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Biomedical subjects

S Furman

Publications and source records attributed to S Furman.

At least 91 records · Page 5Linked to original sources
PubMed1992

Influence of left ventricular function on outcome of patients treated with implantable defibrillators.

BACKGROUND: The outcomes of patients treated with implantable defibrillators were compared between patients with left ventricular ejection fraction greater than or equal to 30% and less than 30%. METHODS AND RESULTS: Of 68 consecutive patients treated with implantable defibrillators, 40 patients (group 1) had left ventricular ejection fraction greater than or equal to 30%, and 28 patients (group 2) had left ventricular ejection fraction less than 30%. Sudden death, surgical mortality, nonsudden arrhythmia-related death (death within 24 hours after an arrhythmic event despite initial termination of the arrhythmia by the implantable defibrillator), total arrhythmia-related death (including sudden death, surgical death, and nonsudden arrhythmia-related death), and total cardiac death were compared between the two groups. Surgical mortality was 4.4% (0% in group 1, 11% in group 2). During the follow-up of 31 +/- 27 months, actuarial survival rates free of events were 97%, 97%, and 97% in group 1 and 96%, 91%, and 82% in group 2 at 12, 24, and 36 months, respectively, for sudden death (p = NS); 97%, 97%, and 97% in group 1 and 85%, 81%, and 72% in group 2 at 12, 24, and 36 months, respectively, for sudden death and surgical mortality (p less than 0.05); 97%, 97%, and 97% in group 1 and 82%, 78%, and 70% in group 2 at 12, 24, and 36 months, respectively, for total arrhythmia-related death (p less than 0.05); and 95%, 95%, and 95% in group 1 and 82%, 69%, and 57% in group 2 at 12, 24, and 36 months, respectively, for total cardiac death (p less than 0.05). Four (57%) of seven nonsudden cardiac deaths during the initial 36-month follow-up period were causally related to arrhythmia (three surgical deaths and one arrhythmia-related nonsudden death). CONCLUSIONS: The outcome of patients treated with implantable defibrillators is strongly influenced by the degree of left ventricular dysfunction. In group 1 patients, surgical mortality, sudden death, and total cardiac death are rare. In group 2, sudden death rate may not be markedly different from that of group 1 patients. However, the risk of therapy (surgical mortality) is high. Many nonsudden cardiac deaths are causally related to arrhythmia (surgical mortality or nonsudden arrhythmia-related death). Therefore, the survival rate free of total arrhythmia-related death is significantly lower in group 2 (70% versus 97% in group 1 at 3 years). Further studies are needed to determine the roles of defibrillator therapy and other therapies in various clinical settings.

Actuarial Analysis↗
PubMed1992

Cardiac pacing and atrial arrhythmias.

Pacemaker patients frequently have concomitant atrial tachyarrhythmias, most importantly atrial fibrillation, because numerous underlying electrical or structural diseases can potentiate both conditions. DDD pacing (or atrial) appears superior to VVI in limiting the occurrence of atrial fibrillation and its associated negative sequela. Sick sinus syndrome, a prior history of atrial fibrillation, and advanced age predispose patients with DDD devices to postimplant atrial fibrillation, yet the majority of these high-risk patients are manageable in DDD throughout their follow-up. DDD patients at significant risk for developing atrial arrhythmias require special attention regarding the selection and programming of their devices. Rate modulation, higher lower rate limits, special approaches toward upper rate limit management, and antitachycardia capabilities may all be important aspects in their management. The combined use of AV node ablation and ventricular or DDD pacing to manage patients with refractory atrial tachyarrhythmias is becoming an increasingly accepted therapeutic approach.

Atrial Fibrillation↗
PubMed1992

Removal of infected transvenous leads requiring cardiopulmonary bypass or inflow occlusion.

Infection, although uncommon, can be the most lethal of all potential complications after transvenous pacemaker implantation. The infection rate at our institution has been 0.56% (42 implants) during the preceding 17 years for 7435 transvenous pacemakers implanted in 4333 patients. Four of the 42 patients required use of cardiopulmonary bypass or inflow occlusion to remove the infected transvenous leads. Seven patients had their pacemakers implanted elsewhere and were transferred to our medical center for treatment. One patient died postoperatively because of persistent sepsis from a retained lead segment. All other patients survived, and none had recurrent infection. We recommend removal of all hardware if there is infection of the pacemaker system. If traction or other methods fail to remove the transvenous portion of the pacemaker system, open methods of removal, although rarely required, are safe and effective and should be used without delay.

Adolescent↗
PubMed1991

Exacerbation of ventricular arrhythmias during the postoperative period after implantation of an automatic defibrillator.

The postoperative course of 68 consecutive patients treated with an implantable defibrillator during the period from 1982 through 1990 was studied. In 46 patients (group 1), no concomitant surgery was performed during the implantation. In 22 patients (group 2), concomitant surgery (coronary artery bypass [n = 12], valve replacement [n = 3] or arrhythmia surgery [n = 7]) was performed. All patients in group 1 were clinically stable before surgery, receiving an antiarrhythmic regimen chosen by serial drug testings. The same regimen was continued postoperatively. Eight of the 46 patients in group 1 whose condition had been stable in the hospital for 19 +/- 25 days preoperatively developed multiple episodes of sustained ventricular tachycardia 4 +/- 9 days after implantation while receiving the same antiarrhythmic regimen. Although the exacerbation was transient in some patients, six required different antiarrhythmic therapy and one eventually died. Two additional patients had frequent and prolonged episodes of nonsustained ventricular tachycardia that could trigger the defibrillator, requiring changes in the antiarrhythmic regimen. Another patient had progressive cardiac failure and died on day 5. A marked (sevenfold) increase in asymptomatic ventricular arrhythmias was noted in 42% of the remaining 35 patients. In group 2 (combined surgery), one patient developed refractory ventricular tachycardia 3 days postoperatively and died on that day. Three patients developed frequent nonsustained ventricular tachycardia postoperatively, requiring changes in the antiarrhythmic regimen. The overall surgical mortality rate was 4.4% (4.3% in group 1 and 4.5% in group 2) and was due to refractory ventricular tachycardia in two patients and cardiac failure in one.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1991

Benefits of implantable defibrillators are overestimated by sudden death rates and better represented by the total arrhythmic death rate.

Benefits of the implantable defibrillator on survival were studied in 56 consecutive patients (concomitant coronary bypass or arrythmia surgery in 15) during an 8 year period between 1982 and 1990. During a follow-up period of 29 +/- 25 months, six patients had a sudden death and eight patients had a nonsudden cardiac death. Nonsudden cardiac deaths included three surgical deaths (death within 30 days after the surgery; two in patients without and one in a patient with concomitant cardiac surgery), one arrhythmia-related nonsudden death (death within 24 h after an arrhythmic event despite initial termination of the arrhythmia by the implantable defibrillators) and four nonarrhythmic cardiac deaths. The actuarial survival rate free of events at 1, 2 and 3 years was 96%, 96% and 92%, respectively, for sudden death, 91%, 91% and 87% for sudden death and surgical mortality and 89%, 89% and 85% for total arrhythmic death (sudden death, surgical mortality and arrhythmia-related nonsudden death). Thus, in patients treated with an implantable defibrillator, 1) the rate of sudden death is low (8% at 3 years); 2) 50% of nonsudden cardiac deaths are causally related to arrhythmia (surgical mortality or arrhythmia-related nonsudden death); 3) the total arrhythmic death rate is substantially higher than the sudden death rate; and 4) benefits of an implantable defibrillator are overestimated by reported sudden death and nonsudden cardiac death rates. The benefits may be better represented by the total arrhythmic death and nonarrhythmic cardiac death rates.

Actuarial Analysis↗
PubMed1991

Influence of clinical characteristics and shock occurrence on ICD patient outcome: a multicenter report. The Bilitch Registry Group.

Data on 1,281 patients from the Bilitch implantable cardioverter defibrillator (ICD) registry were reviewed to evaluate ICD patient characteristics and survival, and the impact of ICD shock occurrence on outcome. The mean ejection fraction was 34.3%; 78% had coronary disease, 471 patients had at least one shock thought to be appropriate, and 231 patients died. Causes of death included: arrhythmic (41%), nonarrhythmic cardiac (37%), and noncardiac (22%). Cumulative survival from all-cause mortality at 1, 3, and 5 years was 89%, 76%, and 64%; survival from all-cause cardiac death was 93%, 90%, and 76%; survival from arrhythmic death was 96%, 92%, and 87%. Patients who had received a shock had a trend towards a worse long-term prognosis. Shock patients also had a small increase in the prevalence of coronary disease and a somewhat lower ejection fraction than the remainder of the population.

Cause of Death↗
PubMed1991

Retrograde (ventriculoatrial) conduction in congenital complete heart block.

Retrograde ventriculoatrial (VA) conduction is documented at the time of dual chamber pacemaker implantation in a 36-year-old patient with congenital complete atrioventricular (AV) block. Programmed ventricular stimulation with stimuli of increasing prematurity demonstrated a lack of decremental conduction via a unidirectional retrograde pathway. Because retrograde VA conduction has been associated with pacemaker mediated endless loop tachycardia, the status of retrograde conduction should be assessed in all patients undergoing dual chamber pacemaker implantation, including those with congenital complete AV block who have previously been considered to have no conductive tissue between atria and ventricles.

Adult↗
PubMed1991

Pacemaker infection with Mycobacterium avium complex.

A 21-year-old. HIV negative, malnourished, homeless woman with congenital heart block had a pacemaker implanted at 7 years of age and multiple procedures thereafter. The most recent of these procedures was replacement of a pulse generator in the right pectoral region. Four months later she had fever, pain, and swelling over the implant site resulting from infection with mixed flora and Mycobacterium avium complex. The pacemaker system was removed by thoracotomy via a median sternotomy and a new DDD pacemaker simultaneously implanted. She was treated with systemic antibiotics--isoniazid, rifampin, ethambutol--for 2 weeks. Six months later she was healthy, pacing well, and apparently free of infection, off all medications.

Adult↗
PubMed1991

Sudden death mortality in implantable cardioverter defibrillator patients.

Implantable cardioverter defibrillator (ICD) prevention of sudden cardiac death (SCD) is not absolute and our experience was reviewed to determine the frequency and nature of SCD in this population. The incidence and cause of mortality in 56 consecutive patients, who underwent ICD implantation beginning May 1982 with follow-up through May 19, 1990 were analyzed. Twenty-one patients died, 33% of the mortality was due to SCD, and 52% of deaths may be considered arrhythmic. The cumulative 1, 3, and 5 year SCD survivals were 93%, 89%, and 75%. All seven patients dying of SCD presented initially with SCD, all received previous shocks prior to SCD, and two of the seven patients had devices that were probably inactive at the time of death. We conclude that ICDs reduce but by no means eliminate arrhythmic death, particularly in those at highest risk for SCD. Arrhythmic death remained the most common cause of death in this population.

Arrhythmias, Cardiac↗
PubMed1991

Occurrence of ICD shocks and patient survival.

Fifty-six consecutive patients who underwent initial implantation of an implantable cardioverter defibrillator (AICD) between May 1982 and January 1990 were analyzed. During a mean follow-up of 31.5 +/- 25 months, 32 (60%) patients experienced a spontaneous shock from their device. Their clinical characteristics and survival were compared to those of 21 patients without shocks. No statistically significant difference was found in the distribution between the two groups in age, sex, cardiac diagnosis, New York Heart Association Class, presenting arrhythmia, or mean follow-up (F/U). The group with shocks had a higher incidence of previous MI (P = 0.021) a lower mean ejection fraction (P = 0.023) and had been tried on a greater number of medical regimens (P = 0.003). The 1-, 3-, and 5-year cumulative survivals were 84%, 69%, and 37% in the group with shocks and 93%, 93%, and 93% for the group without shocks. Our data suggests that the occurrence of a shock is a negative prognostic indicator and that the excellent prognosis of patients without shocks contributes in large part to the favorable outcome of AICD patients.

Electric Countershock↗
PubMed1991

Fate of explanted ICD patients.

UNLABELLED: Of 56 consecutive patients who underwent an initial AICD implantation at our center, we analyzed eight patients who subsequently had their units explanted and not replaced by other antitachycardia devices. The mean age was 57.8 years, mean ejection fraction was 28.4%; six patients had coronary disease and two had cardiomyopathy. The presenting arrhythmia was sudden death in four patients and sustained ventricular tachycardia in four others. Mean follow-up from implant to explant was 25 +/- 22 months, and 22 +/- 10 months from explant to end of follow-up. Reasons for explantation were: infection in five patients, lead fracture in one patient, battery depletion in one patient, and one patient underwent cardiac transplantation. Devices were not reimplanted because of: patient refusal in three patients, physician discretion in two patients (one recurrent infection, one received no shocks over 24 months), cardiac transplantation in one patient, ablation of VT focus in one patient, and one patient died while being treated for infection. Three patients died 2, 21, and 26 months after device explantation of nonsudden cardiac, sudden cardiac and noncardiac causes, respectively. CONCLUSIONS: Preoperative clinical parameters were not indicative of a lower risk of arrhythmic events in these patients as compared to the general population of AICD implantees. Of eight patients, two received alternate nonmedical therapy, one died while receiving treatment for a device-related infection; of the five remaining patients none died of cardiac causes. Termination of AICD therapy for malignant ventricular arrhythmias does not imply imminent sudden cardiac death for most patients treated by alternate modes of therapy.

Anti-Arrhythmia Agents↗
PubMed1991

Ventricular tachycardia/fibrillation: therapeutic alternatives.

It is now clear that no single therapy is appropriate for a consecutive series of patients with ventricular tachycardia or ventricular fibrillation (VT/VF). Drug responders by electrophysiological studies, patients who are not inducible following surgery, and patients treated with an implantable cardioverter defibrillator (ICD) all can have similarly low sudden death rates and virtually identical long-term mortality. However, many patients fail to respond to drugs, and surgical risks are excessive in others, and always higher than for an ICD implant. Nevertheless, overall survival in each of these groups (and probably for patients treated with antitachycardia pacers and ablation) is about 60% at 60 months. Major challenges now are: (1) choosing therapy to maximize risk-benefit ratio; and (2) treatment of the pump failure and progressive disease that now accounts for most cardiac mortality.

Anti-Arrhythmia Agents↗