancreas transplantation. Standard MRI, magnetic resonance angiography, and MR cholangiopancreatography can demonstrate the changes of the anatomy after transplantation. Vascular complications are assessed by MR angiography. Magnetic resonance cholangiopancreatography reveals ductal changes resulting from acute and/or chronic rejection and determines leaks with the use of a secretin-stimulated MR cholangiopancreatography. Serial contrast-enhanced MRI may detect the diminished perfusion that is related to the graft rejection or vascular complications. In this paper, we reviewed types of pancreas transplantation procedures, complications that arise in a short and/or a long term after the transplantation, and their assessment by MRI.

Nocturnal glucose metabolism after bedtime injection of insulin glargine or neutral protamine hagedorn insulin in patients with type 2 diabetes.

AIMS/HYPOTHESIS: Insulin glargine is a long-acting human insulin analog often administered at bedtime to patients with type 2 diabetes. It reduces fasting blood glucose levels more efficiently and with less nocturnal hypoglycemic events compared with human neutral protamine Hagedorn (NPH) insulin. Therefore, bedtime injections of insulin glargine and NPH insulin were compared overnight and in the morning. METHODS: In 10 type 2 diabetic patients, euglycemic clamps were performed, including [6,6'](2)H(2) glucose, to study the rate of disappearance (Rd) and endogenous production (EGP) of glucose during the night. On separate days at bedtime (2200 h), patients received a sc injection of insulin glargine, NPH insulin, or saline in a randomized, double-blind fashion. RESULTS: Similar doses of both insulins had different metabolic profiles. NPH insulin had a greater effect on both Rd and EGP in the night compared with insulin glargine. By contrast, in the morning, insulin glargine was more effective, increasing Rd by 5.8 micromol/kg(-1).min(-1) (95% confidence interval 4.7-6.9) and reducing EGP -5.7 (-5.0 to -6.4) compared with NPH insulin. Nearly 80% of the glucose lowering effect in the morning was due to insulin glargine's reduction of EGP. Its injection was associated with one-third lower morning glucagon levels compared with NPH insulin (P = 0.021). CONCLUSION/INTERPRETATION: Nocturnal variations of EGP and Rd explain the reduced incidence of hypoglycemia and lower fasting glucose levels reported for insulin glargine compared with human NPH insulin.

Prognostic value of heart rate variability after acute myocardial infarction in the era of immediate reperfusion.

INTRODUCTION: The incidence and significance of impaired heart rate variability (HRV) after acute myocardial infarction (AMI) have not yet been evaluated in cohorts of patients in whom early reperfusion was systematically attempted. Therefore, HRV was evaluated in 412 unselected patients with AMI (311 men, mean age: 60+/-12 years, anterior AMI in 172 patients) treated with direct coronary angioplasty (PTCA) within 12 hours of symptom onset (mean 3.5+/-2.0 h). Standard deviation of normal RR intervals (SDNN), square root of the mean of the sum of the squares of differences between adjacent RR intervals (RMSSD) and left ventricular ejection fraction (LVEF, mean: 55+/-15%) were measured 11+/-9 days after AMI before discharge. Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers were prescribed at discharge in 81.1% and 70.1% of patients, respectively. RESULTS: Mean SDNN was 94+/-30 ms (range 14-155). SDNN was <50 ms in 7% of patients. Mean RMSSD was 34+/-32 ms (range 2-234). RMSSD was <15 ms in 21% of patients. Low SDNN (<50 ms) was unrelated to gender, age, infarct location or extension of CHD but was related to low LVEF (p<0.001, logistic regression analysis). During mean follow-up of 4.3+/-3 years, there were 31 deaths; 24 were cardiac. SDNN was higher in long-term survivors (102+/-39 ms) as compared to nonsurvivors (81+/-33 ms, p=0.02) but RMSSD was unrelated to the long-term vital status. Four-year survival of patients with a SDNN <50 ms vs >50 ms was 80% vs 92%, respectively (p<0.001, Kaplan Meier analysis). Low SDNN (odds ratio OR=2.0, p<0.05) but not RMSSD was an independent denominator for long-term mortality as were low LVEF (OR=1.0 decrease in LVEF, p<0.01, proportional hazards model) and age (OR=1.1, p<0.001). Only 3/31 fatalities and 1/24 cardiac deaths were predicted by a SDNN <50 ms and only 5/31 fatalities by a RMSSD <15 ms. CONCLUSION: The incidence of severely depressed HRV in patients after AMI is low (<10%) in the era of early reperfusion of the infarct vessel using direct PTCA. Mortality in patients with a very low HRV when assessed by SDNN is substantial but the positive predictive value of this parameter is low.

Diagnosis of mixed Plasmodium malariae and P. vivax infection in a development aid volunteer by examination of bone-marrow specimens by real-time PCR.

Mixed Plasmodium malariae and P. vivax infections in humans are reported very infrequently. The case of a 27-year-old male who sustained malaria quartana/tertiana caused by an unbalanced mixed P. malariae-P. vivax infection is reported here. Conventional tests and serology for malarial parasites were uniformly negative. Identification and quantification of the parasites were accomplished by examining bone-marrow specimens using specific real-time TaqMan PCR.

A potential important role of skeletal muscle in human counterregulation of hypoglycemia.

CONTEXT: During hypoglycemia, systemic glucose uptake (SGU) decreases and endogenous glucose release (EGR) increases. Skeletal muscle appears to be primarily responsible for the reduced SGU and may be important for the increased EGR by providing lactate for gluconeogenesis (GN). OBJECTIVE: The objective of the study was to test the hypothesis that reduced muscle glucose uptake and increased muscle lactate release both make major contributions to glucose counterregulation using systemic isotopic techniques in combination with forearm net balance measurements. SETTING: The study was conducted at the University of Giessen Clinical Research Center. PARTICIPANTS: Nine healthy volunteers participated in the study. INTERVENTION: A 2-h hyperinsulinemic euglycemic clamp (blood glucose approximately 4.4 mm) was followed by a 90-min hypoglycemic clamp (blood glucose approximately 2.6 mm). RESULTS: Compared with the euglycemic clamp, SGU decreased (21.0 +/- 2.0 vs. 29.6 +/- 1.8 micromol.kg body weight(-1).min(-1); P < 0.001), whereas EGR (11.2 +/- 1.7 vs. 4.9 +/- 1.3 micromol.kg body weight(-1) .min(-1); P < 0.003), arterial lactate concentrations (1051 +/- 162 vs. 907 +/- 115 microm; P < 0.02), systemic lactate release (23.5 +/- 0.9 vs. 17.1 +/- 0.9 micromol.kg body weight(-1).min(-1); P < 0.001), and lactate GN (4.50 +/- 0.60 vs. 2.74 +/- 0.30 micromol.kg body weight(-1).min(-1); P < 0.02) increased during hypoglycemia; the proportion of lactate used for GN remained unchanged (38 +/- 4 vs. 32 +/- 3%; P = 0.27). Whole-body muscle glucose uptake decreased approximately 50% during hypoglycemia (6.4 +/- 1.9 vs. 13.6 +/- 2.9 micromol.kg body weight(-1).min(-1); P < 0.001), which accounted for approximately 85% of the reduction of SGU. Whole-body muscle lactate release increased 6.6 +/- 1.6 micromol.kg body weight(-1). min(-1) (P < 0.01), which could have accounted for all the increase in systemic lactate release and, considering the proportion of lactate used for GN, contributed 1.4 +/- 0.4 micromol.kg body weight(-1).min(-1) (approximately 25%) to the increase in EGR. CONCLUSIONS: Reduced muscle glucose uptake and increased muscle lactate release both make major contributions to glucose counterregulation in humans.