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Device therapy and treatment options in a patient with apical hypertrophic cardiomyopathy: Combination of a leadless pacemaker with a subcutaneous defibrillator
Terapia com dispositivos e opções de tratamento em paciente com cardiomiopatia hipertrófica apical; combinação de pacemaker sem elétrodo com desfibrilador subcutâneo
Nikias Milaras
Autor para correspondência
nikiasmilaras@gmail.com

Corresponding author.
, Panagiotis Dourvas, Christos Danelatos, Stefanos Archontakis, Skesvos Sideris
Cardiology Department, General Hospital of Athens Hippokrateion, Greece
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 60-year-old patient with a medical history of aneurysmal sarcomeric apical hypertrophic cardiomyopathy &#40;<span class="elsevierStyleItalic">MYBPC3</span> mutation&#41; and permanent atrial fibrillation was referred to our clinic for assessment due to two episodes of syncope &#40;<a class="elsevierStyleCrossRef" href="#sec0015">Video 1</a>&#41;&#46; As a first step&#44; 24-h ambulatory electrocardiographic monitoring was utilized and revealed atrial fibrillation with pauses of up to 3&#46;5 s during waking hours and short bursts of non-sustained ventricular tachycardia&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Due to an HCM Risk-SCD score of 7&#46;6&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> we decided to proceed with the placement of a transvenous implantable cardioverter-defibrillator &#40;ICD&#41; in order to address both probable syncopal etiologies&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Following implantation&#44; the patient presented for his yearly reassessment with lower limb edema and mild dyspnea on exertion&#46; Transthoracic echocardiography revealed new-onset severe tricuspid regurgitation &#40;TR&#41; due to anterior leaflet malcoaptation from the right ventricular ICD lead &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1a&#8211;c</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">TR following intravenous device placement is a well-known complication&#44; mainly occurring due to leaflet perforation&#44; avulsion&#44; or damage to the subvalvular apparatus&#46; Further interaction of the device leads can result in impingement of the leaflets&#44; malcoaptation&#44; and significant regurgitation&#46; Leaflet adhesion&#44; fibrosis&#44; and encapsulation further contribute to valve incompetence&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> TR historically is an independent risk factor for all-cause mortality and unfortunately leads to a vicious circle of more TR and right ventricular failure&#46; Secondary TR is known to improve following diuretic therapy&#44; but medical therapy has little effect when primary disease of the valve is present&#46; No relevant prospective data exist in the literature in cases of TR due to pacemaker leads&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">After thorough discussion&#44; we proceeded with extraction of the ICD and implantation of both a leadless pacemaker &#40;LP&#41; and a subcutaneous ICD &#40;s-ICD&#41;&#44; as the latter lacks pacing capability &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1d</a>&#41;&#46; Although leadless and subcutaneous device-based therapies are usually indicated in patients with limited upper extremity venous access&#44; we were faced with a symptomatic iatrogenic valvular insufficiency that led us to device extraction&#46; An attempt at lead removal after a certain period of time is fraught with its own complications and we are not sure if this leads to improvement in the severity of TR or right ventricular function&#46; Simultaneous LP and s-ICD implantation is a viable alternative&#44; although evidence in the literature is scarce&#46; A key concern with combined s-ICD and LP therapy is that pacing spikes and QRS components might be oversensed by the s-ICD and could interfere with ventricular arrhythmia detection algorithms&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> To tackle this&#44; we simultaneously perform LP and s-ICD interrogation in both supine and standing positions pre-discharge&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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