Submammary Device Implantation in Women . Introduction : The frequency of device implantation is increasing in younger patients as our ability to diagnose long‐QT syndrome, hypertrophic cardiomyopathy, Brugada Syndrome, and other life‐threatening disorders earlier has improved. Similarly, use of cardiac resynchronization therapy and ICD therapies has increased in cardiomyopathy patients. Methods and Results : Device implantation in young women has unique considerations. Standard pectoral implants lead to excessive scar formation due to skin tension and interfere with purse straps, bra straps, and seat belts. There are also privacy and body image concerns as the subclavian region is exposed with many contemporary fashions. Results : Over an 11‐year period, we implanted pacemakers, implantable converter‐defibrillators (ICDs) and cardiac resynchronization therapy (CRT) devices (defibrillators or pacemakers) in 60 women, aged 13–70 years, using a 2‐incision submammary approach. Follow‐up surveys were performed using the Florida Patient Acceptance Survey (FPAS). Women with submammary device placement reported significantly greater device acceptance (M = 92.41, SD = 6.46) than women with standard implant technique (M = 70.29, SD = 17.85); t (54) =–6.08, P < 0.001, on the FPAS. Across subscales on the FPAS, women with submammary device placement also reported significantly less body image concern (P < 0.001), less device‐related emotional distress (P < 0.001), and greater confidence in returning to life appropriately (P = 0.01) than women with standard device placement. Conclusion : We present here our technique for submammary device implantation. (J Cardiovasc Electrophysiol, Vol. 24, pp. 476‐479, April 2013)

Body: Background Ibutilide fumarate is a class III antiarrhythmic agent whose sole indication is the acute conversion of atrial fibrillation or atrial flutter to sinus rhythm. Ibutilide blocks potassium channels and activates slow inward sodium channels, which delays repolarization. These actions prolong the action potential in atrial and ventricular refractory periods, leading to arrhythmia termination. Many institutions restrict the use of ibutilide because of the potential risk of polymorphic ventricular tachycardia (PMVT). Limitations include administration only in the presence of a physician, use only in certain monitored units, or an Intensive Care Unit. Methods Over a five-year period, 238 patients, 151 male/87 female, mean age 67.1 years, received intravenous ibutilide at our institution. Ibutilide was administered in four clinical settings: Emergency Department (n=80), Intensive Care Unit (n=11), Telemetry (n=107), and the Cardiac Catheterization /Electrophysiology Laboratory (n=40). Ibutilide was administered by infusion of one milligram over 15 minutes followed by a 15 minute waiting period, the infusion was repeated. The infusion was discontinued if the patient converted to sinus rhythm. Results Conversion to sinus rhythm occurred in 59% of patients outside the cath/EP lab. The incidence of PMVT was 1.7%. Three patients had brief, non-sustained polymorphic ventricular tachycardia and one patient had a sustained PMVT. Our data suggest that ibutilide is safe and efficacious drug when ordered by experienced physicians in properly selected patients in a variety of monitored settings. Ibutilide is ordered at our institution almost exclusively by cardiac electrophysiologists and emergency physicians who routinely consult with the electrophysiologists prior to administration. No deaths occurred in our five-year series. As a result of this study, the policy at our institution is that ibutilide may be administered by nurses on telemetry units. Close Window

Background: Cardiac resynchronization therapy has been shown to improve left ventricular performance in patients with left ventricular dysfunction and a left-sided interventricular conduction delay. This is performed by placing a pacing lead on the lateral left ventricular wall to stimulate the area normally stimulated by the left bundle branch. In patients with right bundle branch block (RBBB), pacing the right bundle branch could also result in resynchronization. Previous studies have shown that right ventricular outflow septal (RVOS) pacing does, in fact, utilize the native conduction system. Methods: 62 consecutive patients, 46 male/16 female, aged 75 +/− 10.5 yr, with RBBB and indications for pacing, underwent RVOS lead placement using commercially available pacing systems. The patients subsequently underwent bedside A-V optimization to achieve the narrowest QRS duration and most “normal” QRS complex. Echocardiography was performed to evaluate changes in wall motion comparing baseline with optimal pacing. Results: Baseline mean QRS duration 146 +/− 20.9 ms Optimized mean QRS duration 111 +/− 20.5 ms Average decrease in QRS duration -35 +/− 21.5 ms p < 0.001 Echocardiography demonstrated improvement in septal contraction abnormalities. Conclusions: 1) RVOS pacing in RBBB patients can significantly narrow the QRS complex on ECG. 2) Septal contraction abnormalities due to RBBB can be improved with RVOS pacing and optimal A-V timing. 3) Further studies are warranted to evaluate this therapy in a heart failure population.

Introduction: Catheter ablation for atrial fibrillation (PVI) is being performed with increasing frequency. This time and labor-intensive procedure is under increasing scrutiny as we look for means to decrease costs of delivering care. Performing these procedures on therapeutic warfarin could shorten hospital stays, eliminate costly low-molecular weight heparin (LMW) use, and decrease procedural heparin administration which could reduce hemorrhage from access sites. Methods: Over a six-year period, 180 patients, 138 M/42 F, mean age 43 yr (18-77 yr), underwent PVI for persistent - 99 pts., and paroxysmal - 81 pts. atrial fibrillation. Mean INR was 2.2 (1.5 - 4.2). Procedures were performed with standard radiofrequency (RF) catheters - 132, Cryoablation - 27, and Ablation Frontiers RF - 21. Procedural time, fluoroscopy time, hospital stays, outcomes, and complications were tracked. Results: 127 of 180 pts. were discharged the day of procedure (OP) from the outpatient unit, 51 pts. stayed one night post-procedure (IP), 2 patients stayed 4 days, one for pulmonary treatment and one for CVA. Mean procedural length was 3.3 hours, mean fluoro time was 52 min. Mean time from hospital admit to discharge was 17.3 hr. Mean time from procedure end to discharge was 11.0 hr. 77% of pts. were free from AF on follow-up on no meds or “pill-in-the-pocket”. 6 complications occurred - 1 phrenic nerve paralysis (resolved), 2 CVAs (one was 72 hrs post PVI), 1 perforation/tamponade, 1 groin bleed requiring evacuation, 1 PV stenosis. There was no difference in outcome for patients discharged OP vs IP. Cost savings by continuing warfarin were LMW = $205/dose X 6 doses - $1230/pt. Cost savings by same day discharge = $1330/day. Conclusions: PVI can be safely performed as an outpatient procedure on therapeutic warfarin with good clinical outcomes. Significant cost savings can be realized from OP PVI from reduced staff, medication, and facilities utilization.

Many institutions restrict the use of ibutilide because of the potential risk of polymorphic ventricular tachycardia (PMVT). Over a 5-year period from June 2000 to May 2005, 238 patients, 151 men and 87 women, with a mean age of 67.1 years (range, 22-94 years), received intravenous ibutilide at our institution. Ibutilide was administered by nurses or physicians in 4 clinical settings: emergency department (n = 80), intensive care unit (n = 11), patient room on telemetry (n = 107), and in the cardiac catheterization/electrophysiology laboratory (n = 40). Conversion to sinus rhythm occurred in 59% of patients outside the catheterization/electrophysiology laboratory. The incidence of PMVT was 1.7%. Three patients had brief nonsustained PMVT and 1 patient had a sustained PMVT. There was no difference in outcome whether a physician was present at the time of ibutilide administration. Our data suggest that ibutilide is a safe and efficacious drug when ordered by experienced physicians in properly selected patients in a variety of monitored settings.

Background: Ibutilide fumarate is a class III antiarrhythmic agent whose sole indication is the acute conversion of atrial fibrillation or atrial flutter to sinus rhythm. Ibutilide blocks potassium channels and activates slow inward sodium channels, which delays repolarization. These actions prolong the action potential in atrial and ventricular refractory periods, leading to arrhythmia termination. Many institutions restrict the use of ibutilide because of the potential risk of polymorphic ventricular tachycardia (PMVT). Limitations include administration only in the presence of a physician, use only in certain monitored units, or an Intensive Care Unit. Methods: Over a five-year period from June 2000 to May, 2005, 238 patients, 151 male/87 female, mean age 67.1 years, received intravenous ibutilide at our institution. Ibutilide was administered in four clinical settings: Emergency Department (n=80), Intensive Care Unit (n=11), Telemetry (n=107), and the Cardiac Catheterization /Electrophysiology Laboratory (n=40). Ibutilide was administered by infusion of one milligram over 15 minutes followed by a 15 minute waiting period, the infusion was repeated. The infusion was discontinued if the patient converted to sinus rhythm. Results: Conversion to sinus rhythm occurred in 59% of patients outside the cath/EP lab. The incidence of PMVT was 1.7%. Three patients had brief, non-sustained polymorphic ventricular tachycardia and one patient had a sustained PMVT. Our data suggest that ibutilide is safe and efficacious drug when ordered by experienced physicians in properly selected patients in a variety of monitored settings. Ibutilide is ordered at our institution almost exclusively by cardiac electrophysiologists and emergency physicians who routinely consult with the electrophysiologists prior to administration. No deaths occurred in our five-year series. Background: Ibutilide fumarate is a class III antiarrhythmic agent whose sole indication is the acute conversion of atrial fibrillation or atrial flutter to sinus rhythm. Ibutilide blocks potassium channels and activates slow inward sodium channels, which delays repolarization. These actions prolong the action potential in atrial and ventricular refractory periods, leading to arrhythmia termination. Many institutions restrict the use of ibutilide because of the potential risk of polymorphic ventricular tachycardia (PMVT). Limitations include administration only in the presence of a physician, use only in certain monitored units, or an Intensive Care Unit. Methods: Over a five-year period from June 2000 to May, 2005, 238 patients, 151 male/87 female, mean age 67.1 years, received intravenous ibutilide at our institution. Ibutilide was administered in four clinical settings: Emergency Department (n=80), Intensive Care Unit (n=11), Telemetry (n=107), and the Cardiac Catheterization /Electrophysiology Laboratory (n=40). Ibutilide was administered by infusion of one milligram over 15 minutes followed by a 15 minute waiting period, the infusion was repeated. The infusion was discontinued if the patient converted to sinus rhythm. Results: Conversion to sinus rhythm occurred in 59% of patients outside the cath/EP lab. The incidence of PMVT was 1.7%. Three patients had brief, non-sustained polymorphic ventricular tachycardia and one patient had a sustained PMVT. Our data suggest that ibutilide is safe and efficacious drug when ordered by experienced physicians in properly selected patients in a variety of monitored settings. Ibutilide is ordered at our institution almost exclusively by cardiac electrophysiologists and emergency physicians who routinely consult with the electrophysiologists prior to administration. No deaths occurred in our five-year series.

Background: Cardiac resynchronization therapy has been shown to improve left ventricular performance in patients with left ventricular dysfunction and a left-sided interventricular conduction delay. This is performed by placing a pacing lead on the lateral left ventricular wall to stimulate the area normally stimulated by the left bundle branch. In patients with right bundle branch block (RBBB), pacing the right bundle branch could also result in resynchronization. Previous studies have shown that right ventricular outflow septal (RVOS) pacing does, in fact, utilize the native conduction system. Methods: 53 consecutive patients, 42 male/11 female, aged 75 ± 10.8 yr, with RBBB and indications for pacing underwent RVOS lead placement using commercially available pacing systems. The patients subsequently underwent bedside A-V optimization to achieve the narrowest QRS duration and most "normal" QRS complex. Echocardiography was performed to evaluate changes in wall motion comparing baseline with optimal pacing. Results:Baseline mean QRS duration 145 ± 18.1 msOptimized mean QRS duration 110 ± 20.7 msAverage Optimal AV Delay 205 ± 45.9 msAverage decrease in QRS duration 34 ± 21.4 msp < 0.001Echocardiography demonstrated improvement in septal contraction abnormalities.Conclusions: 1) RVOS pacing in RBBB patients can significantly narrow the QRS complex on ECG. 2) Septal contraction abnormalities due to RBBB can be improved with RVOS pacing and optimal A-V timing. 3) Further studies are warranted to evaluate this therapy in a heart failure population.

Background: The electrocardiogram (ECG) patterns during pacing from the great cardiac vein (GCV) and the middle cardiac vein (MCV) are not well known.Methods: We recorded 12-lead ECGs during GCV and MCV pacing in 26 patients undergoing implantation of a cardiac resynchronization device. The left ventricular (LV) lead was passed down the GCV (n = 19) or MCV (n = 7) prior to moving it to a lateral or posterolateral vein for permanent implantation.Results and Conclusions: Pacing within the GCV resulted in a left bundle branch block (LBBB) morphology with no or minimal R-wave in V-1 in 14 patients and a right bundle branch block (RBBB) pattern (R > S in lead V-1) in four patients. In one patient, lead V1 during GCV pacing was isoelectric (R = S). A more distal pacing site in the GCV yielded a LBBB pattern in all the patients. All leads placed in the MCV resulted in a LBBB configuration. An ECG pattern with a RBBB pattern was invariably recorded during LV pacing in 125 consecutive outpatients with biventricular pacemakers and LV leads in the posterolatral and lateral coronary veins. Knowledge of the ECG patterns from various pacing sites in the coronary venous system may be helpful for troubleshooting all types of pacing systems, especially those where the coronary venous pacing site is unintentional.

Over a 5-year period, 112 patients (89 male/23 female, mean age 65 years) underwent right ventricular outflow tract (RVOT) placement of permanent active-fixation transvenous pacing/defibrillating leads. At implantation, the pacing threshold was 0.6 +/- 0.3 V at 0.5 ms pulse duration and R wave amplitude was 10.9 +/- 4.9 mV. The defibrillation threshold (DFT) of right-sided implants was 17.7 +/- 3.4 J while that of left-sided implants was 16.1 +/- 3.3 J. Patients were followed at 1 and 3 month postimplant and at six-month intervals thereafter. At mean follow-up of 22.5 +/- 17.5 months (range 1-47 months) there were no lead dislodgments, unsuccessful shock therapies, or failure to sense or pace for bradycardia or tachycardia. Death was not sudden in the 17 patients who died. We conclude that RVOT pacing-defibrillation lead implantation is safe, efficacious, and potentially attractive because preliminary evidence suggests that it may not be associated with the adverse hemodynamic effects of pacing at the right ventricular apex.

The study evaluated all patients undergoing permanent pacemaker and ICD implantation over a 4-year period to determine if anticoagulated patients required normalization of coagulation factors in the periprocedural period. The study included 1,025 (597 men, 428 women, age 24-100 years, mean 72 years) consecutive patients who underwent device implantation using mostly a percutaneous subclavian approach. The procedures were performed without reversal of anticoagulation in 470 patients with INRs >or= 1.5 at the time of the procedure (mean INR 2.6 +/- 1.0, range 1.5-7.5). The complication rate in the anticoagulated group was similar to those in patients with a normal INR. Routine normalization of coagulation factors prior to pacemaker/ICD placement may not be necessary.

This report describes a case of an active-can ICD placed in the thigh. A 74-year-old man on chronic renal dialysis had no venous access from cephalic, subclavian, or jugular approaches. Using long active-fixation leads the device was placed from a femoral approach with good sensing, pacing, and defibrillation parameters.

Right ventricular outflow tract pacing has been shown to increase cardiac output compared with apical pacing. The relation between the baseline QRS duration and paced QRS duration suggests that right ventricular outflow tract pacing utilizes the native conduction system.