Essential role of PET-CT in the management of patients with severe infectious complication CIEDS: multicentre study

Background

With the increasing number of implanted cardiac pacemakers, ICDs and CRTs, the number of serious infectious complications of these procedures increases significantly, especially in the longer term from the primary implantation. The systematic solution is in most cases endovasal extraction of these systems.

Methods

In a multicenter, prospective, randomized, controlled trial evaluating the benefit of CIEDS infection management in 277 patients, a conventional approach using blood cultures, microbiological examinations and TEE versus innovative management of these patients using PET-CT was compared. PET-CT examination is able to differentiate very well the infection of the implant pocket (Figure A) against bacterial endocarditis (Figure B). Thanks to this, it is possible to individualize the management of the patient and to shorten the dates of hospitalization, resp. time to re-implantation of the new system in patients without the presence of bacterial endocarditis.

Results

The results of the multicentre study are summarized in Table 1.

Conclusions

A comprehensive examination of patients with CDRIE using PET-CT significantly shortens hospital stay, time of antibiotic therapy and, as a consequence, leads to a lower incidence of serious complications of extraction procedures.

PET-CT in CDRIE patients

Funding Acknowledgement

Type of funding source: None

[Analysis and comparison of cohorts of patients with implantable cardioverter-defibrillator in primary and secondary prevention]

OBJECTIVE

The aim of this study was an analysis of patients with ICD implanted in primary prevention (PP) in long-term follow-up and comparison with data obtained in secondary prevention patients (SP).

PATIENTS AND METHODS

We assessed 73 patients with PP ICD and 138 patients with SP ICD. Males were in majority with 88% in PP group and 78% in SP group. The average age was 63 years. Majority of patients suffered from coronary artery disease. The mean ejection fraction (LV EF) was 28% in PP patients and 38% in SP patients. The number of affected coronary arteries and medication were similar in both groups. We compared the occurrence of intercurrent diseases, malignant arrhythmias, inappropriate therapies, hospital readmissions and patients' survival.

RESULTS

PP patients had lower LV EF ejection fraction (p < 0.001), higher number of revascularized arteries (p < 0.001) and lower occurrence of inappropriate therapies and arrhythmic storms (p < 0.001). There was higher number of patients with diabetes (p = 0.009), dyslipidemia (p < 0.001) and cerebral artery disease (p = 0.017) among those in PP group. Renal insufficiency was related to a higher risk of death.

CONCLUSIONS

Patients with PP ICD implantation have lower LVEF, and more intercurrent diseases then patients with ICD implanted form SP reasons. Their myocardium is more often revascularized and the occurrence of inappropriate therapy is low. Arrhythmic storm is a typical feature of patients with ICD implanted in secondary prevention.

[Alternative methods of microvolt T wave alternans measurements in patients with left ventricular cardiac dysfunction]

BACKGROUND

The presence of a microvolt T wave alternans (MTWA) is linked with increased risk of malignant arrhythmias and overall mortality. The most common method used for MTWA detection is a bicycle exercise test (BET). Method has still several limitations.

AIM

To confirm that comparable MTWA results may be obtained by atrial and ventricular pacing during electrophysiology. To identify an anticipated relation between MTWA and malignant arrhythmia occurrence, or a death.

METHODS

We obtained MTWA during BET and consequently during atrial and ventricular pacing. All patients underwent a routine electrophysiology testing prior to prophylactic ICD implantation. The results were compared. The occurrence of malignant arrhythmias and death were registered during follow-up.

RESULTS

The group consisted of 39 patients. The results of MTWA obtained by BET, atrial and ventricular pacing did not show a significant difference. No difference was found among the three methods in the number of positive leads, and onset heart rate. Ventricular pacing increases the magnitude of MTWA comparing to the remaining two methods. No relation between MTWA results and occurrence of malignant arrhythmias or death was found.

CONCLUSIONS

Atrial and ventricular pacing lead to comparable MTWA results as BET and may be used as alternative methods in patients where BET is not feasible.

[Influence of spontaneous ventricular premature beat coupling interval on the value of heart rate turbulence]

The heart rate turbulence is promising marker of a sudden cardiac death. The aim of the study is to evaluate the influence of the ventricular premature beat (VPB) coupling interval on the values of turbulence onset (TO) and turbulence slope (TS) parameters in the three groups of patients--"healthy" with ventricular premature beats, pts post myocardial infarction (MI) and pts with chronic heart failure with the left ventricle ejection fraction (LVEF) < 0.35.

PATIENTS AND METHODS

382 pts were examined: healthy--149, post MI--123 and LVEF < 0.35 - 110. The distribution ofVPB was analyzed and the values ofTO and TS were evaluated according to the coupling intervals of VPB--in the intervals 00-50, 51-100 (% of RR interval) and in the intervals 34-66 and 67-100 (% of RR interval).

RESULTS

The coupling interval of spontaneous ventricular premature beats cause the statistically significant variability HRT values in all three groups of pts.

CONCLUSION

The values of TO in the groups of post MI pts and pts with chronic heart failure are higher (risky for sudden cardiac death) after VPB with longer coupling intervals (50-100%, event. 67-100% of RR interval). The TS values are lower (risky for sudden cardiac death) after VPB with longer coupling interval, too. For evaluation of HRT we should use the VPBs with long coupling intervals.

Right ventricular perforation with an ICD defibrillation lead managed by surgical revision and epicardial leads--case reports

The authors present two cases of patients with perforation of the right ventricular wall by the implantable cardioverter defibrillator (ICD) lead. The complication was resolved by cardiosurgical revision and epicardial leads stitched onto the diaphragmatic wall of the heart. The perforation was identified by electrical parameter changes of the leads, echocardiography, and computed tomography. Both patients had satisfactory values of electrical parameters and ICD function with epicardial leads. The importance of regular follow-up and a check of the lead parameters are emphasized.

[SIADH as only paraneoplastic cause of the small cell lung cancer]

62 years old patient was admitted to the hospital with weakness of lower extremities. Using laboratory examination, we found very severe hyponatrenaemia, hypochloraemia and hypotonia of blood plasma, because of SIADH. We searched for the cause of that syndrome and finally we found that the cause of that syndrome was small cell lung cancer with an expansion into the mediastinum and metastases into the skelet.

[Complications with the pocket of cardiostimulator]

BACKGROUND

The number of patients with pacemakers is icreasing. The first reason is longer survival, the second reason is widening indications to cardiostimulation. Along with increasing numbers of performances, we have to recken larger number of complications and these complications solve so, that we avoid more serious damage of a patient.

METHODS AND RESULTS

In our article we focused an possible complications in the area of pacemaker pockets, monitored their appearence, watched the type of complication, the danger of the creation infection endocarditis and we present our own experiences with solving such complications. From the total numer of 3978 surgical interventions was 141 patients indicated for the revision of the pocket.

CONCLUSIONS

Repeated controls of the pocket and early reported of the patients to the specialised clinic is necessary for the safety of tke patients with pacemakers.

[Analysis of the effect of circadian rhythm on the heart rate turbulence in patients without evidence of organic heart disease]

Some studies have demonstrated circadian incidence of sudden cardiac death (SCD), ventricular ectopies, acute coronary syndromes and heart rate variability. One of new parameters applied in non-invasive stratification of sudden cardiac death is heart rate turbulence (HRT). Detection of circadian oscillations in HRT and optimised measurement of HRT can increase the positive predictive value of HRT as a sign of SCD risk. The set consisted of 48 patients in a sequence order aged 45 +/- 12 years (of which 23 men and 25 women), indicated for Holter monitoring ofventricular ectopies who had good left ventricular function with LV EF 0.53 +/- 0.11. HRT was measured in two-hour intervals within a 24 hour period, followed by an analysis of circadian dependence of HRT. A significant circadian oscillation in the TS (turbulence slope) parameter was recorded. No circadian signs were detected for the TO (turbulence onset) parameter. The project is supported by grant no. NR/8478-3.

[Analysis of circadian rhythm influence to heart rate turbulence in patients post myocardial infarction with left ventricular dysfunction]

BACKGROUND

Some study reported circadian occurence of sudden cardiac death, ventricle ectopic activity, acute coronary syndromes and heart rate variability. Heart rate turbulence (HRT) is one of a new markers of noninvasive stratification of sudden cardiac death.

METHODS AND RESULTS

We have evaluated HRT in 120 consecutive patiens post myocardial infarction in mean age 62.7+/-12.4 years (90 M, 30 W), indicated for ecg Holter monitoring with LVEF 0.45+/-0.12 in 2hours interval during 24 hours. We have analysed circadian variation of the HRT.

CONCLUSIONS

The statistically significant circadian patterns were found in turbulence slope parameter of HRT. No significant changes for turbulence onset parameter were described.

Treatment of arrhythmic storm in implantable defibrillator patients

BACKGROUND

A common ICD therapy-related complication is arrhythmic storm (AS). The objective of our study was to define the impact of AS on patients' prognoses in order to compare the total mortality of AS patients with the rest of the group.

MATERIAL/METHODS

We studied 138 patients who received ICDs between 1994 and 2001. Patients who experienced one or more arrhythmic storms were statistically compared with patients who had no accumulation of malignant arrhythmia or no episodes.

RESULTS

One thousand four hundred ninety episodes of arrhythmia were analyzed. Arrhythmia recurrence was present in 71% of the patients. The majority of episodes (78%) were ventricular tachycardias and only 3% of episodes were ventricular fibrillation. Seventy percent of all arrhythmic episodes were asymptomatic. The ICD therapy sensitivity was 99.7%. Thirty-eight arrhythmic storms in 19 patients (14%) were observed during follow-up. The occurrence of AS was twice as high among patients with LVEF <35% than the rest of the group (18% vs. 8%). The total survival of patients with AS was significantly lower than that of the ICD patients who did not experience an AS (36.8% vs. 16.8%, p=0.042). All episodes of arrhythmic clusters during the AS were ventricular tachycardias.

CONCLUSIONS

Arrhythmic storm is a serious risk marker for cardiac death. Ventricular tachycardia is a basic rhythm disorder of AS episodes and occurs significantly more often than ventricular fibrillation. Arrhythmic storm is responsible for a 4.6 times more frequent re-admission to hospital.

[Comparison of the prevalence of non-invasive risk markers of the sudden cardiac death in patients treated by thrombolysis and by percutaneous transluminal coronary angioplasty]

BACKGROUND

Myocardial infarction survivors may develop a higher risk of sudden cardiac death. The risk markers: left ventricular ejection fraction, ventricular premature beats, late potentials on averaged ECG, baroreflex sensitivity and heart rate variability are used as non-invasive stratification markers.

METHODS AND RESULTS

Occurrence of the autonomic and morphologic dysfunction risk markers in the myocardial infarction patients treated by thrombolysis and by primary percutaneous transluminal coronary angioplasty (PTCA) is compared. We studied a cohort of 48 acute myocardial infarction survivors treated by primary PTCA and 96 patients treated by thrombolysis.

CONCLUSIONS

Patients treated by primary PTCA had significantly lower occurrence of premature ventricular beats and pathological parameters of the heart rate variability.

Endothelin-1 Gene Polymorphism in Patients with Malignant Arrhythmias

The endothelins are peptides with vasoconstricting and growth-promoting properties. Endothelin-1 (ET-1) is known with its direct positive inotropic and chronotropic effects on isolated heart and with growth effects. The aim of this pilot study was to investigate the frequency distribution of the common polymorphism of the ET-1 gene and its possible relation with hemodynamic consequences of malignant ventricular arrhythmias in patients with structural heart disease. We studied 26 consecutive patients with malignant ventricular arrhythmias and implantable cardioverterdefibrillators with a mean age of 62.7 +/- 12.2 years and a mean left ventricular ejection fraction of 0.37 +/- 11.0. Taq polymorphism of ET-1 was detected using our original polymerase chain reaction method. The polymerase chain reaction product with a length of 358 basepairs (bp) (primers 5'-CAA ACC GAT GTC CTC TGT A-3' and 5'-ACC AAA CAC ATT TCC CTA TT-3') in its non-mutated form contains a target sequence for TaqI restrictive enzyme, while a mutated product loses this cleavage site. Of 26 patients, nine (34%) had recurrent palpitations and eight (30.8%) had syncopes during their malignant arrhythmias. Nineteen patients were given amiodarone after implantable cardioverter-defibrillator insertion and seven were not treated with amiodarone. Fifteen patients had (++), 11 (+-) and 0 (- -) ET-1 genotype. The risk for syncopes was associated with the (++) genotype of the ET-1 gene (P = 0.01). Patients receiving amiodarone had significantly higher frequency of the (++) genotype (P = 0.011). All our results indicate that the presence of the ET-1 genotype (++) in patients with structural heart disease, severe left ventricular dysfunction and malignant ventricular arrhythmias increases the risk for these patients of hemodynamic collapse during these arrhythmias.

[Care of patients with implanted cardioverters-defibrillators: what every physician should know]

Implantable cardioverter defibrillators have become an integral part of treatment of patients with malignant chamber arrhythmias over last 10 years both in secondary and primary prevention of sudden deaths. Based on monitoring of a group of 182 patients and based on information in literature, authors present a survey of the most frequent situations, rules and complications related to therapy with implantable defibrillators. In the end they try to answer summary of the most frequent questions of internal medicine physicians and GPs concerning patients with this implanted device.

[Specific complications in the treatment with implantable cardioverter-defibrillators]

BACKGROUND

Using implantable cardioverter-defibrillators in treatment of malignant ventricular arrhythmias revealed new complications specific to this therapy. Inappropriate therapy, arrhythmic storm and device related proarrhythmia belong to the most significant complications. The authors describe specific complications in a group of ICD patients, analyze their etiology and prognostic value. There are some recommendations for the management of specific complications.

METHODS AND RESULTS

138 consecutive patients underwent ICD implantation between 1994-2001. Median follow-up was 47,35 months. Average left ventricular ejection fraction was 38 +/- 14% and 71% of patients suffered from coronary artery disease. From the total of 2490 arrhythmic episodes 1490 were evaluated in detail. 253 episodes (17%) were classified as inappropriate therapy. The most common etiology of inappropriate therapy was atrial fibrillation with rapid ventricular response (68%), atrial flutter (13%) and sinus tachycardia (11%). After the therapeutic intervention, 65% of them remained free of inappropriate therapy. There were 38 arrhythmic storms in 19 patients as another serious complication.

CONCLUSIONS

All the observed arrhythmic episodes were ventricular tachycardias (p<0.04). Patients with arrhythmic storm in history had significantly lower survival (p<0.05). The risk factors of cardiac nonsudden death were: age >66 years, left ventricular ejection fraction <35% and arrhythmic storm history. The authors present recommendations for the treatment of the most common specific ICD complications.

Circadian variations in the occurrence of ventricular tachyarrhythmias in patients with implantable cardioverter defibrillators

A circadian distribution has been demonstrated in episodes of sudden cardiac death, acute myocardial infarction, ventricular premature complexes, heart rate variability, and ventricular tachyarrhythmias. The aim of this study was to evaluate the circadian distribution of ventricular tachyarrhythmia episodes in a population of ICD patients. Data were gathered from 72 patients (55 men, 17 women; mean age 62.7 +/- 12.2 years, mean LVEF 0.0037 +/- 0.0011) with ICDs implanted for standard indications. Patients were followed every 3 months over a mean period of 21 +/- 12.8 months. At each examination, symptoms at arrhythmia onset and perception of ICD therapy were recorded, and the ICD memory was interrogated. During follow-up, 1,023 episodes' of malignant ventricular arrhythmias were detected and effectively terminated, 506 of which were fully analyzed. A morning peak in ventricular tachyarrhythmias was demonstrated between 7:00 and 11:00 AM, and an afternoon peak between 6:00 and 7:00 PM. A significantly lower occurrence of VT was observed at 1:00 AM and between 4:00 and 6:00 AM. A circadian distribution in the occurrence of ventricular tachycardias was found. The three striking features of the data are: the early morning peak (about three hours after waking up), relatively stable incidence throughout waking hours, and decline in incidence in the previous period.

Endothelin-1 gene polymorphism in the identification of patients at risk for malignant ventricular arrhythmia

BACKGROUND

The endothelins are peptides with vasoconstricting and growth-promoting properties. Endothelin-1 (ET-1) is known for its direct positive inotropic and chronotropic effects on isolated heart, and for growth effects. The aim of this pilot study was to investigate the frequency distribution of a common polymorphism of the endothelin (ET-1) gene and its possible relation to the hemodynamic consequences of malignant ventricular arrhythmia in patients with structural heart disease.

MATERIAL/METHODS

We studied 26 consecutive patients with malignant ventricular arrhythmia and implantable cardioverter defibrillators (ICD), mean age 62.7 +/- 12.2 years, mean LVEF 0.37 +/- 11. The Taq polymorphism of ET-1 was detected using our original PCR method. The PCR product with a length of 358 bp in its non-mutated form contains a target sequence for the TaqI restrictive enzyme, while the mutated product loses this cleavage site.

RESULTS

Out of the 26 patients, 9 (34%) had recurrent palpitations and 8 (30.8%) had syncopes during their malignant arrhythmic episodes. 19 of the patients were receiving amiodarone after ICD implantation, 7 were not. 15 patients had the (++) and 11 had the (+ -) ET-1 genotype; none had the (- -) genotype. The risk of syncopes was associated with the (++) genotype (p=0.01). Patients with amiodarone had a significantly higher frequency of the (++) genotype (p=0.011).

CONCLUSIONS

All our results suggested that the presence of the (++)ET-1 genotype in patients with structural heart disease, severe left ventricular dysfunction, and malignant ventricular arrhythmia put these patients at a higher risk of hemodynamic collapse during arrhythmic episodes.

[Implantable cardioverter-defibrillators in the prevention of sudden cardiac death]

The aim of this work is to characterize and analyse the spectrum of therapies delivered from implantable cardioverter-defibrillators (ICD), to evaluate their effectivity and to mark the most effective types of antitachycardia stimulations (ATP), cardioversion (CV) and defibrillation (CD). To compare our results with references and give precautions of trouble-shootings. Our patients had implanted ICDs according to standard criteria for ICD implantations. Before discharge from hospital we performed predischarge test of their ICD. Than we followed them periodically each three months. We have observed 72 ICD pts (55 M, 17 F) in the mean age of 62.7 +/- 12.2 years the with mean LVEF was 0.37 +/- 0.11. The mean follow-up was 21 +/- 12.8 months. Each examination was managed through anamnesis of symptoms accompanying the beginning of arrhythmia, the sensation of ICD therapy by patient, followed by interrogation of the ICD memory. All obtained episodes were analysed. During the follow-up 1023 episodes of malignant ventricular arrhythmias were detected and effectively terminated. 7 pts died. During the therapy the ATP reached 83% in comparison with CV, CD which reached only 17%. The dominating symptoms were palpitations and presyncopes. In comparison with initial arrhythmias leading to implantations of ICDs (ventricular fibrillations for most of the cases--54%) the significantly higher number of spontaneous episodes were caused by monomorphic ventricular tachycardias VT (92.0%). We had no sudden cardiac death in our pts. In the indicated pts with a high risk of sudden arrhythmic death, the ICD therapy is characterized as very effective and is associated with high safety, low discomfort and when up to date algorithms for detection being used, then only adequate part of the inappropriate therapies occurs (10% patients, 3.2% from the number of episodes). The therapy by implantable cardioverter-defibrillators has had an important role in treating pts with life-threatening ventricular arrhythmias.

[Selection and long-term effect of treatment in vasovagal neurocardiogenic syncope]

BACKGROUND

Syncope state performed by transient loss of consciousness connected with a postural tone decrease present still an important therapeutical problem. The authors use HUT testing for discovering of vasovagal etiology of a syncope. The aim of the study was to find out the optimal medication in treatment and prevention of VVS by repeated HUT drug testing in a group of positive patients.

METHODS AND RESULTS

We examined a group of 300 patients (172 female and 128 male) age 35.26 +/- 13.47 years with an anamnesis of recurrent syncopes by HUT test. In 83 patients (27%) we set up a diagnosis of VVS. Thirteen patients (15.66%) were only followed without medication. The rest of the group (70 patients, 84.34%) started with a therapy. Testing was performed by repeated HUT according to the "Westminster protocol". HF and BP were measured by FINAPRESS 2,300 made by Ohmeda. The effective therapy was found in 64 patients (91.43%) of the group. For various reasons the therapy was changed and retested in 9 patients (14.06%). Beta1 selective beta-blockers were used in 51 patients (80.96%) theophyllin in 5 patients (7.94%), etilephrin in 6 patients (9.52%) and clonidine in 1 patient (1.59%).

CONCLUSIONS

The therapy of VVS should be set-on according to the effective drug selection by serial drug testing in repeated HUT tests. The article shows a high predictive value of negative HUT test for a long term effect of tested therapy.

[Neural syncope--a current therapeutic problem]

Syncope, a state performed by transient loss of consciousness connected with postural tone decrease present still an important therapeutical problem. It can vary from a benign physiological body reaction to a life-limiting situation. The authors of the article present HUT-testing to be a simple, useful and safe method for discovering vasovagal mechanism of the syncope. They notice the experiences with treatment according to the HUT results. The most frequent types of therapy are the pharmacological and the pacing ones, when the former is appropriate for I and III class of VVS the latter then for the II. class. There are some big studies in progress now which should bring more information about this clinical problem.