Spinal cord stimulation for refractory angina pectoris -a case report-

Burst stimulation for refractory angina pectoris - A case report

BACKGROUND

Refractory angina pectoris (RAP) is a chronic, severe chest pain associated with coronary artery disease that cannot be resolved using optimal medical or surgical approaches. Spinal cord stimulation (SCS) is a suitable treatment option. Conventional waveforms of SCS have shown a potent effect on the tempering of RAP. However, SCS is associated with undesired paresthesia. The new burst SCS waveforms have been reported to have fewer adverse effects.

CASE

We reviewed a case in which RAP was successfully treated with burst SCS in a middle-aged male, with a tonic waveform employed for breakthrough pain as needed.

CONCLUSIONS

Appropriate use of tonic and burst stimulations according to the symptoms is expected to maximize the effect of relieving chest pain induced by RAP.

Pain-induced autonomic dysreflexia secondary to spinal cord injury with significant improvement after spinal cord stimulator implantation

Introduction

Spinal cord stimulation (SCS) has been established as a safe and effective alternative treatment for many conditions. This is a unique case involving SCS in spinal cord injury (SCI) patients with recurrent episodes of autonomic dysreflexia (AD). AD is a sympathetically driven reflexive hypertension in response to a noxious stimuli below the neurological level of spinal cord injury. There is currently limited research and literature regarding SCS application for AD. We present a unique case where pain-induced AD was successfully treated with implantation of SCS, in order to avoid long term opioid use and improve quality of life.

Case presentation

We present a 46-year-old female, with history of chronic incomplete traumatic quadriplegia, with increased frequency of symptomatic AD. After an extensive work-up, it was determined that the likely trigger for the AD episodes was neuropathic and nociceptive pain below the level of the spinal cord injury. Due to the frequency of AD episodes, uncontrolled pain, and concerns of long term opioid usage, she was referred for an evaluation for possible SCS placement. The patient ultimately underwent SCS implantation and battery revision. She had significant improvement of AD episodes after SCS implantation.

Conclusion

This case identifies a unique approach to preventing AD episodes by addressing intractable neuropathic pain with SCS.

Use of Spinal Cord Stimulators in Patients With Pacemakers or Implantable Cardiac Defibrillators: A Review of Documented Accounts of Interference

OBJECTIVES

To assess the currently available evidence regarding associations between spinal cord stimulator (SCS) lead type, clinical indications for device placement, and interference between SCSs and cardiac pacemakers (CPMs)/implantable cardioverter-defibrillators (ICDs).

STUDY DESIGN

Review of case reports and original research studies assessing the interference between SCS and CPM/ICD.

MATERIALS AND METHODS

PubMed and Cochrane databases were searched for articles commenting on the interference between SCS and CPM/ICD. The search criteria which generated the greatest number of relevant studies was (spinal cord stimulator AND [pacemaker OR implantable cardioverter defibrillator]). Additional, empiric review was conducted using JSTOR, ScienceDirect, and EBSCOhost databases; however, no additional eligible studies were identified. Data were extracted, summarized into tables, and quantitatively analyzed using LibreTexts and MedCalc software.

RESULTS

There was no statistically significant interference observed between SCS and CPM/ICD devices in patients regardless of indication for SCS placement and SCS lead polarity.

LIMITATIONS

Limited by variability of patient cases and variability in maximum frequency and amplitude of SCS devices tried in individual cases. Also limited by small sample size and the absence of a standard definition for device interference across studies.

CONCLUSIONS

Interference between cardiac devices and SCSs is a rare occurrence. As there are currently no published guidelines, devices should be interrogated on a case-by-case basis in the SCS trial period (if implanted after cardiac device), during permanent implantation, and during scheduled follow-up visits. Peri-operative testing should include increasing the SCS settings to maximally tolerated levels with cardiac device set at its maximum sensitivity.

Transcatheter treatment for refractory angina with the Coronary Sinus Reducer

AIMS

To evaluate the clinical efficacy of the coronary sinus (CS) Reducer in attenuating angina severity in patients suffering from severe refractory angina.

METHODS AND RESULTS

Patients with refractory angina, objective evidence of myocardial ischaemia and no option for revascularisation were treated with CS Reducer implantation at two medical centres. Six-month follow-up evaluation consisted of clinical assessment of angina severity. Objective assessment of ischaemia at six-month follow-up was performed in one of the two centres. Successful CS Reducer implantation was achieved in 21 of 23 eligible patients, at both centres. No device-related adverse effects were observed during the procedure or the follow-up period. Canadian Cardiovascular Society (CCS) score diminished from a mean of 3.3 at baseline to 2.0 at six months (n=20, p<0.01), exercise duration was prolonged from 3:16 to 5:16 min (min:sec; n=8, p=0.05). Thallium SPECT summed stress score and summed difference score were both reduced (n=9, 21.5±10 vs.13.2±9, p=0.01, and 11.1±6 vs. 4.7±4, p=0.007, respectively). Wall motion score index at peak dobutamine infusion was also significantly improved (n=8, 1.9±0.4 vs. 1.4±0.4, p=0.046).

CONCLUSIONS

CS Reducer implantation was safe and resulted in significant improvement of angina class. The results of the ongoing randomised sham-control trial will address the concern regarding the possible placebo effect, and hopefully further support our encouraging observations.