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Transvenous lead failure associated with cardiac pacing and defibrillation remains an important clinical problem, with an estimated incidence between 1 to 2%. Oversensing of non-physiological signals usually precede lead impedance changes and may result in clinical compliations such as pacing inhibition and inappropriate shocks. Device based algorithms that identify non-physiological signals can be used in conjunction with remote monitoring to facilitate early diagnosis and management of lead failure and avoid serious adverse outcomes. This review highlights mechanisms of lead failure and proposes a diagnostic approach to suspected lead failure. [ABSTRACT FROM AUTHOR]

The Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) has emerged as a promising tool in preventing sudden cardiac death, with fewer complications reported in industry-supported trials from experienced centers. Nonetheless, its broader applicability and long-term real-world outcomes warrant comprehensive evaluation. The study aimed to provide independent long-term S-ICD outcomes. The HONEST study, a nationwide observational study, enrolled all patients receiving S-ICDs in France between 2012 and 2019. These patients are followed by telecardiology and routine clinical follow-ups, with meticulous event adjudication. Out of 5015 patients implanted with S-ICD in France, 4924 (98.2%) were enrolled in the study (mean age 49.9 ± 15.0 years, 23.31% females, 21.79% with electrical heart disease, 36.7% for secondary prevention, mean left ventricular ejection fraction 42.3 ± 16.8%). The cumulative incidence of appropriate shocks increased from 5.10% in the first year to 14.62% by the fifth year (Fig. 1). Early (within 30 days) post implant complications occurred in 3.61%, mainly local complications: infections (0.72%), pocket hematomas (0.94%), and poor wound healing (0.48%). One-year and five-year rates of complications escalated from 9.45% to 27.06% respectively, including inappropriate shocks (5.05% to 13.79%), infection (1.77% to 2.40%), Lead issues (0.21% to 1.47%), premature battery depletion (0.35% to 8.76%), and chronic discomfort (0.28% to 1.42%). Implantation of a pacing system was necessary in 3.09% at 5 years. Definitive S-ICD removals rose to 8.24% by the fifth year, predominantly due to complications, pacing needs, and heart transplant. Among the 547 deaths in the cohort, 51.74% were cardiovascular-related, with 8 directly associated with S-ICD complications and 23 cases of unexplained sudden cardiac deaths. The HONEST study advocates for the S-ICD's broader applicability and emphasizes a personalized approach to optimize outcomes. [ABSTRACT FROM AUTHOR]

Pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs) increasingly automatically record and remotely transmit nonsustained ventricular tachycardia (NSVT) episodes, which may reveal ventricular oversensing. We aimed to develop and validate a machine learning algorithm that accurately classifies NSVT episodes transmitted by PMs and ICDs in order to lighten health care workload burden and improve patient safety. PMs or ICDs (Boston Scientific, St Paul, MN) from 4 French hospitals with ≥1 transmitted NSVT episode were split into 3 subgroups: training set, validation set, and test set. Each NSVT episode was labeled as either physiological or nonphysiological. Four machine learning algorithms—2DTF-CNN, 2D-DenseNet, 2DTF-VGG, and 1D-AgResNet—were developed using training and validation data sets. Accuracies of the classifiers were compared with an analysis of the remote monitoring team of the Bordeaux University Hospital using F2 scores (favoring sensitivity over predictive positive value) using an independent test set. A total of 807 devices transmitted 10,471 NSVT recordings (82% ICD; 18% PM), of which 87 devices (10.8%) transmitted 544 NSVT recordings with nonphysiological signals. The classification by the remote monitoring team resulted in an F2 score of 0.932 (sensitivity 95%; specificity 99%) The 4 machine learning algorithms showed high and comparable F2 scores (2DTF-CNN: 0.914; 2D-DenseNet: 0.906; 2DTF-VGG: 0.863; 1D-AgResNet: 0.791), and only 1D-AgResNet had significantly different labeling from that of the remote monitoring team. Machine learning algorithms were accurate in detecting nonphysiological signals within electrograms transmitted by PMs and ICDs. An artificial intelligence approach may render remote monitoring less resourceful and improve patient safety. [Display omitted] [ABSTRACT FROM AUTHOR]

New-onset left bundle branch block (LBBB) is one of the most frequent complications after transcatheter aortic valve implantation (TAVI) and is associated with delayed high degree atrioventricular (AV) block. The objectives of this study were to determine the incidence of AV block in such a population and to assess the performance and safety of a risk stratification algorithm on the basis of electrophysiology study (EPS) followed by implantation of a pacemaker or implantable loop recorder (ILR). This was a prospective open-label study with 12-month follow-up. From June 8, 2015, to November 8, 2018, 183 TAVI recipients (mean age 82.3 ± 5.9 years) were included at 10 centers. New-onset LBBB after TAVI persisting for >24 hours was assessed by electrophysiology study during initial hospitalization. High-risk patients (His-ventricle interval ≥70 ms) were implanted with a dual-chamber pacemaker recording AV conduction disturbance episodes. Patients at lower risk were implanted with an ILR with automatic remote monitoring. A high-grade AV conduction disorder was identified in 56 patients (30.6%) at 12 months. Four subjects were symptomatic, all in the ILR group. No complications were associated with the stratification procedure. Patients with His-ventricle interval ≥70 ms displayed more high-grade AV conduction disorders (53.2% [25 of 47] vs 22.8% [31 of 136]; P <.001). In a multivariate analysis, His-ventricle interval ≥70 ms was independently associated with the occurrence of a high-grade conduction disorder (subdistribution hazard ratio 2.4; 95% confidence interval 1.2–4.8; P =.010). New-onset LBBB after TAVI was associated with high rates of high-grade AV conduction disturbances. The stratification algorithm provided safe and valuable aid to management decisions and reliable guidance on pacemaker implantation. [Display omitted] [ABSTRACT FROM AUTHOR]

Until recently, remote interrogation and reprogramming of therapeutic cardiac implantable electronic devices (CIEDs) have been virtually nonexistent owing to technical challenges and safety concerns. It could be extremely useful, in particular in case of emergencies, when patients live far from CIED professionals or during enforced physical distancing. We investigated the feasibility and safety of a custom solution for remote interrogation and reprogramming of CIEDs from various manufacturers in various clinically relevant situations. Our solution consists of remote controlling CIED programmers through screen capture and remote cursor control. In this multicenter feasibility study, the primary outcome was technical feasibility (% of success) and safety (absence of complication) of interrogation and reprogramming when indicated in clinically driven encounters. A total of 115 remote interrogations were performed in 110 patients: within the hospital (n = 73), medium range (50–100 km; n = 22), and long range (>5000 km; n = 20). Implanted devices were pacemakers (n = 85) and implantable cardioverter-defibrillators (n = 25) from Abbott (N=13), Biotronik (n = 65), and MicroPort (n = 32). Patients were located in the outpatient clinic, cardiology department, radiology department (magnetic resonance imaging), operating room (per implantation), and intensive care unit. Teleworking was performed in 39 cases. Complete CIED interrogations succeeded in all patients with reprogramming in 56 of 115 sessions (49%). No clinical or technical complications occurred. The time lag for screen interaction was below 1 second. Remote interrogation and reprogramming of CIEDs are feasible and safe across disparate clinical contexts and distances. This strategy may enhance health care access and facilitate medical training, tele-expertise, and telework worldwide. [Display omitted] [ABSTRACT FROM AUTHOR]

The Micra AV leadless pacemaker offers atrioventricular (AV) synchronous pacing by sensing atrial mechanical contraction. However, outcomes have only been reported through 6 months from experienced centers in a limited number of patients. Real-world data are needed. The main outcomes were the overall and major complications rate, as well as the incidence of upgrade for transvenous dual-chamber pacemaker. Major complications were defined as death, requirement of intervention, pacemaker syndrome, system revision, loss of device function, or failure to achieve AV synchrony leading to a shift to VVI mode pacing. The AV-CESAR is a retrospective, multicenter nationwide single-arm observational study, designed to assess the Micra AV in the first 1000 patients in France (NCT05953558). The device was successfully implanted in 830 out of 837 patients included (99.2%). The mean age was 72.3 ± 14.9 years, with 37.3% females. A significant proportion of patients presented with multiple severe comorbidities, including congestive heart failure (50%), cancer (30%), and conditions precluding transvenous pacing (50%). The most common indication (79.3%) was complete AV block with preserved sinus node function. The mean ventricular pacing percentage was 55 ± 12%. The mean follow-up was 13.8 ± 5.2 months. The Kaplan–Meier estimate of the 12-month freedom from major complications was 89.0% (95% CI: 86.5–91.4%) (Fig. 1), with a 2.5% of early (pre-hospital discharge) major complications (1% of cardiac injuries, 0.8% of vascular issues, and 2 deaths related to the device) and 11.5% of late (post hospital discharge) major complications. Among them, 24 (2.9%) patients developed pacemaker syndrome, 11 (1.3%) experienced a delayed pacing threshold rise (>2 V @ 0.24 ms), 2 patients (0.2%) had early battery depletion (< 24 months), and 50 patients (6.1%) failed to achieve AV synchrony leading to a switch into VVI mode. A total of 18 (2.2%) patients received an alternative pacing system: 5 patients (0.6%) underwent dual-chamber pacemaker upgrade for pacemaker syndrome, 7 patients (1%) were upgraded for pacing-induced cardiomyopathy, and 6 patients (0.7%) underwent conventional pacemaker implant for device dysfunction. This first real-world large registry on AV Micra demonstrates good results of mid-term follow-up in patients with a high level of pacing requirement, especially in individuals with medical conditions precluding traditional dual chamber pacing. [ABSTRACT FROM AUTHOR]

Background: While prior Micra trials demonstrated a high implant success rate and favorable safety and efficacy results, changes in implant populations and safety over time is not well studied. The objective of this analysis was to report the performance of Micra in European and Middle Eastern patients and compare to the Micra Investigational Device Exemption (IDE) and Micra Post Approval Registry (PAR) studies. Methods: The prospective, single‐arm Micra Acute Performance European and Middle Eastern (MAP EMEA) registry was designed to further study the performance of Micra in patients from EMEA. The primary endpoint was to characterize acute (30‐day) major complications. Electrical performance was analyzed. The major complication rate through 12 months was compared with the IDE and PAR studies. Results: The MAP EMEA cohort (n = 928 patients) had an implant success rate of 99.9% and were followed for an average of 9.7 ± 6.5 months. Compared to prior studies, MAP EMEA patients were more likely to have undergone dialysis and have a condition which precluded the use of a transvenous pacemaker (p <.001). Within 30 days of implantation, the MAP EMEA cohort had a major complication rate of 2.59%. Mean pacing thresholds were low and stable through 12 months (0.61 ± 0.40 V at 0.24 ms at implant and 12 months). Through 12 months post‐implantation, the major complication rate for MAP EMEA was not significantly different from IDE (p =.56) or PAR (p =.79). Conclusion: Despite patient differences over time, the Micra leadless pacemaker was implanted with a high success rate and low complication rate, in‐line with prior reports. [ABSTRACT FROM AUTHOR]

Background: In repaired tetralogy of Fallot (TOF), little is known about characteristics of patients with rapid ventricular tachycardia (VT). Also, whether patients with a first episode of nonrapid VT may subsequently develop rapid VT or ventricular fibrillation (VF) has not been addressed.Objectives: The objectives of this study were to compare patients with rapid VT/VF with those with nonrapid VT and to assess the evolution of VT cycle lengths (VTCLs) overtime.Methods: Data were analyzed from a nationwide registry including all patients with TOF and implantable cardioverter-defibrillator (ICD) since 2000. Patients with ≥1 VT episode with VTCL ≤250 ms (240 beats/min) formed the rapid VT/VF group.Results: Of 144 patients (mean age 42.0 ± 12.7 years; 104 [72%] men), 61 (42%) had at least 1 VT/VF episode, including 28 patients with rapid VT/VF (46%), during a median follow-up of 6.3 years (interquartile range 2.2-10.3 years). Compared with patients in the nonrapid VT group, those in the rapid VT/VF group were significantly younger at ICD implantation (35.2 ± 12.6 years vs 41.5 ± 11.2 years; P = .04), had more frequently a history of cardiac arrest (8 [29%] vs 2 [6%]; P = .02), less frequently a history of atrial arrhythmia (11 [42%] vs 22 [69%]; P = .004), and higher right ventricular ejection fraction (43.3% ± 10.3% vs 36.6% ± 11.2%; P = .04). The median VTCL of VT/VF episodes was 325 ms (interquartile range 235-429 ms). None of the patients with a first documented nonrapid VT episode had rapid VT/VF during follow-up.Conclusion: Patients with TOF and rapid VT/VF had distinct clinical characteristics. The relatively low variation of VTCL over time suggests a room for catheter ablation without a backup ICD in selected patients with well-tolerated VT.Trial Registration: Clinicaltrials.gov identifier: NCT03837574. [ABSTRACT FROM AUTHOR]

Patients who have undergone cervical surgery may present pain and dysfunction in the upper limb, which is often referred to as failed neck surgery syndrome. Little is known about the effects of an exercise program plus manual therapy in the treatment of prolonged neuropathic pain of the upper quadrant in a patient with failed neck surgery. A 66-year-old woman consulted for neuropathic pain and dysfunction during grasping activities, as a result of failed neck surgery after 12 months. Clinical, functional, and electromyographic measurements were recorded at baseline and after treatment. The patient underwent a treatment for six weeks based on manual therapy for the upper limb and cervical spine and an exercise program for the scapular muscles, rotator cuff and wrist extensor muscles. Positive clinically significant changes were observed in the Neuropathic Pain Questionnaire (DN4) (baseline = 7 points; post-treatment = 4 points), Neck Disability Index (NDI) (baseline = 36; post-treatment = 18 points), QuickDASH (baseline = 78; post- treatment = 32 points), Upper Limb Neurodynamic Test 1 (ULNT-1) (baseline = 75°; post- treatment = 42°) and grip strength (GS) (baseline = 23 kgf; post-treatment = to 32 kgf). Improvements in the surface electromyographic (sEMG) activity of the upper trapezius (UT), infraspinatus (IS) and radial wrist extensors (RWE) muscles also seemed to occur after treatment. Treatment helped relieve neuropathic pain, decrease neck disability, and improve general upper limb function. [ABSTRACT FROM AUTHOR]

The degree and pattern of conduction disease seem determinant when assessing potential cardiac resynchronization therapy (CRT) candidates. In the present review, the authors discuss the available noninvasive techniques that can be used to acquire ventricular activation time maps. They describe what body surface mapping has taught us about left bundle branch block, right bundle branch block, intraventricular conduction delay, and right ventricular pacing and discuss the ability of derived parameters of electrical dyssynchrony to predict long-term clinical response to CRT or His bundle pacing. [ABSTRACT FROM AUTHOR]

Initially, left ventricular (LV) endocardial pacing was performed as a bailout procedure after unsuccessful transvenous cardiac resynchronization therapy implantation in the presence of surgical contraindications. Additional possible advantages of endocardial LV pacing are a more physiologic activation, being less arrhythmogenic, more effective on the hemodynamic level, with better thresholds, and without the risk of phrenic stimulation. Different techniques have been proposed to stimulate the LV endocardium in humans, with feasibility and safety studies involving limited numbers of patients. In this review, we will describe the different techniques proposed to allow LV endocardial pacing, the results observed, and then we will discuss the reasons why LV endocardial pacing seems to be out of fashion today and what are the possible perspectives for development. [ABSTRACT FROM AUTHOR]