Terbutaline for chronotropic support in heart transplantation

Cardiac Implantable Electronic Devices Following Heart Transplantation

Permanent pacemaker (PPM) implantation is required in a subset of patients (∼10%) for sinus node dysfunction or atrioventricular block both early and late after heart transplantation. The incidence of PPM implantation has decreased to <5% with the advent of bicaval anastamosis transplantation surgery. Pacing dependence upon follow-up has been variably reported. An even smaller percentage of transplantation recipients (1.5% to 3.4%) undergo implantable cardioverter-defibrillator (ICD) placement. Rigorous data are lacking for the use of ICDs in the transplantation population and is largely derived from cohort studies and case series. Sudden cardiac death occurs in approximately 10% of transplantation recipients, but multiple nonarrhythmic factors are believed to be responsible, including acute rejection, late graft failure with electromechanical dissociation, and ischemia due to cardiac allograft vasculopathy. This review provides a comprehensive analysis of the existing data regarding the role for PPMs and ICDs in this population, including leadless PPMs and subcutaneous ICDs, special considerations, and future directions.

Hyperinflation of Isoproterenol

The hyperinflation of isoproterenol, a 75-year-old drug, in early 2015 was unbelievable. The attention of health-care professionals, health system administrators, legislators, and the general public was quickly focused on Valeant Pharmaceuticals, purchaser of several generics solely to raise their price. With isoproterenol easily launched toward the top of drug expenditures, pharmacists in many hospitals were forced to engage stakeholders in the investigation and implementation of alternatives, explore utilization and optimize inventory, reduce cost through sterile product preparation, where possible, restrict use to settings that were beneficial to their budget, and become legislative advocates. The alternatives drugs and strategies will be reviewed.