Implantable cardioverter-defibrillators for children and young adolescents: mortality benefit confirmed--what's next?
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Adolescent↗
Biomedical subjects
J B Conti
Publications and source records attributed to J B Conti.
Psychological distress across the course of care: a case study from implantable cardioverter defibrillator to cardiac transplantation evaluation.
The psychological distress of cardiac patients can complicate treatment or the recovery process. This case study presents a 47-year-old male recipient of an implantable cardioverter defibrillator who experienced multiple, consecutive shocks and subsequently developed anxiety and depressive difficulties. Psychological treatment to diminish these symptoms was employed. Despite declining cardiac function, the patient made significant progress in managing this negative affect. Subsequently, he was evaluated for cardiac transplant, and this treatment progress became critical evidence of his psychosocial suitability for transplant.
Defibrillators, Implantable↗
Young at heart: understanding the unique psychosocial adjustment of young implantable cardioverter defibrillator recipients.
This article reviews the data related to psychosocial adjustment of young ICD recipients, postulates theories to explain potential adjustment difficulties to ICD therapy experienced by younger recipients, and suggests clinical management techniques for addressing the unique psychosocial concerns of young ICD recipients. Studies of young ICD recipients suggest that a wide range of psychosocial adjustment issues are prominent in the post-ICD implantation period and that the issues may be different from older ICD recipients. The disability-stress-coping model and the transactional-stress-coping model are postulated as explanations for the unique adjustment concerns of children and adolescents with ICDs. Social comparison theory is also applied to the concerns of young adults with ICDs such that they often lack same age peers to compare experiences with cardiac difficulties. Brief, clinic-based interventions by health care providers, like a screening and referral heuristic and an "ICD Buddy" system, are suggested to increase effective coping and decrease social isolation for young ICD recipients.
Adaptation, Psychological↗
Recognition and correction of subcuticular malposition of pacemaker pulse generators.
Implantation of a cardiac pacemaker should be in the tissue plane deep to the subcutaneous tissue (i.e., between the fatty layer and the pectoralis fascia of the chest wall). Five patients with pacemaker implants between the cutis and the subcutaneous fat presented months later with chronic, unremitting, and often excruciating pain. The pulse generator in each case seemed excessively superficial and displaced, appeared too large for its known size, and was seemingly fixed to the overlying skin with exquisite sensitivity to light touch by a garment or palpation. Each had multiple consultations and treatments for pain, all without effect other than the temporary relief of local anesthesia. In three patients with obvious large subcutaneous fatty layers, the pulse generator was markedly superficial. Wound cultures were sterile in each case. Correction consisted of operative repositioning of the pulse generator into the readily developed subcutaneous tissue plane. In each patient, total and permanent relief of pain was achieved. Subcuticular positioning of permanent pacemaker pulse generators causes chronic pain that is readily relieved by operative repositioning of the pulse generator in the proper tissue plane.
Adult↗
Atrial fibrillation: rate control versus maintenance of sinus rhythm.
Atrial fibrillation is a common tachyarrhythmia encountered in clinical practice. Management has become increasingly complex as the therapeutic options have multiplied. Two basic strategies are available: rhythm control with or without pharmacologic manipulation, and rate control with anticoagulation. To date, no randomized controlled trial that compares the two strategies has been completed, although the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) trial is underway. This review outlines the rationale for each of the two basic treatment strategies, providing an overview of the advantages and disadvantages of each. Included are clinical criteria used in selecting the appropriate treatment plan.
Anti-Arrhythmia Agents↗
Malpositioned ventricular pacing lead in the left ventricle.
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Aged↗
Assessing the psychosocial impact of the ICD: a national survey of implantable cardioverter defibrillator health care providers.
The implantable cardioverter defibrillator (ICD) provides a survival advantage over antiarrhythmic medications for patients with life-threatening ventricular arrhythmias. However, the effect of ICD therapy on quality-of-life and psychosocial functioning are not as well understood. Health care providers (e.g., physicians, nurses) can serve as a valuable source of information related to these ICD outcomes. The purpose of this study was to investigate health care provider perceptions regarding: (1) the quality-of-life and psychosocial functioning of their ICD recipients, (2) the concerns or problems reported by ICD recipients, and (3) the degree of provider comfort in managing these concerns. The final sample of health care providers (n = 261) rated ICD recipients' global quality-of-life and psychosocial functioning, and specific concerns about health care, lifestyle, special population adjustment, marital and family adjustment, and emotional well-being. With regard to quality-of-life, health care providers reported that the majority of ICD recipients were functioning better (38%) or about the same (47%) than before implantation. However, health care providers reported that 15% of recipients experienced worse quality-of-life postimplantation. Similarly, health care providers indicated that 10%-20% of ICD recipients experienced worse emotional functioning and strained family relationships. Moreover, issues related to driving, dealing with ICD shocks, and depression were the most common ICD recipient concerns. Significant differences were noted between physicians and nurses/other health care professionals on a wide range of psychosocial issues. Health care providers generally reported the most comfort dealing with traditional medical issues (i.e., patient adherence), and the least comfort in managing emotional well-being issues (e.g., depression and anxiety). These results suggest that routine attention to ICD quality-of-life and psychosocial outcomes is indicated for health care providers who care for ICD recipients.
Adaptation, Psychological↗
Examining the psychosocial impact of implantable cardioverter defibrillators: a literature review.
BACKGROUND: The implantable cardioverter defibrillator (ICD) has proven to be superior to medications in treating potentially life-threatening ventricular arrhythmias, resulting in reduced mortality rates. Despite the number of patients receiving this therapy, its psychosocial impact is not well understood. HYPOTHESIS: The purposes of this paper are (1) to review the available literature documenting the psychosocial impact of the ICD on patients, (2) to hypothesize possible mechanisms for this psychosocial impact, and (3) to suggest clinical risk profiles and indications for psychological consultation. METHODS: Electronic and library searches (e.g., MEDLINE, PsychLit) were used to gather studies examining the psychosocial impact of the ICD. Only studies investigating psychosocial outcomes (e.g., psychological distress, quality of life, social and role functioning), either prospectively or cross-sectionally, were admitted into the review. No literature reviews or secondary sources were included. RESULTS AND CONCLUSIONS: Current research suggests that ICD-specific fears and symptoms of anxiety (e.g., excessive worry, physiological arousal) are the most common psychological symptoms experienced by ICD recipients, with approximately 13-38% of recipients experiencing diagnosable levels of anxiety. Depressive symptoms are reported at rates that are generally consistent with other cardiac populations. Although the incidence of psychological disorders appears to be similar to that found in general cardiac populations, specific ICD-related concerns such as fear of shock, fear of device malfunction, fear of death, and fear of embarrassment have been identified. Selected psychological theories such as classical conditioning, learned helplessness, and a cognitive appraisal model help to explain the occurrence of psychological symptoms post implantation. Psychosocial adjustment risk profiles indicate that young ICD recipients and those with high discharge rates may experience the most adjustment difficulties.
Adaptation, Psychological↗
Affective distress and implantable cardioverter defibrillators: cases for psychological and behavioral interventions.
The implantable cardioverter defibrillator (ICD) may be associated with some degree of psychological maladjustment, especially in patients experiencing high rates of discharge. This article reviews the psychological literature related to ICDs and presents two case examples illustrating common psychological complications related to multiple discharges. A brief, psychological intervention can be implemented to improve patient adjustment. To explain possible processes by which psychological complications may develop in ICD patients, two well-established psychological theories of learning and behavior, classical conditioning and learned helplessness, are reviewed. Multidisciplinary teams that include consultation with clinical psychologists are suggested for the routine care of ICD patients.
Adjustment Disorders↗
Clinical improvement after atrioventricular nodal ablation for atrial fibrillation does not correlate with improved ejection fraction.
A retrospective review of 15 patients with atrial fibrillation and class III to IV congestive heart failure who underwent atrioventricular nodal ablation demonstrated a marked improvement in their functional abilities. This improvement, however, could not be explained by the improvement in ejection fraction alone.
Adult↗
QT dispersion is a marker for life-threatening ventricular arrhythmias after atrioventricular nodal ablation using radiofrequency energy.
QT dispersion has been cited as a measure of nonuniform myocardial repolarization and a predictor of sudden cardiac death. We describe 38 patients who underwent atrioventricular nodal ablation, 3 of whom had an increase in measured QT dispersion and experienced potentially fatal, pulseless, polymorphic ventricular tachycardia after the procedure.
Cardiac Pacing, Artificial↗
Termination and suppression of idiopathic left ventricular tachycardia by diltiazem.
Idiopathic left ventricular tachycardia is known to be responsive to verapamil in many cases. However, the role of other calcium-channel blockers, such as diltiazem, in treating this specific type of ventricular tachycardia is unknown. We report a case of idiopathic left ventricular tachycardia in a patient with a structurally normal heart, which was terminated and suppressed in the electrophysiology laboratory by a single dose of diltiazem intravenously, and was subsequently suppressed long-term with sustained-release diltiazem. Our finding suggests that idiopathic left ventricular tachycardia may be managed effectively with diltiazem in both the acute and chronic settings.
Adult↗
Induction of atrioventricular node reentrant tachycardia with adenosine: differential effect of adenosine on fast and slow atrioventricular node pathways.
OBJECTIVES: This study sought to evaluate the sensitivity of fast and slow atrioventricular (AV) node pathways to incremental doses of adenosine in patients with typical AV node reentrant tachycardia. BACKGROUND: Although adenosine is known to depress conduction through the AV node, the relative sensitivity to adenosine of the anterograde fast and slow pathways in patients with dual AV node pathways and typical AV node reentrant tachycardia has not previously been studied. METHODS: Sixteen patients with dual AV node physiology and typical AV node reentrant tachycardia and 10 control patients were given incremental doses of adenosine during atrial pacing. RESULTS: In 14 of 16 patients with dual-AV node physiology, administration of small doses of adenosine during atrial pacing led consistently to transient block of impulse conduction in the fast pathway before block in the slow pathway, resulting in abrupt prolongation of the AH interval with continued 1:1 AV conduction. The mean (+/- SD) doses of adenosine required to cause conduction block in the fast and slow pathways were 2.7 +/- 3.0 and 7.2 +/- 4.7 mg, respectively (p = 0.004). In 9 of 16 patients, administration of low dose adenosine led to initiation of AV node reentrant tachycardia. The control patients showed no abrupt increases in AH interval with administration of adenosine during atrial pacing. CONCLUSIONS: In most patients with dual AV node pathways and typical AV node reentrant tachycardia, the fast pathway is more sensitive than the slow pathway to the effects of adenosine.
Adenosine↗
Modification of patient driving behavior after implantation of a cardioverter defibrillator.
Driving habits among recipients of ICDs have not been well characterized previously, yet such information may have implications for development of national policy. This study was undertaken to characterize driving behavior after defibrillator implantation in our patient population. From 1988-1993, 82 ICDs were implanted at the University of Florida. All patients received defibrillator teaching preoperatively and postoperatively with particular emphasis placed on driving restrictions. A standardized questionnaire was developed to ascertain driving behavior, compliance with restrictions, and occurrence of motor vehicle accidents following implantation. The patients were divided into two groups according to whether or not they had received a shock from their device since implantation. Group I patients did, and Group II patients did not. Fifty-two out of 82 (63%, Group I) patients had at least one shock. The remaining 30 patients had received no shocks. Mean age and gender were no different between the two groups. Mean time since implantation was 6 +/- 1.3 years in Group I, compared to 4 +/- 1.5 years in Group II (P = 0.001). Forty-seven out of 52 (90%) and 26 out of 30 (87%) in Groups I and II, respectively, resumed driving after defibrillator implantation. There was no difference in the amount of time that passed prior to resumption of driving. Group I patients drove more, 20.5 +/- 27 miles/day compared to patients in Group II, 8.3 +/- 9.7 miles/day (P = 0.02). No patient experienced device discharge during driving; likewise, no patient was involved in a motor vehicle accident secondary to their device firing. Sixty-seven out of 82 (82%) patients complied with the instructions they thought they heard; seven patients in Group I and eight patients in Group II deliberately did not follow our advice. The majority of patients do comply with physician instructions, although the instructions they remember are not always the instructions given. If a national policy is created to prohibit driving after ICD implantation, effective enforcement may be difficult.
Accidents, Traffic↗
Permanent atrial pacing in cardiac transplant patients.
Thirteen out of 223 consecutive cardiac transplant patients required permanent pacemaker implantation; 11 for sinus node dysfunction and 2 for complete AV block. Patients with sinus node dysfunction were considered for AAIR mode pacemakers if they had intact AV conduction defined as a Wenckebach point of > 120 beats/min. Ten of 11 patients with sinus node dysfunction had a single atrial lead placed. Atrial lead placement was most easily accomplished with a straight, active fixation lead and the use of manually curved stylets to find an optimal position in the donor atrium, although active fixation leads with a preformed atrial J were used as well. Two leads dislodged requiring revision. In contrast, only 1 of 250 atrial leads implanted in nontransplanted hearts dislodged (P < 0.0001). Transvenous endomyocardial biopsies have not caused atrial lead dislodgment. Most transplant recipients requiring permanent pacing have intact AV nodal function and require only atrial pacing. Atrial lead dislodgment requiring lead revision occurs more frequently in heart transplant recipients than in native hearts. Use of a straight active fixation lead with a manually formed curve in the stylet is useful in order to find the optimal position for pacing.
Adult↗
Oversensing of atrial flutter in the recipient atrium of a heart transplant patient with a permanent atrial pacemaker.
Sinus node dysfunction requiring permanent pacemaker implantation is a common problem following heart transplantation. There are unique problems to consider in pacing the transplanted heart. This report describes a case of far-field sensing of atrial flutter in the recipient atrial remnant, with resultant inhibition of the atrial pacemaker in the donor atrium, and symptomatic bradycardia. Although postulated to be a potential problem, oversensing of the recipient atrium has not been reported prior to this case. Awareness of this problem will provide for more effective pacemaker troubleshooting.
Atrial Flutter↗
Bradycardia after heart transplantation: reversal with theophylline.
OBJECTIVES: We attempted to demonstrate that theophylline, an adenosine receptor antagonist, can reverse bradyarrhythmias after orthotopic heart transplantation. BACKGROUND: Sinus node dysfunction, primarily sinus bradycardia, frequently occurs after orthotopic heart transplantation and may lead to permanent pacemaker implantation. Endogenous adenosine has been implicated as a cause of such posttransplantation bradyarrhythmia. METHODS: Twenty-nine transplant recipients (group 1) were given theophylline after bradyarrhythmias developed after transplantation. Data in these patients were compared with those in a control group of 18 patients without bradyarrhythmias (group 2) who were not given theophylline. RESULTS: The mean heart rate in group 1 increased from 62 +/- 7 to 89 +/- 10 beats/min after administration of theophylline (p < 0.0001); the mean heart rate in group 2 was 88 +/- 12 beats/min. Patients in group 1 required more days of temporary atrial pacing (3.5 +/- 1 vs. 1.5 +/- 3, p < 0.04) before the administration of theophylline than did patients in group 2. The length of hospital stay after transplantation did not differ significantly between groups 1 and 2 (17 +/- 7.5 vs. 20 +/- 16 days, p = NS). Age, gender, underlying disease, preoperative use of amiodarone, graft ischemia time or the incidence of moderate to severe rejection were not different between patient groups. CONCLUSIONS: The use of theophylline for posttransplantation bradyarrhythmias increased heart rate and facilitated the withdrawal of chronotropic support. We conclude that theophylline offers effective and specific therapy for heart transplant patients with early bradyarrhythmias, reducing the need for implantation of a permanent pacemaker.
Arrhythmia, Sinus↗