An 80‐year‐old woman received a dual chamber pacemaker (Boston Scientific Accolade MRI DR) for pre‐syncopal episodes associated with transient II‐degree atrioventricular block type 1 and 2:1, recorded in 24‐h Holter monitoring. Due to residual AV conduction with I‐degree AV block, the pacemaker was set with the RYTHMIQ® algorithm, in order to reduce inappropriate ventricular pacing. A month later the patient started to complain of severe asthenia and bradycardia (46‐48 bpm). Telemetry‐supported pacemaker control revealed III‐degree AV block with junctional escape rhythm, unmasking missed switch of RYTHMIQ® algorithm.
Introduction Transvenous lead implantation for pacemaker implantation is commonly performed by the cephalic vein cutdown (CVC), subclavian (SVP), or axillary vein puncture (AVP)(1). However, the CVC or AVP should be considered as first choice, according to the last guidelines, due to high rate of lead complications and pneumothorax of SVP. Objective To compare efficacy and safety of AVP compared with CVC for CIED implantation by a meta-analysis. Methods We systematically searched Medline, Embase and Cochrane electronic databases up to September 5th, 2022, for studies that evaluated the efficacy and safety of AVP and CVC reporting at least one clinical outcome of interest. The primary outcome was acute procedural success. The secondary outcomes were pneumothorax, lead failure, pocket hematoma/bleeding, device infection, total procedure time, venous access time and fluoroscopy time. The effect size was estimated using a random-effect model as Risk Ratio (RR) and relative 95% Confidence Interval (CI). Results A total of 8 studies were included enrolling 1926 patients with 3532 leads and average age of 72.3±14.8 years. AVP compared to CVC showed a significant increase in the procedural success (95.7% vs 76.1%; RR: 1.24; 95% CI: 1.09-1.40; p=0.001), (Figure 1). Total procedural time (Mean Difference [MD]: -8.25 min; 95%CI: -10.23- -6.27; p<0.0001) and Venous access time (MD: -6.24 min; 95%CI: -7.01- -5.47; p<0.0001) were significantly shorter with AVP compared with CVC. No differences were found between AVP and CVC for pneumothorax (RR: 0.72; 95% CI: 0.13 - 4.0; p=0.71), lead failure (RR: 0.58; 95% CI: 0.23-1.48; p=0.26), pocket hematoma/bleeding (RR: 0.58; 95% CI: 0.15- 2.23; p=0.43), device infection (RR: 0.95; 95% CI: 0.14- 6.60; p=0.96) and fluoroscopy time (MD: -0.24 min; 95%CI: -0.75- 0.28; p=0.36). Conclusion Our meta-analysis proved that AVP improves procedural success and reduces total procedural time and venous access time compared to CVC. Figure 1 – Forest plots comparing Acute Procedural Success between Axillary Vein Puncture Versus Cephalic Vein Cutdown.
A 68‐year‐old man was admitted with ST‐elevation myocardial infarction and intense rash. He was diagnosed with type 2 Kounis syndrome elicited by drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and received complete revascularization with percutaneous coronary intervention. This case highlights the complex pathophysiology of acute coronary syndrome, and the elusive link between coronary occlusion and ST‐segment deviations at ECG.
Background The diagnostic value of the β-angle in the diagnosis of patients with Brugada Syndrome (BrS) is still unclear. Objective to evaluate the diagnostic accuracy of the β-angle and establish its best cut-off value. Methods We searched databases for studies evaluating sensitivity and specificity of the β-angle in patients with suspected BrS undergoing Sodium Channel Blocker Provocation Test (SCBPT). The pooled sensitivity and specificity were calculated, and the Summary Receiver Operating Characteristic curve was constructed. The effect size was estimated using a random-effect model as Odds Ratio. Results we included 4 studies enrolling 1471 patients (Positive SCBPT: 382 patients; Negative SCBPT: 1089 patients). Patients with positive SCBPT had a higher mean β-angle value than those with negative SCBPT (39.25° vs 22.52°; p<0.0001). The best diagnostic accuracy was observed at the IV Intercostal space (Ic) (AUC: 0.82; 95% CI: 0.78-0.85) compared to IIIic (AUC:0.77; 95% CI: 0.74–0.81) and IIic (AUC: 0.68; 95% CI: 0.64–0.72), Figure 1. The risk of positive SCBPT was significantly increased in patients with a β-angle≥58° than those with a β-angle≥23° (OR:16.33 vs 3.39; p=0.0004). Conclusion A β-angle ≥58° represents the best diagnostic predictor for patients with suspected BrS.
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