UROPACE 2003 Lassos, Sulzer Osypka); from 1996 we perform a personal technique using a jugular approach (JA) in difficult cases or if the standard approach is ineffective.Among 1342 pacing and ICD leads, we attempted to remove 111 ICDL, implanted in 90 pts (79 men, mean age 58.9 years, range 21.80).The indications were septicemia (14 leads), local infection (37 leads), and malfunction (15 leads).The mean implant period was 43.7 months (range 4-123); 95 ICDL were ventricular (2 intravascular), 5 atria1 and 11 can1 leads (1 intravascular).All the ICDL were completely removed.We removed 96 leads using the standard mechanical dilation.For the 15 remaining leads we decided to crossover to JAraching the result of 100% leads removed.No major complications were observed.This experience demonstrates that ICDL can be successfully and safely removed by tran~venou~ approach.The ICDL extraction procedures are more difficult and time consuming than pacing leads; despite the literature data, we observed a better results in ICD extraction than PL.From this study we can conclude that tmnvenou~ ICDL removal is a very effective and safe procedure with high success rate and low complications.The success rate and complications are strongly related to the experience of the staff.The jugular approach allows to achieve a very high success rate strongly reducing major complications.

The authors report the case of a 67 year old man with a previous history of aortobifemoral arterial graft who had unstable angina after carotid endarterectomy. Coronary angiography by the right brachial artery was complicated by a cerebrovascular accident with a reactive coma, convulsions and respiratory problems. Selective angiography of the right vertebral artery showed an image of occlusive thrombosis of the basilar artery. In view of the clinical state and angiographic appearances, the authors decided on immediate intra-arterial thrombolysis with Urokinase which dissolved the clot and reestablished flow in the basilar artery, the cerebellar and posterior cerebral arteries. The outcome was favourable with immediate and good recovery of consciousness and hospital discharge on the sixth day without neurological or radiological sequellae. Cerebrovascular accident is a rare and potentially serious complication of left heart catheterisation which requires immediate cerebral angiography to determine the mechanism and propose an appropriate therapeutic approach.

While carotid sinus syndrome (CSS) is often suspected as a cause of syncope in the elderly, whether it represents an indication for cardiac pacing may remain uncertain. Bradycardia algorithms included in pacemakers are now able to establish a precise relationship between spontaneous asystole and occurrence of symptoms and strengthen the indication for permanent pacing. This study included seven men and three women (70.5 +/- 7.3 years of age) who, over an average period of 54.1 +/- 17 months, had suffered from syncope (12.6 episodes/patient) and presyncope (11.2 episodes/patient) attributed to pure cardioinhibition (2 patients) or mixed CSS (8 patients). Other sources of symptoms were excluded by thorough clinical evaluations, including Holter monitoring, echocardiography, and electrophysiological testing. All patients received a CHORUS 6234 pacemaker, the memory of which includes a dedicated bradycardia detection algorithm capable of storing atrial and ventricular chains, and date and time of the last ten pauses and/or bradycardic events. After a initial period of 14.7 +/- 8 months, during which symptoms were suppressed, the bradycardia algorithm was activated. From then on, a cumulative increase in the number of patients presenting with diurnal pauses was measured (1 month, n = 0; 3 months, n = 6; 9 months, n = 7; 2 years, n = 8). Fourteen episodes of diurnal asystole were recorded. The mean duration of the longest episodes of spontaneous ventricular standstill was 6,319 +/- 1,615 ms and was due to sinoatrial block (n = 7), atrioventricular block (n = 5), and a combination of both (n = 2). In conclusion, activation of the CHORUS bradycardia algorithm allowed confirmation of the appropriateness of permanent pacing in a majority of patients suffering from CSS.

Heart failure (HF) has become a public health problem in industrialized countries. The number of affected patients has increased considerably in the United States 1 Haldeman G.A. Croft J.B. Giles W.H. Rashidee A. Hospitalization of patients with heart failure National Hospital Discharge Survey, 1985 to 1995. Am Heart J. 1999; 137: 352-360 Abstract Full Text Full Text PDF PubMed Scopus (461) Google Scholar as well as in France. 2 Delahaye F. de Gevigney G. Gaillard S. Cheneau E. Epidemiology and economic impact of heart failure in France. Arch Mal Coeur Vaiss. 1999; 91: 1307-1314 Google Scholar Although pharmacologic treatment and the development of new drugs have led to a significant reduction in morbidity and mortality rates, 3 Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med. 1999; 325: 293-302 Google Scholar , 4 Packer M. Bristow M.R. Cohn J.N. Colucci W.S. Fowler M.B. Gilbert E.M. Shusterman N.H. The SOLVD InvestigatorsThe effect of carvedilol on morbidity and mortality in patients with chronic heart failure. US Carvedilol heart failure study group. N Engl J Med. 1999; 334: 1349-1355 Google Scholar , 5 Pitt B. Zannad F. Remme W.J. Cody R. Castaigne A. Perez A. Palensky J. Wittes J. The SOLVD InvestigatorsThe effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999; 341: 709-717 Crossref PubMed Scopus (7860) Google Scholar these rates remain high, and heart transplantation cannot resolve all of these problems. Recently, multisite pacing with ventricular synchronization has been proposed for patients with refractory HF. 6 Cazeau S. Ritter P. Lazarus A. Gras D. Bakdach H. Mundler O. Mujica J. The SOLVD InvestigatorsMultisite pacing. Multisite pacing for end stage heart failure Early experience. Pacing Clin Electrophysiol. 1999; 19: 1748-1757 Google Scholar Preliminary studies suggest that this treatment provides substantial functional benefits for patients. 7 Gras D. Mabo P. Tang T. Luttikuis O. Chatoor R. Pedersen A.K. Tscheliessnigg H.H. Deharo J.C. Puglisi A. Silvestre J. Kimber S. Ross H. Ravazzi A. Paul V. Skehan D. The SOLVD InvestigatorsMultisite pacing as a supplemental treatment of congestive heart failure Preliminary results of the Medtronic Inc. InSync Study. Pacing Clin Electrophysiol. 1999; 21: 2249-2255 Google Scholar This new technique can be considered for patients with symptoms refractory to well-conducted drug treatment regimens associated with severe hypokinetic dilated cardiomyopathy and intraventricular conduction delay, most often of the complete left bundle branch block (LBBB) type. The percentage of patients with this indication for implantation is not currently known. This article assesses its incidence prospectively among a population of hospitalized patients with HF.

The treatment of Neuro-cardiogenic syncope by pacing remains a goal.INOS CLS device (Biotronik-Germany) has a new sensor, the closed loop system (CLS), adaptive to variations of intracardiac impedances according to heart contractility modifications.The aim of this study is to assess the ability of CLS to overcome SBP fall and prevent induced syncope in patients with prior positive tilt testing.Methods: 22 patients (6 females.76.6:1:7.8y .o.) were implanted with INOS CLS because of recurrent syncope (2.1/patient) or presyncope (61patient).In every case, a usual indication of pacemaker was present: paroxysmal SND = 7, AVB = 10, mixed or cardio-inhibiting carotid sinus syndrome = 12, associated with syncopal vasoplegic reactions during tilt testing.After pacemaker implantation, two others tilt testing were done, one with CLS activation, one without CLS activation.Results: During this pre-implantation tilt testing, the maximal vasodepressive reaction was 88.6 + 20 mmHg associated with a moderate bradycardia (122:1:15 ppm).The second tilt testing, after sensor activation, was done in the same conditions 20.6 days later: 72.7% patients became negative with 53.5 + 16 mmHg SBP fall (versus 88.4:1:20 mmHg).The third tilt testing was done without CLS activation (24 days after the first one), allowing negativation in only 26.3% patients. Conclusion:Although there are several limitations (placebo effect of implantation, tilt test reproductibility), there is probably a clinical interest to activate this new sensor in patients who present two potential mechanisms of syncope: paroxysmal asystole but also vasoplegic reactions.

If atrial sensing ability of a single-lead VDD pacemaker is well accepted at rest, the detection quality by atrial floating electrodes remains less recognized during exercise. The aim of this study was to verify, during treadmill test and a continous telemetry, the atrial tracking performance using four different leads technologies. From November 1994 to July 1997, 21 patients (71.3 +/- 6.3 years old, 7 female, cardiopathy: 57%) were paced for isolated high degree (permanent: 13, paroxystic: 8) AV block. The implanted devices were the Vitatron Saphir/Brillant lead (13 patients), Intermedics Unity/425/04-13 lead (5 patients), Pacesetter Addvent (2 patients), and Biotronik Eikos (1 patient). The acute atrial signal amplitude was 1.66 +/- 0.75 mV. The treadmill test used the chronotropic assessment exercise protocol after pacemaker reprogramming to detect atrial undersensing (AV delay < or = 120 ms, no hysteresis, no flywheel, upper rate increase). The mean delay was 31.1 weeks (range 1-100). The testing duration was 6.1 +/- 2.3 minutes, the number of steps was 3.3 +/- 1.3 per patient, and the peak exercise rate was 135 +/- 19 beats/min. At rest, complete atrial tracking was complete in 90% of the patients, and during testing in only 23.8% of the patients, while AV synchronization > 95% was present in 57.1%, > 90% in 71.4%, and > 85% in 90.4% of patients (Vitatron 13/13, Intermedics 3/5, Biotronik 1/1, and Pacesetter 1/2). During the recovery period synchronization was always > 95%. The mean P wave amplitude at rest was 1.1 +/- 0.5 mV; during the first step, 1.04 +/- 0.61 mV; second step, 0.94 +/- 0.53 mV; third step, 0.82 +/- 0.58 mV; fourth step, 0.67 +/- 0.39 mV; and during recovery, 1.13 +/- 0.67 mV. The mean P wave decrease signal at peak of exercise is 0.21 mV (from -1.31 to +0.5). In fact, P wave variations have several patterns: a decrease was measured in 7 patients, an increase in 2 patients, and no significant change in 7 patients. Single-lead VDD P wave identification during exercise was almost accurate. However, often there was progressive lowering of atrial sensing with transient loss of AV synchrony.

If atrial vulnerability parameters are well defined, wavelength (WL) measurement (conduction velocity x refractory period), has never been assessed through an endocavitary electrophysiological exam. We investigated 30 patients (14 female, mean age 63.4 +/- 13 y.o.), 10 with paroxysmal atrial fibrillation (PAF group), 10 with ischemic cerebral injury (ICI group) by comparison with 10 controls (C group). The upper to lower right atrium conduction time and velocity were measured in the right atrium with a decapolar electrode catheter applied along the free wall. Others parameters correlated to atrial excitability were also taken into account: effective (ERP) and functional refractory periods (FRP); spontaneous or paced atrial electrogram (A1) or extrastimulated atrial electrogram (A2) widths, ERP/A2 ratio, provocative atrial testing. Measurements were taken in sinus rhythm and in 600-460 ms paced cycle lengths. If ERP, FRP, A1 widths are the same in the 3 groups, PAF and ICI groups have a significant increased conduction time and lower conduction velocity, leading to a shorter A1 WL during 600 and 460 ms paced rhythms (p < 0.05) and A2 WL during 460 ms paced rhythm. The provocative testing was positive in 60% of PAF and ICI groups, and there is a significant correlation between arrhythmia induction and 600 ms A1 WL or 460 ms A2 WL. This electrophysiological study suggests the possibility of an approach in humans of wavelength concept and proves the presence of correlation between a short wavelength and atrial spontaneous or induced arrhythmias. A no-arrhythmia band (A1 WL > 17 cm during 600 ms paced rhythm, A1 WL > 16 cm or A2 WL > 12 cm during 460 ms paced rhythm) and a fibrillation-band (A1 WL < 12 cm during 600 and 460 ms pacing, A2 WL < 7 cm during 460 ms pacing) can be defined. Therefore, the ICI group has the same atrial pattern as the AF group.

The aim of this retrospective study was to assess short and long-term mortality and morbidity after radiofrequency ablation of the atrioventricular junction in patients with supraventricular arrhythmias resistant to treatment. This cooperative series included 91 patients (47 men, mean age 68 +/- 9 years). The arrhythmia was paroxysmal in 56% of cases. The mean duration of symptoms was 67 +/- 61 months and 45 patients (49.4%) were in the NYHA Classes III and IV. An escape rhythm was present in 58 patients with a mean frequency of 39 +/- 9/min. Early complications were observed in 5 patients (venous thromboses, pulmonary embolism, mild pericardial effusion and haemothorax). The hospital mortality was 4 patients (4.4%). Death was of cardiac origin in 1 case (cardiac failure). The mean follow-up of patients was 14.5 +/- 8.6 months. Eleven patients died during this period, 8 of cardiac causes: cardiac failure (3 cases), sudden death (3 cases), thrombosis of a valve prosthesis (1 patient) and major electrolyte disturbances causing loss of stimulation in 1 case. Six patients had recurrences. Long-term morbidity was either related to cardiac pacing (3 cases) or cardiac failure (3 cases). Thirteen patients were in NYHA Classes III or IV at the end of follow-up. The authors conclude that radiofrequency ablation at the atrioventricular junction is an effective method of treating resistant supraventricular arrhythmias. Complications are not frequent but mortality appears to be high, probably due to the presence of advanced cardiac disease in the majority of cases. Sudden death seems to be rare and unrelated to pacing defects.

The aim of this study was to check the atrial tracking performance of VDD pacemakers connected to atrial floating single VDD leads. Fourteen patients (12 men and 2 women aged 63.7 years) were paced for isolated high degree A-V block. They were implanted with either Vitatron Saphir / Brilliant lend or Intermedics Unity / 425 / 04-13 lead. An exercise stress test was completed. CAEP protocol was used with ECG and P-wave amplitude continuously recorded. P-wave identification with a single lead VDD during exercise stress test was almost accurate. In global view, single lead VDD system is an efficient pacing system. However. often there was a progressive lowering of atrial sensing.

The multiplication Of the indication of radiofrequency for curative or palliative treatment of cardiac arrhythmias motivated the Rhythmology Working Group to set up a register of the complications related to this technique. Five thousand six hundred and eighty nine cases from 19 French centres were recensed up to March 1996. There were 2 765 ablations of a Bundle of Kent, 1 579 ablations of slow pathways, 612 ablations of atrial flutter, 25 ablations of atrial tachycardia, 200 ablations of ventricular tachycardia and 499 ablations of the Bundle of His. Eighty five complications (1.5 %), two of which were lethal (0.04 %), were reported. The complications of catheterization (27% of all complications) were pneumothorax (n = 6), arterial trombosis (n = 3), Venous thrombosis with and without pulmonary embolism (n = 8), haematoma (n = 2), femoral pseudoaneurysm (n = 1), arteriovenous fistula (n = 1), infection (n = 2), valvular disease with mitral or aortic regurgitation (n = 3). Other complications were specific to the ablation itself: skin burns at the site of the patch (n = 2), ventricular fibrillation (n = 3), coronary events (n = 2), Vascular events (n = 2), tamponade (n = 12), one of which was lethal, and transient or permanent complete atrioventricular block (n = 32) complicating ablation of antero and posteroseptal accessory pathways, atrial flutter and slow intranodal reentry pathways (n = 25). One lethal cerebral haemorrhage occurred the day after an ablation procedure. It was not possible to identify a predictive factor in these complications apart from the operator's experience. There were 1.4 % of complications in Kent bundle ablations, 1.9 % in ablation of slow pathway, 0.6; % in atrial flutter and tachycardia, 1.5 % for ventricular tachycardia and 1.9 % for Bundle of His. The authors concluded that the prevalence of complications, though small with minimal risk of mortality (0.04 %), should incite physicians to reserve this technique for symptomatic patients or those with potentially lethal arrhythmias.

Infections after cardiac pacemaker implantation are rare (0.13 to 12.6%) but potentially severe complications. Staphylococcus is the genus most frequently isolated (72 to 100% of cases). The use of systematic prophylactic antibiotics remains controversial. From November 1991 to October 1993, 207 consecutive patients were submitted to a series of measures designed to reduce the risk of infection: a) intravenous bolus injection of Cefamindole, 15 minutes before implantation, b) cutaneous disinfection with iodinated polyvindone, c) injection of an ampoule of rifampin before closure of the pacemaker in the pouch, d) absence of drainage system. Patients were predominantly female (60.9%), with a mean age of 77 +/- 10 years, frequently suffering from heart disease (53.8%). The indication for implantation was atrioventricular block (39.7%), carotid sinus syndrome (27.5%), atrial arrhythmia (27.5%), resection of the node-His tract (5.3%). This procedure corresponded to the first implantation in 88.4% or replacement of a previous pacemaker in 11.6% of cases and the pacing mode was single-chamber (38.4% or replacement of a previous pacemaker in 11.6% of cases and the pacing mode was single-chamber (38.7%), or double chamber (61.3%). The mean duration of the procedure was 51.5 min +/- 30 min. The mean follow-up was 12.7 +/- 5 months. The overall mortality was 14% (11 cases of cardiac failure, 6 sudden deaths, 4 cerebrovascular accidents, 4 cases of pneumonia, 4 neoplasms). Only one infectious problem (endocarditis, i.e. 0.48%) was observed.