If you would like to respond to these questions, please email us at eplabdigest@hotmail.com or go to www.eplabdigest.com and click on the email discussion group link. Our website is constantly being updated, so please check back often!

Alliance Medical Corporation and Vanguard Medical Concepts recently announced plans to merge. We spoke with the CEO of Alliance Medical, John Grotting, to find out more information.

Objective: To present a case of amplitude-dependent anodal stimulation. Background: Pacing stimulation of both right and left ventricles has become practical with the introduction of biventricular pacemakers. This results in “resynchronization” of ventricular activation, which can lead to dramatic improvement in clinical congestive heart failure (CHF) status. However, anodal stimulation in biventricular pacemakers negates the beneficial clinical outcome due to lack of left ventricular (LV) pacing or simultaneous right ventricular (RV) and LV pacing. Therefore, recognizing anodal stimulation is important. Methods: Observational case report. Results: Amplitude-dependent anodal stimulation was encountered during biventricular pacemaker implantation. Conclusion: This case illustrates the relatively uncommon phenomenon of anodal stimulation pacing, and its occurrence at only high outputs. It also demonstrates identification of left ventricular versus right ventricular capture through the us

In the third installment of the “Troubleshooter’s Casebook” series, the author discusses changing guidelines for device implantation.

Thousands of implantable cardiac defibrillators (ICDs) have been implanted in patients every year since 1985.^1,2 The device clearly is life saving for high-risk patients with lethal arrhythmias. Although some patients have lost consciousness before a shock from an ICD is delivered, far more are awake and alert when they receive this life-saving therapy. Many patients describe this experience as feeling as if a lighting bolt hit them or as being kicked in the chest by a horse.³

Prolonged temporary pacing is associated with frequent complications. We describe a patient with aortic endocarditis and acquired tri-fascicular block in whom back-up pacing was indicated. Using a Seldinger technique via a subclavian approach, a permanent active-fixation lead was positioned in the right ventricle. The lead was tunnelled subcutaneously for 6 cm, and the proximal end was connected to a standard single-chamber pulse generator. The procedure was well tolerated, and over a period of four months there were no complications or infection. The PR interval subsequently reduced in duration to 200 ms and as no episodes of AV block had occurred, the lead was easily removed with retraction of the helix and gentle traction.

The presence of persistent left superior vena cava (PLSVC) “is the most common congenital anomaly of the SVC system.”^1,4 Although considered a common anomaly, it is a rare but non-debilitating condition. A patient may not present any appreciable symptoms to the clinician if there are not any additional associated abnormalities. The presence of PLSVC is usually discovered during the cannulation of the superior vena cava for placement of a Swan Ganz catheter, central line or a pacemaker/ICD lead.