This report of pacemaker implantations in the extreme elderly reveals rates of implant complications comparable to data from younger patient populations while experiencing a higher 30-day all-cause mortality (that may be attributable to elevated all-cause mortality rates in this age group).
Joint ventures in property development can bring considerable benefits
to the parties. For example, in a joint venture involving a local
authority the authority will be able to play a positive role in urban
regeneration while the developer will gain credibility and hopefully
obtain a smoother planning process. Examines the strengths and
weaknesses of the three classic joint venture arrangements: joint
venture companies; partnerships; and “contractual” joint ventures.
Cardiac resynchronization therapy (CRT) is a well established treatment modality in heart failure. Using standard techniques, placement of the left ventricular (LV) lead is usually successful; however LV lead placement failure remains a clinical problem. In the present report, the standard over-the-wire technique was not successful due to absence of the necessary support to place the lead into a tortuous vein. This was achieved using balloon occlusion of the great cardiac vein distal to the target vessel. An 81 year old female candidate for CRT presented for biventricular pacemaker implantation. After placement of the right ventricular lead, the CS was cannulated and an occlusive venogram was performed. A lateral branch was selected as the target vessel. Initial attempts at cannulating the vessel were unsuccessful due to the guidewire and telescoping delivery system prolapsing into the great cardiac vein. The acute angle prevented instrumentation of the branch with the tools available. A second parallel CS sheath was advanced to drive a balloon catheter used to occlude the great cardiac vein distal to the target vessel. This provided support for the guidewire and lead allowing their advancement through the tortuous vessel. Consecutive traction on the balloon during also helped to reflect the lead towards the vessel. The lead remained stable in its final position on the lateral wall of the LV with appropriate thresholds and no diaphragmatic stimulation. We report a case where balloon occlusion of the great cardiac vein distal to the target branch aided in advancing the LV lead into the desired position. This approach can be used in navigating lead placement to branches thought to be unreachable. Techniques such as this can decrease the failure rate of CRT implants.
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