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Injury to axillary and subclavian arteries during cardiac rhythm device implantation might lead to significant mortality and morbidity especially in those with a low body mass index (BMI). We report the case of 65-year-old underweight male patient with BMI of 15.1 (height 166 cm, weight 41.8 kg) with long-standing dilated cardiomyopathy who underwent cardiac resynchronization therapy with defibrillator implantation. Left pre pectoral pocket as well as three separate axillary vein accesses were obtained smoothly. While suturing the right ventricular lead sleeve to the underlying muscle a significant amount of arterial bleed was suddenly encountered without a clear source. Traumatic injury to the axillary artery caused by the suture needle was suspected. An immediate angiography of the left axillary artery via femoral approach showed a significant axillary artery side branch leakage adjacent to the sleeve suture site. A covered stent was deployed to the axillary artery which effectively controlled the bleeding immediately. The procedure was then carried out in the usual manner.

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BACKGROUND: The implantable cardioverter-defibrillator (ICD) is effective in the prevention of sudden cardiac death in high-risk patients. Little is known about ICD use in the Arabian Gulf. We designed a study to describe the characteristics and outcomes of patients receiving ICDs in the Arab Gulf region. METHODS: Gulf ICD is a prospective, multi-center, multinational, and observational study. All adult patients 18 years or older, receiving a de novo ICD implant and willing to sign a consent form will be eligible. Data on baseline characteristics, ICD indication, procedure and programing, in-hospital, and 1-year outcomes will be collected. Target enrollment is 1500 patients, which will provide adequate precision across a wide range of expected event rates. RESULTS: Fifteen centers in six countries are enrolling patients (Saudi Arabia, United Arab Emirates, Kuwait, Oman, Bahrain, and Qatar). Two-thirds of the centers have dedicated electrophysiology laboratories, and in almost all centers ICDs are implanted exclusively by electrophysiologists. Nearly three-quarters of the centers reported annual ICD implant volumes of ≤150 devices, and pulse generator replacements constitute <30% of implants in the majority of centers. Enrollment started in December 2013, and accrual rate increased as more centers entered the study reaching an average of 98 patients per month. CONCLUSIONS: Gulf ICD is the first prospective, observational, multi-center, and multinational study of the characteristics and, the outcomes of patients receiving ICDs in the Arab Gulf region. The study will provide valuable insights into the utilization of and outcomes related to ICD therapy in the Gulf region.

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BACKGROUND: Rotational angiography is one of the latest angiographic modalities to map the coronary venous tree anatomy. It provides a significant reduction in both contrast agent usage and radiation dose (up to 30%), without compromising the clinical utility of images. Hence, the present study was conducted to describe a new technique to minimize the amount of contrast media used during cardiac resynchronization therapy (CRT) implantation. METHOD: The SL3 sheath was inserted into the right atrium via the femoral vein followed by withdrawal of the dilator. The tip of the sheath was manipulated to the vicinity of the coronary sinus (CS) ostium (OS). The CS was entered using a deflated balloon catheter. The sheath was then advanced gently beyond the CS OS. Occlusive venography was performed using 5-8 ml of contrast media in a rotational view starting from 45 degrees LAO to 0 degrees AP while holding the inflated balloon for a few seconds. RESULT: Data from 30 consecutive patients who underwent CRT implantation were analyzed. The feasibility of rotational angiography, while occluding the CS with a specialized long, preshaped sheath and using an ordinary cath-lab imaging machine, was supported by the correctly delineated CS anatomy of all patients without any complications and death related to the placement of the CS catheters or sheaths. The mean contrast dose used for the entire procedure in all patients undergoing CRT was 14.76 +/- 6.8 ml. CONCLUSION: Use of rotational CS occlusive venography utilizing an ordinary cath-lab X-ray machine minimizes the use of contrast media during CRT implantation without compromising the visualized anatomy.

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We reported a case of a 72-year-old male, known diabetic on insulin, referred because of complete atrioventricular block. He was found to have acute hepatitis during which he developed transient atrial arrhythmia, and sinus node dysfunction. His cardiac symptoms disappeared completely after hepatitis improvement. All of his cardiac investigations were normal including electrocardiogram, echocardiography and thalium stress test. At 3 and 6 months follow up, his Holter monitoring did not show any further arrhythmia, and he denied any further episodes of palpitation or pre-syncope. We reviewed the literature regarding the relationship between hepatitis and atrial arrhythmia.

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We describe a case with pacemaker implantation for cardiac resynchronization therapy (CRT) in a patient with complex congenital heart disease, facilitated by cardiac computed tomography (CT) and coronary sinus (CS) venography. A 37-year-old male presented with congenitally corrected transposition of the great arteries and mesocardia, along with a history of two open heart surgeries (closure of atrial septal defects and a ventricular septal defect, and pulmonary valvectomy at age 7; mechanical tricuspid valve replacement at age 13). He showed symptoms of progressive heart failure (NYHA class III) with significant impairment of the systemic right ventricular function. He also developed permanent atrial fibrillation with a junctional rhythm at a rate of 45 beats per minute. Biventricular pacing without an atrial lead was considered to be the best option available. CRT implantation was facilitated by proper identification of CS anatomy utilizing cardiac CT and CS venography and was performed without any complications. At follow up, a postero-anterior chest X-ray showed the final position of the right-sided ventricular (left ventricular morphology) lead pointing to the apex and the left ventricular lead at the posterolateral aspect of the systemic ventricle (right ventricular morphology).

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BACKGROUND: Over a period of years general anesthesia has been a standard anesthetic technique for defibrillation threshold (DFT) testing at the time of implant. DFT testing without general anesthesia cover has gained limited acceptance. Use of local anesthesia combined with deep sedation for DFT testing might facilitate and simplify these procedures by reducing the procedural time, staff time, avoiding inefficient service in organizing anesthetic cover; thereby improving patient compliance. OBJECTIVE: The objective of this study was to evaluate feasibility, safety and efficacy of conscious sedation for DFT testing during Implantable cardioverter defibrillators (ICD) implantation. METHOD: Data of 87 non-selected patients who achieved adequate sedation with titrated doses of midazolam and pethidine were analyzed retrospectively. These medications were administered by a circulating nurse under the supervision of the implanting physicians. All hemodynamic measures, treatment and complications were monitored and recorded throughout the procedure. RESULTS: A retrospective analysis of data from 87 patients who underwent ICD implantation and DFT testing under conscious sedation at our center was reported. The mean dose of midazolam and pethidine administered was 4.9 ± 1.8 and 47.7 ± 20 mg, respectively. During the period of conscious sedation, no patient depicted episode of sustained apnea. No major complication or mortality was reported. CONCLUSION: Use of conscious sedation as an alternative to the use of general anesthesia for DFT testing during ICD implantation is found to be feasible, safe and effective, with an added advantage of reduced procedural time and improved patient compliance.