Incidence of premature battery depletion in subcutaneous cardioverter-defibrillator patients. Insights from a multicenter registry

Funding Acknowledgements

Type of funding sources: None.

Introduction

A subset of more than 35,000 S-ICD is under FDA advisory, warning of the potential of premature battery depletion (PBD), caused by a faulty low-voltage capacitor. Based on internal data, the manufacturer projects the incidence at 3.7% after 5 years. Data independent from the manufacturer is sparse.

Methods

This study was a multicenter effort of 14 centers in Europe, the US, and Canada. Consecutive patients who received a S-ICD at the participating centers were included in this retrospective analysis. Patients with the 1010 S-ICD generator model, and those without available follow-up information were excluded. Data was collected and managed using REDCap electronic data capture tools hosted at the University Hospital Cologne.

The primary endpoint in this registry was device explantation, generator replacement, or generator failure. Reasons for explantation, replacement, or failure were collected. Device longevity was defined in months. It was calculated as the time from device insertion to the time of replacement, or explantation, or failure, where applicable. Premature battery depletion was defined as the occurrence of battery depletion requiring generator replacement after 60 months or less.

The study complies with the Declaration of Helsinki. Ethics committee approval was obtained. This study is registered with Clinicaltrials.gov.

Results

Data of n=1,102 S-ICD devices was analyzed. The registry comprised of S-ICD generators implanted between 03/2015 and 09/2021 (43.4% A209 model and 56.6% A219 model). Of these, 611 devices (55.4%) were identified by the Boston Scientific serial number lookup tool as affected by the advisory. The mean and median follow-up duration was 2.43±1.66 and 2.29 years, respectively.

During follow-up, 110 devices (10%) were explanted after 2.9±1.7 years. Battery depletion was the indication in 52. The endpoint of PBD (battery depletion after less than 5 years) was met in 37 devices (6% of the devices under advisory), after 4.1±0.6 years.

In 58 cases, the S-ICD was explanted for reasons other than battery depletion.

Infection (16), system upgrade (20), heart transplant or LVAD therapy (7), and inappropriate shocks or inappropriate sensing (7) were the most common indications.

Discussion

This registry provides a systematic and manufacturer independent analysis of premature battery depletion in S-ICD patients. In the affected devices, the incidence of premature battery occurred in 6%. This is higher than what is projected by the manufacturer. The rate of PBD increases notably around the 4-year mark.

Conclusion

S-ICD generators under advisory suffer from PBD at a higher incidence than previously reported. Patients equipped with these devices should be closely monitored.

Electrocardiographic characteristics of patients with coronavirus disease 2019 (COVID-2019) related pneumonia at first presentation

Funding Acknowledgements

Type of funding sources: None.

Purpose

To evaluate electrocardiographic (ECG) characteristics at first presentation in patients with possible coronavirus disease (COVID-19) pneumonia.

Methods and results

356 patients presenting at the emergency room with possible COVID-19 pneumonia based on clinical presentation and computed tomography findings were included and subdivided into a COVID-19 positive group ([COVID-19-positive], n = 231, 65%) and a COVID-19 negative group ([COVID-19-negative], n = 125, 35%) based on polymerase chain reaction tests.

The study population was predominantly middle aged-elderly (67 ± 14 year; n = 235, 66% male). Mortality rate was 24% after 1-month follow-up. There were no significant (NS) differences in sex, age, and mortality between the COVID-19-positive and COVID-19-negative group. 

Atrial fibrillation (AF) was common (9%), though its prevalence was NS (regression analyses adjusted for age and sex) different in the COVID-19-positive vs. the COVID-19-negative group. ECG characteristics reflecting atrial enlargement and repolarization abnormalities were frequently present (<38% and 14% respectively). No significant differences were found between the COVID-19-positive vs. the COVID-19-negative group for the majority of morphological ECG characteristics (Figure 1 for more detailed data). 

Conclusion

AF and ECG characteristics reflecting atrial enlargement and repolarization abnormalities are commonly present in COVID-19 patients. The prevalence of these ECG characteristics however do NS differ from their COVID-19-negative counterparts.

[Dissection of the superior mesenteric artery: a rare cause of abdominal pain]

HISTORY

A previously healthy 47-year-old man had suffered from intermittent subacute abdominal pain for six weeks. He had no significant past medical history except of smoking (30 pack years).

INVESTIGATIONS

Physical examination and laboratory tests were unremarkable. Sonography and endoscopy showed no pathological findings. Eventually contrast-enhanced computed tomography revealed dissection of the superior mesenteric artery and an additional angiography showed a false aneurysm.

TREATMENT AND COURSE

Because of the extended dissection thrombarterectomy was preferred to percutaneous stent placement. Five months later the patient was free of symptoms and continues to take 100 mg aspirin daily.

CONCLUSIONS

Although spontaneous visceral artery dissection is uncommon, awareness of this event is crucial for diagnosis and therapy to prevent hemorrhage and potential bowel infarction. This case highlights the importance of computed tomography in the work-up of nonspecific abdominal pain.

Prognostic relevance of occult tumor cells in lymph nodes of colorectal carcinomas: an immunohistochemical study

PURPOSE

Whereas lymph node metastases in colorectal carcinoma are an important prognostic factor, the prognostic relevance of occult tumor cells in lymph nodes is not elucidated at present. Therefore, our study intended to assess the rate of patients with occult tumor cells in histopathologically negative lymph nodes. Furthermore, we tried to evaluate an eventual influence of these occult tumor cells on patients' prognoses.

METHODS

For examination, we used paraffin blocks of lymph nodes, tumor-negative by conventional histopathology, from 49 patients with colorectal carcinoma (Stage I-III) after a curative (R0) tumor resection in 1987. After preparation of tissue blocks using the serial sectioning technique, the specimens were stained with the alkaline phosphatase, antialkaline phosphatase method and two monoclonal antibodies (AE1/AE3 and Ber-EP4).

RESULTS

In 13 of 49 patients (26.5 percent), we disclosed tumor cells, mostly located in subcapsular sinuses as single cells or in groups. There was a good correlation between the detection rate and N category, tumor stage, and grading. Moreover, 33 percent of patients in Stage I/II with occult tumor cells (N0+) developed a local relapse and/or distant metastases in contrast to 12 percent of patients without tumor cells (N0-). With a median follow-up of 84 months, we found no difference in disease-free survival between the tumor cell negative and positive groups in Stage I/II patients.

CONCLUSION

The results show that occult tumor cells might increase the risk for development of a local tumor relapse and/or distant metastases but do not influence patients' prognoses at all.

Nerve cell loss in the thalamic centromedian-parafascicular complex in patients with Huntington's disease

The centromedian-parafascicular complex represents a nodal point in the neuronal loop comprising striatum--globulus pallidus--thalamus--striatum. Striatal neurone degeneration is a hallmark in Huntington's disease and we were interested in estimating total neurone and glial number in this thalamic nuclear complex. Serial 500-microns-thick gallocyanin-stained frontal sections of the left hemisphere from six cases of Huntington's disease patients (three females, three males) and six age- and sex-matched controls were investigated applying Cavalieri's principle and the optical disector. Mean neurone number in the controls was 646,952 +/- 129,668 cells versus 291,763 +/- 60,122 in Huntington's disease patients (Mann-Whitney U-test, P < 0.001). Total glial cell number (astrocytes, oligodendrocytes, microglia, and unclassifiable glial profiles) was higher in controls with 9,544,191 +/- 3,028,944 versus 6,961,989 +/- 2,241,543 in Huntington's disease patients (Mann-Whitney U-test, P < 0.021). Considerable increase of fibrous astroglia within the centromedian-parafascicular complex could be observed after Gallyas' impregnation. Most probably this cell type enhanced the numerical ratio between glial number and neurone number (glial index: Huntington's disease patients = 24.4 +/- 8.1; controls = 15.0 +/- 5.2; Mann-Whitney U-test, P < 0.013). The neurone number in the centromedian-parafascicular complex correlated negatively, although statistically not significantly, with the striatal neurone number. This lack of correlation between an 80% neuronal loss in the striatum and a 55% neurone loss in the centromedian-parafascicular complex points to viable neuronal circuits connecting the centromedian-parafascicular complex with cortical and subcortical regions that are less affected in Huntington's disease.

[Tumor cell dissemination in bone marrow and peritoneal cavity. An immunocytochemical study of patients with stomach or colorectal carcinoma]

The tumor spread and the radicality of surgical resection are the most important facts in a patient's prognosis. In spite of curative tumor resection many patients die from metastases or local tumor recurrence. One possible reason is early dissemination of tumor cells which cannot be detected with clinical methods of examination. For this reason the aim of our study was to examine both bone marrow and peritoneal lavage for disseminated tumor cells with an immunocytochemical technique in patients with a gastrointestinal carcinoma. We also wanted to find out whether there was any correlation between the incidence of tumor cell detection and the TNM classification, staging and tumor grading and whether disseminated tumor cells have any prognostic significance. Our study included 54 patients who underwent surgery in our clinic for a carcinoma of the stomach (20 patients) or the colorectum (34 patients) from November 1993 to December 1994. At the beginning of the operation bone marrow had been taken from the iliac spine, and the abdomen was irrigated with 1000 ml saline solution immediately after laparotomy or laparoscopy. After cell separation with Ficoll density centrifugation 5 x 10(5) cells were applied per slide by a cytospin technique. For detection of the tumor cells we used the APAAP technique and the following monoclonal antibodies: KL1, CK2, anti-CEA, 17-1A (bone marrow) and Ber-EP4, B72.3, anti-CEA and 17-1A (peritoneal lavage). Altogether 77% of all patients had tumor cells in the bone marrow and 69% in peritoneal lavage fluid. It was possible to detect tumor cells in bone marrow (67%) and peritoneal lavage fluid (25%) even of patients with T1 tumors. The percentage increased with depth of wall infiltration. There was a marked difference in bone marrow aspirates between patients with lymph-node-negative tumors (N0) and those with lymph-node-positive tumors (N+): 65% had tumor cells in N0 and 85% in N+ stages. This trend was also seen in patients with (M1) and without (M0) metastases, in both bone marrow aspirates and peritoneal lavage fluid. In bone marrow there was a good correlation of tumor cells with staging, but in peritoneal lavage fluid this was not so. Finally, we detected tumor cells more often in bone marrow and peritoneal lavage fluid of patients with poorly differentiated tumors (G3) or diffuse Lauren type than in patients with moderately differentiated tumors (G2) or intestinal Lauren type. After a median follow-up period of 12.5 months patients with disseminated tumor cells had a lower survival rate than patients without tumor cells.

Laboratory diagnosis of HCMV-related disease in renal transplant patients - pp65 antigen detection versus nested PCR

BACKGROUND

Sixty-five renal transplant (Tx) recipients were monitored for signs and symptoms of human cytomegalovirus (HCMV) infection.

OBJECTIVES

Different diagnostic markers were evaluated for early and correct diagnosis of HCMV disease.

STUDY DESIGN

Blood and urine samples were obtained in weekly intervals and the following markers were determined: (1) IgG and IgM antibodies in serum using immunofluorescence and ELISA tests; (2) viral shedding in urine by rapid centrifugation culture (RCC); (3) viral antigen (pp65) in peripheral blood leukocytes (PBL) by immunofluorescence and (4) viral DNA in PBL by nested PCR (NPCR).

RESULTS

Twenty-two patients remained free of HCMV infection, 18 patients developed clinical symptoms of HCMV disease, and 25 patients remained asymptomatic in spite of laboratory signs of HCMV infection. For the early detection of HCMV disease, the highest sensitivity was achieved using NPCR (100%) and pp65 antigen detection (94%). RCC and IgM serology were less sensitive (62% and 40% respectively). The differences of sensitivity were significant. Clinical specificity was 47% for NPCR, 79% for pp65 antigen detection, 66% for RCC, and 68% for IgM serology.

CONCLUSION

In contrast to NPCR, pp65 antigen detection was closely correlated with the appearance of clinical disease and proved to be a useful marker in the monitoring of antiviral therapy.

Cortical and striatal neurone number in Huntington's disease

The total cortical and striatal neurone and glial numbers were estimated in five cases of Huntington's disease (three males, two females) and five age- and sex-matched control cases. Serial 500-microns-thick gallocyanin-stained frontal sections through the left hemisphere were analysed using Cavalieri's principle for volume and the optical disector for cell density estimations. The average cortical neurone number of five controls (mean age 53 +/- 13 years, range 36-72 years) was 5.97 x 10(9) +/- 320 x 10(6), the average number of small striatal neurones was 82 x 10(6) +/- 15.8 x 10(6). The left striatum (caudatum, putamen, and accumbens) contained a mean of 273 x 10(6) +/- 53 x 10(6) glial cells (oligodendrocytes, astrocytes and unclassifiable glial profiles). The mean cortical neurone number in Huntington's disease patients (mean age 49 +/- 14 years, range 36-75 years) was diminished by about 33% to 3.99 x 10(9) +/- 218 x 10(6) nerve cells (P < or = 0.012, Mann-Whitney U-test). The mean number of small striatal neurones decreased tremendously to 9.72 x 10(6) +/- 3.64 x 10(6) (-88%). The decrease in total glial cells was less pronounced (193 x 10(6) +/- 26 x 10(6)) but the mean glial index, the numerical ratio of glial cells per neurone, increased from 3.35 to 22.59 in Huntington's disease. Qualitatively, neuronal loss was most pronounced in supragranular layers of primary sensory areas (Brodmann's areae 3,1,2; area 17, area 41). Layer IIIc pyramidal cells were preferentially lost in association areas of the temporal, frontal, and parietal lobes, whereas spared layer IV granule cells formed a conspicuous band between layer III and V in these fields. Methodological issues are discussed in context with previous investigations and similarities and differences of laminar and lobar nerve cell loss in Huntington's disease are compared with nerve cell degeneration in other neuropsychiatric diseases.