Complications of epi- and endocardial pacing in children

Aim To analyze complications of cardiac pacing in children depending on the implantation method. Actuality Recently epicardial lead implantation becomes more and more popular either due to more serious complications of transvenous pacing or due to possibility of choice of hemodynamically optimal pacing zone. Methods and materials 242 patients with pacemakers are under our supervision. Epicardial pacemakers were implanted to 145 patients, endocardial – to 97 patients. In “old era” in most children the primary epicardial implantations were performed at RV free wall. In 27 children, having primary implantation at our Institute lately, the epicardial lead was placed at LV apex, or endocardial – at RV apex. Results The comparative analysis of complications of epi- and endocardial implantation showed the following results: 22% of complications at epicardial stimulation, and at transvenous stimulation – 45%. The most often complications at epicardial stimulation (53%) were connected with hemodynamic disorders – dyssinchronous cardiomyopathy. Hemodynamic complications, connected with dyssinchrony of endocardial RV pacing, were disclosed in 16%. The most often complication of endocardial stimulation was TV insufficiency (32%). Venous vessel thrombosis was diagnosed in 9%. Epicardial and transvenous lead failure was discovered in similar percentage ratio (28%). Infectious complications of transvenous pacing, especially, bacterial endocarditis, took place in 6,8%. Thus, progressive bacterial endocarditis and TV insufficiency (3d deg.) appeared in one patient in 10 years after the primary implantation. Afterwards, elimination of endocardial system by open surgery, TV plasty followed by epicardial pacing implantation are required. Infection of pacing site was disclosed in both types of implantation (1%). Perforation of atrial endocardial lead was found in two cases (4%). A case of mechanical complication (cardiac strangulation) was diagnosed in a child (3%) in four years after the primary implantation of epicardial pacing system. Pericarditis was recorded immediately after the epicardil pacemaker implantation in 9% of cases. Our center performs epicardial lead implantation with the help of midline sternotomy that provides clear approach to right atrium. However, the difficulties of lead fixation at LV apex appear here. It concerns, especially, the patients after CHD correction as the repeated sternotomy in them presents high risk of RV insufficiency. Nevertheless, the given approach is still the best possible with epicardial pacing if there is a “preclude”, sufficient experience of CHD correction. Conclusion The possibility of choice of optimal epicardial pacing site exceeds risks of leads and midline sternotomy. Any primary pacemaker implantation in children of any age with ventricular lead should be epicardial. FUNDunding Acknowledgement Type of funding sources: None.

The global burden of chromoblastomycosis

Background Chromoblastomycosis (CBM), represents one of the primary implantation mycoses caused by melanized fungi widely found in nature. It is characterized as a Neglected Tropical Disease (NTD) and mainly affects populations living in poverty with significant morbidity, including stigma and discrimination. Methods and findings In order to estimate the global burden of CBM, we retrospectively reviewed the published literature from 1914 to 2020. Over the 106-year period, a total of 7,740 patients with CBM were identified on all continents except Antarctica. Most of the cases were reported from South America (2,619 cases), followed by Africa (1,875 cases), Central America and Mexico (1,628 cases), Asia (1,390 cases), Oceania (168 cases), Europe (35 cases), and USA and Canada (25 cases). We described 4,022 (81.7%) male and 896 (18.3%) female patients, with the median age of 52.5 years. The average time between the onset of the first lesion and CBM diagnosis was 9.2 years (range between 1 month to 50 years). The main sites involved were the lower limbs (56.7%), followed by the upper limbs (19.9%), head and neck (2.9%), and trunk (2.4%). Itching and pain were reported by 21.5% and 11%, respectively. Malignant transformation was described in 22 cases. A total of 3,817 fungal isolates were cultured, being 3,089 (80.9%) Fonsecaea spp., 552 (14.5%) Cladophialophora spp., and 56 Phialophora spp. (1.5%). Conclusions and significance This review represents our current knowledge on the burden of CBM world-wide. The global incidence remains unclear and local epidemiological studies are required to improve these data, especially in Africa, Asia, and Latin America. The recognition of CBM as NTD emphasizes the need for public health efforts to promote support for all local governments interested in developing specific policies and actions for preventing, diagnosing and assisting patients.

Outcomes of Evisceration or Enucleation by Resident Trainees in Patients with Endophthalmitis or Panophthalmitis

Background To evaluate the outcomes of evisceration or enucleation with primary implantation performed by ophthalmology resident trainees in patients with endophthalmitis or panophthalmitis. Methods In this retrospective analysis, the clinical records of all patients diagnosed with endophthalmitis or panophthalmitis who underwent enucleation or evisceration with primary implantation over a 13-year period were reviewed. The predictive factors related to implant exposure or extrusion were identified using multivariate analysis. Results Sixty-six patients, with a median age of 46.8 years, were enrolled. Thirty-six (55%) out of 66 patients were diagnosed with panophthalmitis. The most common causes of endophthalmitis or panophthalmitis were trauma (13 patients) and corneal ulcer perforation (10 patients). Enucleation was performed in 53 patients (80%). Four patients (6%) had implant exposure, and 4 patients (6%) had implant extrusion. Multivariate analysis demonstrated that Pseudomonas aeruginosa infection (P = 0.021, adjusted odd ratio [aOR] 33.75) and not receiving intravitreal antimicrobial drugs before the eye removal procedure (P = 0.02, aOR = 30.11) were associated with implant exposure or extrusion. Patients with panophthalmitis who underwent evisceration had a higher rate of implant exposure or extrusion than those who underwent enucleation (P = 0.031, aOR 38.38). Other complications included socket discharge in 14 patients, lower lid laxity in 5 patients who underwent the lateral tarsal strip procedure, and wound dehiscence in 3 patients. At the last visit, 65 patients had successful prosthesis fitting. Conclusion This study suggests that evisceration or enucleation with primary implant placement in patients with recalcitrant endophthalmitis or panophthalmitis can be performed by resident trainees with acceptable surgical outcomes and a low rate of serious complications.

The Use of the Ahmed Glaucoma Valve Drainage System in the Surgical Treatment of Childhood Glaucoma

Purpose – to evaluate the effectiveness of surgical treatment of glaucoma in children with implantation of the Ahmed Glaucoma Valve drainage system, depending on the form of the disease. Materials and methods. 124 implantations of the Ahmed Glaucoma Valve FP8 drainage system, model FP8, were performed in the Kaluga branch of the IRTC «Eye Microsurgery» for children with various forms of glaucoma for the period of time from 2010 to 2020. The range of children age was from 0 to 18 years old. Primary implantation was performed in 48 cases. 76 implantations were performed after previous glaucoma interventions. 23 patients were operated on in both eyes. The operation was performed with organ-preserving purpose for 26 patients at different ages. Implantation was performed for the eyes with low visual capabilities (below 0.06) in 34 cases. Results. It was noted to decrease in the level of IOP in various types of glaucoma in children in the early postoperative period, in 100% of cases. The level of IOP remained within the normal range in 68% of cases in terms of up to 1 year. The reasons of the increase in the level of ophthalmotonus were associated with the formation of a fibrous capsule above the drainage body and a disturbance in the flow of intraocular fluid in 32% of cases. An increase of IOP was noted up to 3 years in fifty per cent of cases. IOP was regulated by the appointment of antihypertensive medicine in the eyes, where the increase of IOP was not accompanied by significant visual signs of the formation of a fibrous filter pad. Otherwise, the inspection zone of the filtration pad was conducted an audit with excision of the fibrous tissue forming above the drainage body area. As a result, the level of IOP has reached normal values. Conclusion. Along with traditional treatment methods, operations using the Ahmed drainage system are promising in the treatment of childhood glaucoma. In case of some types of congenital glaucoma, they may be the operations of the first choice (in the associated and all secondary types of glaucoma). Undoubtedly, this type of surgery requires further improvements. Including the development of materials to cover the drainage system, which will interfere with severe scarring processes.

Penoscrotal Incision for the Primary Implantation of an Artificial Urinary Sphincter

Background: The artificial urinary sphincter (AUS) has become the gold standard to treat severe stress urinary incontinence in men. The traditional placement of an AUS requires 2 incisions. The cuff is placed through a perineal incision and the reservoir and pump are placed via an inguinal incision. The implantation of an AUS is also possible via a single penoscrotal approach. Objectives: The objective is to demonstrate that the penoscrotal approach is not inferior to the perineal approach. Methods: Retrospective review of a single surgeon database from 2014 to 2019 was performed. A total of 40 patients have undergone implantation of an AUS via a penoscrotal incision. The outcome of patients was followed for an average of 31.3 months for adverse outcomes. Results: A primary American Medical Systems 800 sphincter was placed in 40 patients via a penoscrotal incision. The average age was 72 years. The average operating time was 35 minutes. The average cuff size was 4 cm. There were no infections of the prothesis so far. Three patients required a revision, 2 other patients needed an explant of the AUS, 1 patient underwent a cystectomy because of persistent radiocystitis. After activation of the sphincter, 33 patients (82.5%) were completely dry or using 1 pad per day for accidents. The remainder were all improved. Conclusions: AUS implantation via a single penoscrotal approach is not inferior to the perineal approach and has several advantages. The operating time is shorter and the procedure requires only 1 incision which both reduce the risk of infections, while the continence results are similar for both approaches.

The second official report from Japanese registry for mechanical assisted circulatory support (J-MACS): first results of bridge to bridge strategy

Background The Japanese registry for mechanical assisted circulatory support (J-MACS) is a prospective registry to collect all data of implantable left ventricular assist device (LVAD) (and part of paracorporeal VAD) established in 2010. The first analytical report was published in 2017. The organization running J-MACS was used to be the pharmaceuticals and medical devices agency (PMDA), but has been changed to the council for clinical use of ventricular assist device related academic societies in 2017. Methods Since 2018, we changed the analytical methods as follows: first, we eliminated paracorporeal VAD from the analysis. Second, we included not only primary implantation but bridge to bridge (BTB) implantation of LVAD. Third, we added the analyses of adverse events that were not included in the previous analysis. Results As of Oct 2018, 711 primary LVAD implants and 168 BTB implants were enrolled. Survival rate of primary LVAD was 93% at 360 days and 91% at 720 days, and that of BTB was 86% at 360 days and 82% at 720 days. Conclusion We first reported the results of BTB in the second official report of J-MACS. The prognosis after LVAD implantation has been kept good in Japanese circumstances.