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Pacing-induced cardiomyopathy (PICM) consists of heart failure (HF) associated with a drop in the left ventricular ejection fraction (LVEF) in the setting of high-burden right ventricular pacing, with presentation that may range from subclinical to severe. Time to manifestation can go from weeks to years after device implantation. Treatment typically consists in an upgrade to a cardiac resynchronisation therapy (CRT) or His bundle pacing (HisP). Several risk factors for PICM have been described and should be considered before pacemaker (PM) implantation, as thorough patient selection for de novo CRT or HisP, may preclude its manifestation. We present the case of an 82-year-old patient presenting with acute congestive HF and new severely reduced LVEF, 30 days following dual chamber PM implantation for high-grade atrioventricular block. Treatment with HF medication and upgrade to a CRT permitted rapid resolution of the symptoms and normalisation of the LVEF at 1-month follow-up.

Background: Age-related differences on leadless pacemaker (LP) are poorly described. Aim of this study was to compare clinical indications, periprocedural and mid-term device-associated outcomes in a large real-world cohort of LP patients, stratified by age at implantation. Methods: Two cohorts of younger and older patients (≤50 and > 50 years old) were retrieved from the iLEAPER registry. The primary outcome was to compare the underlying indication why a LP was preferred over a transvenous PM across the two cohorts. Rates of peri-procedural and mid-term follow-up major complications as well as LP electrical performance were deemed secondary outcomes. Results: 1154 patients were enrolled, with younger patients representing 6.2% of the entire cohort. Infective and vascular concerns were the most frequent characteristics that led to a LP implantation in the older cohort (45.8% vs 67.7%, p < 0.001; 4.2% vs 16.4%, p = 0.006), while patient preference was the leading cause to choose a LP in the younger (47.2% vs 5.6%, p < 0.001). Median overall procedural (52 [40–70] vs 50 [40–65] mins) and fluoroscopy time were similar in both groups. 4.3% of patients experienced periprocedural complications, without differences among groups. Threshold values were higher in the younger, both at discharge and at last follow-up (0.63 [0.5–0.9] vs 0.5 [0.38–0-7] V, p = 0.004). Conclusion: When considering LP indications, patient preference was more common in younger, while infective and vascular concerns were more frequent in the older cohort. Rates of device-related complications did not differ significantly. Younger patients tended to have a slightly higher pacing threshold at mid-term follow-up.

A 64-year-old man with diabetes mellitus was diagnosed with a non-ST-segment elevation myocardial infarction and was treated with stent implantation. Four days later, he developed an electrical storm (ES) that persisted despite antiarrhythmic drugs and sedation. External defibrillation was performed more than 100 times over 2 hours. After ruling out the common causes of polymorphic ventricular tachycardia, an ES was considered because of brady-dependent R-on-T phenomenon, presumably precipitated by antiarrhythmic drugs. Temporary transvenous atrial overdrive pacing allowed complete suppression of premature ventricular complexes and ventricular fibrillation.

A 72-year-old man presented for routine dual chamber pacemaker interrogation 13 years following insertion for sick sinus syndrome. Increased noise, impedance and threshold of the right ventricular (RV) lead were identified. RV capture was maintained with an overall RV pacing burden of 47%. A routine generator replacement was scheduled alongside RV lead replacement. Fluoroscopy at the start of the procedure revealed an unexpected striking fracture of the RV pacing lead with complete separation of the proximal and distal portions within the RV. The patient was asymptomatic and described no predisposing factors. He underwent implantation of a new ventricular lead and generator and has remained well. This case demonstrates clear RV lead fracture as a late complication of pacemaker implantation despite maintained capture. This emphasises the need for a chest X-ray when a change in device parameters is noted at device interrogation even in the absence of symptoms.

An 88-year-old woman presented to our hospital due to an 18-hour history of worsening central chest pain. She had a dual-chamber pacemaker due to second-degree Mobitz type II atrioventricular block implanted 10 years ago. Her risk factors included hypertension and hypercholesterolaemia. Her

Temporary epicardial pacing frequently is employed after cardiac surgery, and can have a significant impact on a patient's hemodynamics, arrhythmias, and valvulopathies. Given that anesthesiologists often are involved intimately in the initial programming and subsequent management of epicardial pacing in the operating room and intensive care unit, it is important for practitioners to have a detailed understanding of the modes, modifiable intervals, and potential complications that can occur after cardiac surgery. Because this topic has not been reviewed recently in anesthesia literature, the authors attempted to review relevant epicardial pacemaker specifics, discuss modes and parameters that apply to the perioperative period, present an algorithm for mode selection, describe the potential effects of epicardial pacing on valvulopathies and hemodynamics, and, finally, discuss some postoperative considerations.

Performance of the leadless pacemaker capable of atrioventricular (AV) synchronous pacing in de novo patients warrants further investigation.The aims of this study were to assess what programming changes are needed to achieve proper atrial tracking and to study the percentage of AV synchrony (AVS) the device can provide under real-world conditions.Consecutive patients undergoing Micra AV implantation between June 2020 and November 2021 were studied. Reprogramming of atrial sensing parameters during follow-up was performed by following device counters. AVS was studied with an ambulatory 24-hour Holter monitor and automatically analyzed by an electrocardiogram delineation system. The primary end point was AVS ≥85% of total cardiac cycles during 24-hour Holter electrocardiogram monitoring.Thirty-one patients who remained in VDD mode were studied, and all of them required manual reprogramming. The automatic A3 window end was deactivated, and a fixed and short value was set in all patients throughout follow-up. AVS significantly increased from 68.7% ± 14.7% at 24-hour follow-up to 83.9% ± 7.4% at 1-month visit (P = .001). At 1-month visit, shorter A3 window end time (P = .019), higher A4 threshold (P = .011), and deactivation of the automatic A3 window (P = .054) were independently related to higher AVS. A total of 2,291,953 Holter-recorded cardiac cycles were analyzed. Median AVS during 24-hour daily activities was 87.6% (interquartile range 84.5%-90.6%). Twenty of 26 patients (79.6%) reached AVS ≥85% of cardiac cycles.High rates of AVS can be achieved in real-world patients undergoing leadless pacing. Manual reprogramming of the atrial sensing parameters is essential to optimize mechanically sensed atrial tracking.

Left bundle branch pacing is a physiological pacing modality with a low and stable threshold. The electrophysiological characteristics and mechanisms of bipolar pacing remain unclear.This study aimed to assess the electrophysiological characteristics of bipolar pacing of left bundle branch pacing and to infer the mechanisms underlying each electrocardiogram and electrogram waveform morphology.A total of 65 patients who strictly met the criteria for left bundle branch capture were enrolled. The changes in the morphology of the electrocardiogram and electrogram during the threshold testing with different outputs on unipolar and bipolar pacing were recorded. The electrophysiological characteristics were then analyzed.Four distinct morphologies and 3 different types of transitions during bipolar pacing threshold testing were identified; we labeled the 4 types of morphologies as nonselective (NS)-bipolar-left bundle (LB), NS-cathodal-LB, selective (S)-cathodal-LB, and left ventricular septal-cathodal. Except left ventricular septal-cathodal, the other 3 types (NS-bipolar-LB, NS-cathodal-LB, and S-cathodal-L) had a short and constant VWith a higher output on bipolar pacing, NS-bipolar-LB capture had the shortest V

Transcutaneous cardiac pacing (TCP) is a lifesaving procedure for patients with certain types of unstable bradycardia. We aimed to assess the difference in the pacing thresholds between the anteroposterior (AP) and anterolateral (AL) pacer pad positions. The second aim was to characterize the severity of chest wall muscle contractions during TCP.In this prospective crossover trial, we enrolled patients presenting to the electrophysiology laboratory for elective cardioversion. After successful cardioversion, sedated participants were sequentially paced in both positions. The study procedure concluded after successful capture or inability to achieve capture by 140 mA (the pacer's maximum output) in both positions. Pacing thresholds were compared between positions, using a student's paired t-test, assigning a value of 141 mA to any trials with non-capture.Forty-one patients were screened; 20 were enrolled in the study. Seven participants were excluded from the paired analysis (three were prevented from pacing in the second position at the anesthesiologist's discretion, and 4 did not capture in either position). The study population consisted of 14 men and 6 women with a median age of 65 years. The mean pacing threshold was 33 mA lower (P = 0.001, 95% CI 20-45) in the AP (93 mA) versus the AL (126 mA) position. The median contraction severity score was 3 in the AL position versus 4 in the AP position (P = 0.005).Placing pacer pads in the AP position requires less energy to capture. Major resuscitation guidelines may favor the AP position for TCP.gov Identifier: NCT03898050 https://clinicaltrials.gov/ct2/show/NCT03898050.

Background. Pacemakers are used to treat syncope in patients with bradyarrhythmia; however, the risk of recurrent syncope has only been investigated in few and smaller studies. Objective. The aim of this study was to investigate the risk of recurrent syncope after pacemaker implantation in patients with bradyarrhythmia and prior syncope. Methods. This retrospective, population-based cohort study included patients with a prior syncope and implantation of a pacemaker using data from the Danish nationwide registers from 1996 to 2017. Cumulative incidence and cox regression was used to estimate the 5-year incidence and the risk of recurrent syncope, respectively. Results. In total, 11,126 patients (median age: 78 years, interquartile range: 69–85, 56% male) were included and the 5-year cumulative incidence of recurrent syncope was 19.6% (95% confidence interval (CI): 18.8–20.3%). Sinus node dysfunction (hazard ratio [HR]: 1.29, 95%CI: 1.17–1.42) and unspecified type of bradyarrhythmia (HR: 1.32, 95%CI: 1.15–1.52) were associated with an increased risk of syncope compared to advanced atrioventricular (AV) block. Male sex (HR: 1.22, 95%CI: 1.22–1.34), cerebrovascular disease (HR: 1.17, 95%CI: 1.05–1.30), and prior number of syncopes were significantly associated with a higher HR of recurrent syncope. Conclusion. Almost one-in-five patients with bradyarrhythmia and prior syncope who had a pacemaker implanted had a recurrent syncope within five years. A higher risk of syncope was observed among patients with sinus node dysfunction and unspecified type of bradyarrhythmia compared to AV block. Male sex, cerebrovascular disease, and prior number of syncopes were associated risk factors of recurrent syncope.

In dogs, single lead ventricular pacing, ventricular sensing, inhibition response, rate adaptive (VVIR) pacemakers are routinely used to treat third degree atrioventricular block. The objectives of this study were to investigate the heart rate distribution in dogs with VVIR pacemakers, and report changes when activity settings were adjusted.Eighteen client-owned dogs with VVIR pacemakers for third degree atrioventricular block.This observational study consisted of a review of medical records of dogs with VVIR pacemakers. For dogs with50% of paced beats at the lower pacing rate, the activity daily living (ADL) and exertion responses were increased. Re-evaluations were performed after 6-12 months.Heart rate distribution similar to healthy dogs was absent for all dogs. In nine dogs, the ADL and exertion responses were increased to the highest level. Of these, three dogs showed no improvement in heart rate distribution; for two dogs, one with an epicardial pacemaker, several activity settings were adjusted and pacing at higher heart rates was observed at re-evaluation. Four dogs died or were lost to follow-up. Clinical signs had resolved for all dogs after pacemaker implantation.Default activity settings of VVIR pacemakers do not result in heart rate distribution equivalent to healthy dogs. Increasing the ADL and exertion response settings to the highest levels did not improve the pacemaker rate response. Further investigations into the role of dog size, generator positioning, pacemaker settings, and whether rate responsiveness is required for dogs' quality and quantity of life are warranted.

To evaluate safety of leadless pacemaker implantation through the internal jugular vein in a larger cohort with longer follow-up. Moreover, feasibility of non-apical pacing as well as relation between pacing site and QRS duration were assessed.Eighty Two consecutive patients, who received a leadless pacemaker though the internal jugular vein, were included. Electrical parameters were measured at regular follow-up and any complications were registered. Paced QRS interval was compared for three pacing sites, RVOT, RV mid septum, and RV apical septum.In all patients, the leadless pacemaker was implanted successfully. In 69 patients, the device was implanted in a non-apical position. In 71% of cases, the device could be deployed at first attempt. The median fluoroscopy time was 4.4 min (range 0.9-51) The paced QRS interval was significantly narrower for non-apical pacing sites compared to apical pacing si 156 vs. 179 ms. p = .04, respectively. During mean follow-up of 16 months (range 0-43 months), electrical parameters remained stable. Two complications occurred, which could be resolved during the implant procedure. There were no access site related complications.The jugular approach for leadless pacemaker implantation is feasible and may avoid vascular complications. It facilitates non-apical positioning of leadless pacemakers leading to a narrower paced QRS interval. The jugular approach allows for immediate post procedural ambulation.

Leadless pacemakers (LPs) are emerging as alternative cardiac implantable devices for the treatment of bradyarrhythmia. This article aims to review the data behind the safety and efficacy of these devices while highlighting their pros and cons.Prospective non-randomized studies and registries have found that LPs are associated with lower rate of device-related complications mainly driven by lower need for lead-related interventions as compared to traditional pacemakers. On the other hand, cardiac perforation appears to occur more frequently with LPs. LPs are associated with lower rate of device-related complications as compared to the traditional pacemakers. However, the rate of pericardial effusion is higher and is more severe. As we transition to multi-chamber LPs, it is important to ensure the safety and efficacy of these devices.

Small studies have suggested left ventricular (LV) rapid pacing has similar safety and efficacy to conventional right ventricular (RV) rapid pacing in transcatheter aortic valve implantation (TAVI). However, there are limited data on the comparative rates of tamponade. The study compared the rate of cardiac tamponade between LV and RV-pacing during TAVI.Between 2008 and 2021, 1226 consecutive patients undergoing transfemoral or transaxillary TAVI were included. 470(38.3%) patients had TAVI deployment with RV-pacing and 756(61.7%) with LV-pacing. The primary outcome was the frequency and cause of cardiac tamponade. Secondary outcomes included efficacy, procedure duration and crossover rates.There was a trend to less tamponade with LV-pacing, which did not reach statistical significance [11(2.3%) vs 11(1.5%);P = 0.27]. There was no significant difference in the frequency of tamponade due to annular tear [4(0.9%) vs 9(1.2%);P = 0.59] or LV free-wall perforation [1(0.2%) vs 2(0.3%);P = 0.86]. The frequency of tamponade due to RV perforation was significantly lower in the LV-pacing group [0 vs 6(2.3%);P 0.005)]. Two patients with tamponade due to RV perforation required emergency sternotomy of whom one died. Deployment success was similar (99% vs 99.6%;P=NS). Procedure duration was shorter with LV-pacing (70 vs 80 mins;P 0.005). Crossover to RV-pacing was low (0.9%). There were no embolizations caused by loss-of-capture in either group.LV-pacing appears equally efficacious and is associated with a lower risk of tamponade due to RV perforation caused by the temporary pacing wire. LV-pacing was not associated with an increased risk of tamponade due to LV free-wall perforation.

BACKGROUND Cardiac resynchronization therapy (CRT) using bi-ventricular pacing (BVP) is effective in patients with heart failure, left bundle branch block (LBBB), and reduced left ventricular function. Left bundle branch area pacing (LBBAP) has been reported as an alternative option for CRT. OBJECTIVE The purpose of this study was to assess the feasibility and outcomes of LBBAP in patients who failed conventional BVP because of coronary venous (CV) lead complications or who were nonresponders to BVP. METHODS At 16 international centers, LBBAP was attempted in patients with conventional CRT indication who failed BVP because of CV lead complications or lack of therapeutic response to BVP. Heart failure hospitalization (HFH) and death, echocardiographic outcomes, procedural data, pacing parameters, and lead complications including CV lead failure are reported. RESULTS LBBAP was successfully performed in 200 patients (CV lead failures 156; nonresponders 44) (age 68 +/- 11 years; female 35%; LBBB 55%; right ventricular pacing 23%; ischemic cardiomyopathy 28%; nonischemic cardiomyopathy 63%; left ventricular ejection fraction [LVEF]

Sequential synchronized atrioventricular (AV) pacing provides enhanced electrophysiologic parameters which contribute to improved hemodynamic parameters and increased cardiac performance to subsequently confer a clinical advantage over traditional ventricular pacing. Current temporary transvenous pacemaker catheters are limited to only one electrode which paces solely the right ventricle, thus lacking the capability to provide the optimal pacing mode. A new multilead pacemaker device was developed in response to the need for improved temporary pacing through the utilization of sequential synchronized atrioventricular pacing (TAVSP). It consists of seven preformed, preshaped nitinol wires electrodes, of which four are for intra-atrial and three for intraventricular positioning and endocardial contact, respectively. Each wire carries a ball tip designed to minimize tissue trauma and provide a high current density for adequate myocardial capture. The device is not yet Food and Drug Administration approved.To present the unique structural components and mechanical properties of a novel sequential synchronized AV pacing device for temporary insertion and to report its first-in-human application with an analysis of the early clinical experience.Following a process of development and proof of concept of the novel pacing modality in an animal model which demonstrated feasibility and safety, a series of patients who were candidates for the device application was identified. During left and right heart catheterization, the novel temporary pacing catheter was inserted transvenously and delivered in most patients under fluoroscopy or echocardiography. The catheter was deployed to its target right heart anatomic sites and then activated in an AV sequential mode. The technical aspects, the corresponding clinical utilization, and device performance were documented and analyzed.The series included 10 enrolled subjects. During planned left and right heart catheterization, the novel TAVSP device was inserted transvenously and then delivered and deployed successfully in a timely fashion in all patients. The pacing catheter achieved proper threshold and impedance in all (100%) patients. The performance of all ventricular leads was adequate; however, in 1 (10%) patient poor performance of the atrial leads was detected. The device was successfully retrieved in all patients. No adverse arrhythmia, impaired hemodynamics, or clinical adverse events occurred. No technical difficulties, component failure, or wires thrombosis were detected. All patients sustained the device application without sequala and were discharged home.Initial clinical experience with the utilization of a novel TAVSP demonstrates feasibility and safety in humans. The TAVSP modality potentially offers improved pacing capability and subsequent hemodynamic benefits over the current temporary pacing catheters. Further experience with the clinical application of this pacing catheter is warranted.

Implanting a ventricular demand leadless pacemaker (VVI-LPM) for patients with non-atrial fibrillation (AF) bradyarrhythmias such as sick sinus syndrome (SSS) or high-grade (i.e., second- or third-degree) atrioventricular (AV) block is not recommended unless they have limited vascular access or a high infection risk; nevertheless, an unexpectedly high number of VVI-LPM implantations have been performed. This study investigated the clinical outcomes of these unusual uses.Methods and Results:This study retrospectively analyzed 193 patients who were newly implanted with a VVI-LPM or an atrioventricular synchronous transvenous pacemaker (DDD-TPM) for non-AF bradyarrhythmias at a high-volume center in Japan from September 2017 to September 2020. Propensity score-matching produced 2 comparable cohorts treated with a VVI-LPM or DDD-TPM (n=58 each). Each group had 20 (34%) patients with SSS and 38 (66%) patients with high-grade AV block. During a median follow up of 733 (interquartile range 395-997) days, there were no significant differences between the VVI-LPM and DDD-TPM groups regarding late device-related adverse events (0% vs. 4%, log-rank P=0.155), but the VVI-LPM group had a significantly increased readmission rate for heart failure (HF) (29% vs. 2%, log-rank P=0.001) and a tendency to have higher all-cause mortality (28% vs. 4%, log-rank P=0.059).The implantation of a VVI-LPM for non-AF bradyarrhythmias increased the incidence of HF-related rehospitalization at the mid-term follow up compared to the use of a DDD-TPM.

The long-term implications of pacemaker insertion in younger adults are poorly described in the literature.We performed a retrospective analysis of consecutive younger adult patients (18-50 yrs) undergoing pacemaker implantation at a quaternary hospital between 1986-2020. Defibrillators and cardiac resynchronisation therapy devices were excluded. All clinical records, pacemaker checks and echocardiograms were reviewed.Eighty-one (81) patients (median age 41.0 yrs IQR=35-47.0, 53% male) underwent pacemaker implantation. Indications were complete heart block (41%), sinus node dysfunction (33%), high grade AV block (11%) and tachycardia-bradycardia syndrome (7%). During a median 7.9 (IQR=1.1-14.9) years follow-up, nine patients (11%) developed 13 late device-related complications (generator or lead malfunction requiring reoperation [n=11], device infection [n=1] and pocket revision [n=1]). Five (5) of these patients were40 years old at time of pacemaker insertion. At long-term follow-up, a further nine patients (11%) experienced pacemaker-related morbidity from inadequate lead performance managed with device reprogramming. Sustained ventricular tachycardia was detected in two patients (2%). Deterioration in ventricular function (LVEF decline10%) was observed in 14 patients (17%) and seven of these patients required subsequent biventricular upgrade. Furthermore, four patients (5%) developed new tricuspid regurgitation (moderate-severe). Of 69 patients with available long-term pacing data, minimal pacemaker utilisation (pacing5% at all checks) was observed in 13 (19%) patients.Pacemaker insertion in younger adults has significant long-term implications. Clinicians should carefully consider pacemaker insertion in this cohort given risk of device-related complications, potential for device under-utilisation and issues related to lead longevity. In addition, patients require close follow-up for development of structural abnormalities and arrhythmias.

A 72-year-old female with frequent palpitation was referred for radiofrequency ablation. The baseline 12-lead electrocardiogram and echocardiography results were normal. At baseline, the atrio-His (AH) and His-ventricular (HV) intervals were 90 and 41 ms, respectively. Dual atrioventricular (AV) nodal physiology or ventriculoatrial (VA) conduction was not observed during programmed atrial and ventricular stimulation. After isoproterenol infusion, VA conduction became decremental and concentric, with the earliest atrial activation seen at the His bundle (HB) region during ventricular pacing. A supraventricular tachycardia with a long RP interval (SVT) was induced by atrial extra-stimulation, without any jump-up in the AH interval. During the SVT, the AH and HV intervals were 180 and 180 ms, respectively, and the earliest atrial activation was recorded in the HB region (Figure 1A). During the SVT, transient 2:1AV conduction was observed (Figure 1B). Ventricular overdrive pacing at a pacing cycle length (CL) of 360 ms was performed during the SVT with a CL of 390ms (Figures 2A and B). Based on these observations, what is the mechanism of this tachycardia?

The present study aimed to evaluate the feasibility and safety of the novel left bundle branch pacing (LBBP) procedure that uses isoelectric interval as an endpoint for lead implantation.A total of 41 patients with indications for pacing were enrolled. All patients underwent a novel LBBP procedure guided by recording an isoelectric interval as an endpoint for lead implantation. The procedural details and electrophysiological characteristics were then analyzed.A total of 38/41 (92.7%) cases were confirmed of left bundle branch (LBB) capture. An isoelectric interval was observed in 36/41 cases (87.8%). A total of 36/41 (87.8%) cases with LBB potential were observed. The mean unipolar LBBP threshold at the implant was 0.5 ± 0.2 V. The mean sensed amplitude of the R wave and the pacing impedance at the implant were 12.9 ± 5.0 mV and 723.5 ± 117.1 Ω. During the final threshold testing, a transition from non-selective to selective LBBP (S-LBBP) was demonstrated in 26 patients. A transition from non-selective LBBP (NS-LBBP) to left ventricular septal myocardial capture was observed in 12 patients.Using an isoelectric interval as an endpoint to guide the LBBP was feasible in a high proportion of captured LBB cases.

Transvenous pacemaker (PM) implantation is a complication in patients undergoing transcatheter aortic valve implantation (TAVI). Recently, a second generation of leadless PMs able of atrioventricular (AV) synchronous pacing has been introduced and could be an alternative when ventricular pacing is required after TAVI. Real-world data on Micra AV after TAVI are still lacking. Our aim was to determine the per- and post-procedural outcomes in patients with Micra AV leadless PM implantation after TAVI.A total of 20 consecutive patients underwent Micra AV leadless PM implantation after TAVI between November 2020 and June 2021.The main indication for ventricular pacing was high-degree AV block (55% of patients) and left bundle branch block (LBBB) associated with prolonged HV interval (45% of patients). At discharge, mean (SD) ventricular pacing threshold was 0.397 ± 0.11 V at 0.24 ms and ventricular impedance was 709.4 ± 139.1 Ω. At 1-month follow-up, 95% of patients were programmed in VDD pacing mode. Mean (SD) ventricular pacing threshold was 0.448 ± 0.094 V at 0.24 ms. In patients with ventriculargt; pacing gt; 90% (n = 5), mean AM-VP was 72.5% ± 8.3%. Pacing threshold at 1 month was not significantly different compared to discharge (p = .1088). Mean (SD) impedance was 631.0 ± 111.9 Ω, which remained stable at discharge (p = .0813). No procedural complications occurred during implantation. At 1-month follow-up, two patients displayed atrial under-sensing.Micra AV leadless PM implantation after TAVI is associated with a low complication rate and good device performance at 1-month post-implantation.

Left bundle branch area pacing (LBBAP) has been performed exclusively using lumen-less pacing leads (LLL) with fixed helix design. This registry study explores the safety and feasibility of LBBAP using stylet-driven leads (SDL) with extendable helix design in a multicenter patient population. This study prospectively enrolled consecutive patients who underwent LBBAP for bradycardia pacing or heart failure indications at eight Belgian hospitals. LBBAP was attempted using SDL (Solia S60; Biotronik) delivered through dedicated delivery sheath (Selectra3D). Implant success, complications, procedural, and pacing characteristics were recorded at implant and follow-up. The study enrolled 353 patients (mean age 76 ± 39 years, 43% female). The mean number of implants per center was 25 (range: 5-162). Overall, LBBAP with SDL was successful in 334/353 (94%), varying from 93% to 100% among centers. Pacing response was labeled as left bundle branch pacing in 73%, whereas 27% were labeled as myocardial capture. Mean paced QRS duration and stimulus to left ventricular activation time measured 126 ± 21 ms and 74 ± 17. SDL-LBBAP resulted in low pacing thresholds (0.6 ± 0.4 V at 0.4 ms), which remained stable at 12 months follow-up (0.7 ± 0.3, p = .291). Lead revisions for SDL-LBBAP occurred in 5 (1.4%) patients occurred during a mean follow up of 9 ± 5 months. Five (1.4%) septal coronary artery fistulas and 8 (2%) septal perforations occurred, none of them causing persistent ventricular septal defects. The use of SDL to achieve LBBAP is safe and feasible, characterized by high implant success in low and high volume centers, low complication rates, and stable low pacing thresholds.

Although epicardial pacing wires are routinely inserted after cardiac surgical procedures, there is little in the medical literature to help standardise their use and identify associated risks and benefits. Much of the decision-making surrounding pacing wires are based on the surgeon's preference and vary highly between centers.A literature review was conducted exploring the evidence, indications, and current practice for temporary pacing wires. Risk factors for developing post-operative arrhythmias necessitating use of temporary pacing wires and complications were also reviewed.Although temporary epicardial pacing wires have a crucial role to play in the post-operative recovery period, the current literature suggests that they should be considered on an individual basis in all high-risk patients including increased age, low ejection fraction, diabetes mellitus, elevated pulmonary artery pressures, prolonged cross clamp time, pacing required to wean from bypass, pre-operative arrhythmia, and multiple valvular and transplant operations. Although complications from pacing wires are low, this figure is likely underreported and further studies are required to focus on the risks and benefits of insertion.

Left bundle branch pacing (LBBP) provides electrical and mechanical synchrony at low and stable pacing output and effectively corrects distal conduction system disease. The criteria for differentiating LBBP from LV septal pacing has not been validated in large trials. There are several electrocardiography-based and intracardiac electrogram-based criteria to confirm LBB capture. In this section, the authors review these criteria and their overall accuracy.

Asymptomatic or silent atrial fibrillation (AF) has long been a clinical problem due to the incidence of ischemic stroke. A method is needed to predict the development of silent AF before the occurrence of ischemic stroke. This study was focused on the symptoms of AF, especially palpitation, in pacemaker patients. We assessed the hypothesis that absence of palpitation during rapid ventricular pacing could be a predictor of future onset AF being asymptomatic.In this study, we assessed the presence of symptoms during RV pacing and AF symptoms on 145 pacemaker patients at the outpatient clinic by VVI pacing at 120 ppm. The relationship between symptoms during RV pacing and symptom during AF was assessed. The predictive value of absence of symptom during RV pacing on AF being asymptomatic was assessed.Of 145 patients, 74 had previous AF episode. Among the AF patients, absence of symptom during VVI pacing was associated with AF being asymptomatic.Of 145 patients, 71 had no previous AF events. There were 14 patients who had new-onset AF or atrial flutter (AFL) after the device implantation. Four of the 14 patients (28.6%) were symptomatic during first AF/AFL episode, and 10 (71.4%) were asymptomatic during first-onset AF. All ten patients who were asymptomatic during cardiac pacing test were asymptomatic during their initial episodes of AF as well.This study showed that absence of symptoms during rapid ventricular pacing was associated with first-onset AF being asymptomatic.

Left bundle branch area pacing (LBBAP) aims to capture the cardiac conduction system in area of the left bundle branch. Currently, LBBAP is mainly performed using lumen-less pacing leads (LLLs) with preshaped sheath. However, the data on LBBAP with stylet-driven leads (SDLs) without sheath is limited.This study presents the feasibility, safety, and pacing characteristics of LBBAP using SDLs without the support of sheath.A total of 25 patients with bradycardia indications who received LBBAP implantation with an attempt of SDL (FINELINE II 4471 lead, Boston Scientific, MA, US) between August 2020 and April 2021 at Sir Run Run Shaw Hospital were included in this retrospective cohort study. Twenty of them finally were paced with SDL in priority (SDL-LBBAP group). Twenty propensity score matching patients who underwent LBBAP with LLL (Select Secure 3830 lead, Medtronic, MN, US) and 20 right ventricular septal pacing (RVSP) with regular active fixation lead respectively in the same period (the LLL-LBBAP group and RVSP group) were compared using ECG characteristics, pacing parameters and complications during 6-month follow-up.LBBAP was successful with SDL in 23 of 25 patients (92%) and 20 of them were paced with SDL first. In the SDL-LBBAP group, the average age was 70.4 ± 8.2 years, and 55% of patients were male. Paced QRS duration and the stimulus to peak left ventricular activation time (Sti-LVAT) in SDL-LBBAP group were similar with those in LLL-LBBAP group and significantly shorter than those in RVSP group (126.1±14.1 ms vs. 124.8±10.9 ms, p = 1.00; 77.7 ± 11.2 ms vs. 73.5 ± 9.3 ms, P = .75; 126.1 ± 14.1 ms vs. 147.7 ± 22.5 ms, P.001; 77.7 ± 11.2 ms vs. 97.0 ± 13.2 ms, P.001). The pacing threshold and R-wave amplitude of SDL-LBBAP group were 0.53 ± 0.18V and 11.53 ± 3.63 mV at baseline respectively, which were comparable with the other two groups. During the 6-month follow-up, the pacing parameters remained stable and no lead-related complications were recorded.It is feasible and safe to use stylet-directed pacing lead for permanent LBBAP without a delivery sheath. Similar to LLL, LBBAP using SDL showed stable parameters and narrower paced QRS duration compared with RVSP, which could be an alternative to LLL in LBBAP.

Left bundle branch area pacing (LBBAP) maintains electrical and mechanical synchronization of the ventricles. It is a relatively physiological pacing mode, with low and stable pacing threshold and wider indications. LBBAP in children has been rarely reported.This study observed 12 children attempted LBBAP from January 2019 to January 2021 in the department of pediatric cardiology of Anzhen Hospital prospectively. Clinical data, pacing parameters, electrocardiograms, intracardiac electrograms, echocardiographic measurements and complications were recorded at implant and during follow-up.The 12 patients aged between 3 and 14 years old and weighted from 13 to 48 kg. Eleven patients were diagnosed with third-degree atrioventricular block and 1 patient (case 4) suffered from cardiac dysfunction due to right ventricular apical pacing (RVAP). Left bundle branch area pacing was successfully achieved in all patients with narrow QRS complexes and V1 lead showed changes like right bundle branch block in the pacing electrocardiogram. Left ventricular ejection fraction in case 4 recovered on the 3rd day after LBBAP. The median of left ventricular end diastolic diameter Z score of the 12 patients decreased from 1.75 to 1.05 3 months after implantation (p0.05). The median of paced QRS duration was 103 ms. The median of pacing threshold, R-wave amplitude and impedance were 0.85 V, 15 mV and 717 Ω respectively and remained stable during follow-up. No complications such as loss of capture, lead dislodgement or septal perforation occurred.Left bundle branch area pacing can be performed safely in children with narrow QRS duration and stable pacing parameters. Cardiac dysfunction caused by long-term RVAP can be corrected by LBBAP quickly.

Objective The leadless cardiac pacemaker is typically implanted percutaneously and has been widely used for patients who have already undergone valve surgery. We sought to determine the feasibility and safety of implanting the leadless pacemaker under direct visualization during valve surgery. Methods We performed a retrospective analysis of consecutive adult patients (n = 15) who underwent implantation of a leadless pacemaker under direct visualization at the time of valve surgery. Indications for single-chamber pacing were sick sinus syndrome with pauses (53.3%), atrial fibrillation with slow ventricular rates (13.3%) or complete heart block (6.6%), and elevated risk for postoperative heart block (26.6%). Leadless pacemaker performance and pacing percentage were assessed. Results Patients' age was 67.5 ± 17 years, 6 patients (40%) were male, and 14 patients (93%) had atrial fibrillation. Isolated tricuspid valve replacement was performed in 5 patients (33.3%), and the remainder underwent multivalve surgery that included concomitant tricuspid valve repair/replacement. In 93% of the patients (n = 14), the immediate post–cardiopulmonary bypass pacing thresholds were normal (≤2.0 V at 0.24 ms) and normalized in the remaining patient by the next morning. The impedance/sensing values were normal and stable through follow-up (151 ± 119 days) in all patients. Reliable leadless pacemaker performance allowed for deferral of temporary epicardial wires in 11 patients (73%). There were no procedural complications or device malfunction. Conclusions Leadless cardiac pacemaker implantation during valve surgery is feasible and safe. This hybrid approach to pacing may simplify the perioperative management of patients undergoing valve surgery who have an indication for single-chamber pacing.

Left bundle branch area pacing (LBBAP) has emerged as a promising physiologic pacing strategy. Though many clinical studies have established the feasibility and safety of LBBAP, the data for very elderly patients are lacking.This study aimed to assess the feasibility and safety of LBBAP in very elderly patients (≥80 years).Two hundred and forty consecutive patients who received LBBAP implantation were retrospectively enrolled in the present study. Inclusion criteria were patients with atrioventricular block, atrial fibrillation with a slow ventricular response, and heart failure with bundle branch block. The patients were divided into two groups: those aged ≥80 years and those aged80 years. LBBAP implantation was successfully performed in 48 of 53 (90.6%) very elderly patients and 162 of 187 (86.5%) counterparts. In the very elderly group, the mean (standard deviation [SD]) age was 84 (3) years, mean (SD) paced QRS duration was 112.4 (9.0), and the mean (SD) stimulus to R wave peak time was 82.0 (14.2) ms. Mean (SD) pacing thresholds and mean (SD) R wave sensing were 0.61(0.21) V and 12.1 (4.7) mV at implant. Pacing parameters in very elderly patients were similar to those in their counterparts. During a median follow-up of 6 months, pacing parameters remained stable. Five patients in the very elderly group developed complications (1 with septal perforation during the procedure, 1 with pocket hematoma, 1 with pacing threshold increase, and 2 with micro lead dislodgement during follow-up).LBBAP is safe and effective in patients ≥80 years old. LBBAP can be considered as an alternative method for delivering physiological pacing in this special population.

Right ventricular pacing (RVP) dependence could impair left ventricular ejection fraction (LVEF). This study aimed to illuminate the relationship between RVP proportion and LVEF, as well as disclosing independent predictors of RVP dependence.Patients indicated for permanent pacemaker implantation were included (2016-2020). The ventricular pacing lead was placed in right ventricular apex or septum. Pacing mode programming followed universal standard. Electrocardiographic, echocardiographic, and serological parameters were collected. RVP dependence was defined according to its influence on LVEF. This study was of case-control design. Included patients were matched by potentially confounding factors through propensity score matching. A total of 1183 patients were included, and the mean duration of follow-up was 24 months. Percentage of RVP 80% hardly influenced LVEF; however, LVEF tended to decrease with higher RVP proportion. High degree/complete atrioventricular block (AVB) [odds ratio (OR) = 5.71, 95% confidence interval (CI): 3.66-8.85], atrial fibrillation (AF) (OR = 2.04, 95% CI: 1.47-2.82), percutaneous coronary intervention (PCI) (OR = 2.89, 95% CI: 1.24-6.76), maximum heart rate (HRHigh RVP percentage (80%) indicating RVP dependence significantly correlates with poor prognosis of cardiac function. High degree/complete AVB, AF, ischaemic aetiology, PCI history, HR

Real-world safety data on the use of transcatheter pacing systems particularly in very elderly patients is still limited. The aim of this analysis was to investigate the effect of age on the safety and efficacy of leadless pacemaker implant.From May 2016 through July 2019, 577 patients were implanted with a leadless single-chamber pacemaker according to current pacing indication in 15 Italian cardiologic centers. The population was divided into age quartiles for evaluation, including (1) 70 years, (2) 70-77 years, (3) 78-83 years, and (4) ≥ 83 years. Procedural data, complications, and electrical parameters were collected at baseline and during the follow-up.Procedural-related complication occurrence was very low ( 1.0%) and similar in the four subgroups according to age even if the older patients were more frail. No cardiac tamponade was reported. Among the groups, no difference was observed in procedural time, fluoroscopy time duration, and electrical parameters (mean pacing impedance: 750 ± 192 and 599 ± 156, mean pacing threshold: 0.7 ± 0.5 and 0.7 ± 0.6, and mean right ventricular sensing 10.7 ± 6.1 and 11.5 ± 4.8 at implant and last follow-up, respectively).The reported data demonstrated a high degree of safety during leadless implant across all patient ages. Procedural complications and device electrical measurements were similar among the different ages.

In the present article we report the case of a patient at high risk of infection wearing a subcutaneous ICD (S-ICD) due to previous system extractions, hospitalized for symptomatic BBR VT and underwent radiofrequency catheter (RF) ablation. Afterwards, to prevent the possible progression of the infra-His conduction disease to a complete block, it was decided to implant a pacemaker system. Since the high infectious risk, and the patient's firm refusal to implant another transvenous system given the previous extractions he underwent in the past, it was decided to implant a leadless pacemaker with atrioventricular synchrony.

This systematic review aims to evaluate the incidence and predictors of pacemaker-induced cardiomyopathy (PICM) in patients undergoing right ventricular pacing.A literature review was conducted using MeSH terms (Right ventricular pacing, Pacemaker-related cardiomyopathy, Pacemaker-induced cardiomyopathy) in PubMed, EMBASE, Web of science CINAHL, and the Cochrane Library until October 2021. All data reporting the incidence of PICM after implantation of right-sided pacemakers or implantable cardioverter-defibrillator (ICD) were retrieved from the eligible studies.Out of 3,625 articles, 20 studies met the inclusion criteria that included 5,381 patients. . The mean age of the patients ranged between 55.8 ± 13.5 and 77.4 ± 10.8 years. The mean incidence of PICM was 25.7%. Mean ejection fraction (EF) at baseline ranged from 48 ± 1% and 62.1 ± 11.2%, while mean EF at follow-up ranged between 33.7 ± 7.4% and 53.2 ± 8.2%. Three studies reported a decline of20% EF at follow-up. RV pacing was associated with a considerable risk of PICM, with biological factors, such as male gender, old age, increased QRS duration, and chronic RV pacing burden playing an important role in the development of disease.

Left bundle branch block (LBBB) is common in heart failure patients, and could induce dyssynchrony of ventricular contraction, deterioration of cardiac function, and increased mortality. Cardiac resynchronization therapy (CRT) with biventricular pacing reduces ventricular dyssynchrony, heart failure hospitalization, and all-cause mortality in heart failure patients with LBBB. However, there are approximately 30% nonresponders and 10% of patients remain untreated owing to an unsuitable coronary sinus vein. His bundle pacing (HBP) is a more physiological pacing modality which has showed inspiring outcomes in heart failure patients with LBBB, but is limited by implantation challenges, lower success rates, and high pacing capture threshold. Recently, left bundle branch pacing (LBBP), defined as the capture of left bundle branch via transventricular septal approach, has emerged as a newly physiological pacing modality, which is implanted slightly distal to the His bundle. Early clinical studies have demonstrated the procedural feasibility of LBBP with rare complications and high success rate. Recent studies have indicated its potential to be an alternative for CRT. Synchronization effect and the current status of LBBP in the field of CRT are summarized in this paper.

Recently, conduction system pacing, including His bundle and left bundle branch area pacing (LBBAP), has emerged as an alternative pacing procedure for right ventricular (RV) pacing. The current study aimed to compare the clinical outcomes of LBBAP and conventional RV midseptal pacing (RVMSP) in patients with heart failure (HF) with preserved ejection fraction (HFpEF) and HF with midrange ejection (HFmrEF) requiring frequency RV pacing due to atrioventricular block (AVB).A total of 89 patients with HFpEF and HFmrEF requiring RV pacing due to symptomatic AVB were enrolled between September 2018 and April 2021, among whom 43 and 46 underwent LBBAP and RVMSP, respectively.No significant differences in baseline characteristics were observed between the two groups. The LBBAP group had a significantly shorter paced-QRS duration and paced left ventricular activation time (LVAT) compared to the RVMSP group (123.4 ± 10.4 ms vs. 152.3 ± 12.3 ms, p .001 and 68.3 ± 10.0 ms vs. 95.2 ± 12.3 ms, p .001, respectively). The LBBAP group had significantly lower N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at the 6-month follow-up compared to the RVMSP group [459.6 pg/ml (240.4-678.7) vs. 972.7 pg/ml (629.5-1315.9), p = .01]. More patients in the LBBAP group exhibited a significant improvement in NT-proBNP, defined as a 50% decreased from baseline levels.LBBAP maintains physiological ventricular activation and contributes to greater improvement in NT-proBNP value 6 months after implantation in patients with HFpEF and HFmrEF compared to RVMSP.

Syncope, whose cause is unknown after an initial assessment, has an uncertain prognosis. It is critical to identify patients at the highest risk who may require a pacemaker and to identify the cause of recurrent syncope to prescribe proper therapy. The aim of this study was to evaluate the effect of permanent pacing on the incidence of syncope in patients with unexplained syncope and electrophysiology study (EPS)-proven atrioventricular (AV) node disease.This was an observational study based on a prospective registry of 236 consecutive patients (60.20 ± 18.66 years, 63.1% male, 60.04 ± 9.50 bpm) presenting with recurrent unexplained syncope attacks admitted to our hospital for invasive EPS. The decision to implant a permanent pacemaker was made in all cases by the attending physicians according to the results of the EPS. A total of 135 patients received the antibradycardia pacemaker (ABP), while 101 patients were declined.The mean of reported syncope episodes was 1.97 ± 1.10 (or presyncope 2.17 ± 1.50) before they were referred for a combined EP-guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (49.19 ± 29.58 months), the primary outcome event (syncope) occurred in 31 of 236 patients (13.1%), and 6 of 135 (4.4%) patients in the ABP group as compared to 25 of 101 (24.8%) in the no pacemaker group (p 0.001).Among patients with a history of unexplained syncope, a set of positivity criteria for the presence of EPS-defined AV node disease identifies a subset of patients who will benefit from permanent pacing.

Limited evidence guides management of conduction abnormalities following TAVR. Standardized clinical pathways may reduce variability in care while minimizing bradyarrhythmic morbidity, length of stay (LOS), and pacemaker (PPM) implantation rates.A multidisciplinary consensus pathway to standardize post-TAVR management was developed. We evaluated (1) pathway adherence; (2) LOS; (3) PPM implantation rates; (4) 1-month survival, and (5) late heart block. Exploratory analyses evaluated factors associated with PPM implantation.A total of 181 consecutive patients without prior PPM who underwent TAVR between February 2020 and February 2021 (mean age 77.9 ± 9.1, 38% women) were included. Average LOS was 3.0 days (± 2.7), and no deaths related to syncope/bradyarrhythmia were reported by 1 month. Overall, 93% of the 181 patients were managed by pathway; deviations were due to failure of discharge with a heart monitor when it was clinically indicated for either pre-existing RBBB or new PR prolongation/new LBBB. PPM implantation occurred in 19 patients by discharge, and 21 by 1-month (13%). In our exploratory analysis, pre-existing RBBB, transient peri-procedural heart block, and LOTUS valves were associated with pacemaker implantation: OR (CI) of 8.16 (3.06-21.78), 6.83 (1.94-24.03), and 8.32 (1.11-62.49), respectively.This report illustrates that a standardized protocol for the management of conduction abnormalities after TAVR can be implemented with high compliance, safe management of conduction disturbance, and relatively short LOS with discharge supported by ambulatory monitoring.