New developments in cardiac device therapy

The systemic right ventricle (SRV), defined as the morphological right ventricle supporting the systemic circulation, is relatively common in congenital heart disease (CHD). Our review aimed at examining the current...

Background: The incidence of heart failure (HF) is rapidly increasing, introducing a significant burden and challenges in clinical practice. Non-pharmacological cardiac device therapy has been established as an essential component of optimal HF management, particularly for the prevention of sudden cardiac death and the improvement of HF symptoms, left ventricular (LV) systolic function, quality of life, and eventually survival.Current Concepts: Cardiac resynchronization therapy (CRT) can correct atrioventricular or inter/intraventricular dyssynchrony, thereby improving LV systolic function. Recently, the concept of CRT is being expanded, including His bundle (HB), HB-optimized LV, left bundle branch (LBB), and LBB optimized LV pacing CRTs. Newly introduced CRT approaches by stimulating the cardiac conduction system are expected to correct dyssynchrony better and consequently exhibit better CRT outcomes than the conventional biventricular pacing CRT. The current versions of implantable cardioverter-defibrillators (ICDs) or CRT devices can continuously monitor multiple biosignals. CRT/ICD can calculate a single index by combining these multiple bio-signal data for early detection of HF aggravation. Recently, subcutaneous and transvenous ICDs showed comparable safety and efficacy in HF patients. In drug-refractory HF patients without LV dyssynchrony, cardiac contractility modulation therapy provides some promising results.Discussion and Conclusion: Recent technological advancements have improved the efficacy and safety of cardiac device therapy. Therefore, cardiac device therapy should be used more actively to manage HF patients better.

The term ‘device therapy’ is used in cardiology to refer to three different types of implantable cardiac-rhythm-management devices: pacemakers, implantable cardioverter defibrillators (also known as ICDs), and cardiac resynchronization therapy devices (also known as CRT devices). There has been a steady increase in the number of patients receiving these cardiac devices; in relation to CRT devices, the increase has been almost exponential.

Cardiovascular diseases (CVDs) and chronic kidney disease (CKD) are frequently interconnected and their association leads to an exponential increase in the risk of both fatal and non-fatal events. In addition, the burden of arrhythmias in CKD patients is increased. On the other hand, the presence of CKD is an important factor that influences the decision to pursue cardiac device therapy. Data on CKD patients with device therapy are scarce and mostly derives from observational studies and case reports. Cardiac resynchronization therapy (CRT) is associated with decreased mortality, reduced heart failure symptoms, and improved renal function in early stages of CKD. Implantable cardioverter defibrillators (ICDs) are associated with a significant reduction in the mortality of CKD patients only for the secondary prevention of sudden cardiac death. Cardiac resynchronization therapy with defibrillator (CRT-D) is preferred in patients who meet the established criteria. The need for cardiac pacing is increased three-fold in dialysis patients. CKD is an independent risk factor for infections associated with cardiac devices.

Cardiac magnetic resonance (CMR) imaging may allow more appropriate selection of patients for cardiac device implantation and/or cardiac surgery. In this prospective observational study we evaluated the impact of CMR imaging on cardiac device and surgical therapy. All CMR examinations performed in a single centre over a 2 year period were prospectively recorded in a dedicated database under 4 clinical pathways [cardiomyopathy, viability, tumour/mass and arrythmogenic right ventricular cardiomyopathy (ARVC)]. Baseline data entered included planned cardiac device implantation and/or cardiac surgical intervention. Patients were contacted 6 months following CMR to evaluate the impact of CMR on planned therapy. Cost savings due to CMR were calculated as the number of surgical or device procedures averted following CMR scanning multiplied by their respective cost weights. Of 732 CMR examinations performed, the clinical pathway was cardiomyopathy in 488 (67 %), ARVC in 118 (16 %), viability in 92 (12 %) and tumour/mass in 34 (5 %). Six month follow-up was available in 666/732 patients. Following CMR, 56/150 (37 %) of patients with an initial plan for device implantation or cardiac surgery, did not undergo the planned intervention (P < 0.001, one-sample exact binomial test). Of 516 patients without an initial device or surgical plan, 33 (6 %) CMR resulted in device implantation or cardiac surgery (P < 0.001, Chi squared). Overall, the estimated saving due to CMR-guided management changes was AUD$737,270. CMR has a significant impact on patient management and offers potential cost savings with respect to selection of device and surgical therapy for cardiac disease.

Cardiac pacing and device therapy / , Cardiac pacing and device therapy / , کتابخانه دیجیتال جندی شاپور اهواز

The 7th international Dead Sea symposium (IDSS) on cardiac arrhythmias and device therapy was held in Tel Aviv from October 17–20th 2004. Those who have attended some of the earlier IDSS conferences already knew that this meeting is worth while and colleagues who participated for the first time will confirm that the 7th IDSS was a very successful congress, despite being in Tel Aviv rather than the marvellous landscape surrounding the Dead Sea. There were more than 400 attendees from 21 countries, experts in electrophysiology and physicians in training enjoyed lectures given by faculties from 12 different countries. The IDSS congress offered new science, reviews of current knowledge in the field of pacing and implantable cardioverter defibrillator (ICD) therapy, excellent training courses, “how to” workshops on physiological pacing, management of difficult ICD implantations, and a live demonstration of echocardiographic assessment of haemodynamic improvement after cardiac resynchronization with biventricular pacing (given by M.V. Pitzalis and M. Feinberg). Of note was the idea to arrange a session for physicians in internal medicine to raise issues with specialists in electrophysiology and for the latter to discuss the relevant cardiology. This included dyslipidemia, diabetes mellitus, hypertension, renal failure and syncope in the elderly – all in the context of arrhythmias. …

Heart failure: Cardiac device therapy in elderly patients—insights from 'real world' practice

A major issue of cardiac implantable electronic device therapy in pediatric patients is the high incidence of lead dysfunctions and associated reinterventions. This study aims to analyze the timing and mode of generator and lead dysfunction. Retrospective single-center analysis of 283 children and young adults with an epicardial pacemaker or implantable cardioverter defibrillator therapy from 1998 to 2018. Mean age at implant was 6.1 years (SD±5.8 years) and median follow-up 6.4 years (IQR, 3.4-10.4 years) with a total of 1998.1 patient-years of cardiac device therapy. A total of 120 lead-related complications were observed in 82 patients (29.0%). They were detected by device interrogation (n=86), symptoms (n=13), intraoperative findings (n=7), routine chest radiography (n=5), routine ECG (n=4), patient alert sound by device (n=3), and physical examination (n=2). It was possible to find the date of the event on the device memory in 21 out of 120 lead dysfunctions (18%) with a median time interval between occurrence and detection of 1.3 months (IQR, 0.2-5.0 months). Moreover, 20 generator-related complications were found in 13 patients. Early recognition of lead and generator dysfunction remains challenging in pediatric patients. As symptoms are relatively rare conditions in the context of PM and ICD dysfunction, close patient monitoring is mandatory, even in asymptomatic patients with a good clinical course. To further improve the safety of pediatric pacing systems, more durable epicardial electrodes are desirable.

Guidelines help clinicians to deliver high-quality care with therapies based on up-to-date evidence. There has been significant progress in the management of heart failure with regards to both medication and cardiac device therapy. These advances have been incorporated into national and international guidelines with varying degrees of success. This article reviews current guidance from the National Institute of Health and Care Excellence in the UK and compares this with European Society of Cardiology guidelines, and evaluates how differences between them may impact on clinical practice.

Introduction: The National Institute for Health and Care Excellence (NICE) published guidelines on implantable cardioverter defibrillators (ICD) in 2006 and cardiac resynchronisation therapy (CRT) in 2007. Since then, trials have shown benefit in additional populations including ICDs in non-ischaemic cardiomyopathy and CRT in patients with atrial fibrillation or less symptomatic heart failure, while echocardiography dyssynchrony has shown low correlation with clinical response. NICE's 2014 device therapy guidelines recognise these changes. We sought to explore the impact of these updated guidelines on our patient population, and their implications for future device implantation practice. Methods: The clinical and pacing notes of 223 patients receiving an ICD, CRT-P or CRT-D between April 2006 and December 2007 were reviewed to establish what device was recommended by contemporary NICE guidance at implantation. 2014 guidelines were then applied to the same population to determine their potential impact. Results: 170 patients received an ICD of whom 89 had records available for audit. 71 patients received CRT-P and 63 received CRT-D, all of whom were audited. Mean age was 64.5, 72.2 and 65.5 years and females accounted for 15%, 34% and 13% in the three groups respectively. Defibrillators were implanted for secondary prevention in 64/152 (42%) patients. The device implanted, the device indicated by the 2006/07 guidelines and that recommended by applying the 2014 guidelines are compared in figure 1. The device patients received did not always fulfil NICE guidance. Reasons included implantation of primary prevention ICDs in patients with non-ischaemic cardiomyopathy or chanelopathy (24), CRT in AF (23) or NYHA class 2 (15) not fulfilling certain investigative criteria such as echocardiographic dyssynchrony (16) or non-sustained and inducible VT (12), or patient choice, e.g. in declining a defibrillator when receiving CRT (2). The main effect of the 2014 guidance is a 51% increase number of CRT devices indicated - 85 in 2006/7 to 128 in 2014. Many investigations are now not required, including 25 dyssynchrony echos, 20 Holter monitors and 14 VT stimulation studies. Seventy-eight patients from the original cohort survived to generator replacement of whom five were upgraded to CRT-D, two were upgraded from single to dual chamber devices and 11 had device or lead revisions (predominantly due to lead advisories). One patient chose to have their device downgraded from CRT-D to CRT-P. Conclusions: New NICE guidance for device therapy increases the numbers of patients with both CRT and ICD indications. The most significant change is however, the increasing number of patients for whom CRT is recommended, highlighting the need for careful consideration of the patient's clinical condition and treatment preference, particularly as more patients now approach generator change. ![Graphic][1] [1]: /embed/inline-graphic-1.gif

ObjectivesTo identify differences in patient characteristics, clinical practice and outcomes of cardiac implantable electronic device (CIED) therapy between Japan and the USA.DesignA cross-sectional study.SettingNationally representative administrative databases from Japan and...

IntroductionThe role of cardiac implantable electronic device (CIED) therapy in patients with ATTR-wt (senile) amyloid is not very well defined. It is unknown whether there is mortality benefit or harm...

Cardiac device therapy provides not only treatment options for bradyarrhythmia but also advanced treatment for heart failure and preventive measures against sudden cardiac death. In heart failure treatment it enables synergistic reverse remodelling and reduces pharmacological side effects. Cardiac resynchronization therapy (CRT) has revolutionized the treatment of reduced left ventricular ejection fraction (LVEF) and left bundle branch block by decreasing the mortality and morbidity with improvement of the quality of life and resilience. Conduction system pacing (CSP) as an alternative method of physiological stimulation can improve heart function and reduce the risk of pacemaker-induced cardiomyopathy. Leadless pacers and subcutaneous/extravascular defibrillators offer less invasive options with lower complication rates. The prevention of infections through preoperative and postoperative strategies enhances the safety of these therapies.

In the last two decades, morbidity and mortality of patients with chronic heart failure could be further reduced by improved pharmacological and cardiac device therapies. However, despite these advances, there is a substantial unmet need for novel therapies, ideally specifically addressing repair and regeneration of the damaged or lost myocardium and its vasculature, given the limited endogenous potential for renewal of cardiomyocytes in adults. In this respect, cardiac cell-based therapies have gained substantial attention and have entered clinical feasibility and safety studies a decade ago. Different cell-types have been used, including bone marrow-derived mononuclear cells, bone marrow-derived mesenchymal stem cells, mobilized CD34+ cells, and more recently cardiac-derived c-kit+ stem cells and cardiosphere-derived cells. Some of these studies have suggested a potential of cell-based therapies to reduce cardiac scar size and to improve cardiac function in patients with ischemic cardiomyopathy. While first clinical trials examining the impact of cardiac cell-based therapy on clinical outcome have now been initiated, improved understanding of underlying mechanisms of action of cell-based therapies may lead to strategies for optimization of the cardiac repair potential of the applied cells. In experimental studies, direct in vivo reprogramming of cardiac fibroblasts towards cardiomyocytes, and microRNA-based promotion of cardiomyocyte proliferation and cardiac repair have recently been reported that may represent novel therapeutic approaches for cardiac regeneration that would not need cell-administration but rather directly stimulate endogenous cardiac regeneration. This review will focus mainly on recently completed clinical trials (within the last 2 years) investigating cardiac cell-based therapies and the current status of experimental studies for cardiac cell-based repair and regeneration with a potential for later translation into clinical studies in the future.