Improvements in 25 Years of Implantable Cardioverter Defibrillator Therapy

In 1980, Dr. Michel Mirowski and his team inserted the first implantable cardioverter defibrillator (ICD) in a patient. Initially, ICD therapy was not widely accepted, and many physicians actually considered this therapy unethical. Large secondary and primary prevention trials, demonstrating a beneficial effect of ICD therapy in selected patients not only on arrhythmic death but also on all-cause mortality, stimulated a rapid growth in the number of implants and increased patient’s and physician’s acceptance. Improvements in size and weight, arrhythmia discrimination capabilities, battery technology, shock waveform and output, monitoring capabilities and defibrillator electrode technology eventually resulted in the current large number of yearly implants. Today, almost 40 years after the conception of the ICD and 25 years after the first human implant, ICD therapy is the treatment of choice for patients at risk for life-threatening arrhythmias either as secondary or primary prevention. Furthermore, with the more recent addition of resynchronisation therapy to standard ICD therapy, it became possible to treat selected patients with advanced symptoms of heart failure and to lower the risk of sudden death.     

Inappropriate Shock Delivered By Implantable Cardioverter Defibrillator - Cardiac Resynchronization Therapy (ICD-CRT) Due To Myopotential Oversensing

The clinical efficacy of ICD-CRT therapy depends on accurate sensing of intracardiac signals and sensing algorithms. We report the occurrence of sensing abnormality in a patient with ICD-CRT. In this patient, oversensing of myopotentials during strenuous muscular activity resulted in an inappropriate ICD-CRT discharge. Although modern ICDs are highly effective in detecting and terminating malignant tachyarrhythmias, their detection specificity must be improved. It is possible to find the mechanism of arrhythmia by EGM. Simple device reprogramming make it possible to avoid the oversensing of myopotentials.     

Ventricular Tachycardia Storm in Cardiac Sarcoidosis: A 76-Day-ICU-Nightmare

Ventricular Tachycardia (VT) is a life threatening complication in a patient with Cardiac Sarcoidosis. The management becomes extremely challenging when it is refractory to traditional anti-arrhythmic drugs. Herein, we describe a case where a 33-year-old patient with VT storm, with an implantable cardioverter defibrillator (ICD), was managed by medications, sedation, ventilator support and multiple Radio-Frequency (RF) ablation procedures over 76- days ICU stay period.     

Unintended Harm and Benefit of the Implantable Defibrillator in an Unfortunate 19-Year-Old Male: Featuring a Sequence of Rare Life-threatening Complications of Cardiac Procedures

All procedures have inherent risk. Our patient endured a sequence of rare life-threatening complications from commonly preformed procedures. The sequence of these complications was; large pericardial effusion post implantable cardioverter-defibrillator (ICD) implantation with echocardiographic signs of tamponade, left main narrowing post radiofrequency ablation, and late stent thrombosis post coronary intervention with a bare metal stent. All these occurred to one unfortunate young man. Furthermore, our patient demonstrated an unintended benefit of ICD which saved his life.     

Fragmented QRS as a Predictor of Appropriate Implantable Cardioverter-defibrillator Therapy

Background

Fragmented QRS (fQRS) has been shown to be a marker of local myocardial conduction abnormalities and a predictor of cardiac events in selected populations. We hypothesized that the presence of a fQRS might predict arrhythmic events in patients who received an implantable cardioverter-defibrillator (ICD), regardless of the indications for implantation.

Methods and Results

A cohort of 107 consecutive patients (mean age, 53 years; 82% male) who underwent an ICD implantation was studied. We defined fQRS, on a routine 12-lead ECG, as the presence of an additional R wave or notching in the nadir of the S wave in 2 consecutive leads corresponding to a major coronary artery territory. In the presence of bundle branch block, more than 2 notches in the R or S waves in 2 consecutive leads were required to characterize fQRS. Patients were followed for 21.3±23 months for appropriate ICD therapy (antitachycardia pacing and/or shock). ICDs were implanted predominantly in patients with ischemic cardiomyopathy (N=45, 42.1%), followed by Brugada syndrome (N=26, 24.3%). fQRS presented in 42 patients (39.3%). During follow-up, patients with fQRS received more appropriate ICD therapy than those without fQRS (45.2% vs. 10.8%, P<0.0001). After adjustment for covariates, fQRS remained an independent predictor for appropriate ICD therapy (hazard ratio=5.32, 95% confidence interval=2.11-13.37, P<0.0001).

Conclusion

The presence of fQRS appeared to be directly associated with appropriate ICD therapy.     

可植入式心室辅助装置动物模型的建立

目的探讨建立可植入式心室辅助装置研究的实验动物模型。方法选取体质量120-180 kg小公牛7只,常规全麻后左侧第4肋间开胸,建立体外循环,体外循环辅助下诱颤后,植入自主研发的国产可植入式心室辅助装置（DIVAD,domestic-made implantable ventricular assist device）,DIVAD机械性能参数接近国际同类产品,泵尺寸29.5mm×72 mm,重量158 g,体外转速可达9000 r/min,流量可达8 L/min,整合流量计,并可通过体外控制器监测控制。DIVAD连接左室及降主动脉,转速3500-8000 r/min左右,行左室辅助。术后撤除体外循环,持续监测动物生命体征及DIVAD运转情况。肝素静滴维持ACT在正常值1.5-2倍之间。结果7只小牛术后全部复跳,均能成功撤离体外循环辅助,最长存活时间超过93 h,最短存活时间0.5 h,平均存活时间20.28 h。结论小牛可以作为DIVAD研究的合适动物模型,其围手术期处理有相应特点,小牛DIVAD实验模型的建立对于进一步研究改进DIVAD有重要作用。     

两种心衰模型大鼠心功能的比较

目的　比较两种心衰模型大鼠心功能的特点。方法　用腹主动脉、下腔静脉穿刺造瘘法及冠脉结扎法建立不同的心衰模型 ,用Doppler超声心动图及心脏称重的方法比较其心功能的各项参数。结果　两组大鼠的相对心脏重量均有所增高。造瘘组射血分数有所下降 ,但心输出量、血压维持正常 ,而冠脉结扎组术后 3周射血分散、心输出量和平均动脉压均明显下降 ,等容舒张期延长。结论　腹主动脉、下腔静脉穿刺造瘘所造成的是高输出量心衰 ,而冠脉结扎法所造成的是低输出量心衰 ,其心衰程度更为严重。Doppler超声心动图为大鼠心功能的检测提供了一种简单、可靠、可随访的无创伤性检查方法。     

一种新型植入式装置无线数据传输方法

提出了一种植入式装置无线数据传输方法,以射频电磁波作为信息传输媒介,实现体内植入式装置与体外程控仪的双向通信。文中提出的＂b it-by-b it＂遥测方式可以显著降低起搏器等植入式装置的功耗,延长其使用寿命。     

Azygos Vein Lead Implantation For High Defibrillation Thresholds In Implantable Cardioverter Defibrillator Placement

Evaluation of defibrillation threshold is a standard of care during implantation of implantable cardioverter defibrillator. High defibrillation thresholds are often encountered and pose a challenge to electrophysiologists to improve the defibrillation threshold. We describe a case series where defibrillation thresholds were improved after implanting a defibrillation lead in the azygos vein.     

Patient Preferences Regarding Device Reuse and Potential of Devices for Reuse - A Study in a Veteran Population

BackgroundMany cardiac patients need and undergo device implants. Veterans’ preferences regarding post-mortem handling of devices are not known. Cardiac patients in low- and middle-income countries who need but cannot afford devices rely on donations. Charitable organizations have successfully provided devices for reuse to such patients.ObjectiveWe estimated the number of devices with potential for possible reuse in a veteran population.MethodsBetween January and December 2008, at a tertiary medical center, veterans with implanted cardiac devices were surveyed using a questionnaire for their preferences regarding post-mortem handling. One choice was donation to charity for reuse. Although altruistic, it is unclear what percent of such devices have reuse potential. Retrospective chart review of veterans who underwent device implants between 1992 and 2007 identified a cohort of patients with Implantable Cardiac Defibrillators (ICDs) who had died by April 31st 2009. In this cohort, ICDs implanted in the year preceding the patient’s death were counted as having reuse potential.Results94 of 97 veterans completed the survey. 56% were unaware of how devices are handled after death. The top three preferences for postmortem handling were: return to manufacturer, return to hospital and donation for reuse. 88% were willing to sign an advance device directive. Retrospective review identified 161 veterans who had received 301 ICDs. Of these, 77 ICDs (25%) had median reuse potential of 3.1 years.ConclusionIn a VA cohort of deceased patients a substantial proportion of devices had reuse potential. Further research is needed to direct health policy.     

Predictors of mortality amongst recipients of implantable cardioverter defibrillators for secondary prevention of cardiac arrest

Background

Implantable Cardioverter-defibrillators (ICD) reduce mortality in survivors of cardiac arrest (CA). We investigated the predictors of mortality after ICD implantation in survivors of CA.

Methods

Retrospective review of clinical records and social security death index of all patients who received an ICD in a preexisting database of survivors of CA at the University of Pittsburgh Medical Center was performed. Multivariate analyses using the Cox proportional hazard model were performed with backward elimination to identify independent predictors of the time to death, and Kaplan-Meier curves were plotted.

Results

Eighty patients (64 men) with a mean age of 64.4±12.5 years were followed for 4.7±2.3 years after ICD implantation. Survival rates were 93.8%, 65% and 50% at 1, 5, and 10 years, respectively. Independent predictors of time to death were determined to include age (hazard ratio (HR) = 1.91 per 10-year increase, p = 0.003), serum creatinine ≥ 1.3 mg/dL (HR = 2.56, p = 0.004), and QRS width >120 ms (HR = 5.14, p = 0.012).

Conclusions

In this sample of ICD recipients secondary to CA, older age, elevated serum creatinine, and wider QRS duration were independent predictors of mortality. The presence of more than one risk factor in the same patient was associated with higher mortality rates. Whether interventions such as biventricular pacing can offset this increase risk of death warrants further investigation.     

Cardiac sarcomere mechanics in health and disease

The sarcomere is the fundamental structural and functional unit of striated muscle and is directly responsible for most of its mechanical properties. The sarcomere generates active or contractile forces and determines the passive or elastic properties of striated muscle. In the heart, mutations in sarcomeric proteins are responsible for the majority of genetically inherited cardiomyopathies. Here, we review the major determinants of cardiac sarcomere mechanics including the key structural components that contribute to active and passive tension. We dissect the molecular and structural basis of active force generation, including sarcomere composition, structure, activation, and relaxation. We then explore the giant sarcomere-resident protein titin, the major contributor to cardiac passive tension. We discuss sarcomere dynamics exemplified by the regulation of titin-based stiffness and the titin life cycle. Finally, we provide an overview of therapeutic strategies that target the sarcomere to improve cardiac contraction and filling.     

植入类医疗器械医疗机构的法律责任探讨

植入类医疗器械的法律责任属于医疗产品损害责任,既有医疗损害责任的特点,又有产品责任的特点。就产品责任而言,医疗机构一般承担无过错责任,即无论医疗机构是否有过错,患方均可向医疗机构追责。且如医疗机构不能指明缺陷产品的生产者,也不能指明缺陷产品的供货者,还应当承担最终责任。在植入类医疗器械的管理使用过程中,医疗机构应从严把采购关,完善购销记录,加强告知及培训,以及医疗器械不良事件报告和监测等几个方面来规避法律责任。     

牛心肌钙蛋白T的纯化

以小牛心肌为原料,用匀浆提取、热处理、硫酸铵沉淀、ＤＥＡＥ—纤维素柱层析纯化了牛心肌钙蛋白Ｔ（ｃＴｎＴ）。纯化的蛋白在ＳＤＳ—聚丙烯酰胺凝胶电泳上为一条带,分子量为３７,０００道尔顿。用ＴｒｏｐｏｎｉｎＴ快速半定量试纸条测定该蛋白,呈现强阳性反应。这说明我们纯化的蛋白为牛心肌钙蛋白Ｔ。     

Removal of the Cardiac Troponin I N-terminal Extension Improves Cardiac Function in Aged Mice

The cardiac troponin I (cTnI) isoform contains a unique N-terminal extension that functions to modulate activation of cardiac myofilaments. During cardiac remodeling restricted proteolysis of cTnI removes this cardiac specific N-terminal modulatory extension to alter myofilament regulation. We have demonstrated expression of the N-terminal-deleted cTnI (cTnI-ND) in the heart decreased the development of the cardiomyopathy like phenotype in a β-adrenergic-deficient transgenic mouse model. To investigate the potential beneficial effects of cTnI-ND on the development of naturally occurring cardiac dysfunction, we measured the hemodynamic and biochemical effects of cTnI-ND transgenic expression in the aged heart. Echocardiographic measurements demonstrate cTnI-ND transgenic mice exhibit increased systolic and diastolic functions at 16 months of age compared with age-matched controls. This improvement likely results from decreased Ca²⁺ sensitivity and increased cross-bridge kinetics as observed in skinned papillary bundles from young transgenic mice prior to the effects of aging. Hearts of cTnI-ND transgenic mice further exhibited decreased β myosin heavy chain expression compared to age matched non-transgenic mice as well as altered cTnI phosphorylation. Finally, we demonstrated cTnI-ND expressed in the heart is not phosphorylated indicating the cTnI N-terminal is necessary for the higher level phosphorylation of cTnI. Taken together, our data suggest the regulated proteolysis of cTnI during cardiac stress to remove the unique cardiac N-terminal extension functions to improve cardiac contractility at the myofilament level and improve overall cardiac function.     

胰岛素及cAMP对培养人动脉平滑肌细胞HDL受体功能的影响

对胰岛素ｃＡＭＰ对培养人动脉平滑肌细胞（ＳＭＣ）ＨＤＬ受体功能的影响进行了研究,结果发现：胰岛素使ＳＭＣＨＤＬ受体的结合容量Ｂｍａｘ即受体数目显著下降,而对ＳＭＣＨＤＬ受体的Ｋｄ值亲和力无影响;ｃＡＭｐ则ＳＭＣＨＤＬ受体亲和力增加,而对受体数目无影响。