Can amiodarone pulmonary toxicity be predicted in patients undergoing implantable cardioverter defibrillator implantation?

Implantable cardioverter defibrillator (ICD) implantation is rapidly becoming accepted as primary therapy for malignant ventricular arrhythmias. Many patients undergoing ICD implantation are on concomitant antiarrhythmic drugs to decrease shock frequency, slow tachycardia rate, and suppress supraventricular arrhythmias. Amiodarone is a potent antiarrhythmic agent that is also frequently used in the treatment of patients with refractory ventricular arrhythmias. Ten to forty percent of patients undergoing ICD implantation will also be taking amiodarone. It has been reported to cause pulmonary toxicity in about 5% of patients per year. Acute amiodarone toxicity presenting as adult respiratory distress syndrome has been reported much less frequently. Although perioperative morbidity due to amiodarone has been described, the risk, predictability, and consequences of acute pulmonary toxicity from amiodarone in patients undergoing ICD implantation have not been previously described. We reviewed the records of 99 consecutive patients undergoing ICD implantation at our institution from October 1987 to April 1992. Thirty-nine patients were taking 480 +/- 230 mg of amiodarone (median 400 mg, lower 20th percentile 400 mg, upper 80th percentile 800 mg) for 291 +/- 554 days prior to ICD implantation. Ten patients taking amiodarone developed acute pulmonary toxicity clinically manifesting as diffuse pulmonary infiltrates on chest radiography and adult respiratory distress syndrome with hypoxia (arterial pO2 < 60 mmHg) without evidence of pneumonia or elevated pulmonary capillary wedge pressure (PCW < or = 15 mmHg). Of the 60 patients not taking amiodarone none developed adult respiratory distress syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)     

Admission to an intensive care unit after transvenous implantable cardioverter defibrillator implantation: analysis of risk factors

The endocrine abnormality that causes slipped capital femoral epiphysis (SCFE) has not been revealed. Recent studies have shown that parathyroid hormone (PTH) and 1,25-dihydroxyvitamin D [1,25-(OH)2D] are involved in growth-plate chondrogenesis and matrix mineralization. Thus we examined in 13 patients with SCFE the serum levels of three immunoreactive forms of PTH (iPTH): the whole peptide [(1-84)PTH], the fragment containing the COOH-terminal portion (C-PTH), and the midportion (M-PTH). Additionally, serum levels of 25-hydroxyvitamin D [25-(OH)D] and 1,25-(OH)2D were measured. We found that the levels of M-PTH were significantly lower than those of controls, whereas levels of C-PTH and (1-84)PTH were not significantly different from those of controls. Similarly, levels of 1,25-(OH)2D were also significantly lower than control levels. In patients with initially low levels of M-PTH and 1,25-(OH)2D in whom the levels were monitored over a period, all levels returned to normal within a year after the onset of disease. The deficiency of M-PTH or 1,25-(OH)2D during the growth spurt could result in SCFE, although in this study, we cannot deny the possibility that the slippage may cause the deficiency.     

Comparison of three cardioverter defibrillator implantation techniques: initial results with transvenous pectoral implantation

A total of 121 patients underwent epicardial (n = 32), transvenous abdominal (n = 30), and transvenous pectoral (n = 59) ICD implants. Perioperative complications were defined as those occurring within 30 days after surgery. Hospital costs were calculated with $750 per day as a fixed charge. Duration of surgery was the time between the first skin incision and the last skin suture. Severe perioperative complications that were life-threatening or required surgical intervention occurred in the epicardial (6%) and transvenous (10%) abdominal groups, but not in the pectoral group. Perioperative mortality occurred only in the epicardial abdominal group, predominantly in patients with concomitant surgery (18%), and in 5% of patients without concomitant surgery. The duration of surgery was significantly shorter for transvenous pectoral implantation (58 +/- 15 min, P < 0.05) compared to transvenous abdominal implantation (115 +/- 38 min). Epicardial abdominal ICD implantation had the longest procedure time (154 +/- 31 min). The postimplant hospital length of stay was significantly shorter for pectoral implantation (5 +/- 3 days, P < 0.05) compared to transvenous (13 +/- 5) and epicardial (19 +/- 5) abdominal implantation. Total hospitalization costs significantly decreased in the pectoral implantation group ($4,068 +/- $2,099 for the pectoral group vs $14,887 +/- $4,415 and $9,975 +/- $3,657 for the epicardial and the transvenous abdominal group, respectively, P < 0.05). These initial results demonstrate the advantage of transvenous pectoral ICD implantation in terms of perioperative complications, procedure time, hospital length of stay, and hospitalization costs.     

Runaway pacemaker in an implantable cardioverter defibrillator

INTRODUCTION: Runaway pacemaker is a potentially catastrophic complication of any permanent pacing system. METHODS AND RESULTS: A 70-year-old man was found to have erratic behavior of his implantable cardioverter defibrillator (ICD) during a routine outpatient interrogation. His device was turned off, and he was hospitalized in preparation for a pulse generator replacement. During his hospitalization, his ICD unexpectedly began pacing rapidly. Despite prompt resuscitation attempts, the patient died. Postmortem examination of the device demonstrated a crystal oscillator failure. CONCLUSION: A previously unrecognized component malfunction is a potentially lethal complication of ICDs.     

Extraction of pacemaker and implantable cardioverter defibrillator leads

To determine the mechanisms by which human immunodeficiency virus type 1 (HIV-1) crosses the placenta into the fetal blood, 12 matched samples of serial maternal blood, term placentas, and infant blood obtained from a cohort of pregnant women in Cameroon identified as predominantly infected by subtype A viruses were studied. HIV-1 env sequences were detected by polymerase chain reaction (PCR) in both chorionic villi and enriched trophoblastic cells of all 12 placentas but at variable rates of detection. Heteroduplex mobility assay analysis showed the presence of multiple HIV-1 env quasispecies in sequential maternal peripheral blood mononuclear cell samples, but only a small number of env variants were found in chorionic villi and enriched trophoblastic cells. These data indicate that HIV-1 env sequences are always present in term placentas of seropositive women, contrasting with the low frequency at which infection is diagnosed by PCR in neonates with tat, gag, and env primers. Maternal HIV-1 variants appear to undergo a strong negative selection by different cell populations within the placental villi.     

An overview of the fifth-generation implantable cardioverter defibrillator

It has been established that treatment with an implantable cardioverter is effective for life-threatening arrhythmia including ventricular tachycardia (VT) and ventricular fibrillation (VF). Although most third and fourth-generation implantable cardioverter defibrillator (ICD) models are effective for the treatment of VT and VF, they often misinterpret supraventricular tachycardia (SVT), and the incidence of inappropriate therapy delivered is as high as 20 to 40%. To solve this clinical problem, the dual-chamber ICD was developed. According to the current reports on a study of the main fifth-generation ICD models that have been clinically used, 86 to 100% sensitivity regarding discrimination was obtained. In addition, the sensitivity for delivering appropriate therapy for VT was 97 to 100%. Since the indications for ICD therapy are being expanded, additional improvement of the device and adequate patient selection are recommended.     

A review of the implantable cardioverter defibrillator trials

Intravenous immunoglobulin is now used in a wide range of neurological conditions. However, side effects are relatively common, treatment is expensive and sustained benefit unusual without repeated administration. This article aims to provide clinicians with an overview of the potential benefits and drawbacks of intravenous immunoglobulin in neurological practice and concludes with suggested guidelines for its use in adults.     

Right ventricular implantable cardioverter defibrillator lead implantation through a persistent left superior vena cava

A 60-year-old woman required implantation of an ICD because of a hypotensive ventricular tachycardia refractory to four different antiarrhythmic drugs. Preoperative diagnostics revealed a persistent left SVC as the only major venous return from the upper part of the body to the heart. Under local anesthesia, a tripolar lead was advanced through the left SVC into the right ventricular apex. Following successful testing, an active can ICD device was implanted, which is functioning well during a follow-up period of 9 months.     

Cardiomyoplasty combined with implantation of a cardioverter defibrillator

Congenital absence of the scaphoid without associated thumb or radial hypoplasia is a rare condition. This report is the third case presented in the literature of this condition. The case presented is of a patient who presented initially with wrist pain. Radiographs revealed a congenitally absent scaphoid and examination revealed no evidence of thumb hypoplasia. A brief review of the literature on congenital absence of the scaphoid is discussed.     

Effect of extracorporeal shock wave lithotripsy on implantable cardioverter defibrillator

Extracorporeal shock wave lithotripsy (ESWL) is frequently used for nephrolithiasis of the upper urinary tract. Because of the powerful shock wave and electromechanical forces created, this therapy has been contraindicated in the patient with an implantable cardioverter defibrillator (ICD). To determine whether or not ESWL affects ICD devices, we subjected ten devices to a full course of ESWL. The devices were then returned to the manufacturer to undergo bench analysis, which revealed no abnormalities in function. Additionally, one device was placed in the pathway of the shock wave, resulting in a discharge of the device despite a frequency of ESWL of 100 shocks/min (well below the rate cutoff of that device). Manufacturer analysis of this device, likewise, revealed no abnormalities even though the device had been exposed to the focal point of the shock wave. We conclude that contralateral ESWL is not contraindicated for the patient with an ICD. We do, however, recommend a post-procedure evaluation to ensure appropriate function of the ICD.     

Cardiomyoplasty after implantation of a pacemaker and cardioverter/defibrillator

Presently, a combination of two surgical methods improves the survival of patients with advanced ventricular dysfunction: implantable cardioverter/defibrillator implantation (which prevents sudden cardiac death) and cardiomyoplasty (which prevents further dilatation of the heart and provides additional cardiac assistance). We report the clinical course of a patient who had cardiomyoplasty after cardioverter/defibrillator implantation and pacemaker insertion. It is a rare case in which three different devices cardioverter/defibrillator, pacemaker, and cardiomyostimulator) are functioning together without crosstalk.     

Left ventricular malposition of a transvenous cardioverter defibrillator lead: a 3-year follow-up

A case of left ventricular malposition of a transvenous implantable cardioverter defibrillator lead through an atrial septal defect is presented. The patient has been continually anticoagulated with warfarin. A 3-year follow-up has thus far been uneventful.     

Short-term and long-term outcome of left heart function after cardioverter defibrillator implantation

The usefulness and problems of implantable cardioverter defibrillators (ICD) were examined in patients with reduced heart function. Of 36 patients who received ICD for refractory ventricular tachycardia (VT) or ventricular fibrillation (VF), VT and/or VF was associated with underlying heart disease in 26 patients, and VF without underlying heart disease in 10. Of the former 26 patients, 13 with left ventricular ejection fraction (LVEF) of less than 30% were assigned to group A, 13 with LVEF of greater than 30% to group B, and the other 10 with idiopathic VF to group C. Intraoperative death, cardiac death due to heart failure, sudden death, functional status of the ICD, exacerbation of heart failure symptoms and complications were compared between the three groups. There were no intraoperative deaths in any of the groups. During the median follow-up period of 36 +/- 22 months, there was only one sudden death in group A. There were no significant differences between the three groups. There were five cardiac deaths in group A, but none in groups B or C. The cardiac death-free rates 12, 24, and 36 months after implantation in group A were 83%, 60% and 50%, respectively. These values significantly differed from those in groups B and C (p < 0.05). The number of patients who received defibrillation therapy was higher in group A (p < 0.05). Defibrillation therapy was administered earlier in group A than in groups B and C (p < 0.05). The incidence of exacerbation of heart failure after implantation was 69%, 23% and 0% in groups A, B, and C, respectively. In group A, defibrillation therapy was administered in all patients with exacerbation of heart failure. The administration of defibrillation therapy significantly differed from that in patients without exacerbation of heart failure (p < 0.05). Exacerbation of heart failure during the postoperative acute stage occurred in both patients in group A in whom an epicardial lead system was used, but not in the four patients in group B or five in group C (p < 0.05). There were no differences in the incidence of other complications between the three groups. In group A, patients with reduced heart function, ICD greatly decreased the risk of sudden death. However, heart failure mortality remained high. Therefore, ICD may have limitations for improved prognosis. In group A patients, defibrillation therapy was administered in all patients with exacerbation of heart failure or death due to heart failure. In patients with reduced heart function, treatment for heart failure and prophylaxis of VT and/or VF should be administered.     

Influence of the implantable cardioverter defibrillator on survival: retrospective studies and prospective trials

Frequent losses of heterozygosity observed at several chromosomal loci in primary lung cancers have indicated the existence of several tumor suppressor genes associated with this type of cancer. We have examined loss of heterozygosity on chromosomal arm 8p in 49 cases of non-small cell lung carcinoma, using 14 restriction fragment length polymorphism markers. Of 42 cases informative with at least one marker, 21 showed allelic loss, including 15 of 32 adenocarcinomas and 5 of 9 squamous cell carcinomas. The frequency of allelic loss on 8p was similar at all clinical stages. Deletion mapping defined a single common region of deletion in these tumors within an 8 cM interval at 8p21.3-p22 flanked by the loci defined by cMSR-32 and cC18-245.     

Perceived quality of life before and after implantation of an internal cardioverter defibrillator

One thousand three hundred and seventy-five (1375) persons, who were vaccinated against Rabies with Purified Chick Embryo Cell (PCEC) vaccine from 1984 to 1993, were included in this ten-year longitudinal study, conducted to observe the consistency, immunogenicity, inocuity, safety and efficacy of PCEC vaccine under controlled trial and field conditions. The study period was divided into three phases. Phases I and II covered the premarketing controlled trial and Phase III the post-marketing serosurveillance study of the vaccine. During Phase I, fifteen healthy volunteers were given a pre-exposure regime of vaccine on Day 0, 7 and 21, and the rest 15, simulated post-exposure regime on Day 0, 3, 7, 14, 30 and 90. All the subjects had satisfactory antirabies antibody response with mean titres, of 7.08 and 5.72 I.U./ml respectively, and minimal side reactions. In the Phase II, from 1984-85, 56 persons with proven rabid animal bites were given post-exposure vaccination and all had satisfactory antibody titres with mean titre of 4.45 I.U./ml after 6th dose of vaccine and with minimal side reactions. 19 to 36 months follow up after vaccination revealed no vaccine failures. In the Phase III post-marketing field study conducted from 1985 to 1993, 1289 persons reported to our Centre for consulation and antirabies antibody titre estimation following PCEC vaccination. One thousand two hundred and fifty-two (1252) persons took post-exposure vaccination following bites by rabid animals, contact with an hydrophobia patient and 37 high risk personnel took pre-exposure vaccination.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bronchopericardial fistula after placement of an automatic implantable cardioverter defibrillator: radiographic and CT findings

OBJECTIVE: We describe our experience with bronchopericardial fistula as a complication of infection in patients who have undergone placement of automatic implantable cardioverter defibrillator systems. CONCLUSION: Bronchopericardial fistula should be suspected in patients who present with hemoptysis and who have undergone placement of an automatic implantable cardioverter defibrillator using pericardial or epicardial defibrillator patches. Air between a defibrillator patch and the heart on chest radiographs or CT is diagnostic.     

Laparoscopic hernia repair of an incisional hernia secondary to placement of an implantable cardioverter defibrillator

We present the laparoscopic repair of a large incisional hernia secondary to placement of a subcostal ICD pulse generator. Laparoscopic repair of large incisional hernias provides a unique and technically feasible form of repair in the 2%-13% of patients who will develop an incisional hernia following an abdominal surgery. This form of hernia repair is associated with minimal morbidity and prompt resumption of patient activities and work.     

The quality of life after the implantation of a cardioverter/defibrillator in malignant arrhythmias

Quality of life after implantation of an automatic implantable cardioverter/defibrillator (ICD) was assessed by questionnaire in 43 patients (38 males, 5 females; mean age 57 +/- 16 years) with treatment-resistant symptomatic ventricular arrhythmias. 37 of the 43 patients felt better after ICD implantation. 23 were always conscious of having an ICD, but 18 had got used to it in less than 2 months. 15 patients reported being afraid of an ICD shock, while eight noted physical discomfort caused by the ICD. Limitations concerning their professional, recreational and social activities were reported by six patients. 41 of the 43 patients confirmed that the ICD had been helpful, enabling 23 to return to an active life. 42 would recommend implantation to others if indicated. These data demonstrate that there is a remarkably high degree of acceptance of the ICD. Survival rate after implantation is thus not the only criterion of success. All aspects of the quality of life should be taken into consideration before implantation is decided upon.     

Combined use of a true-bipolar sensing implantable cardioverter defibrillator in a patient having a prior implantable spinal cord stimulator for intractable pain

Reported is a case involving a patient with a previously implanted spinal cord stimulator (SCS) who presented for an implantable cardioverter defibrillator (ICD). The SCS device was located in the left lower abdominal quadrant with a stimulation electrode array placed on the dorsal aspect of the spinal cord at the T-11 thoracic level. Interaction testing demonstrated that the biopolar sensing transvenous ICD system (Medtronic 7221 Cx PCD) did not detect the stimulator's output at burst rates ranging from 20-130 pulses/s, even with the ICD set to its maximum sensitivity of 0.15 m V and the stimulator programmed to the highest patient tolerated output combinations of 5 V, 0.45 ms in the bipolar configuration and 3 V, 0.45 ms in the unipolar (i.e., case-electrode) configuration.