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Background: Leadless pacemaker (LP) therapy has been proved effective in cases where traditional transvenous right pacing (TRP) failed. TRP through a bioprosthetic tricuspid valve (BTV) has always been considered an unpreferable solution because of possible deleterious effect of permanent pacing leads on BTV function and specifically on tricuspid regurgitation (TR). Very limited data exist about the feasibility and safety of LP implantation in this setting. Methods: We describe two cases of LP implantation through BTV in patients with failure of epicardial pacemaker implanted after cardiac surgery. The focus is on technical description of the procedure and on electrical and echocardiographic evaluation at implantation and at the follow‐up. Results: In both cases, skilled and careful handling of the delivery system as well as proper use of X‐ray oblique views was determinant for atraumatic successful valve crossing. Likewise, an accurate selection of the deployment site inside the right ventricle, far enough from the valve to avoid valvular dysfunction, was important for successful implantation. Electrical parameters of LP were satisfying at implantation and at the follow‐up. The echocardiogram after implantation and at the follow‐up showed no mechanical interference of LP with prosthetic valve, no significant TR, and absence of significant changes in the biventricular function. Conclusion: Our data seem to support feasibility and safety of this type of procedure in skilled hands, allowing efficacious pacing without valvular dysfunction or right ventricular (RV) physiology impairment. [ABSTRACT FROM AUTHOR]

Introduction: Early evidence suggests that multipoint left ventricular pacing (MPP) may improve response to cardiac resynchronization therapy (CRT). It is unknown whether this benefit is sustained and cost‐effective. We used real‐world data to evaluate long‐term impact of MPP‐ON clinical status, heart failure hospitalizations (HFH) and costs. Methods: The Italian registry on multipoint left ventricular pacing is a prospective, multicenter registry of patients implanted with MPP‐enabled CRT devices. For this analysis, clinical and echocardiographic data were collected through 24 months and compared between patients with (MPP‐ON) or without (MPP‐OFF) early MPP activation at implant. The total cost of each HFH was estimated with national Italian reimbursement rates. Results: The study included 190 MPP‐OFF and 128 MPP‐ON patients with similar baseline characteristics. At 1 and 2 years, the MPP‐ON group had lower rates of HFH vs MPP‐OFF (1‐year hazard ratio [HR]: 0.14, P =.0014; 2‐year HR: 0.38, P =.009). The finding persisted in a subgroup of patients with consistent MPP activation through follow‐up (1‐year HR: 0.19; P =.0061; 2‐year HR: 0.39, P =.022). Total HFH per‐patient costs were lower in the MPP‐ON vs the MPP‐OFF group at 1 year (€101 ± 50 vs €698 ± 195, P <.001) and 2 years (€366 ± 149 vs €801 ± 203, P =.038). More MPP‐ON patients had ≥5% improvement in ejection fraction (76.8% vs 65.4%, P =.025) and clinical composite score (66.7% vs 47.5%, P =.01). Conclusions: In this multicenter clinical study, early MPP activation was associated with a significant reduction in cumulative HFH and related costs after 1 and 2 years of follow‐up. [ABSTRACT FROM AUTHOR]

Background: Multipoint pacing (MPP) may improve clinical outcomes in patients with cardiac resynchronization therapy defibrillators (CRT‐D), but its impact on battery longevity in a real‐world population has not been investigated in large trials. Objective: Compare projected battery longevity in CRT‐D patients with and without MPP during long‐term follow‐up. Methods: The Italian registry on multipoint left ventricular pacing (IRON‐MPP) is a prospective, multicenter registry of patients implanted with MPP‐capable CRT‐D devices. Projected battery longevity during follow‐up was compared for patients with MPP (MPP ON) vs single‐site (MPP OFF) left ventricular pacing at CRT‐D implantation. A sub‐analysis excluded crossover patients with MPP activation or deactivation occurring after implantation. A second sub‐analysis excluded patients with a right or left ventricular pacing amplitude >2.5 V. Results: Out of 237 CRT‐D patients (71 ± 9 years, 81% male) followed for 1.9 ± 0.8 years, 102 (43%) had MPP ON at implantation. Programmed atrial and ventricular outputs and percentage of pacing were similar between groups. MPP was associated with a 0.44 years reduction in projected battery longevity (P = .03) during long‐term follow‐up. Results were similar for the first and second sub‐analyses, with a 0.57 years (P < .001) and 0.71 years (P < .001) reduction in projected longevity, respectively. Conclusion: In this long‐term real‐world registry, early MPP activation is associated with less than a 1‐year reduction in projected battery life compared to single‐site biventricular pacing. [ABSTRACT FROM AUTHOR]

Background: Various lead designs have been developed to accommodate different coronary sinus anatomies. Our objectives were to compare electrical parameters of straight and spiral left ventricular leads, to evaluate capture thresholds and impedances using different pacing vectors, and to study evolution of thresholds over time. Methods: The RALLY‐X4 study enrolled patients implanted with a lead from the Acuity X4 family (straight, spiral short, or spiral long). Electrical parameters (including capture thresholds from all 17 vectors) were measured at baseline and follow‐up. Results: Data from 795 patients who were successfully implanted were analyzed. Straight and spiral leads had similar proportions of patients with thresholds <2.5 V/0.4 ms using the distal electrode (61‐65% of patients) or from at least one of the proximal (E2‐E4) electrodes (81‐83% of patients). Unipolar vectors had significantly lower thresholds and impedances than bipolar vectors, with similar measurements compared to extended bipolar configurations. Capture thresholds increased with more proximal electrodes for all leads. Over a mean follow‐up of 1 year, a slight decrease in capture thresholds was observed. Conclusion: Straight and spiral quadripolar leads allow to obtain clinically acceptable capture thresholds from at least one of the proximal electrodes in >80% of patients. Pacing vectors significantly affect electrical parameters, with higher thresholds in more proximal electrodes and lower thresholds with unipolar and extended bipolar configurations. Capture thresholds slightly decreased over a mean follow‐up of 1 year. [ABSTRACT FROM AUTHOR]

Aims: We sought to determine whether atrioventricular junction ablation (AVJA) in patients with cardiac resynchronization therapy (CRT) implantable cardioverter-defibrillator (ICD) and with permanent atrial fibrillation (AF) has a positive impact on ICD shocks and hospitalizations compared with rate-slowing drugs.Methods and Results: This is a pooled analysis of data from 179 international centres participating in two randomized trials and one prospective observational research. The co-primary endpoints were all-cause ICD shocks and all-cause hospitalizations. Out of 3358 CRT-ICD patients (2720 male, 66.6 years), 2694 (80%) were in sinus rhythm (SR) and 664 (20%) had permanent AF-262 (8%) treated with AVJA (AF + AVJA) and 402 (12%) treated with rate-slowing drugs (AF + Drugs). Median follow-up was 18 months. The mean (95% confidence intervals) annual rate of all-cause ICD shocks per 100 patient years was 8.0 (5.3-11.9) in AF + AVJA, 43.6 (37.7-50.4) in AF + Drugs, and 34.4 (32.5-36.5) in SR patients, resulting in incidence rate ratio (IRR) reductions of 0.18 (0.10-0.32) for AF + AVJA vs. AF + Drugs (P < 0.001) and 0.48 (0.35-0.66) for AF + AVJA vs. SR (P < 0.001). These reductions were driven by significant reductions in both appropriate ICD shocks [IRR 0.23 (0.13-0.40), P < 0.001, vs. AF + Drugs] and inappropriate ICD shocks [IRR 0.09 (0.04-0.21), P < 0.001, vs. AF + Drugs]. Annual rate of all-cause hospitalizations was significantly lower in AF + AVJA vs. AF + Drugs [IRR 0.57 (0.41-0.79), P < 0.001] and SR [IRR 0.85 (073-0.98), P = 0.027].Conclusion: In AF patients treated with CRT, AVJA results in a lower incidence and burden of all-cause, appropriate and inappropriate ICD shocks, as well as to fewer all-cause and heart failure hospitalizations.Clinical Trial Registration: NCT00147290, NCT00617175, NCT01007474. [ABSTRACT FROM AUTHOR]

Apatient with Brugada syndrome implantedwith subcutaneous implantable cardioverter defibrillator (S-ICD) had oversensing episodes treated with S-ICD shocks. Comparable artifacts were not evocable with S-ICD pocket manipulation. The fluoroscopy excluded S-ICDmacroscopic damage. The device extraction revealed undamaged pulse generator and connector, but the lead was inappropriately tunneled under the sixth rib. Then the S-ICD malfunction was due to lead microscopic damage caused by the lead rubbing the rib surface. [ABSTRACT FROM AUTHOR]

A 77‐year‐old patient, with permanent atrial fibrillation, underwent successful Micra transcatheter pacing system (MTPS) implantation. Once begun the pull‐back of the tether, an increasing resistance was felt by the operator until complete blockage. A challenging recapture of MTPS into the delivery system was performed. The retrieved MTPS showed an indissoluble knot close to the docking button that blocked the running of the tether, and a long clot inside the delivery system. The new design of internal handle components of MTPS recently updated seems to favor clot formation. We suggest a reconsideration of the standard recommendations about delivery system flushing and design of the inner flushing tube system. [ABSTRACT FROM AUTHOR]

Background: Outpatient electrical cardioversion (EC) of atrial fibrillation is currently the standard of care. Shock-related arrhythmias may be particularly deleterious in this setting. Preoperative identification of high-risk patients may be very useful. Methods: A retrospective analysis was made of 543 consecutive elective EC procedures in 457 outpatients over an 8-year period in a university cardiological institute. The protocol included adequate anticoagulation, intravenous anesthesia, direct current shock, and a direct observation after a shock to detect procedure-related complications. No patients were excluded due to severity of pathology or comorbidities. Clinical characteristics, energy delivered, medications, arrhythmic phenomena, and predictors of success and complications were analyzed. Results: Of 543 ECs performed, 88.2% restored sinus rhythm, which persisted at discharge in 83.2%. No anesthesia-related complications were detected. No thromboembolic complications were detected. Use of a biphasic cardioverter was the only predictor of success (P = 0.0001). The bradyarrhythmic complication rate was 1.5%. No ventricular arrhythmic events were detected. Atrial flutter was present in five of eight patients who developed complications versus 44 of 535 patients who had no complications (P < 0.0005), and prosthetic heart valves in four of eight complicated versus 40 of 535 uncomplicated cases (P = 0.0044). The combination of atrial flutter and prosthetic heart valve was found in four of eight complicated versus 11 of 535 uncomplicated cases (P < 0.0005). Conclusion: Shock-related arrhythmias are essentially bradyarrhythmias. Atrial flutter and previous cardiac surgery identify a subgroup of patients at high risk of postshock bradyarrhythmic complications. [ABSTRACT FROM AUTHOR]