Faculty Bibliography

We present a case of a patient with significant structural heart disease from previous cardiac surgeries who presented for an electrophysiology study and radiofrequency ablation. The case highlights the significance of intra-atrial conduction delays in such patients and potential pitfalls it can present while interpreting intra-cardiac electrograms especially during implantable cardioverter defibrillator (ICD) interrogations.

This article highlights the major changes in the current procedural terminology codes (CPT codes) that were announced by the American Medical Association in January 2009. These new CPT codes were developed to more accurately reflect current cardiac device monitoring capabilities, long-distance telemetry and remote interrogation as well as follow-up practices. Some of these new code sets are structured differently than the CPT codes that they replace. Specifically, the new codes for remote monitoring do not have separate professional (-26) and technical components (-TC) applied to an individual code. Instead, the new remote monitoring codes have separate CPT codes that represent the professional and technical components. The new device programming codes are generally defined by the number of leads, rather than the type of generator. Also, the period of time included in the specific type of service is indicated as per encounter, 30 or 90 days. Furthermore, two new periprocedural device evaluation and programming codes have been introduced.

The recent advisory of Medtronic Sprint Fidelis leads has resulted in significant controversy over proper management of patients. The current manufacture's guidelines recommend programming specific device alerts with close follow-up and implantable cardioverter-defibrillator lead replacement in patients with evidence of breach in lead integrity. Recently, several studies have identified significant limitations in this method of surveillance. We report the case of a pacemaker-dependent patient with an ischemic cardiomyopathy, who presented with cardiac arrest and evidence of fracture of the pace/sense portion of a Sprint Fidelis lead during postmortem interrogation. Likely mechanisms leading to his ultimate demise are discussed.

BACKGROUND:In the past 2 years, multiple implantable cardioverter-defibrillator (ICD) manufacturers have issued recalls on ICD models due to the potential for serious malfunction and even patient death. Previous studies examining the relationship between these recalls and patients' psychological well-being have been limited by small sample size and conflicting results. The purpose of this study is to examine the association between ICD recalls and patients' anxiety, depression, and quality of life. METHODS:Patients were drawn from an outpatient electrophysiology clinic at a tertiary care hospital in New York City. Patients who had devices subject to a recall (cases) were identified from lists provided by device manufacturer and controls (patients with ICDs not subjected to a recall) were drawn from a convenience sample of outpatients. The survey instrument consisted of two validated questionnaires--Hospital Anxiety and Depression Score (HADS) and MacNew heart disease health-related quality of life (QOL) instrument. In addition, a series of Likert-type scales were designed to elucidate patients' concerns related to the following domains: anger, trust, hope, concerns regarding ICD shock, fear of death (FOD), and physicians' ability to reduce their concern about the ICD recall. Data were analyzed using simple descriptive statistics and bivariate analyses (chi(2) and t-test) as appropriate. RESULT/RESULTS:Sixty-one cases and 43 control patients were enrolled. Thirty-two patients (52%) with devices subject to a recall opted for a generator replacement. There were no significant differences in the mean scores on the HADS scale, or the MacNew QOL scale between these two groups of patients (cases and controls). Subgroup analysis within the group of patients whose ICDs were recalled (cases) revealed a reduced QOL among patients with a class I recall (reasonable probability that the product will cause serious adverse health consequences or death) as compared to those with a class II recall (product may cause temporary or medically reversible adverse health consequences) (P = 0.01). Both cases and control patients reported having reduced trust in the health-care system. On the whole, however, patients were satisfied with the way their physicians dealt with the recall. There was no significant change in the overall concern of ICD shocks or FOD between the two groups. CONCLUSION/CONCLUSIONS:In this study of ICD recall, we found no difference in the levels of anxiety, depression, or QOL expressed by patients with an ICD subject to a recall as compared to those without. These findings may be a reflection of good physician-patient communication, which might have reduced any anxiety associated with recalls.

A case of successful laser extraction of a defibrillator lead with baffle stenting in a 15-year-old boy with dextrocardia, L-transposition, ventricular septal defect, and pulmonic stenosis status-post Senning/Rastelli repair is presented. Six-month follow-up revealed a significant increase in exercise tolerance and maximum oxygen consumption (VO(2)max).

OBJECTIVES/OBJECTIVE:This study was designed to determine whether the signal-averaged electrocardiogram of the P-wave (SAPW) is an independent predictor of recurrence of atrial fibrillation (AF) post cardioversion (CV), and to assess atrial remodeling using SAPW. BACKGROUND:There are limited electrophysiologic data to predict the recurrence of AF post-CV. The electrical remodeling that occurs post-CV is poorly understood. METHODS:Sixty-four patients with persistent AF undergoing CV were prospectively enrolled. SAPW parameters were measured the day of CV and repeated at 1 month. These SAPW parameters were compared to other baseline indices for the recurrence of AF. RESULTS:Sixty patients (94%) had successful CV. At 1 month, 22 (37%) maintained sinus rhythm (SR). The SAPW total duration decreased significantly in those who remained in SR (159 ms +/- 19 to 146 ms +/- 17; P < 0.0001). Only the duration of AF (46 +/- 50 days vs 147 +/- 227 days, P = 0.03) and the presence of left ventricular hypertrophy (LVH, 12% vs 65%, P = 0.0006) were significantly associated with recurrence of AF. Atrial size strongly correlated with the SAPW duration in patients who remained in SR (R(2)= 0.67, P = 0.003) but not in those who returned to AF (R(2)= 0.11, P = 0.65). CONCLUSIONS:Atrial electrical reverse remodeling occurs in patients with AF who maintain SR post-CV. This remodeling is likely inversely related to the duration of AF and LVH. SAPW duration does not predict recurrence of AF post-CV.

We report the case of a 47-year-old white man who presented with 1-year history of palpitations while swallowing. Event monitor confirmed the episodes were atrial tachycardia. Medical management with a calcium channel blocker did not alleviate the patient's symptoms. Gastrointestinal endoscopy did not reveal any abnormality. Electrophysiologic study was performed to identify and map the tachycardia. Swallowing during the procedure was used to repeatedly induce the tachycardia. A focal right atrial tachycardia that was mapped to the lower posterior right atrium was successfully ablated. Follow-up at 6 months and 1 year showed complete resolution of symptoms. An in-depth review of the literature and all published case reports of swallowing-induced atrial tachycardia is presented, and possible mechanisms of this rare form of tachycardia are discussed.

Coronary anomalies are divergent and can occur in up to 1% to 2% of patients. The most common of these anomalies is separate ostia of the left anterior descending and left circumflex arteries, followed by origin of the circumflex coronary artery from the right coronary artery and the left coronary artery from the right sinus of Valsalva, either as a separate ostium or as a part of single coronary artery. Anomalous origin of right coronary artery from the left sinus of Valsalva with a separate ostium or from the left main coronary artery is very rare. These coronary anomalies may be incidentally diagnosed on routine angiography or may present with myocardial ischemia, infarction, or sudden death. A case is described in which all 3 coronary arteries were originating from the left sinus of Valsalva as a common trunk (single coronary artery), which trifurcated to left anterior descending, left circumflex, and right coronary artery.