Management of pacemaker patients after myocardial infarction

Myocardial infarction (MI) is the leading cause of death and disability in the population. Effective restoration of coronary blood flow in the infarction-dependent artery during percutaneous coronary intervention contributes to the regression of structural and functional remodeling of the left ventricle. Meanwhile, in 18% of cases, patients with myocardial infarction require implantation of a pacemaker because of the cardiac conduction disorders, among which atrioventricular blockade is the leading one. The need for pacemaker implantation is determined by the clinical features and the type of bradycardia complicating myocardial infarction. The scope of preventive measures at the stage of outpatient specialized cardiac care for patients with myocardial infarction and pacemaker includes medical, physical, and psychological rehabilitation. In addition, the presence of an implantable pacemaker necessitates specialized dynamic monitoring by an arrhythmologist, including programming the pacemaker. Performing a magnetic test allows to assess the efficiency of the pacemaker, the level of its charge and promptly determine the need to its replacement. Determination of the pacing threshold ensures efficient operation of the implantable device. After discharge from the hospital, a schedule for checking the pacemaker is determined, namely, 3 months after the date of implantation of the pacemaker, then 1-2 times a year. In the event of complaints of dizziness, fainting or damage of the pacemaker implantation site, the pacemaker check is carried out unscheduled. Patients with a history of myocardial infarction and an implantable pacemaker should be informed about the limitations that may be associated with the presence of a pacemaker. It is recommended to exclude contact with possible sources of electrical interference as much as possible, to avoid medical physiotherapy using galvanic currents. When using industrial or household equipment, safety precautions must be followed.

Persistent Cutibacterium (Formerly Propionibacterium) acnes Bacteremia and Refractory Endocarditis in a Patient with Retained Implantable Pacemaker Leads

Cutibacterium (formerly Propionibacterium) acnes (C. acnes) is a commensal bacteria commonly found on the human skin and in the mouth. While the virulence of C. acnes is low in humans, it does produce a biofilm and has been identified as an etiologic agent in a growing number of implant-associated infections. C. acnes infections can prove diagnostically challenging as laboratory cultures can often take greater than 5 days to yield positive results, which are then often disregarded as contaminant. Patients with recurrent bacteremia in the setting of implantable devices warrant further studies to evaluate for an associated valvular or lead endocarditis. The patient in this report demonstrates how cardiac device-related endocarditis secondary to C. acnes can be overlooked due to the indolent nature of this pathogen. This patient presented with an implanted cardiac pacemaker device, as well as retained leads from a prior pacemaker. Transesophageal echocardiography was required to confirm the diagnosis in the setting of multiple positive blood cultures and negative transthoracic echocardiograms over a period of 4 years. The purpose of this report is to highlight the difficulties encountered in diagnosing C. acnes endocarditis in a patient with a cardiac implantable electronic device and persistently positive blood cultures.

Attack Graph Modeling for Implantable Pacemaker

Remote health monitoring systems are used to audit implantable medical devices or patients’ health in a non-clinical setting. These systems are prone to cyberattacks exploiting their critical vulnerabilities. Thus, threatening patients’ health and confidentiality. In this paper, a pacemaker automatic remote monitoring system (PARMS) is modeled using architecture analysis and design language (AADL), formally characterized, and checked using the JKind model checker tool. The generated attack graph is visualized using the Graphviz tool, and classifies security breaches through the violation of the security features of significance. The developed attack graph showed the essentiality of setting up appropriate security measures in PARMS.

External and Implantable Pacemakers and Defibrillators

Approximately 250,000 pacemakers are implanted every year in the United States.26 As the population continues to age, the number is likely to increase; therefore, it is imperative for all physicians, especially anesthesiologists, to become familiar with implantable cardiac devices and the appropriate management of patients with these devices. Anesthesiologists must be comfortable evaluating and managing patients with pacemakers and/or defibrillators during the perioperative period, as more of this patient population present for noncardiac, elective surgery. This requires a strong understanding of the types of devices, indications, settings, and functionality. In addition, it is important to understand and anticipate possible interactions during surgery with surgical instruments, such as bi- and monopolar electrocautery. This review provides a brief overview of the history of implantable devices, presents the guidelines regarding indications for placement, discusses important management considerations, and concludes with recent advances and future directions. This review contains 1 figures, 5 tables, and 30 references. Key Words: cardiac, defibrillator, electrophysiology, external, implantable, pacemaker, pacing, transcutaneous, transvenous