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66 Left bundle branch area pacing in a non-electrophysiology centre
BackgroundWhen it comes to device therapy, LV lead placement in heart failure patients with left ventricular dyssynchrony and broad QRS complex is the gold standard of care. Left bundle branch area (LBBA) pacing is a potentially evolving technique that may replace LV lead placement for cardiac dyssynchrony, requiring less technical skills than HIS-bundle pacing. With this in mind, we have established a program for LBBA pacing in University Hospital Limerick, a non-electrophysiology centre.MethodsThe implanting cardiology team attended a one-day hands on course, run by Biotronik, in London, to upskill in implantation technique for successful placement of LBBA leads.ResultsTo date, 14 patients have undergone LBBA lead placement. Indications include: pacing requirement of at least 20% with normal/mildly impaired LV function and a broad QRS complex; LV lead displacement with failure to reposition; and failure to place LV lead for CRT implantation. Successful LBBA lead placement during procedure is measured using the Left Ventricular Activation Time (LVAT) with a target of <80ms, the R-wave Morphology in Lead V1 (RWMP) targeted at >30ms, and visualization of R’ during lead implantation. Post procedure success is measured by assessing QRS duration via 12-lead ECG, targeted at <120ms. 12 of the 14 implantations were deemed complete success, with LVAT <80ms, RWMP >30ms, R’ visualization, and narrow QRS complexes on 12-lead ECG following implantation. 1 patient had partial success, with only R’ visualized and a narrow QRS post implantation. 1 patient had suboptimal lead position. There were no complications from procedure, notably pneumothorax, haematoma formation, infection, or lead dislodgement.ConclusionOur initial experience with LBBA pacing in a non-electrophysiology centre has shown that this new technique is not only feasible, but can be performed with a very high success rate. LBBA pacing provides a practical functional alternative to LV lead placement.
Journal Article
440 Long-Term Outcomes of POEM in Achalasia With a Minimum Follow-Up of 3, 4, and 5 Years: A Meta-Analysis
INTRODUCTION:Per-oral endoscopic myotomy (POEM) has promising safety and efficacy outcomes in short-term studies. However, long-term follow-up data are limited. The aims of this study was to review and analyze the clinical outcomes and failure rates of of studies that reported a minimum post-POEM follow-up of 3, 4 and 5 years.METHODS:A systematic review of POEM performed for the treatment of achalasia was performed. We searched major medical databases (Pubmed, Medline, Ovid, Cochrane and EBSCO databases) from inception till May 2019. Major conference abstracts and presentations were searched. Statistical analysis was performed using Med Calc Software (Ostend, Belgium). Clinical success was defined as Eckardt score ≤3 and failure was defined as Eckardt score >3 on follow up.RESULTS:A total of 8 retrospective and prospective studies fulfilled inclusion criteria (Table 1). The studies originated from China, Czech Republic, Japan and USA. The total number of patients included in this study was 671. Eight studies (671 patients) with follow up data post-POEM of a minimum of 3 years were included in the 3 year analysis. Four studies (407 patients) with 4 year follow up data post-POEM were included in the 4 year analysis. Three studies (97 patients) with 5 year follow up data post-POEM were included in the 5 year analysis. There was no heterogeneity between studies. The overall clinical success rate at the 3, 4 and 5 year follow up was 88% (95% CI 85-91%), 87% (95% CI 83-90%), 84% (95% CI 76-90%) respectively (Figure 1). The overall failure rates at 3, 4 and 5 year follow up were 11.7% (95% CI 9-15%), 13% (95% CI 10-17%) and 16% (95% CI 10-24%) respectively. There was no significant difference in clinical success or failure rates.CONCLUSION:Our study demonstrates that POEM is effective and safe for treating achalasia during the long term follow up to 5 years. Randomized controlled trials are needed to validate these findings.Table 1.Study characteristics
Journal Article
P233 Thoracic ultrasonography as a predictor of pleurodesis success in malignant pleural effusion
BackgroundOver 50 000 patients with malignant pleural effusion (MPE) are seen annually in the UK. The majority develop recurrent symptomatic disease requiring definitive treatment. MPE is most frequently managed with talc slurry pleurodesis via intercostal chest drain. This involves a lengthy inpatient stay and has a success rate of around 70%, with no means of predicting which patients will suffer pleurodesis failure. Thoracic ultrasound (TUS) is widely used by respiratory physicians, and data from animal and human studies suggest it can identify pleural adhesions (through the absence of normal lung sliding) in a range of conditions. By extension, TUS may allow clinicians to diagnose the presence or absence of adhesions post-pleurodesis in MPE, identifying patients suitable for discharge or needing further intervention.Abstract P233 Table 1Ultrasonographic pleurodesis score at day 0 (pre-pleurodesis) and day 1 (24 hours post-pleurodesis) in patients being treated for malignant pleural effusionSuccessful pleurodesis n=11/15 (73.3%) patientsFailed pleurodesis n=4/15 (26.7%) patients p value unpaired t-test Day 0 pleurodesis score (mean±SD, total out of 18)10.89±3.986.50±1.290.054 Difference=4.39 (95% CI −0.09 to 8.86)Day 1 pleurodesis score (mean±SD, total out of 18)13.45±2.636.75±2.940.002 Difference=6.70 (95% CI 3.08 to 10.33)Change from day 0 to 1 (mean±SD)2.57±3.980.25±3.590.326 Difference=2.32 (95% CI −2.59 to 7.23)MethodWe recruited 18 adult patients with MPE undergoing drainage and talc slurry pleurodesis to a prospective single-centre cohort study. Patients underwent standardised TUS assessment pre- and post-pleurodesis, evaluating pleural sliding and adhesions at nine points (three anterior, three lateral, three posterior) across the affected hemithorax. Lung sliding was graded as per Zhu et al.,1 creating a total pleurodesis score out of 18. Pleurodesis failure was defined as radiological and symptomatic fluid recurrence in the same hemithorax requiring further intervention at any point up to 3 months post-pleurodesis. Patients also completed a questionnaire addressing satisfaction with TUS assessment.Results3/18 patients (16.7%) died before 1 month follow-up. Of 15 patients seen at one month, 11 (73.3%) had successful pleurodesis and 4 (26.7%) had failed. No patient had delayed pleurodesis failure between 1 and 3 month follow-up. There was a significant difference observed in the day 1 TUS pleurodesis score between patients who went on to have successful pleurodesis and those who failed during follow-up (table 1). TUS assessment was acceptable to patients, with none considering it either time-consuming or unwilling to have it again if needed.ConclusionOur data suggest TUS assessment 24 hours post-pleurodesis for MPE predicts success or failure of this intervention, with significant implications for clinical care. A larger randomised study is now underway to further evaluate this hypothesis.ReferenceChest2005;128(2):934–9.
Journal Article
Defining the Learning Curve of Flexible Ureterorenoscopy and Laser Lithotripsy
Purpose: To investigate the impact of learning curve (LC) on flexible ureterorenoscopy (f-URS). Materials and Methods: Patients who underwent kidney stone surgery in a urology clinic from a tertiary health care institution with f-URS were enrolled in the study. Patient characteristics, the properties of kidney and kidney stones were recorded. Also, f-URS-related parameters, hospitalization time, the success of the procedure, and complications were noted. Patients were categorized equally into 4 groups, the first 20 f-URS cases in Group 1, and the last 20 f-URS cases in Group 4. Groups were compared according to patient preoperative parameters, intraoperative outcomes, success rate and complication rate. Results: Time from the induction of anaesthesia to insertion of flexible ureterorenoscope was 18.6 min in group 1 and 17.2 min in group 2; then it significantly decreased to 15.0 min for cases 40 through 60 and 12.4 min for cases 60 through 80 (p = 0.001). Operation time in group 3 and group 4 was significantly shorter than in group 1 and group 2 (p = 0.001). Also, fluoroscopy time was significantly longer in group 1 (82.9 seconds) and reached a plateau in group 3 (50.3 seconds) and group 4 (41.7 seconds) (p = 0.001). Additionally, after the 20th case, we achieved a significantly higher success rate in comparison to the first 20 cases (65% in group 1, 85% in group 2, 85% in group 3, and 90% in group 4, p = 0.001). Conclusion: Flexible ureterorenoscopy is a surgery that requires high technique and experience. The present study found that success of f-URS reached satisfactory levels after 20th cases. In addition, 40 cases may be enough for surgical proficiency regarding decreases in preparation time, operation time, and fluoroscopy time.
Journal Article
The 10x rule : the only difference between success and failure
\"Achieve \"Massive Action\" results and accomplish your business dreams! While most people operate with only three degrees of action-no action, retreat, or normal action-if you're after big goals, you don't want to settle for the ordinary. To reach the next level, you must understand the coveted 4th degree of action. This 4th degree, also know as the 10 X Rule, is that level of action that guarantees companies and individuals realize their goals and dreams. The 10 X Rule unveils the principle of \"Massive Action,\" allowing you to blast through business clichéZs and risk-aversion while taking concrete steps to reach your dreams. It also demonstrates why people get stuck in the first three actions and how to move into making the 10X Rule a discipline. Find out exactly where to start, what to do, and how to follow up each action you take with more action to achieve Massive Action results. Learn the \"Estimation of Effort\" calculation to ensure you exceed your targets Make the Fourth Degree a way of life and defy mediocrity Discover the time management myth Get the exact reasons why people fail and others succeed Know the exact formula to solve problems Extreme success is by definition outside the realm of normal action. Instead of behaving like everybody else and settling for average results, take Massive Action with The 10 X Rule, remove luck and chance from your business equation, and lock in massive success.\"-- Provided by publisher.
Book
Management of Male Urethral Stricture Disease: review article
Male urethral stricture disease is prevalent and has a substantial impact on quality of life and health-care costs. Management of urethral strictures is complex and depends on the characteristics of the stricture. Data show that there is no difference between urethral dilation and internal urethrotomy in terms of longterm outcomes; success rates range widely from 8–80%, with long-term success rates of 20–30%. For both of these procedures, the risk of recurrence is greater for men with longer strictures, penile urethral strictures, multiple strictures, presence of infection, or history of prior procedures. Analysis has shown that repeated use of urethrotomy is not clinically effective or cost-effective in these patients. Long-term success rates are higher for surgical reconstruction with urethroplasty, with most studies showing success rates of 85–90%. Many techniques have been utilized for urethroplasty, depending on the location, length, and character of the stricture. Successful management of urethral strictures requires detailed knowledge of anatomy, pathophysiology, proper patient selection, and reconstructive techniques.
Journal Article