Impact of Right Ventricular Dysfunction on Outcomes After Transcatheter Edge-to-Edge Repair for Secondary Mitral Regurgitation

ObjectivesThis study sought to assess the impact of right ventricular dysfunction (RVD) as defined by impaired right ventricular-to-pulmonary artery (RV-PA) coupling, on survival after edge-to-edge transcatheter mitral valve repair (TMVR) for severe secondary mitral regurgitation (SMR).BackgroundConflicting data exist regarding the benefit of TMVR in severe SMR. A possible explanation could be differences in RVD.MethodsUsing data from the EuroSMR (European Registry on Outcomes in Secondary Mitral Regurgitation) registry, this study compared the characteristics and outcomes of SMR patients undergoing TMVR, according to their RV-PA coupling, assessed by tricuspid annular plane systolic excursion-to-systolic pulmonary artery pressure (TAPSE/sPAP) ratio.ResultsOverall, 817 patients with severe SMR and available RV-PA coupling assessment underwent TMVR in the participating centers. RVD was present in 211 patients (25.8% with a TAPSE/sPAP ratio <0.274 mm/mm Hg). Although all patients demonstrated significant improvement in their New York Heart Association (NYHA) functional class, there was a trend toward a lower rate of NYHA functional class I or II among patients with RVD (56.5% vs. 65.5%, respectively; p = 0.086) after TMVR. Survival rates at 1 and 2 years were lower among patients with RVD (70.2% vs. 84.0%, respectively; p < 0.001; and 53.4% vs. 73.1%, respectively; p < 0.001). On multivariate analysis, a reduced TAPSE/sPAP ratio was a strong predictor of mortality (odds ratio: 1.62; 95% confidence interval: 1.14 to 2.31; p = 0.007).ConclusionsRVD, as shown by impairment of RV-PA coupling, is a major predictor of adverse outcome in patients undergoing TMVR for severe SMR. The often neglected functional and anatomic RV parameters should be systematically assessed when planning TMVR procedures for patients with severe SMR.     

Closure of the subclavian artery puncture site with a percutaneous suture device after removal of an arterial pacemaker lead.

We describe the closure of a subclavian artery puncture site with a percutaneous suture device after removal of a pacemaker lead 1 week after its inadvertent positioning in the left ventricle via the subclavian artery. The lead was retracted from the left ventricle into the aorta and linked to a guiding catheter introduced via femoral artery access. The lead and the guiding catheter were removed from the artery to the subclavian area. This manoeuvre allowed the placement of a percutaneous arterial suture device (Perclose) to close the puncture site.     

Laparoscopic repositioning of a dislocated pacemaker into the rectovesical pouch

Dislocation of the epicardial pacemaker into the peritoneal cavity is an uncommon but potentially life‐threatening complication. We report a case of a 74 year old with an abdominally implanted epicardial pacemaker that migrated through the peritoneum to the excavatio rectovesicalis. The laparoscopic approach was chosen because of the increased risks of perioperative morbidity and decreased survival. The generator was implanted into a pocket beneath the anterior rectus sheath and the lead was peritonalized with a running suture. In conclusion, a laparoscopic retrieval is feasible and safe in the treatment of a displaced pacemaker in the rectovesical pouch.     

Effect of atrial lead position on atrial automatic capture verification

Introduction: Optimizing atrial automatic capture verification based on atrial-evoked response (AER) detection requires maximizing the signal artifact ratio (SAR), that is, AER to stimulation artifact (ART). This study evaluated the effect of bipolar atrial lead position on sensed AER, ART, and SAR.
Methods and Results: A custom-made external research system (INSIGNIA^AC, Boston Scientific Corp. St Paul, MN, USA) was used to perform an automatic voltage step-down atrial pacing protocol at three different right atrial lead positions (A-appendage, L-lateral wall, and S-septal wall) in each studied patient. The atrial pacing and the AER sensing configurations were independent. The pacing was unipolar in an A_tip-Can configuration while sensing was in A_ring-I_ndiff. Data from 16 patients (mean age 71.1 ± 9.6 years) and six-lead models from five different manufacturers were analyzed. Study results show that with all lead types, the atrial lead placement had no significant effect on AER_min, ART_max, and SAR_min and only one patient had an SAR that was not sufficient to support successful automatic capture verification at all tested atrial pacing sites.
Conclusion: The atrial pacing site has minimal effect on AER sensing when using an independent pace/sense configuration. The leads placed at all tested sites were found to have the parameters sufficient to support the atrial automatic capture verification in all but one patient.     

Three-dimensional vectorcardiography to predict CRT-responder

Cardiac resynchronization therapy (CRT) is an accepted treatment for congestive heart failure (NYHA III-IV), but a substantial number of patients show no response to therapy. LBB, QRS width and echocardiographic measurements are parameters for indication, but they are not valid to predict hemodynamic response. A new method based on vector ECG analysis can deliver additional information, such as: parts or areas with late excitation, and with slow or fast depolarization speed. Electrical excitation is a prerequisite for contraction; this leads to the hypothesis that areas with late electrical activation will contract later. Algorithms for analysis of the vector ECG (determination of the vector -- time, area and speed) may help to identify responders and non-responders.     

Schrittmacherabhängigkeit und/oder rezidivierende ICD-Therapien

Bridging pacemaker-dependent patients or patients with repetitive ICD therapies after device and lead extraction is often challenging. Temporary pacing by means of an active fixation lead connected to an external reusable permanent pacemaker, or of a subxiphoidally implanted pacemaker with an epicardial lead is a safe option for bridging pacemaker-dependent patients after device and lead explantation. The wearable cardioverter defibrillator (WCD; LifeVest^®) is a safe and effective tool for patients who need a continuous monitoring and ICD backup after device explantation.     

Graduating internal medicine residents' self-assessment and performance of advanced cardiac life support skills

Internal medicine residents in the US must be competent to perform procedures including Advanced Cardiac Life Support (ACLS) to become board-eligible. Our aim was to determine if residents near graduation could assess their skills in ACLS procedures accurately. Participants were 40 residents in a university-based training program. Self-assessments of confidence in managing six ACLS scenarios were measured on a 0 (very low) to 100 (very high) scale. These were compared to reliable observational ratings of residents' performance on a high-fidelity simulator using published treatment protocols. Residents expressed strong self-confidence about managing the scenarios. Residents' simulator performance varied widely (range from 45% to 94%). Self-confidence assessments correlated poorly with performance (median r = 0.075). Self-assessment of performance by graduating internal medicine residents was not accurate in this study. The use of self-assessment to document resident competence in procedures such as ACLS is not a proxy for objective evaluation.     

Clear cell sarcoma of the stomach

AIMS: To investigate the role of the tumour suppressor gene PTEN in the tumorigenesis and growth of sporadic vestibular schwannomas, and to characterize the cellular distribution of the PTEN protein in relation to the MIB-1 proliferation index in these tumour. METHODS AND RESULTS: Immunoexpression of the PTEN protein was observed within the neoplastic Schwann cells in 21 out of 30 sporadic schwannomas examined (70%). PTEN expression was consistently stronger in Antoni A areas than in Antoni B areas. High levels of PTEN immmunoexpression in schwannomas were associated with an increased MIB-1 labelling index. Occasionally, vascular endothelial cells also showed PTEN immunoreaction. By polymerase chain reaction-single strand conformation polymorphism screening, no mutations were found in the complete protein coding region of the PTEN gene. CONCLUSIONS: The PTEN tumour suppressor gene is expressed in the majority of sporadic schwannomas. The maintained expression of the PTEN protein, together with the lack of detectable mutations in this gene, suggests that the function of the PTEN tumour suppressor gene is not altered in sporadic vestibular schwannomas.     

Determinants of the quality of life (QoL) in patients with an implantable cardioverter/defibrillator (ICD)

OBJECTIVES: In high-risk cardiac patients the treatment of life-threatening arrhythmias with an implantable cardioverter/defibrillator (ICD) extends survival. Other important outcome criteria are treatment side effects especially the quality of life (QoL). Knowledge of the variables that influence QoL is important for therapy decisions in ICD patients. METHODS: Ninety-three ICD patients evaluated their QoL by the SF-36 after 1-6 years of ICD implantation. The QoL was studied in relation to cardiac function (severity of heart failure, ejection fraction), treatment course (number of shocks), coping styles and psychiatric syndromes. RESULTS: About 30% of the somatic QoL (physical role function, pain) is determined by the patients' somatization tendency, i.e. the extent to which they suffer from non-specific symptoms (sweating, weakness in the legs, nausea). The severity of heart failure had little influence on the physical QoL. The emotional QoL is primarily determined by phobic anxiety of ICD patients. CONCLUSIONS: Psychiatric symptoms are the most important factors to determine the QoL in ICD patients. Behavioural treatment procedures of phobic anxieties and somatization could improve QoL in ICD patients.