Inappropriate Discharges by the Implantable Cardioverter Defibrillator During Postoperative Testing: Implications for Intraoperative Assessment

Inappropriate shocks were delivered to a patient while in sinus rhythm by an implantable cardioverter defibrillator (ICD) during routine prehospital discharge testing. This was induced by the standard programmer when the "read" telemetry sequence was initiated. The ICD was removed and found to suffer from electrical artifact that was sensed as ventricular tachycardia during telemetry. To avoid inadvertent telemetry-induced shocks during routine testing, all ICDs should be interrogated, using a standard programmer, intraoperatively, with the unit in "defibrillation on" mode.     

Dual Sensor VVIR Mode Pacing: Is It Worth It?

Dual sensor ventricular demand rate responsive (VVIR mode) pacing was compared with single sensor rate responsive pacing to assess whether this new development should be more widely incorporated in modern pacemaker devices. A within patient randomized, double-blind crossover study involving ten patients, mean age 67.4 years (70% male), had Medtronic Legend Plus dual sensor VVIR pacemakers implanted for high grade A V block and chronic or persistent paroxysmal atrial fibrillation. Performance values were compared to 20 healthy control subjects of a similar age and gender. Patients were both subjectively and objectively assessed after 2 weeks of out-of-hospital activity in VVIR mode (minute ventilation sensing), VVIR mode (activity sensing), VVIR mode (dual sensor), and VVI mode (no rate response). All patients were assessed for subjective preference for, and objective improvement in, any pacing modality as assessed by standardized daily activity protocols and graded exercise treadmill testing. Subjective perception of exercise capacity and functional status was significantly lower in VVI mode (P < 0.05) compared to any of the VVIR modes, which did not differ. After completion of the study 70% of patients chose VVIR as their preferred mode, with 30% expressing no preference. Forty percent preferred activity sensor WIR mode pacing, 30% preferred dual sensor VVIR mode pacing, and 70% found either dual sensor WIR mode, minute ventilation sensor WIR mode, or both modalities least acceptable. No patient found activity sensing WIR mode least acceptable. Graded treadmill testing revealed significantly lower exercise tolerance during WI mode pacing (P < 0.01) compared to the VVIR modalities, which did not differ. Overall, chronotropic response was best with dual sensor pacing during standardized daily activity protocols and during the standard car journey. The data from this study suggest that there is no marked clinical advantage obtained from the use of dual sensor devices over current activity sensing ventricular demand rate responsive pacemakers, but with the probable added disadvantages of increased size, complexity, cost, and decreased longevity.     

Pacemaker Upgrade for Recurrent Pacemaker Syndrome Using a Redundant Contralateral Electrode in a Patient with Bilateral Venous Stenoses

Following His-bundle ablation and VVIR pacemaker implantation, severe Pacemaker syndrome developed and was treated with DDDR pacing in a 70-year-old woman. Due to bilateral subclavian vein stenosis, DDDR pacing could not be maintained and an unusual method of restoring atrioventricular synchrony is described using the contralateral redundant atrial electrode connected to the ipsilateral dual chamber pacemaker and ventricular electrode.     

Twister

A 75-year-old male presented with an extensive anterior myocardial infarction. He underwent primary coronary angioplasty to the proximal left anterior coronary artery, which was successful and uncomplicated. Several days later he sustained a cardiac arrest and was successfully resuscitated. An electrophysiological study revealed inducible ventricular tachycardia. An automatic implantable cardioverter defibrillator (ICD) was placed in a subcutaneous abdominal position. After the device was implanted, the patient developed pneumonia and a hematoma in the generator pocket.     

Human peritoneal B-1 cells and the influence of continuous ambulatory peritoneal dialysis on peritoneal and peripheral blood mononuclear cell (PBMC) composition and immunoglobulin levels

In mice, peritoneal B cells are composed of a unique B-1 cell population which can repopulate the intestinal lamina propria with IgA-producing cells, as well as contribute to the majority of serum IgM. In this study, peritoneal lymphocytes from patients starting continuous ambulatory peritoneal dialysis (CAPD) and from women undergoing bilateral tubal ligation (BTL) were analysed for the presence of a B-1 cell population as well as the expression of potential homing receptors. Up to 63% of the peritoneal B cells express surface antigen CD5, and most peritoneal lymphocytes express the mucosal homing receptors, α4β7 and αEβ7. When analysing serial samples collected from patients from the beginning of dialysis to 1 year, no marked changes were observed in serum or salivary immunoglobulin levels, although the peritoneal lymphocyte population was reduced by 50%. These data suggest that the phenotype of human peritoneal B-1 cells is similar to that of mice, but the contributions to the immune system may differ.