Risultati per: Il pacemaker si ricarica con il battito del cuore

Circulation, Volume 148, Issue Suppl_1, Page A14137-A14137, November 6, 2023. Stress-induced cardiomyopathy (SCMP) after permanent pacemaker (PPM) implantation is rare. Here, we report an additional case which was initially misdiagnosed as another disease due to atypical symptoms after PPM implantation.Case presentation:A 79-year-old woman with dizziness and dyspnea for one month visited Cardiology Department. She had a history of hypertension, dyslipidemia, diabetes-mellitus and stage IV chronic kidney disease. We confirmed complete atrioventricular block. Left ventricular ejection fraction (LVEF) was normal. PPM implantation was successfully performed without complications. The next day she felt very well with no symptoms. On the second day, she suddenly developed a fever and complained severe left neck pain. She had cough, sputum and general weakness without chest pain. C-reactive protein level increased and systolic blood pressure was decreased. We started antibiotics considering infection. We also checked implantation site, but there were no signs of infection. On the third day, echocardiography showed decreased LVEF (30%), akinesia of apical and medium segments of LV wall with preserved kinetics of basal segments without pericardial effusion (Figure 1). There was no significant stenosis on coronary angiography and we confirmed SCMP. After few days, her blood pressure and symptoms were improved. We prescribed sacubitril-valsartan, bisoprolol and furosemide. At 10 days after implantation, she was discharged with improved symptoms.Conclusion:Our case emphasizes that even successful implantation of PPM without complications can be a potential risk of SCMP. In the absence of typical cardiac symptoms after PPM implantation, a poor general condition may also be considered as a sign of SCMP. Therefore, it is necessary to monitor the patient for at least three more days after PPM implantation.

Circulation, Volume 148, Issue Suppl_1, Page A18510-A18510, November 6, 2023. Background:The new Aveir VR (Abbott Medical, CA) active-fixation leadless pacemaker (LP) is the second LP system to become available in the United States after the Micra (Medtronic, MN) and offers design improvements over its predecessor, the Nanostim. It uses a unique mapping capability to help reduce repositioning attempts prior to fixation and utilizes a helical fixation mechanism for implantation and chronic retrieval. We describe the current largest real world descriptive single center experience with the new Aveir VR LP.Method:We describe characteristics and outcomes of patients who underwent implantation with the single chamber Aveir VR between May 2022 and June 2023. Data was collected from electronic medical records, and procedural logs. Variables collected included demographics (eg age, sex, race), procedural characteristics (e.g., procedure length, fluoroscopic duration), hospital length of stay and time to discharge, pacing parameters and complications.Results:A total of 88 patients underwent implantation with the single chamber Aveir VR. The most common indications were symptomatic bradycardia due to sinus node dysfunction (50%), atrioventricular block (34%), and atrial fibrillation with bradycardia (12.5%). Average age was 73.4 years, 52.3% were male, and 53.4% were African Americans. The median procedure duration was 83 minutes (range 36 – 298) and median fluoroscopy time was 10.3 minutes (range 1.4-41.6). Procedure duration improved from a median of 97.5 minutes in the first 10 cases to a median time of 64.5 minutes in the last 10 cases. The average number of mapping locations was 1.7, implant location was RV Apical Septum in 92% of patients, and 0.1% of patients required repositioning. The average R wave amplitude at implant was 7.3 mV (range 2.5-18 mV), average impedance was 763 Ω (range 310-1800), and average pacing threshold was 0.99V (range 0.25-4.5) at 0.4ms. There were no periprocedural complications with any of the implantations. The median hospital length of stay was 5.75 days (range 0.25-77.5), with median time from implant to discharge in elective patients of 50.5 hours.Conclusion:Our experience demonstrates that implantation of the single chamber Aveir VR LP to be safe and effective, comparable to trial data.

Circulation, Volume 148, Issue Suppl_1, Page A13515-A13515, November 6, 2023. Background:BLOCK HF study demonstrated that biventricular pacing was superior to conventional right ventricular pacing in heart failure (HF) patients with atrioventricular (AV) block. An adaptive cardiac resynchronization therapy algorithm (aCRT) provides continuous pacing timings of AV delays based on periodic automatic evaluation of electrical conduction even in the patients with AV block, and is effective in patients with CRT devices. However, it is uncertain whether this algorithm has better benefits even in patients with pacemaker dependency.Methods:Between Jan/2016-Dec/2022, a total of 359 patients were implanted CRT devices. Pacemaker-dependent CRT patients with aCRT algorithm function were selected from them. Sixty-five patients with pacemaker dependency (31 patients using the aCRT algorithm [adaptive group] and 34 patients not using the aCRT algorithm [non-adaptive group]) were included in the analysis. Pacemaker dependency was defined as absence of spontaneous ventricular activity during sensing test at VVI 30 bpm or long atrioventricular delay ( >300ms). The primary endpoint was a composite clinical outcome of all cause death and/or HF hospitalization.Results:There were no significant differences in baseline characteristics between two groups. During a median follow-up of 1,067 days (interquartile range 553-1,776 days), the aCRT reduced the risk of the composite clinical outcome in patients with pacemaker dependency (log-rank P=0.0187, Figure). In addition, use of the aCRT algorithm was an independent predictor of the composite clinical outcomes in the multivariate analysis (hazard ratio 0.32, 95% confidence interval: 0.12-0.88, P=0.028).Conclusions:The aCRT algorithm was useful and significantly reduced the risk of the clinical outcome, even in patients with pacemaker dependency.

Circulation, Volume 148, Issue Suppl_1, Page A18597-A18597, November 6, 2023. Introduction:Obstructive sleep apnea (OSA) is associated with cardiovascular (CV) morbidity and mortality ranging from asymptomatic bradycardia to sudden death. Studies have shown that sleep-related bradyarrhythmias, decrease with continuous positive airway pressure (CPAP) and are unlikely to develop symptomatic bradycardia in the long-term. AHA/ACC/HRS recommends to evaluate and treat suspected or documented conduction disorder during sleep including patients who have received or are being considered for permanent pacemaker (PPM).ObjectiveWe aim to examine the number of sleep studies and CPAP performed and address the barriers of under-diagnosis and treatment with post intervention quality improvement initiative.Methods:We performed retrospective analysis of patients >18 years admitted for elective PPM placement from 01/10/2021-01/01/2023. Categorical variables were reported as number and percent and numerical variable was reported as mean. Multiple logistic regression was used to identify predictors for compliance and sleep study prescription. All statistical analyses were performed with SAS software, version 9.4.ResultsOf 423 patients, mean age was 78.1 years, 56.50% were males, 96.9% were Caucasians and mean BMI was 30.1 kg/m2. Only 34.75 % (N= 147/423) received sleep study. 93.2% (N=137/147) were diagnosed with OSA and 82.9% (N=122/137) were treated with CPAP. Only 63.1% were compliant with CPAP. Males were more complaint with CPAP [OR 3.13 (95% CI 1.36-7.18, p=0.0072)]. Mean BMI at OSA diagnosis was 33.7 kg/m2and 30.1 kg/m2at PPM implantation. Weight loss was noted but most patients remained obese. Males, age ≥80 and obesity were significant predictors to get sleep study. After study outcomes, we adopted a standardized algorithm for risk assessment, incorporated EHR reminder and educated doctors. The intervention is currently ongoing.ConclusionData on underutilization of sleep study helped us to work with administration to produce a protocol for screening high risk patients. Treating sleep apnea not only alleviates apnea-related symptoms but also improves CV outcome by avoiding unnecessary pacemaker implantation and minimizing unnecessary health care cost. If effective, this strategy can be a model for other hospitals.

Circulation, Volume 148, Issue Suppl_1, Page A15554-A15554, November 6, 2023. Introduction:Around one in five patients with atrial fibrillation (AF) has a diagnosis of sinus node dysfunction (SND).Hypothesis:There will be lower incidence of pacemaker implantation (PPM) among patients with AF and SND who undergo catheter ablation (CA) compared to anti-arrhythmic drugs (AAD).Methods:Data were collected from 2014-2022 utilizing Optum Clinformatics database, an administrative claims database for commercially insured and Medicare Advantage beneficiaries in the United States. Adult patients with concomitant AF and SND, and prior history of taking at least one AAD were identified and classified into CA or AAD cohort based for subsequent treatment. Patients were excluded if they had a prior history of PPM, implantable cardiac defibrillator, catheter or surgical ablation, AV nodal ablation, valvular procedure, left atrial appendage occlusion, or high grade/complete heart block. Inverse probability treatment weighting technique was applied to balance sociodemographic and clinical comorbid characteristics between the cohorts. Weighted Cox regression model was used to evaluate the differential risk of incident PPM. Sub-analyses were performed by AF type (paroxysmal and persistent AF).Results:There were 1,206 patients in AAD cohort and 1,624 patients in CA cohort. Incidence rate (per 1,000 person-year) of PPM was 55.8 (95% CI 47.1-64.5) for CA cohort and 117.8 (95% CI 101.7-133.9) for AAD cohort and the 3-year cumulative incidence of PPM was 23.1% (95% CI 20.0%-26.2%) and 13.8% (95% CI 11.6%-15.9%), respectively. Weighted Cox regression model indicated that CA had 43% lower risk of incident PPM compared to AADs (hazard ratio [HR] 0.57; 95% CI 0.46-0.71). Those with paroxysmal AF (HR 0.48; 95% CI 0.34-0.69) had lower need for PPM compared to persistent AF (HR 0.57; 95% CI 0.40-0.81).Conclusions:Patients with AF and SND treated with CA were observed to have significantly lower risk of incident pacemaker implantation compared to those who had AAD.

Circulation, Volume 148, Issue Suppl_1, Page A14956-A14956, November 6, 2023. Background:The outcomes of leadless pacemaker (LP) implantation after transvenous lead removal (TLR) of infected cardiac implantable electronic devices (CIED) are not well-established.Objective:This study sought to describe the outcomes of LP implantation following TLR of infected CIED.Method:We conducted a literature search using PubMed and Embase for a combination of term includingleadless pacemaker implantation,transvenous lead extraction, transvenous lead removal,transvenous lead explant,infected cardiac implantable electronic device. The inclusion criterion was LP implantation after TLR of infected CIED. The exclusion criterion was TLR for non-infectious reason. Study end-points were procedural complications and LP infection.Result:Of 132 publications reviewed, 13 studies with a total of 253 patients (74 ± 14 years of age, 69% males) were included. Amongst, 56.8% had systemic CIED infection and 43.2% had isolated pocket infection.Staphylococcus Aureuswas the most common causative organism in 33% of the reported patients. Of 253 patients included, 105 patients (41.5%) underwent concomitant LP implantation during TLR procedure, and 36 patients (14.2%) had transvenous pacing as a bridge from TLR to LP implantation. During the LP implantation, 1 patient (0.4%) had an intra-procedural complication requiring sternotomy. Post-LP implantation, 2 patients (0.8%) developed groin hematoma, 2 patients (0.8%) developed femoral arteriovenous fistula, and 1 patient (0.4%) developed pericardial effusion requiring pericardiocentesis. During a mean follow-up of 11.3 ±10.6 months, 3 patients (1.2%) developed pacemaker syndrome, 1 patient (0.4%) developed acute on chronic heart failure exacerbation, and only 1 patient (0.4%) developed LP-related infection requiring LP retrieval.Conclusion:This study suggests that LP implant is feasible and safe post-removal of infected CIED with cumulative adverse events at 4% and a reinfection rate of 0.4%.

Circulation, Volume 148, Issue Suppl_1, Page A18348-A18348, November 6, 2023. Introduction:Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy where local deposition of amyloid fibrils causes heart failure, arrhythmias, and conduction system abnormalities. Involvement of the AV nodal and infra-hisian conduction system increases the need for a permanent pacemaker (PPM). Studies have noted worse outcomes in patients with implantable-cardioverter defibrillator placement in amyloidosis, but a comparison with PPM is lacking. We sought to analyze readmissions in CA patients following PPM placement utilizing National Readmission Database (NRD).Methods:NRD (2016 to 2020) was queried to identify adults with a diagnosis of CA who underwent PPM implantation using ICD-10 CM and PCS codes. The primary outcome was a 30-day readmission rate. Secondary outcomes were in-hospital mortality, length of stay (LOS), total hospital charge (THC), and predictors of readmission. Multivariate/univariate logistic and linear regression analyses were used to analyze the outcomes and adjust for possible confounders.Results:A total of 1,027 encounters of CA who underwent PPM were identified, of which 975 were discharged alive. Within 30 days from discharge, 141 (14.5%) were readmitted. Those readmitted had a longer LOS and higher burden of comorbidities while were similar in age, sex, hospital characteristics, and household income status. Readmissions lead to an additional mean THC of $55,079 and a mean LOS of 6.3 days. The top five causes of readmissions were heart failure (23%), sepsis (6.6%), hypertensive heart disease (4%), bradycardia (3.5%), and acute kidney injury (3.2%). Figure-1 shows the forest plot of a multivariate analysis of independent factors associated with readmissions.Conclusions:Our findings show that up to 15% of patients with CA who undergo PPM implantation get readmitted with heart failure being the most common etiology. Optimizing comorbidities with PPM implantation in CA may provide better outcomes and reduce admissions.

Circulation, Volume 148, Issue Suppl_1, Page A15258-A15258, November 6, 2023. Introduction:The His Bundle-Ventricular (HV) interval is a measure of the conduction time between the bundle of His and the ventricular myocardium and has been shown to predict atrioventricular block (AV) in patients with conduction disease. Routine HV interval measurement during electrophysiology (EP) studies affords an opportunity to assess the utility of the HV interval as a marker for future conduction disease in a broader sample.Methods:We analyzed consecutive EP studies from over 600,000 primary care and cardiology patients in the Mass General Brigham network. We assessed associations between HV interval and incident pacemaker (PPM) implantation in Cox proportional hazard models adjusted for age, sex, hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, heart failure, atrial fibrillation, and stroke. Person-time began 30 days after index EP study to exclude PPM implant triggered by study findings. Cumulative risk was plotted using Kaplan-Meier curves and the functional form of the relationship between HV and PPM was fit using multivariable-adjusted splines.Results:Of 22,019 individuals with at least one EP report, we identified 3,283 patients (age 61.1±13.6, 63% male, 91.6% White) with an HV interval measurement. In multivariable-adjusted models, a longer HV interval was associated with increased risk of PPM implant (hazard ratio [HR] 1.24 per 10ms increase, 95% CI 1.08-1.43). When assessed at binary cutoffs, there were progressively larger increases in risk of incident PPM implantation (HV ≥55: HR 1.94 (1.28-2.93); HV ≥70: HR 2.18 (1.04-4.56); HV ≥100: HR 7.75 (2.18-27.5)). PPM implant risk increased linearly until 90ms, above which risk increased sharply (Figure).Conclusions:Among patients undergoing EP study, a prolonged HV interval was a strong risk marker for incident PPM implantation. Patients found to have a prolonged HV interval during EP study merit close observation for the development of overt conduction disease.

Circulation, Volume 148, Issue Suppl_1, Page A14849-A14849, November 6, 2023. Background:During Micra leadless pacemaker (LP) implantation, continuous heparin is infused to prevent thrombus within the sheath and on the device. Early guidance from the manufacturer (Medtronic) recommended an initial systemic heparin bolus to further prevent thrombus formation. However, systemic heparin may increase the risk of implant complications. Thus, many operators have moved away from routine boluses. However, there is a paucity of data on the impact of heparin bolus on outcomes.Methods:We reviewed all Medtronic Micra LP implants at our institution from 9/2014 to 9/2022. The decision to bolus with heparin was at the operator discretion.Results:Among 621 LP implants, 326 received a heparin bolus, 243 did not, and 52 patients had unknown bolus status. In the cohort, 50.4% were men. Mean age at implant was 76.8 ± 14.9 years. Mean follow up was 1.7 ± 1.4 years. There were no significant differences in device electrical parameters (R wave sensing, impedance, and capture thresholds), right ventricular pacing burden (RVP), or left ventricular ejection fraction (LVEF) comparing heparin bolus vs. no bolus at both initial interrogation and long-term follow up (Figure). There was no difference between groups in the number of attempted device deployments per implant procedure (1.42 ± 0.81 vs 1.31 ± 0.66, p=0.15). Implant-related adverse events were also similar between bolus and no-bolus groups: access-site hematoma (5 vs 7, p=0.99), pseudoaneurysm (1 vs 1, p=0.99), cardiac perforation (1 vs 1, p=0.99), 30-day re-hospitalization (15 vs 21, p=0.98) and 30-day all-cause mortality (14 vs 16, p=0.57). There was 1 additional non-fatal cardiac perforation in a patient with unknown bolus status.Conclusion:Routine systemic bolus of heparin can be safely omitted in appropriately selected patients undergoing LP implant. Heparin bolus may still be considered in long cases requiring multiple device deployments or in patients with high risk for thrombotic complications.

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