Biomedical subjects
Publications and source records attributed to J A Trigano.
This report describes a pacing lead insertion through a persistent left superior vena cava in the VDD pacing mode, with a large retrograde lead course allowing the optimal positioning of the sensing electrodes in the right atrium.
Interference with cardiac pacemakers and defibrillators by cellular phone and electronic article surveillance systems is shown in experimental studies with disparate findings. Interaction occurrence in real life is a convincing but rare experience. Device model, distance, power output and technology of the source are different and sometimes uncontrollable factors. As a result it remains difficult to quantify the true incidence of interaction and associated health risk. Nevertheless, simple recommendations commonly help the patients to prevent the interference.
OBJECTIVES: We studied the incidence, clinical signs and severity of heart perforations occurring after transvenous pacemaker implantation. PATIENTS AND METHODS: A series of 16 consecutive cases of heart perforation observed in one cardiac pacing unit from 1989 to 1998 were reviewed. RESULTS: Heart perforation occurred after implantation in 9 cases; the verall incidence for all lead implantation was 0.57%. The ventricle was perforated in 6 cases, the atrium in 1, and an undetermined site in 2 cases. Active fixation was involved in 5 cases, passive fixation in 4. A bipolar lead was used in 7 cases and a unipolar lead in 2. Heart perforation occurred after prior external stimulation in 7 cases, including one case with tamponnade requiring emergency pericardial drainage after implantation. Repositioning the lead in the ventricle was sufficient in 6 cases and a thoracotomy for an atrial wound was performed in 1 case. Difficulties in right ventricular catheterism due to kyphoscoliosis in elderly subjects was found to be a risk factor. CONCLUSION: Heart perforation following transvenous pacemaker implantation is an exceptional complication with currently used material. Tamponnade is extremely rare. Besides verifying the mechanical performance of the leads, prevention requires a rigorous protocol for catheterism and wall fixation.
This report describes a patient admitted for the treatment of a pocket infection occurring 5 months after a dual chamber pacemaker implantation. The ventricular lead had been inadvertently placed into the left ventricle through the arterial system. After careful examination using transesophageal echocardiography and left heart angiogram, successful percutaneous extraction was performed without complication.
OBJECTIVES: Assess the efficacy of an anesthetic cream for cardiac catheterization. PATIENTS AND METHODS: Percutaneous anesthesia was studied in a series of 100 consecutive patients undergoing cardiac catheterization. The anesthesia was composed with an eutetic mixture of local anesthetics and applied precisely over the puncture area in a randomized controlled study. After admission, patients were randomized into two groups: 50 patients received lidocaine infiltration and 50 patients received associated cream and infiltration. Percutaneous anesthesia was to be applied 2 hours before entering the operating room. RESULTS: No complication developed with this cream combined with lidocaine infiltration. Serum concentration indicated very low levels which were very well tolerated. Patient comfort improved with the anesthetic cream-lidocaine infiltration association. CONCLUSION: The use of an anesthetic cream is safe and effective, especially combined with lidocaine infiltration during cardiac catheterization. Cost is high and the association might be reserved for special indications (obesity, children).
Intrapulmonary artery displacement of a permanent ventricular lead is reported to be a severe form of lead coiling and is attributed to the failure of the fixation procedure. The lead instability indicated a need for surgical correction.
During reoperation for pacemaker implantation, venous catheterisation of the homolateral subclavian vein encountered obstruction at the brachiocephalic vein. Balloon angioplasty of the severe brachiocephalic stenosis was performed via the femoral vein. After repeat subclavian venous catheterisation two new pacing wires could be introduced without difficulty followed by active fixation in the atrium and passive fixation in the ventricular apex. The initial ventricular pacing wire was isolated and respected. The femoral vein approach gave simple and direct access to the site of dilatation at a distance to the operative field which was shielded from an infectious risk. The technique and results of percutaneous venous recanalisation have not been extensively analysed during reoperation for cardiac pacing. In chronic cardiac pacing, the success of homolateral operation despite venous occlusion or stenosis, ensures preservation of the venous capital.
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Transcutaneous cardiac pacing was abandoned when endocardial pacing was developed, but it has now come back, with a new methodology, in cardiological intensive care. Its safety and efficacy have been improved by 50 to 100 sq. cm electrodes, impulses of 20 to 40 ms duration and programmed energy. A perfect electrocardiographic analysis can be obtained by specific treatment of the pacing signal. New research work has begun concerning the sequence of activation. The hypothesis of simultaneous atrial and ventricular pacing, which has been put forward after the first experimental studies, is seldom confirmed by clinical data: it has been demonstrated that pacing is exclusively ventricular and that its influence on haemodynamics is equivalent to that of endocardial ventricular pacing. Transcutaneous pacing is the only technique that can be used in non-hospital extensive care, and this leads to the concept of mobile units performing defibrillation, ensuring electrophysiological monitoring and capable to treat circulatory arrests due to pause or ventricular tachyarrhythmias. Transcutaneous pacing is being reconsidered in cardiology units, where it can be used to reduce ventricular tachycardias, since it has the advantage over endocardial pacing or being immediately applicable and completely safe.
Noninvasive transcutaneous cardiac pacing has evolved from a simple stand alone unit with no ventricular sensing to a complete cardiac arrest resuscitation system combining synchronous pacing and defibrillation capabilities and using a single set of multifunction electrodes. In current instrumentation, four configurations exist including stand alone unit, modular configuration, built-in monitor and recorder, and built-in monitor, recorder and defibrillator. In present day devices, ventricular sensing, extensive programmability, and large surface electrodes are general features. Capture monitoring requires specific integrated electrocardiographic capability. Future developments are expected to involve low threshold electrode technology, integrated mechanical monitoring, and interdevice electrode compatibility.
Electrocardiographic evaluation of modern pacing systems requires sustained documentation during iterative programming procedures, exercise testing or Holter monitoring. Documentation of a prolonged period of time in standard electrocardiography is based on horizontal compression. The value and limitations of a vertical compression with no change in horizontal chronology and waveform morphology are evaluated. The signal taken from a selected surface lead is introduced into an oscilloscope triggered by an electrocardiographic event along the horizontal axis. A continuous vertical monitoring provides a vertical superimposition of the consecutive cycles. The brightness is proportional to the amplitude of the signal and introduces a third dimension. The three-dimensional technique results in an original image allowing report miniaturization at standard 25 or 50 mm/sec paper speed. Appropriate lead selection and use of the brightness as a marker event allow reliable atrial activity identification. In rate responsive pacing evaluation, the procedure is specifically convenient to full disclosure of the chronotropic response. The main limitation is a high sensitivity to noise during recording. Further developments are to be expected based on computer-assisted electrocardiography.
Bradyarrhythmia or asystole is the most common rhythm disturbance with ventricular fibrillation and tachycardia, for 30-40% of patients admitted in intensive coronary care units. Already use in the therapy of bradyarrhythmia or asystole, as a method of emergency, immediately in place, the external pacing is very useful in an out of hospital therapy with personnel skilled in its use until the initiation of support therapy in coronary care units. Actually, with less significant side effects (no severe pain, no strong muscular contractions, no skin burns) and a best innocuity and tolerance based on the employment of larger adhesive pre-gelled patches, temporary transcutaneous cardiac stimulation is not only confined to unconscious patients but also in case of severe bradycardia, complete AV block in conscious patients. Our hemodynamic study shows a good level of systemic pressure and of cardiac index to permit the transport of patients in coronary care units in good conditions. Furthermore, the experimental study demonstrates the importance of the polarity of the electrodes and of the duration of the stimulus (more than 10 ms) to minimize the threshold (mA/cm2) so as to increase the tolerance in clinical application. Transcutaneous cardiac pacing is a simple and rapid pacing procedure with effective hemodynamic results for victims of out-of-hospital cardiac arrest and can be easily used in conscious patients without any complication.
In a pacemaker-dependent patient, the hemodynamic response during external transcutaneous and endocardial sequential pacing was evaluated by left ventricular pressure monitoring. A single ventricular pacing mode with hemodynamic effect of atrioventricular asynchrony was shown during external pacing.
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An observation of angina aggravated in a concomitant manner with the introduction of treatment with beta blockers is reported. The exacerbation of a vasospastic component with this treatment is evoked on clinical, electrical and coronarographic grounds.
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The aim of this prospective study was to assess the value of complementary investigations in the diagnosis and follow-up of embolic heart disease. Forty-six patients having presented a systemic embolism cardiac origin underwent a standard work up which included clinical examination, ECG, chest X-ray and 2D echocardiography. Other investigations were carried out in some patients: CT cardiac scan (11 cases), gamma scintigraphy with Indium III labelled platelets (6 cases) and angiocardiography (12 cases). The diagnosis of an embolic cardiac lesion was made after the standard investigations in 82% of cases. The remaining 18% of cases hall had echocardiographic abnormalities and enable the diagnosis of clinically imapparent conditions: mitral valve prolapse, aneurysm of the interatrial septum, valvular calcification and cardiomyopathy. A potentially embolic mass was visualised in 18 patients; 6 valvular vegetations, 12 left atrial or ventricular thrombi. The other specialised radionuclide, angiographic and CT investigations only confirmed the echocardiographic diagnosis of intravavitary thrombosis. These results were confirmed surgically in 19% of cases. This study shows that complementary investigations especially echocardiography, allow diagnosis of latent embolic cardiac lesions, some of which may benefit from surgical treatment. In addition, potentially embolic intracardiac masses may be visualised, so confirming the origin of systemic emboli. When surgery is not indicated, echocardiography is a good method of following up the results of medical treatment in some of these masses.
Thirteen consecutive cases of cardiac hydatic cyst were studied. The cysts were usually multiple, predominantly left ventricular. There were two cases of rupture of left ventricular cysts with systemic embolism, and three ruptures of right ventricular cysts causing pulmonary embolism. The average age of the patients was 31 years: 12 patients lived in regions where hydatid disease was endemic. Other localisations of hydatic disease were found in 7 cases. Two patients were completely asymptomatic. Three patients presented with a tumoral syndrome. The presentation was atypical simulating coronary artery disease in 2 cases, valvular heart disease in 2 cases, pericarditis in 2 cases and bronchopneumonia in 3 cases. The electrocardiogramme showed sinus rhythm in all cases and changes of subepicardial ischaemia in 8 cases and acute cor pulmonale in 3 cases. Chest X-ray showed a localised deformation of the cardiac silhouette in 5 cases and calcification in 4 cases. Direct angiocardiographic signs were present in 2 out of 8 cases; usually there was an indirect image of endocavitary filling defect. The tumour was demonstrated by 2D echocardiography in the three most recent cases. The value of CAT was assessed in the last 2 cases: it was absolutely diagnostic in 1 case of septal localisation. The results were poor in the second case due to the presence of mitral calcification. Twelve patients underwent surgery; there were 3 deaths due to rupture and 1 death before surgery. The clinical presentation of cardiac hydatid disease is very variable and the diagnosis is difficult.(ABSTRACT TRUNCATED AT 250 WORDS)