Where should the implantable ECG event recorder be placed?

Aim of our study was the comparison of bipolar ECG quality (with a 4 cm lead distance) at different sites within the anterior thorax to find the preferable implantation site for an ECG event recorder (ECG-ER). In 70 patients a bipolar ECG with a short electrode distance and in the vertical position was registered at the following sites: left and right subclavicular, left and right parasternal (4th-5th ICR), left and right anterior axilla (4th-5th ICR), at the heart apex and subxiphoidal. Then it was compared to the standard lead II. In 34 patients, an additional comparison between vertical and horizontal ECG registration was performed at the above mentioned sites. During implantation of an ECG-ER in 5 patients, ECG signals were compared with electrodes placed towards the skin or towards the muscle. The best ECG quality (greatest QRS amplitude, visible P-wave and pacemaker spike, measurable QT period and bundle-branch block) and the best agreement with standard lead II was found in 67% left parasternal, significant less often (p < 0.001) right parasternal (14.3%), left subclavicular (7.1%), apical (5.7%), and subxiphoidal (4.3%). In a vertical electrode position a significantly higher QRS amplitude and a more often visible P wave was found in comparison to a horizontal electrode position. In all cases, there was good agreement between bipolar surface ECG at the implantation site and ECG-ER stored signals. When the ECG-ER is positioned with electrodes towards the muscle, significant noise-signal occurred in all 5 patients. Only in 3 patients was a P wave visible, but with a slightly greater QRS amplitude than in ECG-ERs positioned with electrodes towards the skin. From these results, it is recommended to implant ECG-ERs vertically with electrodes towards the skin and in the parasternal position.     

Self-terminating ventricular fibrillation recorded by an implantable loop recorder as a cause of syncope – A case report

Ventricular fibrillation (VF) is the most common arrhythmia leading to sudden cardiac death, but in rare cases VF can manifest as a syncope, provided that it will self-terminate. We present a case of a 45-year old female with a history of unexplained syncopal episodes despite exhaustive diagnostics. Implantable loop recorder documented an episode of idiopathic, self-terminating VF as a cause of syncope.     

Neurological syndrome after R-CHOP chemotherapy for a non-Hodgkin lymphoma: what is the diagnosis?

A 63-year-old man was admitted to our Oncology department for management of a follicular non-Hodgkin lymphoma, stage IV A FLIPI 5. The patient entered chemotherapy following the R-CHOP schedule, and a PET scan after three cycles showed partial remission. One week later he was admitted to our hospital after developing serious pain in his left arm resulting in an impaired function, right facial hemiplegia, and ophthalmoplegia. Neuroimaging studies and laboratory features were negative. Given his symptoms, we suspected Miller Fisher syndrome and the patient was administered high dose immunoglobulin, but showed no improvement. Finally, chemotherapy with methotrexate 3 g/mq was initiated, but his condition progressively worsened and the patient died 2 months later. We suggest that any patient with neurological symptoms who has received rituximab should undergo PCR analysis for all neurotropic viruses together with neurophysiological and neuroimaging studies.