Complications Associated with Pectoral Implantation of Cardioverter Defibrillators

Pectoral placement of ICD pulse generators is now routine after downsizing of these devices. However, the safety of this approach is not well documented. The aim of this study was to evaluate complications in a large cohort of patients undergoing initial pectoral ICD implantation. The subjects for this study were 1,000 consecutive patients receiving a Medtronic Jewel ICD at 93 centers worldwide. Cumulative follow-up for all patients was 634 patient-years, with 64.9% of patients followed for 6 months or longer. The complications evaluated were erosion, pocket hematoma, seroma, wound infection, dehiscence, device migration, lead fracture, and dislodgment. In this series, 1.8% of patients experienced a pocket complication with only 3 (0.3%) erosions and 2 (0.2%) infections. Lead complications were observed in 2.1% of subjects, most commonly early dislodgment of the RV lead. We conclude that pectoral implantation of a downsized ICD system can be performed with a low rate of complications. However, careful attention to anchoring techniques and close early monitoring is important given the 1.7% rate of lead dislodgment that occurred primarily during the first month following implantation.     

Bidirectional Bundle Branch Reentry Tachycardia Associated with Ebstein's Anomaly: Cured by Extensive Cryoablation of the Right Bundle Branch

A 30-year-old woman with Ebstein's anomaly presented with a sustained, wide QRS complex tachycardia exhibiting a left bundle branch block morphology. Serial electrophysiological studies revealed right and left bundle branch reentry tachycardias refractory to many conventional antiarrhyfhmic drugs, Radiofrequency and direct current catheter ablation of the right bundle branch failed to control the tachycardias. The patient subsequently underwent extensive endocardial cryoablation to the right bundle branch resulting in cure of her arrhythmia.     

Institutional Switch from Transfemoral to Transradial Vascular Access for Percutaneous Coronary Intervention was Associated with a Reduction in Bleeding Events: A Singlecenter Experience of >10,000 Consecutive Cases

Background

Transradial (TR) access for percutaneous coronary intervention (PCI) reduces bleeding compared with transfemoral (TF) access, and may reduce mortality in specific patient subsets. However, switching from TF to TR access is associated with a learning curve and it is unclear whether benefits observed in randomized trials translate into practice. We sought to characterize the trends in bleeding and mortality rates at our institution, as we changed from being a TF to predominantly TR center over a 5‐year period.

Methods and Results

10,213 consecutive patients presenting for PCI were included (mean age 65.0 ± 11.6 years, 76.1% male, 48.0% PCI for acute coronary syndrome) over 5 years at a single center with PCI volume >2,000 cases per annum. Patients were stratified by initial arterial access site (TR or TF) and outcome measures included temporal trends in TR procedural failure, 30‐day bleeding complications and all‐cause 1‐year mortality. TR procedural failure fell to a consistently low rate within 1 year (11.8% in 2008 to 2.9% in 2009, P < 0.001). As TR volume increased, the annual 30‐day bleeding rate fell (1.64% in 2008 to 0.68% in 2012, P = 0.006). TR access predicted reduced 30‐day bleeding (OR 0.17 [95%CI 0.07–0.38], P < 0.001), but was not a predictor of 1‐year survival (HR 0.78 [95%CI 0.58–1.05], P = 0.10).

Conclusion

Successful transition from TF to TR PCI at our institution was rapid and associated with a reduction in 30‐day bleeding. These data should encourage other centers considering the adoption of TR access. (J Interven Cardiol 2015;28:296–304)

     

Follow-up of Gambian children recruited to a pilot safety and immunogenicity study of the malaria vaccine SPf66

A pilot safety and immunogenicity trial of the malaria vaccine SPf66 was undertaken in The Gambia in 1993. One hundred and fifty infants aged 6–11 months were immunized with either 0.5 mg or 1.0 mg of SPf66 produced either in Colombia or in the USA or with a control vaccine. Children who received SPf66 experienced more clinical attacks of malaria than did children in the control group during the first period of surveillance and the difference in incidence between children who had received high dose Colombian vaccine and the control children was statistically significant at the 5% level. During the 1995 malaria transmission season, 127 children from the original cohort of 150 were observed. During 18 weeks of intensive surveillance, the incidence of clinical malaria was again higher among children who had received SPf66 than among children who had received inactivated polio vaccine (6.23 vs 4.89 clinical attacks per 1000 days at risk), the effect being most marked among children who were in the high dose groups, but differences between groups were now no longer statistically significant .     

Extrahepatic Biliary Obstruction by Hepatocellular Carcinoma

An unusual case of hepatocellular carcinoma that presented as an obstructing intraluminal hepatic and common bile duct mass is reported.     

Anatomy of the Coronary Sinus and Epicardial Coronary Venous System in 620 Hearts: An Electrophysiology Perspective

Anatomy of the Coronary Venous System . Introduction: Cannulation of the coronary sinus (CS) is a prerequisite for left ventricular (LV) pacing and certain ablation procedures. The detailed regional anatomy for the coronary veins and potential anatomic causes for difficulty with these procedures has not been established. Methods and Results: Therefore, we performed macroscopic measurements in 620 autopsied hearts (mean age 60 ± 23 years, 44% female). The CS was preserved for analysis in 96%. Sixty‐three percent had a Thebesian valve that covered the posterior aspect of the CS ostium with extension to the superior (50%) and inferior aspects (18%) and was obstructive with fenestrations in 3 specimens. Partial or near occlusive valves were present occasionally at the ostium of the great cardiac vein (Vieussens; 8%) and middle cardiac vein (5%). Ninety‐three percent had left atrial branches, and 41% had at least one branch with lumen > 3 French. For CRT lead placement, the mid‐lateral LV was accessible from the middle cardiac vein (20%), the left posterior vein (92%) or the anterior interventricular vein (86%). Among specimens where the left phrenic nerve was preserved it crossed the LV mid‐lateral wall in 45%. Conclusions: Epicardial coronary vein anatomy is variable, and the mid‐lateral LV wall can potentially be accessed through various tributaries of the epicardial veins. The orientation of the Thebesian valve favors cannulation of the CS from an anterior (ventricular) and inferior approach. Anterobasal, mid‐lateral, and inferior apical LV coronary veins lie in proximity to the course of the phrenic nerve. (J Cardiovasc Electrophysiol, Vol. 24, pp. 1‐6, January 2013)