TY - JOUR
AB -   P1195 Complex approach to treatment of severe catecholaminergic polymorphic ventricular tachycardia in a 12-years-old boy T S Loevets T S Loevets National Almazov Medical Research Centre, Pediatric Cardiovascular Diseases Research Department, Saint Petersburg, Russian Federation D S Lebedev D S Lebedev National Almazov Medical Research Centre, Interventional Arrhythmology Research Department, Saint Petersburg, Russian Federation E S Vasichkina E S Vasichkina National Almazov Medical Research Centre, Pediatric Cardiovascular Diseases Research Department, Saint Petersburg, Russian Federation S V Gureev S V Gureev National Almazov Medical Research Centre, Interventional Arrhythmology Research Department, Saint Petersburg, Russian Federation V K Lebedeva V K Lebedeva National Almazov Medical Research Centre, Interventional Arrhythmology Research Department, Saint Petersburg, Russian Federation T A Lyubimtseva T A Lyubimtseva National Almazov Medical Research Centre, Interventional Arrhythmology Research Department, Saint Petersburg, Russian Federation S A Termosesov S A Termosesov Research Clinical Institute of pediatrics, Children’s center of arrhythmias, Moscow, Russian Federation A A Kostareva A A Kostareva National Almazov Medical Research Centre, Institute of Molecular Biology and Genetics, Saint Petersburg, Russian Federation S V Garkina S V Garkina National Almazov Medical Research Centre, Interventional Arrhythmology Research Department, Saint Petersburg, Russian Federation R B Tatarsky R B Tatarsky National Almazov Medical Research Centre, Interventional Arrhythmology Research Department, Saint Petersburg, Russian Federation T M Pervunina T M Pervunina National Almazov Medical Research Centre, Institute of Perinatology and Pediatrics, Saint-Petersburg, Russian Federation T L Vershinina T L Vershinina National Almazov Medical Research Centre, Pediatric Cardiovascular Diseases Research Department, Saint Petersburg, Russian Federation National Almazov Medical Research Centre, Pediatric Cardiovascular Diseases Research Department, Saint Petersburg, Russian Federation National Almazov Medical Research Centre, Interventional Arrhythmology Research Department, Saint Petersburg, Russian Federation Research Clinical Institute of pediatrics, Children’s center of arrhythmias, Moscow, Russian Federation National Almazov Medical Research Centre, Institute of Molecular Biology and Genetics, Saint Petersburg, Russian Federation National Almazov Medical Research Centre, Institute of Perinatology and Pediatrics, Saint-Petersburg, Russian Federation Introduction: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare genetically determined syndrome characterized by electrical instability of cardiomyocytes, associated with sympathic nervous system activation, which leads to sudden death due to polymorphic VT (PVT). The early debut of the disease is associated with more severe course and refractory to treatment. A 12 y.o. patient B. came to our Center. He complained of recurrent syncopies provoked by minimal physical or emotional exertion . The 1st syncope appeared at the age of 7 years. Their amount, durability and severity increased progressively. Syncope was accompanied by a respiratory arrest, cyanosis, tonic convulsions. The patient regained consciousness after cardiopulmonary resuscitation. Neurological and endocrine pathology were excluded. Primary cardiological examination (ECG, ECHO) also revealed no pathology. According to Holter, at the age of 10.5 years, at the moment of syncope, recurrent PVT with the transition to ventricular fibrillation (VF) 336-340 bpm lasting 1 min 10 sec was recorded. A β-blocker was prescribed. A single-chamber ICD was implanted and programmed for electrotherapy for the VF zone from 300 msec in the form of a shock of 10J. Bradycardia was installed as a VVI mode with a base rate of 30 per min. There were restrictions in titration of target doses of β-blockers due to sinus bradycardia (SB): minimum HR 33 bpm. Within 8 months after the ICD implantation 13 motivated shocks were registered. Through Holter held in hospital at the moment of presyncope after the minimum physical activity, a recurrent PVT with 160-209 bpm and transition to the VF with spontaneous recovery was shown. Total duration of this episode was 5 min 10 sec. Firstly we changed ICD parameters of VF detection and sensitivity to the R wave. Then having considered the recurrence of VT, impossibility of adequate β-blockers therapy due to severe SB, we replaced the ICD by a dual-chamber device using the predominantly atrial frequency-adaptive stimulation with a basic frequency of 70 bpm. Normalization of heart rate allowed to increase the dosage of β-blockers by 4 times. Genetic analysis showed replacement in the ryanodine receptor gene RYR2 R4959Q. One year later a positive dynamics was revealed due to combined therapy, namely absence of sustained VT, ICD shocks and syncopies. The patient’s quality of life significantly improved, but a polymorphic ventricular premature beats and non-sustained VT were registered during exercise stress test despite the optimal dose of β-blockers. 2 months later, the child underwent videothoracoscopic selective left-sided sympathectomy, after which heart rate disturbances were not registered. Conclusion: Only complex approach to diagnosing and treatment (medication, interventional) helped us to control the CPVT and led to the absence of syncopies/ICD shocks, which resulted in significant improvement of the quality of life and social adaptation. View largeDownload slide Abstract P1195 Figure. View largeDownload slide Abstract P1195 Figure. P1196 Usefulness of simultaneous position analysis during ambulatory electrocardiogram monitoring J Ahn J Ahn Busan National University Hospital, Busan, Korea Republic of J S Park J S Park Busan National University Hospital, Busan, Korea Republic of H W Lee H W Lee Busan National University Hospital, Busan, Korea Republic of J H Choi J H Choi Busan National University Hospital, Busan, Korea Republic of H C Lee H C Lee Busan National University Hospital, Busan, Korea Republic of K S Cha K S Cha Busan National University Hospital, Busan, Korea Republic of T J Hong T J Hong Busan National University Hospital, Busan, Korea Republic of Busan National University Hospital, Busan, Korea Republic of Funding Acknowledgements: The Bio & Medical technology development program of the NRF funded by the Korean government Background: Ambulatory Electrocardiogram (ECG) monitoring is an important diagnostic tool to evaluate the presence of arrhythmia. However, same ECG can have different clinical significance according to the patient’s position such as lying or running. Methods: We developed and reported an inertial measurement unit (IMU)-based human sensor last year. This sensor was attached on the upper sternum to the patient undergoing 24 hour ambulatory ECG monitoring. After the exam, data stored in sensor were extracted and then analyzed. Position was roughly categorized as lying, sitting or standing, walking, running, and fast running. Sensor data displayed each position state as linear graph continuously during 24 hours. Therefore simultaneous position state could be assessable during clinically ambiguous ECG. Results: During the first month of the beginning of this study, a total of 27 patients wore the sensors. Among them, two useful findings were observed. #1 case, 49-yo male did not have any bradycardia-related symptom. However ambulatory ECG showed long pause for 7.5 seconds at 11:27pm (Fig A). He had refused pacemaker strongly because he never felt dizziness. Sensor data showed ‘lying’ position during that ECG section (Fig B), which meant the long pause occurred during resting state. Although high grade atrioventricular block generally requires pacemaker, it has been deferred in this patient according to exclusively vagal tone related bradycardia on the basis of sensor data and his strong insist. #2 case, ECG of 76-yo male complaining of palpitation showed sinus tachycardia at 12:51pm. At that time position data showed ‘running’, excluding the diagnosis of inappropriate sinus tachycardia or psychologic problem. Conclusions: Simultaneous position analysis with ambulatory ECG monitoring is useful to interpret the clinical significance of ambiguous ECG section. View largeDownload slide Abstract P1196 Figure. View largeDownload slide Abstract P1196 Figure. P1197 Leadless pacemaker implantation in subacute humoral rejection in cardiac transplantation G Palmiero G Palmiero AO dei Colli-Monaldi Hospital, Department of Cardiology, Naples, Italy S De Vivo S De Vivo AO dei Colli-Monaldi Hospital, Department of Cardiology, Naples, Italy P Caso P Caso AO dei Colli-Monaldi Hospital, Department of Cardiology, Naples, Italy A D"onofrio A D"onofrio AO dei Colli-Monaldi Hospital, Department of Cardiology, Naples, Italy AO dei Colli-Monaldi Hospital, Department of Cardiology, Naples, Italy A 62-year-old man, who underwent orthotopic heart transplant due to end-stage ischemic heart disease in 2008, was admitted to our hospital in July 2018 due to shortness of breath and recurrent syncopal episodes. Transthoracic echocardiogram showed moderate left ventricular systolic dysfunction (LVEF 40%). In the suspicion of graft rejection, donor-specific HLA antibodies (DSA) assays were performed and panel reactive antibodies (PRA) class I (anti-A1, MFI 10.646) and class II (anti-DQ6, MFI 1.405) were identified. A coronary angiogram with IVUS was performed and showed no signs of cardiac allograft vasculopathy (CAV). Then, humoral graft heart rejection was diagnosed and specific therapies with plasmapheresis and i.v. human immunoglobulins were started. In ECG monitoring, alternating sinus pauses and atrial fibrillation with rapid ventricular rate were detected. In view of symptomatic sick sinus syndrome and high risk of infection, secondary to immunosuppressive therapy, a definitive pacemaker implantation was considered and a Micra transcatheter pacing system (TPS) implanted. The device was deployed in the mid-septal position with acceptable parameters (impedance 710 Ohm, sensing 4.25 mV, and threshold 0.38 V at 0.24 ms). At three-months follow-up there were no rehospitalisation due to HF and no evidence of embolic and infectious complications. Sinus node dysfunction requiring permanent pacing is present in about 6% of patient with orthotopic transplant and may represent a sign of graft rejection requiring aggressive immunosuppressive therapy. Leadless pacemaker seems to represent a promising alternative to classical pacemaker implantation also in subacute graft rejection, given its lower risk of lead- and pocket-infection. P1198 Automatic pacing output failure as a cause of repeated syncope M Markovic M Markovic Clinical Hospital Merkur, Zagreb, Croatia M Stipinovic M Stipinovic Clinical Hospital Merkur, Zagreb, Croatia D Pocanic D Pocanic Clinical Hospital Merkur, Zagreb, Croatia I Premuzic Mestrovic I Premuzic Mestrovic Clinical Hospital Merkur, Zagreb, Croatia Clinical Hospital Merkur, Zagreb, Croatia Long-term studies have showed that ventricular pacing threshold may rise over time, therefore algorithms of automatic pacing output management were developed to ensure both patients safety and device longevity (1). These algorithms are deemed safe for patients (1,2,3). We present a 76-years-old patient admitted to our ward due to repeated syncopal episodes. Patient had a single lead VVI pacemaker (implanted in 2016, after ERI of previous device implanted 2006) due to 3rd degree AV block and atrial fibrillation, with a bipolar active fixation lead from another manufacturer (implanted 2006). Before admission to our ward patient was evaluated with pacemaker check-up in ER of another hospital, then ambulatory by a cardiologist/arrhythmologist and finally at hospital in which the device was implanted. Pacemaker function was declared nominal. Patient noted that each night between 00:30 and 01:00 he experiences light-headiness, dyspnea, loss of muscle tone and sometimes complete loss of consciousness. Pacemaker had an automatic capture option switched on with a safety margin of 1,2 V; settings were: Vent. Stimulation 2,4V/0,4ms bipolar, sensitivity 4,0. Last measured threshold was 1,2 V obtained on the same day at 01:08 AM. The testing protocol was set to start at 00:30 with Threshold test start at 3,0 V. Patient had very few spontaneous ventricular activity, histogram showed >99% ventricular pacing therefore he was declared pacemaker dependent. No VHRE were noted (High rate limit was set to 180). Histogram of the last 24 hours showed 50% loss of ventricular pacing with ventricular activity of 80-90 bpb (Figure 1A) in hours between 00:30 and 01:00 AM. Capture threshold test was performed two times with automatic protocol and automatic measurement of evoked response. Tests showed ventricular intracardiac electrogram threshold of 0,5V/0,4ms, and 0,6V/0,4ms respectively (Figure 1B). While doing both threshold test patient lost consciousness. Finally capture with surface ECG was performed showing threshold 2,0V/0,4ms and 1,6/1,25 ms respectively (Figure 1C) We are showing failure of a generally very safe algorithm (3) with testing period lasting for more than 30 minutes in which patient was in functional exit block. Repetitive syncopal episodes in a pacemaker patient require throughout device check, and rechecking of any automatic protocol is warranted. We would also like to remind that threshold testing with ECG is warranted. Possible cause of inappropriate threshold testing is aging electrode, high tip polarization due to old and different manufacturer electrode, or pacemaker filter and sense configuration failure as unipolar sensing and discordant pacing and sensing configuration yield best results of capture control (3). View largeDownload slide Abstract P1198 Figure 1. Showing histograms and testing View largeDownload slide Abstract P1198 Figure 1. Showing histograms and testing P1199 An unusual pacemaker-induced tachycardia M Coutinho Cruz M Coutinho Cruz Hospital de Santa Marta, Serviço de Cardiologia, Lisbon, Portugal G Portugal G Portugal Hospital de Santa Marta, Serviço de Cardiologia, Lisbon, Portugal A Viveiros-Monteiro A Viveiros-Monteiro Hospital de Santa Marta, Serviço de Cardiologia, Lisbon, Portugal A Lousinha A Lousinha Hospital de Santa Marta, Serviço de Cardiologia, Lisbon, Portugal B Valente B Valente Hospital de Santa Marta, Serviço de Cardiologia, Lisbon, Portugal P Silva-Cunha P Silva-Cunha Hospital de Santa Marta, Serviço de Cardiologia, Lisbon, Portugal R Cruz-Ferreira R Cruz-Ferreira Hospital de Santa Marta, Serviço de Cardiologia, Lisbon, Portugal M Martins-Oliveira M Martins-Oliveira Hospital de Santa Marta, Serviço de Cardiologia, Lisbon, Portugal Hospital de Santa Marta, Serviço de Cardiologia, Lisbon, Portugal A 29 year-old female patient with double inlet left ventricle, ventricle septal defect, malposition of the great arteries and subpulmonary obstacle, submitted to a modified Fontan procedure at 9 years of age, presented with severely symptomatic brady-tachy syndrome (palpitations and syncope). Since venous access to the right ventricle was absent (due to the flow of systemic venous blood from the right atrium to the pulmonary artery bypassing the ventricles), and the AV conduction was good, it was decided to implant an AAI permanent pacemaker. A single lead was placed in the right atrium lateral wall because of suboptimal pacing threshold in the conventional positions. A generator with a ventricular port plug was used. The day after, the patient complained of palpitations. The ECG in Figure 1A shows a repetitive cycle of an atrial paced beat (Ap) and an atrial intrinsic beat (Ai), both followed by a ventricular intrinsic beat (Vi). The Ap-Ap and Ai-Ai intervals are 1000 ms, with a ventricular rate of 120 bpm. Device interrogation revealed that it was programmed in DDD instead of AAI mode. Parameters were: lower rate limit (LRL) 60 bpm; upper tracking rate 120 bpm; post-ventricular atrial refractory period (PVARP) 280 ms; paced AV delay 220 ms. Figure 1B depicts the intracardiac electrograms and pacing intervals overlaying the ECG. In the atrial channel, an Ap is followed by an atrial intrinsic beat in the refractory period (Ar), followed again by an Ap. As mentioned before, the ventricular port on the generator was plugged and it was not possible neither to sense nor to pace the ventricle. As such, the ventricular paced beats (Vp) are inconsequential with respect to actual ventricular activation. This unusual kind of "pacemaker-induced tachycardia" is only possible because of the simultaneous occurrence of a set of conditions. Firstly, a pacemaker with a single atrial lead was programmed in a DDD mode. This mode initiated an AV delay and a PVARP after the Ap. The next Ai is then sensed during the refractory period and does not reset the pacing intervals. Secondly, the absence of a ventricular lead also precludes the Vi after the Ar to be sensed and reset the VA interval. Thirdly, the patient’s intrinsic rhythm during this period is timed to occur before the end of the programed PVARP so that this interval prevents it from being sensed outside the refractory period. Lastly, the patient’s intact AV conduction allows all Ap and Ar to be conducted to the ventricle and the rate to rise to 120 bpm. Careful programming and deep understanding of pacing functions is crucial to the management of these patients. View largeDownload slide Abstract P1199 Figure 1 View largeDownload slide Abstract P1199 Figure 1 P1200 Endocardial left ventricular pacing and AV node ablation in a patient with ebsteins anomaly and mechanical tricuspid valve replacement with an inaccessible coronary sinus M Chapman M Chapman James Cook University Hospital, Cardiology, Middlesbrough, United Kingdom J Mcminn J Mcminn James Cook University Hospital, Cardiology, Middlesbrough, United Kingdom S James S James James Cook University Hospital, Cardiology, Middlesbrough, United Kingdom A J Turley A J Turley James Cook University Hospital, Cardiology, Middlesbrough, United Kingdom James Cook University Hospital, Cardiology, Middlesbrough, United Kingdom Introduction: Ebstein’s anomaly is characterised by apical displacement of the tricuspid valve (TV), an "atrialised" portion of the right ventricle (RV) and dilatation of the true tricuspid annulus. Permanent pacing is infrequently required but due to RV anatomical abnormalities and high rates of TV intervention, endocardial RV pacing is rarely performed and surgically implanted epicardial leads are often used. Other options include implantation of pace-sense leads via the coronary sinus (CS). Clinical Presentation: A 52-year-old was referred to our centre with difficult to control atrial flutter. He had Ebstein’s anomaly and underwent a mechanical TV replacement aged 12-yrs. He had undergone 2 previous ablations as well as several cardioversions, which failed to maintain sinus rhythm. Echocardiography (TTE) had shown evidence of cardiomyopathy, presumed tachycardia induced. In view of this unsuccessful rhythm control strategy and poor ventricular rate control, we were asked if we could perform cardiac pacing and AVN ablation. Cardiac computed tomography showed that his TV replacement was sited very basally such that the CS drained into the RV and was therefore not accessible for pacing (Figure one). Leadless LV pacing (WiCS-EBR) was deemed unsuitable as it requires co-implantation of a conventional pacing system in order to trigger. The patient did not want to consider an epicardial surgical approach. We therefore offered a trans-septal LV lead along with AVN ablation. Venous access was obtained via left subclavian and right femoral veins. A 5 french (Fr) sheath was inserted via the subclavian vein and an 0.032" guidewire advanced into the right atrium. A 10Fr sheath was inserted into the right femoral vein. Intracardiac echocardiography guided trans-septal puncture was performed using a 10Fr SL1 catheter and BKR1 XS trans-septal needle. This also allowed imaging of the left atrial appendage. The 0.032" guidewire was snared from the femoral approach and advanced across the intra-atrial septum into the left atrium. Subclavian access was then upsized to a 9.5Fr sheath. A select secure transvenous pacing system (Medtronic) was used. We were unable to advance the select secure guide catheter across the atrial septum. We switched to an MB2 CRT delivery catheter, which crossed with ease. A 69cm Medtronic 3830 lead was implanted into the basolateral wall of the LV. The AVN was inaccessible from a trans-venous route as his mechanical TV replacement was sited above the triangle of Koch. The AVN ablation was undertaken via retrograde aortic approach. The His was ablated in the LV septum with one application of RF energy (40W for 60sec) using a D/F irrigated catheter. The patient remained on anti-coagulation throughout. Conclusion: This case highlights an alternative option to surgery for patients requiring ventricular pacing in the presence of TV replacement and an inaccessible CS. View largeDownload slide Abstract P1200 Figure. View largeDownload slide Abstract P1200 Figure. P1201 Repeated MRI and cyberknife therapy for Parkinson"s disease in a patient with epicardial leads T Skowerski T Skowerski Medical University of Silesia, Department of Cardiology, School of Health Sciences, Katowice, Poland A Kulach A Kulach Medical University of Silesia, Department of Cardiology, School of Health Sciences, Katowice, Poland Z Gasior Z Gasior Medical University of Silesia, Department of Cardiology, School of Health Sciences, Katowice, Poland Medical University of Silesia, Department of Cardiology, School of Health Sciences, Katowice, Poland Funding Acknowledgements: None A 68-old year male patient with a history of symptomatic AV II degree block had a pacemaker with endocardial leads implanted in September 2009. Two months later due to exit block, he was admitted for RV lead replacement. Then, due thrombosis of the left brachiocephalic vein, the endocardial leads had been removed and the patient had epicardial leads implanted with pacemaker placed in the abdominal wall. Since then the device parameters had been stable and regularly checked during follow-up visits (Table 1.). In 2014 Patient was diagnosed with Parkinson’s disease. In may 2017, because of an excerebration and therapy resistance of Parkinson"s disease, the patient was qualified for Cyberknife therapy, an MRI had to be performed in order to plan the procedure. Due to severe neurological symptoms, despite contraindications, we decided to proceed with an MRI. The scans were performed with a 1.5T scanner (GE OPTIMA); the device was programmed DOO mode during the study - the patient was pacemaker dependent (VP >95%). We did not observe any complications during/after MRI. The device parameters remained unchanged (see table) immediately and after one-month post-MRI and subsequent successful Cyberknife therapy. In April 2018 the pacemaker was replaced with Ensura MRI Surescan because of the end of battery life. The epicardial leads were left intact. A few months after Cyberknife the Parkinson’s disease symptoms relapsed and another MRI was suggested to plan Deep Brain Stimulation. In August 2018 another MRI was performed. The device parameters also remained unchanged. The problem of the safety of MRI in patients with an implanted cardiac device is becoming more and more serious and affects a larger group of people every year. It is estimated that 50-75% of individuals with a pacemaker will require MRI. We present a case of the patient with epicardial leads that had an MRI performed two times without any complication. There are not many studies regarding this topic - most of them report no serious issues after MRI in patients with epicardial leads. In our opinion, if an MRI is the only diagnostic tool left and is crucial for the patient"s treatment, the epicardial leads should not be a contraindication. Study Atrial impedance (ohms) Ventricular impedance (ohms) Atrial capture threshold (V@;msec) Ventricular capture threshold (V@;msec) Atrial sensing threshold (mV) Ventricular sensing threshold (mV) Before 1st MRI 537 738 0.875@;0.4 1.3@;0.4 >5.6 >15 After 1st MRI 522 722 0.75@;0.4 1.0@;0.5 0.7-1 15-17 Before 2nd MRI 515 790 0.5@;0.4 1.0@;0.4 0.7-1 >15 After 2nd MRI 506 652 0.75@;0.4 1.25@;0.4 0.7-2.8 >15 Study Atrial impedance (ohms) Ventricular impedance (ohms) Atrial capture threshold (V@;msec) Ventricular capture threshold (V@;msec) Atrial sensing threshold (mV) Ventricular sensing threshold (mV) Before 1st MRI 537 738 0.875@;0.4 1.3@;0.4 >5.6 >15 After 1st MRI 522 722 0.75@;0.4 1.0@;0.5 0.7-1 15-17 Before 2nd MRI 515 790 0.5@;0.4 1.0@;0.4 0.7-1 >15 After 2nd MRI 506 652 0.75@;0.4 1.25@;0.4 0.7-2.8 >15 Table 1. Pacemaker parameters View Large Study Atrial impedance (ohms) Ventricular impedance (ohms) Atrial capture threshold (V@;msec) Ventricular capture threshold (V@;msec) Atrial sensing threshold (mV) Ventricular sensing threshold (mV) Before 1st MRI 537 738 0.875@;0.4 1.3@;0.4 >5.6 >15 After 1st MRI 522 722 0.75@;0.4 1.0@;0.5 0.7-1 15-17 Before 2nd MRI 515 790 0.5@;0.4 1.0@;0.4 0.7-1 >15 After 2nd MRI 506 652 0.75@;0.4 1.25@;0.4 0.7-2.8 >15 Study Atrial impedance (ohms) Ventricular impedance (ohms) Atrial capture threshold (V@;msec) Ventricular capture threshold (V@;msec) Atrial sensing threshold (mV) Ventricular sensing threshold (mV) Before 1st MRI 537 738 0.875@;0.4 1.3@;0.4 >5.6 >15 After 1st MRI 522 722 0.75@;0.4 1.0@;0.5 0.7-1 15-17 Before 2nd MRI 515 790 0.5@;0.4 1.0@;0.4 0.7-1 >15 After 2nd MRI 506 652 0.75@;0.4 1.25@;0.4 0.7-2.8 >15 Table 1. Pacemaker parameters View Large P1202 Decrease of the pacing rate after chemotherapy in a patient with sick sinus syndrome due to cardiac tumor infiltration T Yamada T Yamada Toranomon Hospital, Cardiovascular Center, Tokyo, Japan N Nishiyama N Nishiyama Toranomon Hospital, Cardiovascular Center, Tokyo, Japan Y Isonaga Y Isonaga Toranomon Hospital, Cardiovascular Center, Tokyo, Japan M Morise M Morise Toranomon Hospital, Cardiovascular Center, Tokyo, Japan C Komiyama C Komiyama Toranomon Hospital, Cardiovascular Center, Tokyo, Japan A Harima A Harima Toranomon Hospital, Cardiovascular Center, Tokyo, Japan M Kuwabara M Kuwabara Toranomon Hospital, Cardiovascular Center, Tokyo, Japan Y Tomita Y Tomita Toranomon Hospital, Cardiovascular Center, Tokyo, Japan T Kodama T Kodama Toranomon Hospital, Cardiovascular Center, Tokyo, Japan Y Fujimoto Y Fujimoto Toranomon Hospital, Cardiovascular Center, Tokyo, Japan M Wakatabe M Wakatabe Toranomon Hospital, Cardiovascular Center, Tokyo, Japan A Sato A Sato Toranomon Hospital, Cardiovascular Center, Tokyo, Japan K Tanaka K Tanaka Toranomon Hospital, Cardiovascular Center, Tokyo, Japan Y Naruse Y Naruse Toranomon Hospital, Cardiovascular Center, Tokyo, Japan H Mitani H Mitani Toranomon Hospital, Cardiovascular Center, Tokyo, Japan Toranomon Hospital, Cardiovascular Center, Tokyo, Japan Case A 65-year-old woman had undergone bone marrow transplantation (BMT) for acute myeloid leukemia (AML) and then she maintained remission 4 years ago. She suffered from recurrent syncope and facial edema especially in the morning. During hospitalization, she had an attack of syncope with sinus arrest after termination of the atrial fibrillation (SSS: sick sinus syndrome). The echocardiography showed the huge mass lesion in the right atrium. The CT scan revealed the mass lesion spread from the lateral wall of right atrium to atrial septum with infiltration of mediastinum around superior vena cava (SVC) and pulmonary veins (Figure1A). It also seemed almost complete occlusion of SVC and developing collaterals to azygos vein. We suspected that the cardiac tumor was the mass lesion of post-transplant lymphoproliferative disorders (PTLD) and the direct invasion of cardiac tumor led SSS and SVC syndrome. We needed to perform pacemaker implantation for SSS and to obtain a biopsy of the mass in order to make a diagnosis and determine the therapy. In terms of the pacemaker implantation, we thought that the pacemaker leads could not pass through the occlusion site of SVC. On the other hand, in terms of the biopsy, we needed more than 5 mm cubes of the tissue to make a diagnosis if there is possibility of the PTLD. We considered the transcatheter tumor biopsy and leadless pacemaker implantation, but the vulnerability of mass was unclear and the required size of a biopsy was too large for transcatheter. So we performed punch biopsy and epicardial lead implantation with small thoracotomy. The biopsy provided pathlogical diagnosis of the relapse of AML. And then, she started to receive chemotherapy using Azacitidine. The tumor size was markedly decreasing and WT1-mRNA which was the tumor marker for leukemia decreased to less than 50 copy from 3100 copy. The pacing rate was decreasing to 2 percent from more than 75 percent with 6 courses of chemotherapy (Figure1B). Conclusions To our knowledge, this is the first report describing cardiac relapse of AML after BMT cause for SSS and SVC syndrome, furthermore these findings are improving in the tumor size and even the pacing rate with chemotherapy. View largeDownload slide Abstract P1202 Figure. View largeDownload slide Abstract P1202 Figure. P1203 Challenging implantation of a transvenous implantable cardioverter-defibrillator system in a patient with congenitally corrected transposition of the great arteries and dextrocardia L Kaiser L Kaiser University Heart Center Hamburg, Cardiology and Electrophysiology, Hamburg, Germany D Chung D Chung University Heart Center Hamburg, Cardiology and Electrophysiology, Hamburg, Germany A Schlichting A Schlichting University Heart Center Hamburg, Cardiology and Electrophysiology, Hamburg, Germany E Zengin E Zengin University Heart Center Hamburg, General and Interventional Cardiology, Hamburg, Germany S Hakmi S Hakmi University Heart Center Hamburg, Cardiovascular Surgery, Hamburg, Germany S Willems S Willems University Heart Center Hamburg, Cardiology and Electrophysiology, Hamburg, Germany N Gosau N Gosau University Heart Center Hamburg, Cardiology and Electrophysiology, Hamburg, Germany University Heart Center Hamburg, Cardiology and Electrophysiology, Hamburg, Germany University Heart Center Hamburg, General and Interventional Cardiology, Hamburg, Germany University Heart Center Hamburg, Cardiovascular Surgery, Hamburg, Germany Background : Sudden cardiac death due to malignant tachyarrhythmias is amongst the leading causes of mortality in adults with complex congenital heart disease (ACHD). Unfamiliar anatomy, previous surgical correction and difficult vascular access pose significant challenges for the placement of implantable cardioverter-defibrillators (ICD) in ACHD patients. Case Report: We report the case of a 35-year-old male patient with congenitally corrected transposition of the great arteries (ccTGA) and dextrocardia who presented to our emergency department (ED) with recurrent palpitations, dizziness and cold sweats. Echocardiography showed a worsened ejection fraction (33%) of the anatomically right systemic ventricle, a known ventricular septal defect and a mild to moderate stenosis of the pulmonary valve. Interrogation of a previously implanted internal loop recorder revealed several episodes of sustained ventricular tachycardias (VT) matching the time of recent symptoms. The diagnosis was confirmed by electrophysiological study (EPS) and the patient underwent successful VT ablation, focussing the systemic (right) ventricle. However, due to the high risk of recurrent VT, the additional placement of a transvenous ICD (T-ICD) was planned. Dextrocardia suggested the implantation of a right-sided system as most reasonable approach, but proved itself unfeasible intraoperatively, when defibrillation threshold testing (DFT) was ineffective. An ACHD heart-team was convened and consulted all available imaging data including echocardiography and cardiac magnetic resonance imaging (cMR) with the final recommendation of a left-sided pulse generator implantation. The following revision procedure was performed successfully with explantation of the right-sided system and placement of a left-sided T-ICD system, which proofed immediate detection and termination of ventricular fibrillation (VF) during intraoperative DFT. Five weeks after discharge the patient presented again to the ED with sudden palpitations and syncope. Device interrogation revealed an episode of sustained VT with attempts of antitachycardia-pacing (ATP), followed by successful ICD-shock and VF termination. After the patient was started on amiodarone and ß-blocker therapy was changed to carvedilol, he remained free of further arrhythmic events and is seen regularly for follow-up visits in our ACHD outpatient clinic. Conclusion: Multimodal imaging and an interdisciplinary heart-team approach including cardiac surgeons, electrophysiologists and ACHD-specialized cardiologists is paramount to successful ICD placement and treatment of malignant arrhythmias in complex ACHD. Defibrillation threshold testing still plays a crucial role to ensure effective termination of arrhythmia where complex anatomy impedes conventional shock vector prediction. P1204 Noise oversensing caused by involuntary muscle response inhibits detection of ventricular fibrillation during defibrillation testing S W E Baalman S W E Baalman Amsterdam UMC, University of Amsterdam, Clinical and Experimental Cardiology, Amsterdam, Netherlands K M Kooiman K M Kooiman Amsterdam UMC, University of Amsterdam, Clinical and Experimental Cardiology, Amsterdam, Netherlands A B E Quast A B E Quast Amsterdam UMC, University of Amsterdam, Clinical and Experimental Cardiology, Amsterdam, Netherlands P G Postema P G Postema Amsterdam UMC, University of Amsterdam, Clinical and Experimental Cardiology, Amsterdam, Netherlands S Donnelley S Donnelley Boston Scientific, Minneapolis, United States of America R E Knops R E Knops Amsterdam UMC, University of Amsterdam, Clinical and Experimental Cardiology, Amsterdam, Netherlands Amsterdam UMC, University of Amsterdam, Clinical and Experimental Cardiology, Amsterdam, Netherlands Boston Scientific, Minneapolis, United States of America Introduction of the patient: A 66-year-old man with a history of ischemic cardiomyopathy underwent elective subcutaneous-ICD (S-ICD) replacement. After successful replacement of the S-ICD generator a defibrillation test (DFT) was performed. Ventricular fibrillation (VF) was induced by a 200-mA burst at 50 HZ for 3 seconds. Due to noise oversensing in the primary sensing vector the S-ICD did not reach initial detection and shock therapy was inhibited. VF was terminated with an external 200J shock. A second induction showed the same noise oversensing without any VF detection or delivered shock therapy and a second external shock was applied. After changing the sensing vector from primary to secondary, a third DFT was performed with successful S-ICD sensing and defibrillation. Identification of the problem: we hypothesized that the muscle spasm intrinsic to S-ICD induced VF continued after cessation of the 200-mA burst and caused the sensing issue with subsequent withholding of shock therapy. Therefore, an EP study was performed two months later. We performed three consecutive DFTs: two with, and one without quick acting muscle relaxant. To confirm noise or noise oversensing we evaluated the S-ICD electrogram (S-ECG), intra cardiac ECG, surface ECG, and analyzed data on marked noise provided by the manufacturer. Induction of VF by pacing with an EP catheter, without muscle relaxant, did not produce any visible or marked noise pre-, during or post shock. S-ICD induced VF, without the use of muscle relaxant, resulted in noise oversensing leading to VF detection delay (figure A). However, S-ICD induced VF, with muscle relaxant, did not produce any visible noise (figure B). Questions and findings: A recently published study showed erroneous absence of VF detection during DFT due to noise oversensing in five patients. All these patients were programmed in the primary sensing vector. As noise disappeared after changing the sensing vector in our patient, it is not likely that noise was caused by extraneous signals. The presence or absence of VF detection problems due to noise between the induction methods in this report confirms the assumption that this noise was caused by involuntary muscle spasm associated with S-ICD induced VF. The interpretation of these data provides sufficient confidence that this particular noise problem will not occur during spontaneous VF episodes. Conclusions and implications of clinical practice: Involuntary muscle spasm associated with S-ICD induced VF is a condition that in rare cases can cause a delay or absence of VF detection during DFT. This case shows that noise oversensing only occurs after S-ICD initiated VF without the use of muscle relaxant in the primary sensing vector. Performing a DFT may therefore unmask a challenging problem that is intrinsic to S-ICD induced VF. Changing the sensing vector or the use of muscle relaxants are solutions to overcome the problem of noise oversensing during DFT. View largeDownload slide Abstract P1204 Figure View largeDownload slide Abstract P1204 Figure P1205 Endocardial ICD system implantation in childern by epicardial approch: case series M Sayed M Sayed Aswan Heart Centre, Electrophysiology, Aswan, Egypt OMNIA Kamel OMNIA Kamel Aswan Heart Centre, Electrophysiology, Aswan, Egypt H Hosney H Hosney Aswan Heart Centre, Electrophysiology, Aswan, Egypt Aswan Heart Centre, Electrophysiology, Aswan, Egypt Implantable cardioverter-defibrillators (ICDs) have reduced the incidence of sudden cardiac death in the pediatric population. Inappropriate shocks and lead complications may occur as children grow and increase their physical activity. Furthermore, a patient"s size at the time of implantation can make lead and generator placement difficult. Despite these challenges, support has increased for the use of ICDs in children, even as primary prevention. Here, we present three cases of a pediatric patients with a successfully implanted ICD using an endocardial lead system implanted epicardially with long term follow up. A 2-year-old boy was referred to our hospital for syncope. He had been diagnosed with Jervell and Lange- Nielson syndrome (JLN) by genetic testing (KCNQ1 mutation). As an ordinary intravenous lead system was unsuitable for his small body, chest surgery was performed to place the mini- ICD endocardial system implanted epicardially. The generator was implanted in the abdomen, under the rectus abdominis muscle . The thresholds of pacing, sensing, and impedance of the lead was satisfactory.The defibrillation test was done. During 12 months of postoperative follow-up, appropriate shocks was observed . The thresholds of pacing, sensing, and impedance of the lead was normal. A 8-year old girl was referred to our hospital for syncope due to atrial fibrillation with complete heart block.Her weight was 19 Kg.She had diagnosed as arrhythmogenic right ventricular cardiomyopathy. There was strong family history of SCD.The ICD endocardial system was implanted epicardially . The generator was implanted in the abdomen. The thresholds of pacing, sensing, and impedance of the lead was satisfactory.The defibrillation test was done.During 6 months of postoperative follow-up ,ventricular pacing was 99% with fair sensing and impedance without inappropriate shock. A 5-year old girl was referred to our hospital for aborted cardiac arrest.There was strong family history of SCD. Her echo revealed normal structural heart.A mini-ICD endocardial system was implanted epicardially . The thresholds of pacing, sensing, and impedance of the enocardial lead was satisfactory.The defibrillation test was done. During 6 months of postoperative follow-up, inappropriate shocks was not observed . The thresholds of pacing, sensing, and impedance of the lead was satisfactory. Our experience ,epicardial ICD implantation in children can be effective for secondary prevention of lethal arrhythmia regardless cause of lethal arrythmia. View largeDownload slide Abstract P1205 Figure. endocardial lead system implanted epicar View largeDownload slide Abstract P1205 Figure. endocardial lead system implanted epicar P1206 Subcutaneous ICD and elbow plank: chronicle of an inappropriate shock S I Llerena Butron S I Llerena Butron University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain N Rivas-Gandara N Rivas-Gandara University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain I Roca-Luque I Roca-Luque University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain J Perez-Rodon J Perez-Rodon University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain J Francisco-Pascual J Francisco-Pascual University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain A Santos-Ortega A Santos-Ortega University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain J Rodriguez-Garcia J Rodriguez-Garcia University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain G Pascual-Gonzalez G Pascual-Gonzalez University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain H Tornos-Millet H Tornos-Millet University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain L Duran-Casademont L Duran-Casademont University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain A Salvador-Catalan A Salvador-Catalan University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain A Aguilar-Palacios A Aguilar-Palacios University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain M Riera-Musach M Riera-Musach University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain I Gonzalez-Marquez I Gonzalez-Marquez University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain D Garcia-Dorado D Garcia-Dorado University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain University Hospital Vall d"Hebron, Cardiology, Barcelona, Spain A 33-year-old male patient, with history of transposition of the great arteries (TGA) treated with the Senning procedure, syncope due to fast AF that derived in VF, previous EP studies with failed attempts of inducing other types of ablatable SVTs, amiodarone-induced hyperthyroidism, implantation of subcutaneous ICD in 2016, previous inappropriate shock due to fast AF, consulted because of an ICD shock while exercising. First reviewed on remote monitoring, the episode raised suspicion of an inappropriate shock due to noise. After calling the patient and hearing that the shock happened while he was doing isometric exercises, an in-person visit was scheduled. On interrogation the device showed two episodes detected as VT, one treated with a shock and another one left untreated 12 days earlier. The patient explained that he was performing an exercise known as elbow plank (laying on tips of toes and forearms while holding the position for the maximum possible time), after approximately one minute he felt the shock, which prompted him to rest. The EGM analysis showed multiple irregular signals of low amplitude on top of sinus rhythm initially sensed as noise in both episodes, but, as it continued, the signals gained amplitude and were sensed as tachycardia. During the first episode the device didn’t deliver the shock because it was shorter, whereas in the second -and longer- episode, a 96-Ohm shock was delivered after more than 16 seconds of oversensing (Figure 1). The patient explained that during the exercise he develops tremors due to muscle fatigue, which get more intense as he tries to hold the position for longer periods of time. All electrical parameters of the S-ICD, sensing vector, and electrode impedance were normal, and there was no evidence of myopotentials on isometric testing with pushing both palms together. Since this had happened with the plank exercise we asked the patient to perform it while interrogation of the device was carried out, showing that the normal register developed irregular signals as soon as the exercise started and their disappearance as soon as it stopped, confirming the reproducibility of the artifact. After checking the other sensing vectors and testing different sensitivities of the device, the oversensing of myopotentials during this exercise could not be avoided, so we recommended exercises that don’t involve long periods of isometric effort. Inappropriate shocks due to myopotential oversensing in S-ICD are uncommon, but in some cases this can be sorted out with changes in the sensitivity and/or of the sensing vector. Given the position of the electrode, attention must be paid to the physical activity that patients perform, including the recommendation to avoid prolonged isometric exercises that involve the pectoral muscles. In this case, the characteristics of this specific exercise made it impossible to find a configuration that could avoid myopotential oversensing in a secure manner. View largeDownload slide Abstract P1206 Figure 1 View largeDownload slide Abstract P1206 Figure 1 P1207 Radiation therapy in patients with cardiac implantable electronic devices - findings and experiences after 1300 sessions J T Niedziela J T Niedziela Medical University of Silesia, SMDZ in Zabrze, 3rd Department of Cardiology, Silesian Centre for Heart Disease in Zabrze, Katowice, Poland E Gadula-Gacek E Gadula-Gacek Medical University of Silesia, SMDZ in Zabrze, 3rd Department of Cardiology, Silesian Centre for Heart Disease in Zabrze, Katowice, Poland J Gorol J Gorol Medical University of Silesia, SMDZ in Zabrze, 3rd Department of Cardiology, Silesian Centre for Heart Disease in Zabrze, Katowice, Poland A Kurek A Kurek Medical University of Silesia, SMDZ in Zabrze, 3rd Department of Cardiology, Silesian Centre for Heart Disease in Zabrze, Katowice, Poland S Blamek S Blamek Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Department of Radiotherapy, Gliwice, Poland P Plaza P Plaza Centre for Invasive Cardiology, Electrotherapy and Angiology GVM Carint, Ostrowiec Swietokrzyski, Poland L Miszczyk L Miszczyk Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Department of Radiotherapy, Gliwice, Poland M Tajstra M Tajstra Medical University of Silesia, SMDZ in Zabrze, 3rd Department of Cardiology, Silesian Centre for Heart Disease in Zabrze, Katowice, Poland M Gasior M Gasior Medical University of Silesia, SMDZ in Zabrze, 3rd Department of Cardiology, Silesian Centre for Heart Disease in Zabrze, Katowice, Poland Medical University of Silesia, SMDZ in Zabrze, 3rd Department of Cardiology, Silesian Centre for Heart Disease in Zabrze, Katowice, Poland Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Department of Radiotherapy, Gliwice, Poland Centre for Invasive Cardiology, Electrotherapy and Angiology GVM Carint, Ostrowiec Swietokrzyski, Poland Introduction: Radiation therapy (RT) in patients with cardiac implantable electronic devices (CIED) is considered to be safe. Nevertheless, some precautions must be taken to avoid patients’ complications or device malfunctions. Although management algorithms and possible threaths are described in several documents (recommendations and expert statements), new events associated with RT sessions and some other issues need to be discussed. Purpose: The purpose of our study was to record and describe all events associated with RT in cancer patients with CIED. Methods: The study was conducted in cooperation of tertiary radiotherapy and cardiology departments. The procedures were performed according to the current guidelines for RT in patients with CIED. CIED interrogations were performed in all patients before and after the completion of RT. RT sessions in high-risk patients or in patients with ICD/CRT-D were supervised by cardiologist and CIED interrogations were made before and after each session. CIED parameters were recorded and monitored during the whole RT Results: After more than 1300 RT sessions in 84 cancer patients with CIED, two events were recorded, of which one may be considered as a life-threatening. The T-wave oversensing episode in implantable cardioverter-defibillator (ICD) during paroxysmal atrial tachycardia before RT session occured, resulting in inappropriate VF detection and repeated inadequate shock therapies delivery. It took place when patient entered the RT room, few minutes after previous RT. According to our best knowledge, the reason-cause relation cannot be prooved or excluded. However, previous events of the oversensing during the same arrhythmia were not observed. Conclusions: Patients with CIED should enter the RT room after a safe delay following the previous RT session. P1208 Thoracic magnetic resonance imaging performed safely in a pacing-dependent patient with a non-conditional implantable cardioverter-defibrillator and multiple abandoned leads S Siddiqui S Siddiqui Royal Stoke University Hospital, Department of Cardiology, Stoke-on-Trent, United Kingdom G Dimitropoulos G Dimitropoulos Royal Stoke University Hospital, Department of Cardiology, Stoke-on-Trent, United Kingdom A Patwala A Patwala Royal Stoke University Hospital, Department of Cardiology, Stoke-on-Trent, United Kingdom Royal Stoke University Hospital, Department of Cardiology, Stoke-on-Trent, United Kingdom Background/Purpose: Magnetic resonance imaging (MRI) has unrivalled diagnostic capability. Although the introduction MRI-conditional implantable cardiac devices has allayed some of the traditional safety concerns impeding its use, device implants are still commonly regarded as contraindications for MRI. For example, in the UK it is estimated that among cardiac device patients requiring cardiac MRI, only 1 in 50 scans are performed. MagnaSafe was a prospective multi-centre study which determined the safety of non-thoracic MRI scanning for patients with implantable cardiac devices that are labelled as "non-MRI conditional". However the exclusion criteria were wide-ranging and excluded patients undergoing thoracic scans, pacing-dependent patients with an implantable cardioverter-defibrillator (ICD) and abandoned leads. To date there has not been a similar study that examines the safety of thoracic MRI in patients with non-MRI conditional devices. Here we present the case of a patient safely undergoing thoracic MRI with several other MagnaSafe exclusion criteria. Case History: An 82 year old patient with a history of spinal injury and new onset left arm pain was referred for thoracic spinal MRI. His cardiac device implant history (Fig. 1) included right-sided permanent dual chamber pacemaker implantation at least 10 years earlier. He suffered device-related infection and underwent device extraction and emergency epicardial pacing lead implantation. He then underwent left-sided dual-chamber ICD implantation consisting of a new RV defibrillator lead. The right atrial (RA) lead was tunnelled across from the right and an extension port was used to facilitate this. The unused leads were left abandoned. The patient was pacing-dependent. His final lead count was four; including a left-sided RV ICD lead and tunnelled right-sided RA lead (in use); and right-sided RV pacing lead and epicardial lead (abandoned). The case was discussed at a multi-disciplinary meeting. Due to the suspicion of a potentially operable spinal cord lesion, thoracic and c-spine MRI was deemed necessary. Under the supervision of a radiologist and cardiologist, the scan was performed under agreed protocols. The ICD was de-activated before the procedure and re-activated afterwards. Lead parameters were recorded before and after the procedure. The scan revealed a space-occupying lesion highly suspicious for a tumour at the level of C5/6. There was no difference between lead parameters before and after the scan. Chest X-ray appearances after the scan revealed no appreciable change in lead or device position. Subsequent device check six weeks later was satisfactory with no change in lead parameters. Conclusion: Thoracic MRI appears to be safe in patients with non-MRI conditional cardiac devices, even in the presence of an ICD lead, abandoned leads and pacing dependency. Further evaluation of thoracic MRI in patients with non-MRI conditional cardiac devices is warranted. View largeDownload slide Abstract P1208 Figure. Fig. 1 View largeDownload slide Abstract P1208 Figure. Fig. 1 P1209 DF-4 systems are not always interchangeable between different manufacurers L Binner L Binner University of Ulm, Ulm, Germany S Katthoefer S Katthoefer Krankenhaus der Barmherzigen BrǬder, Internal Medicine II, Trier, Germany L Allaria L Allaria Medtronic Inc., Tolochenaz, Switzerland C Bothner C Bothner University of Ulm, Ulm, Germany J Mccarthy J Mccarthy Medtronic Inc., Minneapolis, United States of America W Rottbauer W Rottbauer University of Ulm, Ulm, Germany University of Ulm, Ulm, Germany Krankenhaus der Barmherzigen BrǬder, Internal Medicine II, Trier, Germany Medtronic Inc., Tolochenaz, Switzerland Medtronic Inc., Minneapolis, United States of America Introduction: The DF-4 ICD lead connector was developed to facilitate ICD lead insertion into the device header and to reduce bulk material assembly in the generator pocket. Specifications of this new connector were published 2010 in the ISO 27186. Interchangeability of leads and generators between the different manufacturers is mandatory. We report three cases in which a Boston Scientific manufactured ICD- lead with DF-4 connector could not be appropriatly introduced into a Medtronic ICD device with DF-4 header. Cases: 1 + 2) Both patients were schedulded for an upgrade to a CRT-D system. Both had a Boston Scientific single chamber defibrillator and an Endotak Reliance SG 0293 or 0296 respectively, defibrillation lead with DF-4 connector implanted. After the connection to a new Medtronic CRT-D device with DF-4 Header the lectrical parameters for the atrial and LV-lead were in normal range, whereas, the ventricular lead demonstrated high impedance values (>3000 Ohm). During repetitive measurements via an external pacing system analyzer normal electrical parameters for the RV-lead could be obtained. After reconnection to the CRT device incomplete introduction into the RV- channel was observed. The leads could not be completely introduced into the RV-channel of the header of the device (about one mm missing). Several attempts to connect the ICD-lead resulted into damage of the pin. One lead was completely removed and replaced by a Medtronic Sprint Quattro 6935M lead. In case two the lead was capped with a silicone cover and fixed in the generator pocket. Adittionallay, a Medtronic Sprint Quattro 6947M-lead (dual coil, active fixation,DF-4 connector, Medtronic, Minneapolis, MN, USA) was placed into the right ventricular outflow tract. Now, electrical measurements demonstrated appropriate parameters in both cases. 3) During routine box change of a dual chamber Boston Scientific system with DF-4 lead to a Medtronic device difficulties in lead insertion into the RV-channel of the device raised, despite the use of sterile medical mineral oil. After six attempts while putting oil on the pin of the ICD-lead proper connection could be obtained. Results: The Boston Scientific DF-4 lead pins as well as the connector heads were according the ISO specifications. While most manufacturers use a relative stiff silicone material in pin design the Boston Scientific pin consists of a soft rubber material. While pushing the pin into the connector channel the soft material is compressed instead of pushing the pin forward. Conclusion: Severe problems may arise connecting a Boston Scientific DF-4 lead into a Medtronic device with DF-4 header. Sterile medical mineral oil should be available in case of difficulties in pin insertion. The ISO standards should also comprise respective constructive pin material. P1210 Acute hemodynamic effects of combined dynamic cardiomyoplasty and cardiac resynchronisation therapies in a patient with dilated cardiomyopathy C Bonanno C Bonanno S. Bartolo Hospital, Cardiology, Vicenza, Italy L Le Vecchia L Le Vecchia S. Bartolo Hospital, Cardiology, Vicenza, Italy M Barbiero M Barbiero Legnago General Hospital, Coronary Care Unit, Legnago, Italy P A Grandjean P A Grandjean Bakken Research Center, Maastricht, Netherlands J Schreuder J Schreuder CD Leycom, Hengelo, Netherlands S. Bartolo Hospital, Cardiology, Vicenza, Italy Legnago General Hospital, Coronary Care Unit, Legnago, Italy Bakken Research Center, Maastricht, Netherlands CD Leycom, Hengelo, Netherlands Introduction: Dynamic Cardiomyoplasty (CMP) is a bioassist surgical treatment for heart failure. It consists in wrapping the latissimus dorsi (LD) muscle around the heart and stimulating it in synchrony with myocardial contractions with burst of impulses to evoke sustained and phasic contractions. This therapy is sometimes associated with CRT-D devices when LBBB occurs. The long-term viability of the transposed LD muscle and need for stimulation have been often questioned. This is the first report of documenting the hemodynamic effects of CMP combined with CRT investigated at long-term (20 y.) Method: Hemodynamic variables were recorded with pressure-volume (PV) system (Inca, CD Leycom) placed in left ventricle. The patient (F, born 1947) received CMP in 1994 (LV HF failure, NYHA III). LD muscle had been stimulated on every 3rd ventricular beat (Medtronic Model 4710) with burst of impulses (4, 31 ms). Patient led an active life, NYHA I-II, for 18 y. In 2014, LBBB developed and a CRT-D implanted (Medtronic Viva Quad). Left ventricle PV investigations were done to optimize and compare the effects of CRT with CMP ON and OFF (series of 22 beats) . Results: With CRT and CMP "OFF", PV analysis showed low EF (21%), low cardiac output (CO) (3.3 L/min). Turning CRT "ON" induced a marked increase in EF (+7%), CO (+.73 L/min) , stroke work (SW) and a decrease in EDV (-5 ml) and end-systolic volume (ESV) (-6 ml), all p<.01. Activating in addition CMP induced a further leftward shift of PV, decreased further EDV (-22 ml), ESV (-14 ml), and end-diastolic pressure (EDP) (-3.6 mmHg), all p<.01, at unchanged CO vs CRT alone. Conclusion: CRT alone resulted in hemodynamic improvements and leftward shift of the PV plane, improved LVEF and CO. Activating in addition CMP resulted in a significant ventricular reverse remodeling i.e. further shifting leftward LV PV plane at a marked lower EDP and EDV (p<.01) while maintaining CO observed with CRT alone. The combination of CMP and CRT therapies provided additional cardiac benefits. It confirms that the reverse remodeling mechanism of CMP observed at 6 mo post-surgery is maintained at long-term and that the transposed LD survives at long-term. LD activation is needed to provide long-term cardiac assistance. View largeDownload slide Abstract P1210 Figure. LV PV loops: CRT and CMP ON/OFF View largeDownload slide Abstract P1210 Figure. LV PV loops: CRT and CMP ON/OFF Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2019. For permissions please email: Journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Clinical case corner 2 - Congenital Heart Disease and Pediatric Cardiology
JO - Europace
DO - 10.1093/europace/euz072
DA - 2019-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/clinical-case-corner-2-congenital-heart-disease-and-pediatric-N8vySWNqvL
SP - ii1043
VL - 21
IS - Supplement_2
DP - DeepDyve
ER -