Troubleshooting During Temporary Epicardial Lead Implantation in a Child with an Erosive Twiddler's Syndrome and Multiple Sternotomies: A case report

Temporary epicardial cardiac pacing in patients with bradyarrhythmias may be used as a bridge to implantation of a permanent pacemaker. The temporary epicardial lead placement may sometimes necessitate a sternotomy that may pose a challenge in patients who have had multiple earlier sternotomies. The difficulty in accessing the epicardium for urgent implantation of temporary epicardial pacing leads depends on the extent of adhesions in such patients. We report an 8-year-8-month-old girl with a pacemaker with an extruded pulse generator and difficult myocardial access due to 5 prior transsternal procedures. The child presented to a tertiary care hospital in Muscat, Oman, in 2021. A trouble-shooting technique was adopted to achieve temporary epicardial pacing to provide time for a course of antibiotic therapy administration. A permanent transvenous pulse generator system was implanted after 7 days of temporary pacing.

Percutaneous Closure of Ventricular Septal Defects in 116 Patients: Experience with different devices

Objectives

This study aimed to review the experience with percutaneous closure of ventricular septal defects (VSDs) at the National Heart Center (NHC) in Muscat, Oman.

Methods

This retrospective study was conducted from November 2008 to December 2017. Patients’ electronic medical records were reviewed to identify their clinical, imaging and interventional data before and after the procedure and on the last follow-up.

Results

A total of 116 patients, the majority of which were female (58%), underwent 118 percutaneous procedures for VSD closure at a median age of 3.54 years (range: 0.25–33 years) and a median weight of 12 kg (range: 3.5–78 kg). The mean diameter of the VSDs as determined by transoesophageal echocardiogram was 5.6 ± 1.9 mm (n = 105). The commonest type of VSD was perimembranous (n = 75, 63.5%). Devices were successfully placed during 111 (94.1%) procedures in 109 (94.0%) patients, with the commonest device being a Amplatzer™ duct occluder I (St. Jude Medical, Little Canada, Minnesota, USA; n = 39, 35.1%). There was no mortality. Early major cardiac complications occurred in six patients (5.5%) with device embolisation being the commonest (n = 4, 3.7%). The median follow-up period was 19 months (range: 1–84 months) in 89 (81.7%) of the patients. One patient (0.9%) required a permanent pacemaker for a complete heart block.

Conclusion

This study has demonstrated a good rate of VSD closure with low morbidity and no mortality using the percutaneous approach with different devices. Long-term follow-up is needed to specifically evaluate the function of adjacent structures and the long-term effects on conduction systems.

Clinical Outcomes of Various Management Strategies for Symptomatic Bradycardia

OBJECTIVE

To determine clinical outcomes of various management strategies for reversible and irreversible causes of symptomatic bradycardia in the inpatient setting.

DESIGN

Retrospective observational study.

SETTING

Emergency room and inpatient.

PARTICIPANTS

Patients presenting to the emergency department with symptomatic bradycardia.

METHODS

We retrospectively reviewed electronic health records of 518 patients from two Mayo Clinic campuses (Rochester and Phoenix) who presented to the emergency department with symptomatic bradycardia (heart rate ≤50 beats/minute) from January 1, 2010 through December 31, 2015. Sinus bradycardia was excluded. The following management strategies were compared: observation, non-invasive management (medications with/without transcutaneous pacing), early permanent pacemaker (PPM) implantation (≤2 days), and delayed PPM implantation (≥3 days). Study endpoints included length of stay and adverse events related to bradycardia (syncope, central line-associated bloodstream infections, cardiac arrest, and in-hospital mortality). Patients who received a PPM were further stratified by weekend hospital admission.

RESULTS

Heart block occurred in 200 (38.6%) patients, and atrial arrhythmias with slow ventricular response occurred in 239 (46.1%) patients. Reversible causes of bradycardia included medication toxicity in 22 (4.2%) patients and hyperkalemia in 44 (8.5%) patients. Adverse events were similar in patients who underwent early compared to delayed PPM implantation (6.6% vs 12.5%, P=.20), whereas adverse events were higher in patients who received temporary transvenous pacing (19.1% vs 3.4%, P<.001). Weekend admissions were associated with increased temporary transvenous pacing, prolonged median time to PPM implantation by 1 day, and prolonged median length of stay by 2 days.

CONCLUSIONS

Delayed PPM implantation was not associated with an increase in adverse events. Weekend PPM implantation should be considered to reduce temporary transvenous pacing and shorten length of stay.

Chronic Low Dose Prostaglandin and Neonatal Heart Block

Long-term prostaglandin use is commonly associated with side effects such as cortical proliferation of the bones, hypertrophic pyloric stenosis, and soft tissue swelling of the extremities. We report a neonate with critical coarctation of the aorta, who developed second and third degree atrioventricular blocks associated with prolonged prostaglandin E1 (PGE1) infusion. Interestingly, these conduction blocks only occurred at low PGE1 dose. The rhythm disturbances resolved promptly with the discontinuation of PGE1 following surgical repair.

A Hybrid ANN-GA Model to Prediction of Bivariate Binary Responses: Application to Joint Prediction of Occurrence of Heart Block and Death in Patients with Myocardial Infarction

BACKGROUND

In medical studies, when the joint prediction about occurrence of two events should be anticipated, a statistical bivariate model is used. Due to the limitations of usual statistical models, other methods such as Artificial Neural Network (ANN) and hybrid models could be used. In this paper, we propose a hybrid Artificial Neural Network-Genetic Algorithm (ANN-GA) model to prediction the occurrence of heart block and death in myocardial infarction (MI) patients simultaneously.

METHODS

For fitting and comparing the models, 263 new patients with definite diagnosis of MI hospitalized in Cardiology Ward of Hajar Hospital, Shahrekord, Iran, from March, 2014 to March, 2016 were enrolled. Occurrence of heart block and death were employed as bivariate binary outcomes. Bivariate Logistic Regression (BLR), ANN and hybrid ANN-GA models were fitted to data. Prediction accuracy was used to compare the models. The codes were written in Matlab 2013a and Zelig package in R3.2.2.

RESULTS

The prediction accuracy of BLR, ANN and hybrid ANN-GA models was obtained 77.7%, 83.69% and 93.85% for the training and 78.48%, 84.81% and 96.2% for the test data, respectively. In both training and test data set, hybrid ANN-GA model had better accuracy.

CONCLUSIONS

ANN model could be a suitable alternative for modeling and predicting bivariate binary responses when the presuppositions of statistical models are not met in actual data. In addition, using optimization methods, such as hybrid ANN-GA model, could improve precision of ANN model.

Utility of the NavX® Electroanatomic Mapping System for Permanent Pacemaker Implantation in a Pregnant Patient with Chagas Disease

Chagas disease is a highly prevalent zoonosis in Mexico, Central, and South America. Early cardiac involvement is one of the most serious complications of this disease, and conduction disturbances may occur at an early age. We describe a young pregnant woman with Chagas disease and a high degree atrioventricular block, who required implantation of a permanent dual chamber pacemaker. Using an electroanatomic navigation EnSite NavX® system the pacemaker was successfully implanted with minimal fluoroscopic exposure. This case demonstrates the safety and feasibility of using an electroanatomic navigation system to guide permanent pacemaker implantation minimizing x-ray exposure in pregnant patients.