Trans-coronary Pacing via Rota Wire Prevents Bradycardia During Rotational Atherectomy: A Case Report

Back ground Rotational atherectomy (RA) is used for plaque modification in patients with heavily calcified coronary lesions. RA can induce significant bradycardia or atrioventricular block requiring for temporary pacemaker insertion. In this report, we present a case of trans-coronary pacing via a Rota wire to prevent bradycardia during RA in the proximal right coronary artery (RCA). Case summary A 72-year-old woman with a one month history of worsening effort angina was admitted to our hospital. Computed tomography coronary angiography disclosed significant coronary stenosis with severe calcification in proximal RCA. Coronary angiography revealed significant coronary stenosis with severe calcification in the proximal RCA. Subsequently, percutaneous coronary artery intervention was performed under the guidance of intravascular ultrasound(IVUS). The pull-back IVUS showed a circumferential calcified lesion in the proximal RCA, that was treated using RA, which induced significant bradycardia requiring temporary pacemaker insertion. Immediately, trans-coronary pacing was provided via a Rota wire placed in the far distal RCA; this was used for back-up pacing during RA. RA was completed by safely modifying the calcified lesion. After successful debulking of the calcified lesion, we dilated with a balloon, and a drug-eluting stent was implanted at the proximal RCA. Final IVUS and angiography showed good stent apposition and expansion. we did not observe any serious intraprocedural complications. Discussion RA is used for plaque modification in patients with heavily calcified coronary lesions. RA can induce significant bradycardia or atrioventricular block requiring for temporary pacemaker insertion via the transvenous route. This method could be an effective method to prevent bradycardia during RA.

Risk and benefits of temporary pacemaker electrodes in adult open-heart surgery—a systematic review

Background To assess the achieved risk and benefits of inserting temporary epicardial pacemaker electrodes after open-heart surgery for potential treatment of postoperative cardiac arrhythmias, and to investigate the extent of its use in clinical practice. Main text A systematic search was conducted in PubMed and repeated in Embase and Scopus using the PRISMA guidelines. The search identified 905 studies and resulted in 12 included studies, where the type of surgery, study design, total number of included patients, number of patients having temporary pacemaker electrodes inserted, number of patients requiring temporary pacing, primary reason for pacing, significant factors predicting temporary pacing, registered complications and study conclusion were assessed. Eight papers concluded that routine insertion of temporary pacemaker electrodes in all postoperative patients is unnecessary. One paper concluded that they should always be inserted, while three papers concluded that pacing is useful in the postoperative period, but did not recommend a frequency of which they should be inserted. Conclusions The literature suggests that the subgroup of younger otherwise healthy patients without preoperative arrhythmia having isolated coronary artery bypass grafting surgery or single valve surgery should not routinely have temporary pacemaker electrodes inserted.

218 Coronary artery disease in athletes: a case report

Aims Despite the proven benefits of regular physical exercise, and although sportsmen are the paradigm of healthy individuals, the athletes population is not risk-free and can suffer severe clinical conditions including coronary artery disease (CAD) and sudden cardiac death (SCD). Identification of athletes with higher cardiovascular risk is a crucial goal of pre-participation screening. Methods and results In this report, we discuss the case of a 79-year-old male. He was a cyclist, who performed a visit to the sports doctor to have issued a certificate for competitive fitness. He was dyslipidaemic, hypertensive, diabetic, and he reported no symptoms. The patient’s ECG revealed an advanced second-degree atrioventricular block. For this reason, he was admitted to the emergency department and he underwent urgent coronary angiography and a temporary Pacemaker. Indeed, a diagnosis of bivasal coronary artery disease was made, and for the first time the patient was subjected to angioplasty of the anterior descending branch and circumflex branch. Subsequently, for the persistence of bradyarrhythmia, he was subjected to a definitive Pacemaker implant. Conclusions The benefits of exercise in the overall population are multiple and indisputable, but in athletes with cardiovascular disease exercise can also be associated with adverse clinical events, including SCD. In veterans, a growing group of athletes, CAD is the most common cause of SCD. Detection of subclinical CAD should be the main objective of veteran athlete screening, since the performance of classical cardiovascular risk stratification based on clinical factors appears to be suboptimal.

Remdesivir-Associated Significant Bradycardia: A Report of Three Cases

Recently, remdesivir was approved by the United States Food and Drug Administration for patients with Coronavirus disease 2019 (COVID-19). We herein describe 3 patients with COVID-19 who showed significant bradycardia and QTc prolongation after remdesivir administration. Bradycardia did not respond to atropine treatment in 2 of the patients, one of whom received theophylline and the other required a temporary pacemaker. Fortunately, the patients’ heart rate and rhythm returned to normal after the discontinuation of remdesivir, albeit it lengthened their hospital stays. Careful monitoring during remdesivir infusion may decrease the risk of adverse cardiovascular side effects.

Blind temporary pacemaker lead insertion using femoral access when fluoroscopy is unavailable: A case report

The temporary pacemaker (TPM) insertion must be done in symptomatic bradycardia to provide adequate heart rate and stable hemodynamic. Transvenous TPM is inserted under fluoroscopy guidance. However, in an extraordinary situation, such as the unavailability of the catheterization laboratory, transvenous TPM insertion can be performed using the blind approach. This case report focused on the procedural aspects of blind transvenous TPM insertion using femoral vein access when fluoroscopy is unavailable. By performing the blind transvenous TPM insertion, the patient should be stabilized as soon as possible. The confirmation of the lead placement using fluoroscopy was needed to ensure that the tip of the electrode was in the proper position.

Impact of the COVID-19 pandemic on emergent pacemaker implantation during lockdown and its aftermath

Background COVID-19 was first considered a pandemic on the 11th of March of 2020 by the World Health Organization. Its impact comprised not only the direct consequences of the disease but a decrease in the follow-up and interventions of patients with cardiovascular (CV) disease. In Portugal and the World, the consequences of this complex paradigm shift on emergent pacemaker implantation rates during and after this pandemic is largely unknown. Purpose We sought to analyse the impact of COVID-19 pandemic on emergent pacemaker implantation rate and patient profile in a tertiary hospital during the first Portuguese lockdown and subsequent post-lockdown period. Methods We retrospectively reviewed the clinical profile of patients who had pacemakers implanted in our hospital in an urgent/emergent setting from March 18, 2020 to May 17, 2020 (lockdown) and May 19 to July 17, 2020 (post-lockdown). This data was then directly compared to the homologous periods from the year before (H1 and H2, respectively). Results A total of 180 patients submitted to emergent pacemaker implantation were included. The cohort was comprised of 29 patients who had a pacemaker implanted during lockdown, 60 post-lockdown, 38 in H1 (+31% vs lockdown) and 53 in H2. Average age and gender proportion were similar for all groups. When comparing lockdown and post-lockdown periods, the number of cases significantly increased in the second period (+106.9%) and there was a tendency for a higher number of temporary pacemaker use (3.4% vs 16.7%; p=0.076). Patients admitted during lockdown were 7.57 times more likely to present with hypotension/shock (odds ratio (OR) 7.57; p=0.013). Regarding lockdown and its homologous 2019 period, there was a decrease in the number of patients admitted (−23.7%). Again, there was a higher tendency for hypotension on presentation during lockdown (p=0.054). In comparison to its homologous 2019 period, post-lockdown saw a slight increase in the number of patients (+13.2%) and more patients presented with bradycardia (16.7% vs 3.8%; p=0.026). Also of note, no patients were admitted to the emergency department during lockdown for anomalies detected on ambulatory tests (Holter, electrocardiogram or implanted loop recorder). Conclusion During lockdown, clinical presentation was generally more severe, with a greater number of patients presenting with hypotension/shock. In addition, there appears to be a lockdown effect on emergent bradyarrhtmias admissions in the post-lockdown period with a profound impact: higher admission rates and more severe presentations including a higher need of temporary pacemaker. Patients with symptoms suggestive of bradyarrhythmias should be advised to present promptly regardless of the pandemic. FUNDunding Acknowledgement Type of funding sources: None. Pacemakers during lockdown/post-lockdown Pacemakers implanted by diagnosis

Application of the improved simple bedside method for emergency temporary pacemaker implantation suitable for primary hospitals

The purpose of the research was to evaluate the safety and effectiveness of the X-ray-free improved simple bedside method for emergency temporary pacemaker implantation as well as the practicability of the method in primary hospitals. Patients [including those suffering from sick sinus syndrome and third-degree and advanced atrioventricular blockage (AVB)] who needed emergency temporary pacemaker implantation from July 2017 to August 2020 in Hunan Provincial People’s Hospital were selected. They were stochastically divided into a research group (95 cases) treated with the improved simple bedside method and a control group (95 cases) with X-ray guidance. The ordinary bipolar electrodes were used in both groups. On this condition, the operation duration, the first-attempt success rate of electrodes, pacing threshold, success rate of the operation, the rate of electrode displacement, and complications in the two groups were separately calculated. The comparison results of the research group with the control group are shown as follows: operation time [(18 ± 5.91) min vs. (43 ± 2.99) min, P < 0.05], the first-attempt success rate of the electrode (97% vs. 98%, P > 0.05), pacing threshold [(0.97 ± 0.35) vs. (0.97 ± 0.32) V, P > 0.05], success rate of the operation (98.9% vs. 100%, P > 0.05), the rate of electrode displacement (8.4% vs. 7.3%, P > 0.05) and complications (3.2% vs. 2.1%, P > 0.05). The emergency temporary pacemaker implantation based on the improved simple bedside method is as safe and effective as the surgical method under X-ray guidance, and the operation is simpler and easier to learn and requires a shorter operating time, therefore, it is more suitable for use in emergency and primary hospitals.

Case Report: The Neuromusclar Triad of Immune Checkpoint Inhibitors: A Case Report of Myositis, Myocarditis, and Myasthenia Gravis Overlap Following Toripalimab Treatment

The neuromuscular adverse events of immune checkpoint inhibitor (ICI) treatment include myositis, polymyalgia rheumatica, myocarditis, and myasthenia syndrome. We report a 47-year old female presenting with external ophthalmoplegia, generalized muscle weakness, and third-degree atrioventricular block 4 weeks after toripalimab treatment for metastatic thymoma. Creatine kinase was elevated to 25,200 U/l and cardiac troponin I to 2.796 ng/ml. Autoantibody profiling shows positive anti-ryanodine receptor and anti-acetylcholine receptor antibodies and negative myositis specific antibodies. Repetitive nerve stimulation did not reveal decrement of compound muscle action potentials. Pulse methylprednisolone and immunoglobulin infusion, together with temporary pacemaker insertion normalized her muscle enzyme levels and cardiac rhythm. This is the first report of overlaping neuromuscular adverse event of toripalimab.