Background Pocket-related complications following the implantation of cardiovascular implantable electronic devices primarily include pocket hematoma, infection, skin erosion or decubitus, device migration, and Twiddler's syndrome, with other pathologies such as nerve impairment or bone lesions being extremely rarely encountered. We report a case of a 20-year old asthenic, non-athlete female patient presenting with a device-generated fracture of the second rib several months after sub-muscular permanent pacemaker implantation due to repeated bilateral pre-pectoral pocket infections. Case presentation A 20-year old female patient was readmitted to our institution 9 months following sub-pectoral implantation of a permanent pacemaker, complaining of severe pocket-related pain, which arose spontaneously in the absence of direct trauma, intense physical activity or vigorous coughing, and was associated with normal day-to-day activity. To rule out a pacemaker re-infection, a native computed tomography and a positron emission tomography—computed tomography of the thorax were performed. Both modalities excluded an infection but showed a healing fracture and a focus of enhanced metabolic activity in the anterolateral part of the right second rib, indicating a non-traumatic or stress fracture of the bone. Consequently, a complete extraction of the pulse generator and both leads was performed and the smallest available single-chamber pulse generator with a single atrial electrode was implanted in the sub-fascial, pre-muscular pocket in the now recovered and uninfected left subclavicular region, alleviating patient’s severe pain symptoms and significantly enhancing her quality of life. Conclusions In the absence of direct trauma, intense physical activity or vigorous coughing, we assume that in this asthenic girl a normal day-to-day motion of the right shoulder has persistently forced the sub-muscularly placed pulse generator toward thoracic wall, putting increased repetitive pressure force on the underlying bones, finally causing a fatigue stress fracture of the second rib. In asthenic phenotype patients with small thorax and short subclavicular distance, a sub-muscular pacemaker implantation can potentially cause unique and unexpected pocket-related adverse events necessitating advanced diagnostics and timely treatment.
Aims Non-compaction cardiomyopathy (NCM) is a congenital heart disease characterized by an arrest of the myocardial compaction process. Although NCM patients have impaired formation of microvasculature, the functional impact of these changes remains undefined. We sought to analyse a potential correlation between myocardial ischemia and heart failure severity in NCM patients. Methods and resultsWe enrolled 41 NCM patients (28 male and 13 female), aged 21-70 years. In all patients, we have determined left ventricular end-diastolic volume (LVEDV), left ventricular ejection fraction (LVEF), and global longitudinal strain (GLS) by echocardiography. At the same time, serum levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) have been measured, and myocardial single-photon emission computed tomography at rest and on stress was used to define significant myocardial ischemia defined as summed difference score ≥ 2. Myocardial ischemia has been demonstrated in 11 patients (27%, Group A), and 30 patients showed no significant ischemic changes (73%, Group B). The groups did not differ in sex, age, kidney, or liver function. When compared with Group B, Group A had significantly lower LVEF (35 ± 15% in Group A vs. 53 ± 11% in Group B, P < 0.001), higher LVEDV (188 ± 52 mL vs. 136 ± 52 mL, P = 0.007), lower GLS (À9.9 ± 5.2% vs. À14.5 ± 4.1%, P = 0.001), and higher NT-proBNP levels (1691 ± 1883 pg/mL vs. 422 ± 877 pg/mL, P = 0.006). Overall, higher summed difference score was associated with lower LVEF (r = À0.48, P = 0.001), higher LVEDV (r = 0.39, P = 0.012), lower GLS (r = 0.352, P = 0.024), and higher levels of NT-proBNP (r = 0.66, P < 0.001).Conclusions The presence of myocardial ischemia in patients with NCM is associated with worse left ventricular function, dilation of the left ventricle, and more pronounced neurohumoral activation.
Background: Transcatheter aortic valve implantation (TAVI) is a new method for patients with severe aortic stenosis at high surgical risk, such as previous cardiac surgery. The presence of mechanical mitral prosthesis might complicate TAVI because of possible interference between both prostheses. Some reports have already demonstrated the feasibility of TAVI in such patients. Case Reports: We report 2 patients with severe symptomatic aortic stenosis who had prior mitral valve replacement that successfully underwent TAVI with Edwards Sapien and CoreValve aortic prosthesis, respectively. Computed tomographic angiography (CTA) was useful for the assessment of the distance between both aortic and mitral prosthesis annuli. Transesophageal echocardiography was crucial for precise positioning of TAV. There were no special technical tips besides precise positioning of the valve prosthesis. In case of Core Valve the goal was the positioning at "zero point" and in case of Edwards Sapien valve a "half-on-half" position according to natural aortic valve. We observed no deformation or dysfunction of aortic and mitral prosthesis in any of the patients. Balloon valvuloplasty prior to implantation helps to observe the mutual effect of the new aortic valve and pre-existent mitral prosthesis. Conclusions: We conclude that TAVI can be safely and successfully performed in patients with mechanical mitral prosthesis carefully considering the altered anatomical conditions. Skillfulness and TAVI experience of the operators should not be neglected.
Introduction: Transcatheter aortic valve implantation is a routine clinical method for patients with severe aortic stenosis at high surgical risk, such as previous cardiac surgery. The presence of mechanical mitral prosthesis might complicate trans-catheter aortic valve implantation because of possible interference between both prostheses. Some clinical reports have already demonstrated the feasibility of trans-catheter aortic valve implantation in such patients.
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