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  • BTL-104 br Study limitations br Conflict of interest

    2019-06-14


    Study limitations
    Conflict of interest
    Case report
    Discussion DFT testing is usually recommended to ensure proper functioning of the ICD/CRT-D and verify that there is no acute lead dislodgement [1,2]. For patients with impaired cardiac function, VF induction and shock delivery can cause an unstable hemodynamic condition and clinical deterioration [3,4]. Gasparini et al. proposed delayed DFT testing for patients with impaired left ventricular function with a CRT-D [5]. The benefits of delayed DFT testing are listed as follows: patients with BTL-104 failure treated with CRT-D show marked clinical improvement, and the risk of lead dislodgement is also reduced. The data obtained from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) have shown that DFT testing is not beneficial for prediction of long-term mortality or shock efficacy [6], and there are several reports proposing that there is some uncertainty regarding DFT testing in patients with severe heart failure from the point of view of safety [7,8]. Bianchi et al. compared clinical outcomes between 2 patient groups: those who underwent DFT testing and those who did not, and they also demonstrated that there was no significant difference in the clinical outcome for 2 years after ICD implantation [9]. We encountered several difficulties in our case. First, the patient was recovering after myocardial infarction and cardiogenic shock, and he might have been unable to tolerate DFT testing. Current ACC/AHA/ESC guidelines recommend a delay of 40 days as the minimum time prior to ICD implantation [10]. These guidelines are based on the results of the DINAMIT trial [11], which evaluated the effectiveness of early implantation (6–40 days after AMI) and failed to demonstrate the efficacy of ICD therapy to reduce total mortality. However, there remains a possibility of significant reduction of arrhythmic death in some patients in the early period after AMI. Second, shock delivery was delayed during DFT testing because of VF undersensing, and it took some time to restore sinus rhythm. Third, we repeated DFT testing after changing the RV sensing sensitivity; this extended DFT testing may have led to hemodynamic instability for this patient, and his clinical condition deteriorated rapidly into fatal cardiogenic shock. There might have been preferable options for this patient, such as: (1) not performing the DFT testing; (2) postponing the DFT testing until the patient recovered completely after the AMI; (3) maintaining the temporary pacing until the clinical condition was more stable and then implanting the ICD or CRT-D. This case served as an important warning on the management of CRT-D in patients with severe heart failure.
    Conflict of interest
    Introduction Bundle branch reentrant ventricular tachycardia occurs in approximately 5% of ventricular tachycardia [1], and there are rare case reports of patients without underlying heart disease. In most cases, it is accompanied by underlying heart disease such as dilated cardiomyopathy or old myocardial infarction [2]. Ventricular tachycardia with a left bundle branch block utilizing the left bundle branch as the retrograde limb and the right bundle branch as the antegrade limb is common, while that with the right bundle branch block utilizing the right bundle branch as the retrograde limb and the left bundle branch as the antegrade limb occurs only occasionally. In recent years, patients presenting with drug-resistant arrhythmias can be completely cured using catheter ablation. In our case, we performed catheter ablation of the right bundle branch for an 11-month-old infant who had drug-resistant bundle branch reentrant ventricular tachycardia. The efficacy of catheter ablation was assessed based on the changes of duration and morphology of the QRS complex. No recurrence of ventricular tachycardia has been observed during 8 years since the procedure was performed. To the extent of our knowledge, no report has been published regarding infant cases. We hereby present our report and discussion.