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Risk of Cardiac Implantable Electronic Device Associated Venous Stenosis
Abstracts
311 Recurrent, Symptomatic, Carotid Body Tumour Mediated Sinoatrial Arrest Presenting in Late Pregnancy S. Lovibond ∗ , A. Yeung MonashHeart, Melbourne, Australia Case: Mrs KG, a 29yo G2P0 with no significant past medical history was admitted at 40/40 for emergency LUSC for failure of progression. Prior antenatal assessment found an initially asymptomatic right neck mass. Ultrasound at 26/40 suggested a 3 cm carotid body tumour. Outpatient postpartum follow up was arranged. Following spinal anaesthesia, she experienced a 20 second unresponsive episode. 4 similar episodes then occurred in the 24 hours following successful delivery. A more detailed history then disclosed 7-8 similar episodes in the preceding two months, usually while lying on the left side. Inpatient telemetry then revealed recurrent sinus pauses up to 11 seconds, with associated syncope. MRI of the neck suggested a carotid glomus tumour measuring 3x2 cm. The tumour was then successfully surgically resected with backup temporary pacing wire insertion preoperatively. No further pauses allowed pacing wire removal and discharge 3 days later. Histology demonstrated a paraganglioma with evidence of lymph node metastasis. She will be followed up. Discussion: Carotid tumours causing sinus arrest have been widely reported1,2,3 . Increasing symptoms in late pregnancy and the peri- and postpartum period may have been exacerbated by hormonally mediated systemic vasodilation. This mechanism may also increase local pressure by the carotid body tumour on the carotid sinus through dilatation of the carotid vasculature. Positioning in the left lateral decubitus position while resting decreases sympathetic activity in comparison to other positions due to decreased aorto-caval compression from the gravid uterus5 . Neck position and subsequent tumour compression may also be implicated. http://dx.doi.org/10.1016/j.hlc.2016.06.312 312 Reverse Atrial Remodelling in Hypertensive Substrate: Beneficial Role of Adjunctive Therapy with Anti-Fibrotic Agent to ACE-I Therapy S. Thanigaimani 1,∗ , J. Kim 1 , A. Brooks 1 , J. Manavis 2 , D. Kelly 3 , W. Lim 1 , M. Neo 1 , P. Kuklik 1 , R. Mahajan 1 , P. Sanders 1 , D. Lau 1 1 University
of Adelaide, Adelaide, Australia Adelaide, Australia 3 University of Melbourne, Melbourne, Australia 2 SAHMRI,
Introduction: The beneficial role of reverse atrial remodelling due to hypertension (HTN) with combination therapy is not fully known. Here we evaluate the impact of antihypertensive, anti-fibrotic (Tranilast) and combined therapy on the atrial substrate in HTN.
S131
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Methods: 12-month old spontaneously hypertensive rats (SHR, n=29) and normotensive Wistar-Kyoto controls (WKY, n=8) were studied. SHR group was divided into HTN controls (n=7) and therapy groups: Perindopril (0.5 mg/kg/day, n=9); Tranilast (600 mg/kg bid, n=7); Perindopril & Tranilast combination (n=6) for 4 weeks. Electrophysiologic studies of superfused atria were performed using a custom multielectrode array to assess effective refractory period (ERP), conduction and AF inducibility followed by detailed histological and immunohistochemistry analysis. Results: All perindopril treated but not tranilast treated animals demonstrate reduced systolic blood pressure levels. All treated groups demonstrate: reduced left ventricular hypertrophy, improved atrial conduction, reduced atrial interstitial fibrosis and myocyte hypertrophy (all p<0.05), leading to reduced AF inducibility (all p<0.05) despite unchanged ERP (p=NS). Additionally, combination therapy resulted in greatest improvement in myocyte hypertrophy, endomysial fibrosis and gap junction proteins expressions (p<0.05 vs. single agent treatment). Conclusion: Perindopril or Tranilast partially reverses the substrate for AF in HTN. Tranilast has similar effects to Perindopril despite not affecting blood pressure levels. Combination of both agents demonstrated an additive effect on reversal of the AF substrate. http://dx.doi.org/10.1016/j.hlc.2016.06.313 313 Risk of Cardiac Implantable Electronic Device Associated Venous Stenosis J. Davis ∗ , P. Gould, J. Hill, B. Peach, A. Claughton, G. Kaye Princess Alexandra Hospital, Brisbane, Australia Introduction: A recognised complication of Cardiac Implantable Electronic Devices implantation (CIED) is venous stenosis or occlusion. With the increasing requirement of device upgrade or system/lead revisions we sought to determine the rate of subclavian stenosis associated with CIED implantation in our institution. Methods: A retrospective review of the radiology database from January 2010 to November 2015 was undertaken in patients with CIEDs who had undergone venography prior to device upgrade or lead revision. Collected data included patient age, CIED type, number of implanted leads, duration of lead implantation and side of implant. Stenosis was graded as occluded, severe and moderate or less. Presence of collateralisation was also assessed. Results: Of 205 patients identified 45% had a dualchamber pacemaker, 13% single-chamber pacemaker, 21% dual-chamber ICD and 15% single-chamber ICD and 6% had a CRT device (5% CRT-D and 1% CRT-P). The mean patient age was 69±13 years. Average duration of implant was 7.0±3.8 years. Fifty-seven (27%) patients had stenosis in whom 9 (5%) had total venous occlusion, 6 (4%) with severe occlusion and 33 (16%) with moderate or less stenosis. Collateralisation was identified in 20 (10%) patients and was associated with higher grade stenosis. The risk of stenosis did not correlate with lead type, number of leads or device type.
Abstracts
S132
Conclusion: Venous stenosis following CIED implantation is common. The risk of stenosis was not associated with number or type of CIED leads. Our data suggests routine subclavian venograms should be considered prior to lead revision or device upgrade. http://dx.doi.org/10.1016/j.hlc.2016.06.314 314 Salmonella Enteritidis Pacemaker Endocarditis without Gastrointestinal Symptoms D. Blusztein ∗ , N. Strathmore Royal Melbourne Hospital, Melbourne, Australia A healthy 47 year old male presented with fevers and pacemaker site tenderness soon after returning from Bali. He and his contacts had no gastrointestinal symptoms. His pacemaker had been inserted 12 years earlier for syncope with documented bradycardia. Blood cultures grew Salmonella Enteritidis but transoesophageal echocardiogram (TOE) did not demonstrate lead vegetations. On oral ciprofloxacin he became culture-negative, but had ongoing pocket tenderness, culminating in device extraction. Extraction revealed an exudative pocket infection. The atrial lead was successfully extracted, but the ventricular lead could not be extracted with laser equipment and remained insitu. Eight hours post-procedure, the patient became febrile and hypotensive, requiring inotropic support. Transthoracic echocardiogram excluded pericardial effusion. A diagnosis was made of septic shock caused by a septic shower. He stabilised within 24 hours and four days later underwent surgical excision of the ventricular lead via sternotomy. Pacemaker-lead cultures grew Salmonella Enteritidis resistant to ciprofloxacin. He was treated with ceftriaxone for four weeks, making a full recovery. A pacemaker was not re-implanted. Discussion: Cardiac Implanted Electronic Device (CIED) infections with Gram-Negative Bacilli are uncommon. Salmonella species are rare, especially without enteric symptoms. Most nontyphoidal Salmonella bloodstream infections do not have a suppurative endovascular focus. TOE may be negative in CIED infections. Percutaneous extraction is not always successful but complete extraction is essential. This extraction was complicated by hypotension due to sepsis, but cardiac or venous perforation must be excluded. Febrile patients with a CIED should be assessed for CIED infection and may ultimately require removal. http://dx.doi.org/10.1016/j.hlc.2016.06.315
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315 Seasonal Variation in Hospital Presentations for Atrial Fibrillation in Australia J. Hendriks ∗ , C. Gallagher, R. Mahajan, K. Nyfort-Hansen, S. Simmons, D. Rowet, M. Middeldorp, D. Lau, P. Sanders Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia Introduction: It is estimated that worldwide, 33.5 million people have Atrial Fibrillation (AF) and its burden as a cause of hospitalisation is increasing. Seasonal variation in AF hospital presentations has been demonstrated in European and North American climates, showing an increased frequency during the winter months. However, there is no data of seasonal patterns of presentations with AF in Australia and the reasons for the heighten presentations with AF remains unknown. Methods: Between May 2013 and May 2015, 2,045 consecutive patients with a primary diagnosis of AF, presented to Emergency Departments (ED) of six hospitals in South Australia. After exclusion of patients who did not meet inclusion criteria, 447 patients comprised the study population. All index presentations and hospitalisations were examined, including patient reported AF-related symptoms and the season they presented to the hospital. Results: Mean age 67 ± 13 years and 56% were male. The type of AF was predominantly paroxysmal AF (67%) and 63% had a CHADS2 -score of < 2. The most commonly reported symptoms were palpitations (75%), shortness of breath (48%), and fatigue (47%). Following the 447 index presentations, 237 patients (53%) were admitted to hospital. Proportionally, ED presentations were more prevalent in the Australian summer (29%), than in autumn (24%), winter (24%) and spring (24%). However this did not result in higher hospitalisation rates in summer (50%) compared to autumn (59%), winter (46%) and spring (59%). Conclusions: In this Australian cohort, we observed an increase in presentations for AF in summer. This contrasts with European and North American AF series which are more prevalent in winter. The reasons for this discrepancy remain unclear but highlight the need for the development of region specific treatment advice to manage AF and prevent hospitalisation. http://dx.doi.org/10.1016/j.hlc.2016.06.316 316 Short and Medium-Term Success of Electrical Cardioversion: The Austin Experience D. Flannery 1,∗ , A. Teh 1,2 , D. O’Donnell 2 1 Eastern 2 Austin
Health, Box Hill, Australia Health, Heidelberg, Australia
Introduction: Atrial fibrillation(AF) is a common and recurrent problem. Electrical cardioversion is an integral part of a
311 Recurrent, Symptomatic, Carotid Body Tumour Mediated Sinoatrial Arrest Presenting in Late Pregnancy S. Lovibond ∗ , A. Yeung MonashHeart, Melbourne, Australia Case: Mrs KG, a 29yo G2P0 with no significant past medical history was admitted at 40/40 for emergency LUSC for failure of progression. Prior antenatal assessment found an initially asymptomatic right neck mass. Ultrasound at 26/40 suggested a 3 cm carotid body tumour. Outpatient postpartum follow up was arranged. Following spinal anaesthesia, she experienced a 20 second unresponsive episode. 4 similar episodes then occurred in the 24 hours following successful delivery. A more detailed history then disclosed 7-8 similar episodes in the preceding two months, usually while lying on the left side. Inpatient telemetry then revealed recurrent sinus pauses up to 11 seconds, with associated syncope. MRI of the neck suggested a carotid glomus tumour measuring 3x2 cm. The tumour was then successfully surgically resected with backup temporary pacing wire insertion preoperatively. No further pauses allowed pacing wire removal and discharge 3 days later. Histology demonstrated a paraganglioma with evidence of lymph node metastasis. She will be followed up. Discussion: Carotid tumours causing sinus arrest have been widely reported1,2,3 . Increasing symptoms in late pregnancy and the peri- and postpartum period may have been exacerbated by hormonally mediated systemic vasodilation. This mechanism may also increase local pressure by the carotid body tumour on the carotid sinus through dilatation of the carotid vasculature. Positioning in the left lateral decubitus position while resting decreases sympathetic activity in comparison to other positions due to decreased aorto-caval compression from the gravid uterus5 . Neck position and subsequent tumour compression may also be implicated. http://dx.doi.org/10.1016/j.hlc.2016.06.312 312 Reverse Atrial Remodelling in Hypertensive Substrate: Beneficial Role of Adjunctive Therapy with Anti-Fibrotic Agent to ACE-I Therapy S. Thanigaimani 1,∗ , J. Kim 1 , A. Brooks 1 , J. Manavis 2 , D. Kelly 3 , W. Lim 1 , M. Neo 1 , P. Kuklik 1 , R. Mahajan 1 , P. Sanders 1 , D. Lau 1 1 University
of Adelaide, Adelaide, Australia Adelaide, Australia 3 University of Melbourne, Melbourne, Australia 2 SAHMRI,
Introduction: The beneficial role of reverse atrial remodelling due to hypertension (HTN) with combination therapy is not fully known. Here we evaluate the impact of antihypertensive, anti-fibrotic (Tranilast) and combined therapy on the atrial substrate in HTN.
S131
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
Methods: 12-month old spontaneously hypertensive rats (SHR, n=29) and normotensive Wistar-Kyoto controls (WKY, n=8) were studied. SHR group was divided into HTN controls (n=7) and therapy groups: Perindopril (0.5 mg/kg/day, n=9); Tranilast (600 mg/kg bid, n=7); Perindopril & Tranilast combination (n=6) for 4 weeks. Electrophysiologic studies of superfused atria were performed using a custom multielectrode array to assess effective refractory period (ERP), conduction and AF inducibility followed by detailed histological and immunohistochemistry analysis. Results: All perindopril treated but not tranilast treated animals demonstrate reduced systolic blood pressure levels. All treated groups demonstrate: reduced left ventricular hypertrophy, improved atrial conduction, reduced atrial interstitial fibrosis and myocyte hypertrophy (all p<0.05), leading to reduced AF inducibility (all p<0.05) despite unchanged ERP (p=NS). Additionally, combination therapy resulted in greatest improvement in myocyte hypertrophy, endomysial fibrosis and gap junction proteins expressions (p<0.05 vs. single agent treatment). Conclusion: Perindopril or Tranilast partially reverses the substrate for AF in HTN. Tranilast has similar effects to Perindopril despite not affecting blood pressure levels. Combination of both agents demonstrated an additive effect on reversal of the AF substrate. http://dx.doi.org/10.1016/j.hlc.2016.06.313 313 Risk of Cardiac Implantable Electronic Device Associated Venous Stenosis J. Davis ∗ , P. Gould, J. Hill, B. Peach, A. Claughton, G. Kaye Princess Alexandra Hospital, Brisbane, Australia Introduction: A recognised complication of Cardiac Implantable Electronic Devices implantation (CIED) is venous stenosis or occlusion. With the increasing requirement of device upgrade or system/lead revisions we sought to determine the rate of subclavian stenosis associated with CIED implantation in our institution. Methods: A retrospective review of the radiology database from January 2010 to November 2015 was undertaken in patients with CIEDs who had undergone venography prior to device upgrade or lead revision. Collected data included patient age, CIED type, number of implanted leads, duration of lead implantation and side of implant. Stenosis was graded as occluded, severe and moderate or less. Presence of collateralisation was also assessed. Results: Of 205 patients identified 45% had a dualchamber pacemaker, 13% single-chamber pacemaker, 21% dual-chamber ICD and 15% single-chamber ICD and 6% had a CRT device (5% CRT-D and 1% CRT-P). The mean patient age was 69±13 years. Average duration of implant was 7.0±3.8 years. Fifty-seven (27%) patients had stenosis in whom 9 (5%) had total venous occlusion, 6 (4%) with severe occlusion and 33 (16%) with moderate or less stenosis. Collateralisation was identified in 20 (10%) patients and was associated with higher grade stenosis. The risk of stenosis did not correlate with lead type, number of leads or device type.
Abstracts
S132
Conclusion: Venous stenosis following CIED implantation is common. The risk of stenosis was not associated with number or type of CIED leads. Our data suggests routine subclavian venograms should be considered prior to lead revision or device upgrade. http://dx.doi.org/10.1016/j.hlc.2016.06.314 314 Salmonella Enteritidis Pacemaker Endocarditis without Gastrointestinal Symptoms D. Blusztein ∗ , N. Strathmore Royal Melbourne Hospital, Melbourne, Australia A healthy 47 year old male presented with fevers and pacemaker site tenderness soon after returning from Bali. He and his contacts had no gastrointestinal symptoms. His pacemaker had been inserted 12 years earlier for syncope with documented bradycardia. Blood cultures grew Salmonella Enteritidis but transoesophageal echocardiogram (TOE) did not demonstrate lead vegetations. On oral ciprofloxacin he became culture-negative, but had ongoing pocket tenderness, culminating in device extraction. Extraction revealed an exudative pocket infection. The atrial lead was successfully extracted, but the ventricular lead could not be extracted with laser equipment and remained insitu. Eight hours post-procedure, the patient became febrile and hypotensive, requiring inotropic support. Transthoracic echocardiogram excluded pericardial effusion. A diagnosis was made of septic shock caused by a septic shower. He stabilised within 24 hours and four days later underwent surgical excision of the ventricular lead via sternotomy. Pacemaker-lead cultures grew Salmonella Enteritidis resistant to ciprofloxacin. He was treated with ceftriaxone for four weeks, making a full recovery. A pacemaker was not re-implanted. Discussion: Cardiac Implanted Electronic Device (CIED) infections with Gram-Negative Bacilli are uncommon. Salmonella species are rare, especially without enteric symptoms. Most nontyphoidal Salmonella bloodstream infections do not have a suppurative endovascular focus. TOE may be negative in CIED infections. Percutaneous extraction is not always successful but complete extraction is essential. This extraction was complicated by hypotension due to sepsis, but cardiac or venous perforation must be excluded. Febrile patients with a CIED should be assessed for CIED infection and may ultimately require removal. http://dx.doi.org/10.1016/j.hlc.2016.06.315
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315 Seasonal Variation in Hospital Presentations for Atrial Fibrillation in Australia J. Hendriks ∗ , C. Gallagher, R. Mahajan, K. Nyfort-Hansen, S. Simmons, D. Rowet, M. Middeldorp, D. Lau, P. Sanders Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia Introduction: It is estimated that worldwide, 33.5 million people have Atrial Fibrillation (AF) and its burden as a cause of hospitalisation is increasing. Seasonal variation in AF hospital presentations has been demonstrated in European and North American climates, showing an increased frequency during the winter months. However, there is no data of seasonal patterns of presentations with AF in Australia and the reasons for the heighten presentations with AF remains unknown. Methods: Between May 2013 and May 2015, 2,045 consecutive patients with a primary diagnosis of AF, presented to Emergency Departments (ED) of six hospitals in South Australia. After exclusion of patients who did not meet inclusion criteria, 447 patients comprised the study population. All index presentations and hospitalisations were examined, including patient reported AF-related symptoms and the season they presented to the hospital. Results: Mean age 67 ± 13 years and 56% were male. The type of AF was predominantly paroxysmal AF (67%) and 63% had a CHADS2 -score of < 2. The most commonly reported symptoms were palpitations (75%), shortness of breath (48%), and fatigue (47%). Following the 447 index presentations, 237 patients (53%) were admitted to hospital. Proportionally, ED presentations were more prevalent in the Australian summer (29%), than in autumn (24%), winter (24%) and spring (24%). However this did not result in higher hospitalisation rates in summer (50%) compared to autumn (59%), winter (46%) and spring (59%). Conclusions: In this Australian cohort, we observed an increase in presentations for AF in summer. This contrasts with European and North American AF series which are more prevalent in winter. The reasons for this discrepancy remain unclear but highlight the need for the development of region specific treatment advice to manage AF and prevent hospitalisation. http://dx.doi.org/10.1016/j.hlc.2016.06.316 316 Short and Medium-Term Success of Electrical Cardioversion: The Austin Experience D. Flannery 1,∗ , A. Teh 1,2 , D. O’Donnell 2 1 Eastern 2 Austin
Health, Box Hill, Australia Health, Heidelberg, Australia
Introduction: Atrial fibrillation(AF) is a common and recurrent problem. Electrical cardioversion is an integral part of a