Myocardial perforation

Fixation mechanism Active fixation leads seem to have advantages and disadvantages. On the one hand, once the screw is retracted, the tip can be easily detached from the endocardium, and the lead, being isodiametric, can be removed more easily than the others [6, 7]. On the other hand, an unscrewed lead is more difficult than a tined one. Fixation mechanisms that cannot be unscrewed, such as the Vitatron Helifix, make the procedure more complex, increasing the risks of myocardial perforation and cardiac tamponade. 

Causes of CVC malfunction (obtainable Qb <300 ml/min with PA = -250 mm Hg [29]) maybe of mechanical nature, such as sharp CVC bending (kinking) or wrong CVC tip position (not in the right atrium). With CVC reaching just deep into superior vena cava, catheter may lean against the vessel wall and cause excessive suction. On the other hand, insertion of the CVC tip too deeply into the atrium bringing it in touch with the atrial floor may result in myocardial perforation. 

NS AIDs Cyclooxygenases (COX-1, COX-2) l Prostaglandins l Thromboxanes l Sensitization of sensory neurons f Inhibition of spinal neurons Nonselective gastrointestinal ulcers, perforation, bleeding, renal impairment COX-2 thrombosis, myocardial infarction, stroke... 

Fig. 2.3 Positron emission tomography (PET) images of resting perfusion and metabolism using FDG showing a large myocardial scar in the LAD proximal to the first septal perforator...

Formation of vegetations may destroy valvular tissue, and continued destruction can lead to acute heart failure via perforation of the valve leaflet, rupture of the chordae tendineae or papillary muscle, or in the patient with PVE, valve dehiscence. Occasionally, valvular stenosis may occur. Abscesses can develop in the valve ring or in myocardial tissue itself. Even with resolution of the process, fibrosis of tissue with some residual dysfunction is possible. 

The AMADEUS registry is a prospective multicenter European registry to evaluate the safety and efficacy of the CARILLON Mitral Contour System in patients with function mitral regurgitation. Joachim Schofer recently presented 6-month clinical outcomes of 48 patients (34). Among the 30 patients with successful device placement, cardiac perforation was noted in three patients at one month and there were two deaths (6.9%) and three myocardial infarctions reported at six months. The regurgitant volume was reduced from 35 16 mL at baseline to 24 12 at six months (P <0.001) and six-minute walk test increased from a mean of 307 meters to 403 meters (P <0.001). 

Celecoxib may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. All NSAIDs may have a similar risk. This risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk. The NSAIDs, Including celecoxib, cause an increased risk of serious Gl adverse events, including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients are at greater risk for serious Gl events. 

There are limits to the reduction of the electrode surface area. Small surface area polished electrodes demonstrate significant polarization potentials, which decrease pacing efficiency. In theory, extremely small electrodes may be designed like arrowheads therefore they may be more likely to penetrate or perforate the myocardial wall. This problem can be overcome by placing a protective soft polymer collar around the base of the electrode to prevent penetration (Fig. 1.12). Such a protective collar, however, may prevent the electrode from making contact with the endocardium. Despite these criticisms, there is no evidence after more than a decade of clinical experience, of any unique problems, associated with very small surface area electrodes. 

Lead dislodgment occurs in approximately 2% of cases despite the use of active fixation leads, and myocardial penetration or perforation occurs in approximately 1% of cases (58). Movement of the lead tip is detected by changes in lead performance and by changes in the paced QRS complex morphology on the surface ECG. The typical paced QRS complex has a left BBB-hke pattern with either a superior (with a right ventricular apex position) (Fig. 16.5) or an inferior (with a right ventricular outflow tract position) (Fig. 16.6) mean frontal plane axis. A right BBB-like pattern may indicate perforation of the lead into the left... 

NSAIDs, including ibuprofen, are contraindicated in patients with active bleeding, ulceration, or perforated viscous. NSAIDs are contraindicated in the setting of acute or chronic renal dysfunction. NSAIDs have been shown to increase the risk of cardiovascular thrombotic events, myocardial infarction, and stroke, especially in patients with known cardiovascular disease or with known risk factors for cardiovascular... 

A protocol from a clinical trial on the CV safety of celecoxib compared to nsNSAIDs in patients with osteoarthritis or rheumatoid arthritis from Scotland, England, Denmark and the Netherlands was published. The primary endpoint is the first occurrence of hospitalisation or death for the AntiPlatelet Trialists Collaboration (APTC) CV endpoint of nonfatal myocardial infarction, nonfatal stroke or CV death. Secondary endpoints include (1) first hospitalisation or death for upper GI ulcer complications (bleeding, perforation or obstruction) (2) first occurrence of hospitalized upper GI ulcer complications or APTC endpoint (3) first hospitalisation for heart failure (4) first hospitalisation for APTC endpoint plus heart failure (5) all-cause mortality and (6) first hospitalisation for new or worsening renal failure. Patients are randomized to receive celecoxib or their previous nsNSAlD. Results of the trial are expected by 2014 [13 j. 

In an observational study of 20 patients with sequential bevacizumab and oral cyclophosphamide (CYC) used for reciurent ovarian cancer, grade 3 and grade 4 toxicities noted were one instance each of myocardial infarction and gastrointestinal perforation and 12 new diagnoses of grade 3 hypertension... 

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