Complications of Third-Generation Implantable Cardioverter Defibrillator Therapy

To determine the incidence of complications of third-generation implantable cardioverter defibrillator (ICD) therapy, 144 patients were prospectively studied who underwent first implant of third-generation devices (i.e., ICD systems with biphasic shocks, ECC storage capability, and nonthoracotomy lead systems). During 21 ± 15 months of follow-up, 41 (28%) patients had one or more complications. No patient died perioperatively (30 days) and no ICD infection was observed during follow-up. Complications included bleeding or pocket hematoma (hemoglobin drop > 2 g/dL) in 5 (3%) patients, prolonged reversible ischemic neurological deficit in 1 (1%) patient, postoperative deep venous thrombosis of leg in 1 (1%) patient, pneumothorax in 2 (1%) patients, difficulty to defibrillate ventricular fibrillation intraoperatively in 2 (1%) patients, generator malfunction in 1 (1%) patient, arthritis of the shoulder in 3 (2%) patients, and allergic reaction to prophylactic antibiotics in 2 (1%) patients. A total of seven lead related complications were observed in six (4%) patients including endocardial lead migration in four (3%) patients. Twenty-three (16%) patients received inappropriate shocks for supraventricular tachyarrhythmias (n = 13), non-sustained ventricular tachycardia (VT) (n = 7), or myopotential oversensing (n = 3). We conclude that serious complications such as perioperative death or ICD infection are rare in patients with third-generation ICDs. Lead-related problems and inappropriate shocks during follow-up are the most frequent complications of third-generation ICD therapy. Recognition of these complications should promote advances in ICD technology and management strategies to avoid their recurrence.     

Cardiovascular responses during effortful active coping and acute experience of anger in women

This study addresses the question of whether effortful active coping and anger provocation add in their effects on cardiovascular responses. Heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) responses of 64 female students were collected during an active versus nonactive coping task with and without provocation. After a baseline period, women did mental arithmetic (active coping) or read numbers aloud (nonactive coping). Half of each group was then additionally provoked. Ratings of the emotional states (Positive and Negative Affect Scale) indicate that provocation led to an increase in anger, but not in fear or negative or positive affect. Effortful active coping and provocation elevated cardiovascular activity. Although active coping enhanced all cardiovascular variables, provocation particularly affected HR and DBP. The effects of active coping and provocation on HR and DBP but not on SBP were additive and probably were produced by different physiological mechanisms.     

Enhanced Detection Criteria in Implantable Cardioverter Defibrillators: Sensitivity and Specificity of the Stability Algorithm at Different Heart Rates

KETTERING, K., et al. : Enhanced Detection Criteria in Implantable Cardioverter Defibrillators: Sensitivity and Specificity of the Stability Algorithm at Different Heart Rates. Sensitivity and Specificity of the Stability Algorithm at Different Heart Rates. The lack of specificity in the detection of ventricular tachyarrhythmias remains a major clinical problem in the therapy with ICDs. The stability criterion has been shown to be useful in discriminating ventricular tachyarrhythmias characterized by a small variation in cycle lengths from AF with rapid ventricular response presenting a higher degree of variability of RR intervals. But RR variability decreases with increasing heart rate during AF. Therefore, the aim of the study was to determine if the sensitivity and specificity of the STABILITY algorithm for spontaneous tachyarrhythmias is related to ventricular rate. Forty‐two patients who had received an ICD (CPI Ventak Mini I, II, III or Ventak AV) were enrolled in the study. Two hundred ninety‐eight episodes of AF with rapid ventricular response and 817 episodes of ventricular tachyarrhythmias were analyzed. Sensitivity and specificity in the detection of ventricular tachyarrhythmias were calculated at different heart rates. When a stability value of 30 ms was programmed the result was a sensitivity of 82.7% and a specificity of 91.4% in the detection of slow ventricular tachyarrhythmias (heart rate < 150 beats/min). When faster ventricular tachyarrhythmias with rates between 150 and 169 beats/min (170–189 beats/min) were analyzed, a stability value of 30 ms provided a sensitivity of 94.5% (94.7%) and a specificity of 76.5% (54.0%). For arrhythmia episodes ≥ 190 beats/min, the same stability value resulted in a sensitivity of 78.2% and a specificity of 41.0%. Even when other stability values were taken into consideration, no acceptable sensitivity/specificity values could be obtained in this subgroup. RR variability decreases with increasing heart rate during AF while RR variability remains almost constant at different cycle lengths during ventricular tachyarrhythmias. Thus, acceptable performance of the STABILITY algorithm appears to be limited to ventricular rate zones < 170 beats/min.     

Depression: Does nutrition have an adjunctive treatment role?

Depression is a serious illness, affecting more than one million Australians each year. It causes significant morbidity and is a major risk factor for deliberate self‐harm and suicide. Depression was traditionally viewed as a personality weakness, for which few treatment options were available. The simplistic view that depression is a personality weakness has changed in recent times. Depression is now widely recognised as a mood disorder with underlying biological (biochemical and genetic) and psychosocial causes and as such is responsive to a number of different treatments. The aim of the present paper is to review the literature related to dietary manipulation and how manipulation may assist in treating this illness. Evidence reviewed supports a potential therapeutic benefit of n‐3 polyunsaturated fatty acids for the alleviation of negative symptoms associated with depression. Omega‐3 polyunsaturated fatty acids, optimal omega balance, folate, tryptophan, vitamin B₆, B₁₂, S‐adenosyl‐L‐methionine and Hypericum perforatum may all serve as adjuncts to psychosocial and pharmacological therapies, with positive implications for long‐term prognosis.     

Impedance Rise, Only Clue to Severe Insulation Damage in a Transvenous Single-Lead AICD-System

We report a case of severe insulation damage 10 months after implantation of a fourth-generation single-lead implantable cardioverter defibrillator in a 45-year-old patient with dilative cardiomyopathy. The measured impedance was > 2000 Ohm and decreased to < 100 Ohm after sligbt pressure was applied to the device. All other parameters including intracardiac ECGs and markers were normal. Despite this delicate finding operative exploration revealed severe insulation damage of the pace-sense arm of the plug and insulation loss proximal to the distal coil of the lead.     

Value of Time- and Frequency-Domain Analysis of Signal-Averaged Electrocardiography for Arrhythmia Risk Prediction in Idiopathic Dilated Cardiomyopathy

Signal-averaged electrocardiography (SAECG) was performed in 120 consecutive patients with idiopathic dilated cardiomyopathy (IDC), and in 60 healthy controls. Time-domain analysis of SAECGs revealed ventricular late potentials in 27 of 120 patients with IDC (23%) compared to 2 of 60 controls (3%; P < 0.05). Frequency-domain analysis of SAECGs showed ventricular late potentials in 9 of 120 patients with IDC (8%) compared to none of the 60 controls (0%, P < 0.05). During a prospective follow-up of 15 ± 7 months, serious arrhythmic events, defined as sustained ventricular tachyarrhythmias or sudden death, occurred in 17 of 120 patients with IDC (14%). The sensitivity, specificity, and positive and negative predictive values of ventricular late potentials for serious arrhythmic events were 35%, 80%, 22%, and 88% for the time-domain analysis, and 18%, 94%, 33%, and 87% for the frequency-domain analysis of SAECG, respectively. Thus, neither the time- nor the frequency-domain analysis of SAECG appears to be useful for risk stratification in the setting of IDC in view of their low sensitivity and low positive predictive value for serious arrhythmic events during follow-up.     

Intestinal and systemic humoral immunological events in the susceptible Balb/C mouse strain after oral administration of Echinococcus multilocularis eggs

The aim of the study was to investigate the systemic and, for the first time, the intestinal humoral events in the susceptible Balb/C mouse strain after oral administration of Echinococcus multilocularis eggs. Thirty-one mice were divided into three groups; W-2 , W-8 and control group. Each mouse of the W-2 and W-8 groups was orally infected with 1,500 E. multilocularis eggs, two weeks and eight weeks before sacrifice respectively. Control group mice received phosphate buffer saline. Measurement of anti- E. multilocularis and non-specific IgG, IgA and IgM, and of a transudation marker, albumin, were performed in serum and intestinal washings by a time-resolved immunofluorometric assay. These results were complemented by microscopic examination of the intestinal mucosa. This infection model is well-suited to the study of mucosal immunity during alveolar echinococcosis. It showed a major specific intestinal response in the early stage of the disease whereas the systemic response predominated later in the disease. Histopathological studies and calculation of the relative coefficient of excretion of Ig also confirmed that the presence of the parasite, even during a short period, was responsible for a local immunological and inflammatory response and for a change in mucosal permeability. Mucosal immunity could thus play a role in tolerance induction against E. multilocularis that could be a prerequisite for the subsequent development of the larvae in the liver, and for the occurrence of the parasitic disease, alveolar echinococcosis .     

Longitudinal Deformation of Contemporary Coronary Stents: An Integrated Analysis of Clinical Experience and Observations from the Bench

Objective: To report clinical experience with longitudinal stent deformation (LSD) and observations from the bench. Background: LSD was recently reported with thin‐strut coronary stents. Whether it is related to a particular stent or constitutes a class‐effect remains debatable. Methods: After 2 cases of LSD were reported, information was sent to operators to warn of this event and identify possible cases. All cases were reviewed to ensure LSD had occurred. Simultaneously, bench testing was conducted to identify the susceptibility of stents to longitudinal compression and whether LSD detection is influenced by fluoroscopic stent visibility. Results: Between July 2010 and November 2011, 2,705 coronary interventions were performed with 4,588 stents (Promus Element = 41.6%, Xience Prime = 24.4%). Six patients with LSD were identified, all with Promus Element (0.31%). Wire bias was a predisposing factor in 4 cases. All patients were treated with postdilatation and/or additional stenting. No adverse events occurred (mean 5.8 months). In bench testing, LSD occured in all examined stents, but at different levels of applied force (weight). Most shortening at 50 g was observed with Promus Element (38.9%), as was the best visibility of LSD on x‐ray images. With postdilatation all stents showed some re‐elongation. Conclusion: In our practice LSD was a rare observation only seen with the Promus Element stent. When subjected to longitudinal compression in a bench test all contemporary stents can be compressed. Compression of Promus Element occurs at a lower force, but it is the only stent where deformations are detected with x ray. Postdilatation can partially improve LSD. (J Interven Cardiol 2012;25:576–585)     

HLA B27 and defects in the T-cell system in Whipple''s disease

The cellular immune system was tested in nine patients with Whipples' disease. Three patients had active disease, and six had been in remission for up to 10 years. Intradermal delayed hypersensitivity reactions to candidin, trichophytin, tuberculin and varidase, T-cell counts as determined by E-rosettes, allogeneic stimulation of lymphocytes in the mixed lymphocyte culture, and mitogenic activation of lymphocytes by concanavalin A, phytohaemagglutinin and by pokeweed mitogen, were tested in the patients and compared with control subjects. HLA typing was performed in all patients. The reaction to tuberculin and varidase, the T-cell counts and the activation of lymphocytes by concanavalin A were significantly reduced in patients with active disease and in patients during remission. The reaction to candidin and trichophytin was poor even in the controls. The mean results of the mixed lymphocyte culture, phytohaemagglutinin, and pokeweed mitogen activation tests were not significantly different from the controls. In patients with active disease the mixed lymphocyte culture reaction and the T-cell counts were less than in patients in remission. The results suggest a persistent defect of T-cells in patients with Whipple's disease, a defect that is more severe in patients with active disease. The finding of HLA B27 in four of thenine patients supports the hypothesis of primary rather than secondary impairment of the cellular immune system in Whipple's disease.