Adult congenital heart disease in Spain: health care structure and activity, and clinical characteristics

INTRODUCTION AND OBJECTIVES

To assess the structure of health care delivery and the clinical characteristics of adults with congenital heart disease (ACHD) attending specialized centers in Spain.

METHODS

A survey was conducted among 32 Spanish centers in 2014. The centers were classified into 2 levels based on their resources. In 2017, a clinical dataset was collected of all consecutive patients attended for a 2-month period at these centers.

RESULTS

A total of 31 centers (97%) completed the survey. Seven centers without specialized ACHD clinics were excluded from the analysis. In 2005, only 5 centers met the requirements for specific care. In 2014, there were 10 level 1 and 14 level 2 centers, with a total of 19 373 patients under follow-up. Health care structure was complete in most centers but only 33% had ACHD nurse specialists on staff and 29% had structured transition programs. Therapeutic procedures accounted for 99% and 91% of those reported by National Registries of Cardiac Surgery and Cardiac Catheterization, respectively. Among attended patients, 48% had moderately complex lesions and 24% had highly complex lesions. Although 46% of patients attending level 2 centers had simple lesions, 17% had complex lesions.

CONCLUSIONS

The structure for ACHD health care delivery in Spain complies with international recommendations and is similar to that of other developed countries. Congenital heart diseases under specialized care consist mostly of moderately and highly complex lesions, even in level 2 centers. It would be desirable to reorganize patient follow-up according to international recommendations in clinical practice.

Wide QRS Complex Arrhythmia with Alternating QRS Morphology: What Is the Mechanism?

A 75-year-old man was admitted due to an electrical storm with appropriate recurrent implantable cardioverter defibrillator (ICD) discharges. The patient had had an extensive anterolateral myocardial infarction with associated severe left ventricular dysfunction 10 years earlier (left ventricular ejection fraction, 25%), and an ICD was placed 9 years before admission for primary prevention of sudden cardiac death. A first invasive study induced up to five ventricular tachycardias and an extensive endocardial substrate ablation was performed. Despite intravenous β-blockers, general anesthesia and procainamide infusion, the patient continued to have recurrent episodes of very slow sustained ventricular tachycardia with a right bundle branch block pattern. In a subsequent invasive study, no mid-diastolic activity was found despite careful mapping during the induced clinical ventricular tachycardia and ablation attempts inside the apical endocardial scar were unsuccessful. A percutaneous epicardial approach with navigation system support (EnSite Precision^TM Cardiac Mapping System v. 2.0, St. Jude Medical, St. Paul, MN, USA) without antiarrhythmic infusion was planned. A wide QRS complex rhythm with alternating QRS morphology was readily induced by epicardial ventricular pacing trains (Fig. 1, top) that elicited both arrhythmia QRS patterns with very long stimulus QRS intervals (Fig. 1, bottom). What is the possible mechanism of this arrhythmia? Do we need further pacing maneuvers during the arrhythmia to localize critical sites at which ablation pulses can predictably be successful?

Safety of Outpatient Implantation of the Implantable Cardioverter-defibrillator

INTRODUCTION AND OBJECTIVES

Strategies are needed to reduce health care costs and improve patient care. The objective of our study was to analyze the safety of outpatient implantation of cardioverter-defibrillators.

METHODS

A retrospective study was conducted in 401 consecutive patients who received an implantable cardioverter-defibrillator between 2007 and 2012. The rate of intervention-related complications was compared between 232 patients (58%) whose implantation was performed in the outpatient setting and 169 patients (42%) whose intervention was performed in the inpatient setting.

RESULTS

The mean age (standard deviation) of the patients was 62 (14) years; 336 (84%) were male. Outpatients had lower left ventricular ejection fraction and a higher percentage had an indication for primary prevention of sudden death, compared to inpatients. Only 21 outpatients (9%) required subsequent hospitalization. The rate of complications until the third month postimplantation was similar for outpatients (6.0%) and inpatients (5.3%); P = .763. In multivariate analysis, only previous anticoagulant therapy was related to the presence of complications (odds ratio = 3.2; 95% confidence interval, 1.4-7.4; P < .01), mainly due to an increased rate of pocket hematomas. Each outpatient implantation saved approximately €735.

CONCLUSIONS

Outpatient implantation of implantable cardioverter-defibrillators is safe and reduces costs. Close observation is recommended for patients receiving chronic anticoagulation therapy due to an increased risk of complications.