Transcatheter leadless permanent pacemaker in complex congenital heart disease with interrupted inferior vena cava: A challenging implantation

31 years lady with complete atrioventricular canal defect, large primum atrial septal defect (ASD), inlet ventricular septal defect (VSD) and Eisenmenger syndrome, presented with atrial flutter and complete heart block. She was not suitable for corrective cardiac surgery and not yet indicated for heart-lung transplantation. She was advised single chamber permanent pacemaker and eventually Micra VR transcatheter leadless pacemaker was finalised for her. Transcatheter leadless pacemaker was deployed in her RV septum despite some unforeseen technical problems. This patient had intrahepatic interruption of IVC with Azygous continuation draining into SVC but this altered venovascular course was detected only fluoroscopically midway during the pacemaker implantation procedure and this was not detected in the preprocedural transthoracic echocardiography. This abnormal venous course was clearly demonstrated in the cardiac CT which was performed only after completion of the pacemaker implantation procedure in this patient. The technical challenges encountered mainly were mostly during the manipulation of the 27F delivery catheter of Micra through this altered cardiovascular anatomy via transfemoral approach and also due to the presence of septal defects. Thus, transcatheter leadless permanent pacemaker was implanted successfully through transfemoral access in this complex congenital heart disease with interrupted IVC and azygous continuation. Besides transthoracic echocardiography, it may be better to perform transesophageal echocardiography or even preferably radiological imaging like cardiac CT or MRI prior to transcatheter leadless pacemaker implantation in patients with complex congenital heart disease to understand the cardiovascular anatomy and plan the procedure.     

Micra leadless pacemaker retrieval in a pediatric patient

We present a case of a 13-year old patient with partially reversibly post-operative heart block who underwent leadless pacemaker placement. After post-anesthesia wretching/gagging episode she developed device microdislodgement and increased/intolerable capture thresholds. The device was removed and another placed with adequate thresholds for good longevity.     

Right ventricular lead implantation facilitated by a guiding sheath in a patient with severe chamber dilatation with tricuspid regurgitation

Implantation of pacemakers can be challenging in the context of dilated cardiac chambers and valvular regurgitation. We report a difficult case of single chamber pacemaker implantation in a patient with restrictrive cardiomyopathy resulting in grossly enlarged atria and severe tricuspid regurgitation. In this situation, use of a slittable guiding sheath, more typically used for coronary sinus lead implantation, greatly facilitated rapid and stable deployment of the right ventricular lead.     

Alternate method for endocardial pacemaker lead implantation: A hybrid mini-thoracotomy approach

Although the conventional methods for endo-cardial pacemaker lead implantation via subclavian or cephalic or axillary vein routes is common, but sometimes due to anatomical variations it is not feasible to access these veins Emergence of newer techniques are useful for lead implantation. This case report focuses on a hybrid approach of combined mini-thoracotomy for endocardial pacemaker lead implantation. This fluoroscopy guided minimal thoracotomy approach with endocardial MRI compatible lead placement had the benefits of simple procedural, minimal hospital stay, low early complication rates and economically viable to the patient.     

Nano-sized titanium(IV) ternary and quaternary complexes with electron-rich oxygen-based bidentate ligands

Some novel ternary and quaternary complexes of titanium(IV) of general formula [Ti(acac)Cl_3−n(OOCR)_n] (R = C₁₅H₃₁ or C₁₇H₃₅ and n = 1-3) have been synthesized by stepwise substitution of chloride ions of [Ti(acac)Cl₃] by straight chain carboxylic acid anions. The complexes are characterized by their elemental analyses, spectral (infrared, FAB mass, ¹H NMR and powder XRD) studies, molecular weight determination and molar conductance measurements. Infrared spectra suggested bidentate chelating nature of both acetylacetonate and carboxylate anions in the complexes. Monomeric nature of the complexes was confirmed by their molecular weight determination and FAB mass spectra. Molar conductance values indicated the complexes to be non-electrolytes in DMF. The complexes exhibited high resistance to hydrolysis. Their powder XRD data indicated the nano-size for the complexes. The coordination number of titanium(IV) in these complexes were found to be six, seven and eight which has been discussed in detail.     

Dual chamber pacemaker implantation in woman with twin pregnancy and Chagas cardiomyopathy guided by 2D transthoracic echocardiography

We present a case of 36-year-old woman with twin pregnancy, Chagas cardiomyopathy and history of multiple episodes of dizziness and syncope. The patient's Holter study revealed sinus pauses of up to 5.3 seconds, frequent premature ventricular contractions (PVC) and some episodes of non-sustained ventricular tachycardia at 110 bpm. To avoid teratogenic radiation, dual chamber pacemaker implantation was performed guided by transthoracic echocardiography. The patient was treated with metoprolol succinate 100 mg once a day to reduce PVC and nonsustained ventricular tachycardia. During follow up, the patient reported complete resolution of syncope and dizziness. She went on to have a normal delivery without complications. PCRs for Chagas in both twins were negative.     

Microanalysis for MDR1 ATPase by high-performance liquid chromatography with a titanium dioxide column

MDR1 is clinically important because it is involved in multidrug resistance of cancer cells and affects the pharmacokinetics of various drugs. Because MDR1 harnesses adenosine 5'-triphosphate (ATP) hydrolysis for transporting drugs, examining the effect on ATPase activity is imperative for understanding the interactions between drugs and MDR1. However, conventional assay systems for ATPase activity are not sensitive enough for screening drugs using purified MDR1. Here we report a novel method to measure ATPase activity of MDR1 using high-performance liquid chromatography equipped with a titanium dioxide column. The amount of adenosine 5'-diphosphate (ADP) produced by the ATPase reaction was determined within 2 min with a titanium dioxide column (4.6 mm ID x 100 mm). The relationship between ADP amount and chromatogram peak area was linear from 5 pmol to 10 nmol. This method made it possible to reduce the amount of purified MDR1 required for a reaction to 0.5 ng, about 1/20th of the conventional colorimetric inorganic phosphate detection assay. This method is sensitive enough to detect any subtle changes in ATPase activity of MDR1 induced by drugs and can be applied to measure ATPase activity of any protein.     

Bioinformatics applied to allergy: allergen databases, from collecting sequence information to data integration. The Allergome platform as a model

Allergens are proteins or glycoproteins that are recognized by IgE produced by the immune system of allergic individuals. Until now around 1,500 allergenic structures have been identified and this number seems not have reached a plateau after 3-4 decades of research and the advent of molecular biology. Several allergen databases are available on Internet. Different aims and philosophies lead to different products. Here we report about main feature of web sites dedicated to allergens and we describe in more details our current work on the Allergome platform. The web server Allergome (www.allergome.org) represent a free independent open resource whose goal is to provide an exhaustive repository of data related to all the IgE-binding compounds. The main purpose of Allergome is to collect a list of allergenic sources and molecules by using the widest selection criteria and sources. A further development of the Allergome platform has been represented by the Real Time Monitoring of IgE sensitization module (ReTiME) that allows uploading of raw data from both in vivo and in vitro testing, thus representing the first attempt to have IT applied to allergy data mining. More recently, a new module (RefArray) representing a tool for literature mining has been released.     

Dual chamber pacing in a patient of hypertrophic cardiomyopathy with failure to wean from mechanical ventilator

We discuss the case of a 63 years old female who required repeated intubation due to recurrent pulmonary edema. She was found to have hypertrophic cardiomyopathy with a gradient of 82 mmHg across the left ventricular outflow tract. Initially adequate rate control and treatment with negative inotropes did not help her condition. Finally a dual chamber pacemaker implantation and atrioventricular node modification lead to successful extubation.     

Outcomes using a single tapered dilator for Micra leadless pacemaker implant

ObjectivesComparison of outcomes, device deployment time (DT), and total time (TT) using a single tapered Coons dilator versus sequential serial dilation for implantation of the Micra leadless pacemaker.BackgroundMicra leadless pacemaker placement requires a 23 French Micra introducer sheath (MIS) for percutaneous delivery. We sought to evaluate outcomes with use of a single tapered Coons dilator (CD) versus sequential serial dilatation (SD) method to facilitate insertion of the Micra introducer sheath.Methods35 patients were included in the SD arm and 49 in the CD arm. DT and TT were recorded in minutes and cost in dollars. Analysis was performed using independent t-test between two groups and one-way ANOVA to evaluate inter-operator variability in the CD arm.ResultsBoth DT and TT were significantly lower for the CD arm (15.1 ± 5.1 vs 23.5 ± 9.3, p < 0.0005 and 29.9 ± 14 vs 39.3 ± 13.5 min, p = 0.000374; respectively). The cost was also significantly lower using a CD versus SD. There was no inter-operator variability in the CD arm between 6 operators (p = 0.177 for DT and p = 0.304 for TT). No complications occurred in the SD arm. There were 3 vascular access site complications in the CD arm, all of which occurred early in the operator’s experience.ConclusionCoons dilator is an efficient and cost-effective method for vascular dilatation to facilitate Micra leadless pacemaker insertion. Rate of complications is low and expected to improve with greater experience.     

Enantioselective addition of diethylzinc to aldehydes catalyzed by titanium(IV) complexes of N-sulfonylated beta-amino alcohols with four stereogenic centers

An N-sulfonylated beta-amino alcohol (R,S,S,R)-9 with four stereogenic centers is prepared. The titanium complex of 9 is an effective catalyst to induce excellent enantioselectivities for diethylzinc addition to aromatic aldehydes with ee values up to 99%. The feature of doubling the quantity of Ti(O-i-Pr)4 required relative to the catalytic system of the Ti complex of bidentate N-sulfonylated beta-amino alcohols suggests that the two N-sulfonylated beta-amino alcohol moieties in 9 behave as two independent bidentate ligands in the catalytic system. The results obtained using ligand 15 having one N-sulfonylated beta-amino alcohol blocked support the argument of two independent active bidentate moieties in 9.     

Leadless pacing in a young patient with cardioinhibitory vasovagal syncope

Vasovagal syncope is characterized by vasodilatation and/or bradycardia and thereby a fall in arterial BP and global cerebral perfusion in response to a trigger. Although it is a benign condition, patients with frequent and traumatic episodes need treatment in order to improve quality of life. We describe the case of a 17-years-old boy suffering from cardioinhibitory syncope. At the end of a complete negative cardiac and neurological examination, a loop recorder was implanted. During the subsequent follow-up the ILR documented a 9-s pause. To improve the patient's compliance, and considering cardioinhibitory syncope as a temporary condition, a leadless pacemaker was eventually implanted.     

Cast titanium overlay denture for a geriatric patient with a reduced vertical dimension

An older patient reporting to the dental surgery for his/her dental treatment is becoming a common occurrence. Improved oral hygiene has meant that teeth are retained for a longer time, along with the potential problems of attrition, decreased vertical dimension, temporomandibular joint discomfort/strain, and poor aesthetics. The case in question is that of a 65-year-old male patient who had severe attrition in the lower arch, temporomandibular joint pain and reduced vertical dimension. The maxillary arch had previously been restored with a fixed partial prosthesis. For restoration of the lower teeth, a removable cast titanium overlay denture was fabricated incorporating an increased vertical dimension. Porcelain facings were placed to restore the aesthetics of the anterior teeth. The titanium was cast in a semi-automatic electric arc, pressure type casting machine. A titanium overlay denture with porcelain facing on the anterior teeth may provide a means of restoring a patient's concerns regarding aesthetics and function.     

An improved preparation method for a titanium (III) media reductant

A detailed method for the formulation of titanium(III) nitrilotriacetate, a sulfur-free, media reductant, is described. Growth of Butyribacterium methylotrophicum on methanol was not significantly inhibited by 5 mM titanium(III) nitrilotriacetate. Concentrations as low as 30 μM effectively reduced cultured media and allowed growth of this obligate anaerobe. This reductant was used to investigate the nutritional requirements for sulfur compounds and growth of fastidious anaerobes in continuous flow culture.     

Membrane and calcium clock mechanisms contribute variably as a function of temperature to setting cardiac pacemaker rate in zebrafish Danio rerio

Here, we show that heart rate in zebrafish Danio rerio is dependent upon two pacemaking mechanisms and it possesses a limited ability to reset the cardiac pacemaker with temperature acclimation. Electrocardiogram recordings, taken from individual, anaesthetised zebrafish that had been acclimated to 18, 23 or 28°C were used to follow the response of maximum heart rate (f_Hmax) to acute warming from 18°C until signs of cardiac failure appeared (up to c. 40°C). Because f_Hmax was similar across the acclimation groups at almost all equivalent test temperatures, warm acclimation was limited to one significant effect, the 23°C acclimated zebrafish had a significantly higher (21%) peak f_Hmax and reached a higher (3°C) test temperature than the 18°C acclimated zebrafish. Using zatebradine to block the membrane hyperpolarisation-activated cyclic nucleotide–gated channels (HCN) and examine the contribution of the membrane clock mechanisms to cardiac pacemaking, f _Hmax was significantly reduced (by at least 40%) at all acute test temperatures and significantly more so at most test temperatures for zebrafish acclimated to 28°C vs. 23°C. Thus, HCN channels and the membrane clock were not only important, but could be modified by thermal acclimation. Using a combination of ryanodine (to block sarcoplasmic calcium release) and thapsigargin (to block sarcoplasmic calcium reuptake) to examine the contribution of sarcoplasmic reticular handling of calcium and the calcium clock, f _Hmax was again consistently reduced independent of the test temperature and acclimation temperature, but to a significantly lesser degree than zatebradine for zebrafish acclimated to both 28 and 18°C. Thus, the calcium clock mechanism plays an additional role in setting pacemaker activity that was independent of temperature. In conclusion, the zebrafish cardiac pacemaker has a limited temperature acclimation ability compared with known effects for other fishes and involves two pacemaking mechanisms, one of which was independent of temperature.