Cardiac Resynchronization Research Articles

Impact of sacubitril/valsartan on atrial fibrillation burden in heart failure: a retrospective observational study

AbstractBackgroundSacubitril/valsartan (an angiotensin receptor‐neprilysin inhibitors [ARNI]) might improve atrial fibrillation (AF) condition, but its added value remains controversial.AimWe aimed to analyse the effect of ARNI on AF burden.MethodWe conducted a single‐centre, retrospective self‐controlled study in a tertiary centre. Data were retrieved from January 2019–January 2023. All cardiac resynchronisation therapy‐implantable cardioverter defibrillator (CRT‐D) carriers on ARNI were included if implantation had been at least 3 months before drug initiation. Proarrhythmic events, equal time length control (before ARNI initiation), and exposure (after ARNI initiation) periods were defined. Echocardiographic data were retrieved if they were up to 1 year old before ARNI initiation and if they were available 3 months to 1 year after initiation. AF burden was defined by frequency and median value of paroxysmal events and the overall variation in AF status was determined. Ethical approval was granted by the Ethics Committee of the Centro Hospitalar e Universitário de Coimbra (Reference no: PI OBS.SF.174‐2022) and the study conforms with the Declaration of Helsinki.ResultsSeventy‐two patients were included in the study (73.3% men). After ARNI, there was a reduction in New York Heart Association functional class ± standard deviation (2.00 ± 0.75 to 1.85 ± 0.61, p = 0.043) and an increase in left ventricular ejection fraction ± standard deviation (from 31.67% ± 9.28% vs 37.33% ± 14.49%, p = 0.027). Before ARNI initiation, 34 patients did not have AF, 19 had paroxysmal AF, 15 had permanent AF, and 2 had persistent AF. The total amount of AF episodes (91 vs 44, p = 0.808) and median paroxysmal episodes (among those with paroxysmal AF or no AF) (5 vs 3, p = 0.121) were numerically reduced after ARNI initiation, though variation was not statistically significant. No differences were found as well regarding ventricular arrhythmias or device therapies.ConclusionARNI did not significantly decrease the number of AF paroxysmal episodes or median number of paroxysmal events per patient. Even though ARNI may have a positive impact on AF burden of heart failure patients, larger studies are needed to provide unequivocal evidence.

Swiss national cardiac device registry: changing trends in pacemaker and ICD procedures over the last two decades

Abstract Background The Swiss National Device and Ablation Registry (SwissEPnet) provides a comprehensive database for cardiac pacemaker and ICD procedures. All Swiss centers performing device implantations are obliged to provide their data in this web-based platform. The purpose of this study was to provide an in-depth look at pacemaker and Implantable -defibrillator (ICD) statistics and changing trends over the course of the last 20 years. Methods and Results We analyzed the database of pacemaker and ICD procedures between January 1, 2003, and December 31, 2022. During the study period, a total of 124 458 pacemaker and cardiac resynchronization (CRT) procedures (mean age 77.7 years; 59.7% male) were performed in 73 centers while 29 133 ICDs and CRT-D procedures (mean age 63.63 years; 80.2 % male) were performed in 56 centers in Switzerland. While the number of pacemaker procedures doubled in 20 years and there has been a constant increase in the mean age of patients receiving a pacemaker, the number of ICD procedures has more than tripled and now plateaued with a mean age which remained stable over time. Throughout the study period, the main indications for de novo pacemaker implantations were AV block in 41.7% of patients, followed by sick sinus syndrome combined with tachy-bradycardia syndrome (29.6%) and atrial fibrillation (AF) with slow ventricular conduction (13.7%). The main indication for ICD implantation was primary preventive (66.7%). Since 2016 there has been a decline in primary preventive interventions. Fluoroscopy and procedure durations remained stable over time in pacemaker and ICD procedures. Newer technologies, such as leadless pacemakers and CRT procedures required more fluoroscopy time, but this has also decreased over time. While regular battery changes remained stable (80% in pacemakers, 68% in ICDs), the proportion of DDD and CRT upgrades has increased. The overall reintervention rate due to device-associated infections was 2.4% in pacemaker- and 2.8% in ICD procedures. Since 2013, there has been a steady increase in lead removals/extractions, which were performed mainly due to device-related infections, but also because of lead dysfunctions and worsening electrical parameters. Conclusions In the last 20 years, there was a pronounced increase in the number of pacemaker procedures and a marked increase in the number of ICD procedures which has plateaued now. In younger technologies there is decreasing trend in fluoroscopy time by stable procedure times. Overall, there is a constant increase in mean age of patients receiving a pacemaker, while the mean age of patients receiving an ICD did not change during follow up. Female patients are constantly younger and undergo ICD implantation significantly less often than men. Despite of a stable infection rate, there has been a significant increase in lead removal and extractions in Switzerland.

Left bundle branch area pacing in the setting of cardiac amyloidosis: a case series

Abstract Background Cardiac amyloidosis (CA) is a highly prevalent cause of congestive heart failure. It often requires cardiac pacing due atrioventricular conduction (AV) system disorders, often with cardiac resynchronization (CRT) to prevent development/deterioration of left ventricular (LV) dysfunction. Left bundle branch area pacing (LBBAP) is an emerging alternative to CRT, offering a strict physiological LV activation and very limited use of iodinated contrast. The feasibility of LBBAP in CA is considered limited due to the presence of septal pseudohypertrophy which theoretically limits left-sided conduction system engagement. Purpose To evaluate the feasibility and effectiveness of LBBAP in cardiac amyloidosis. Methods Consecutive patients with CA (both light-chain -AL- or wild-type transtiretin -wtATTr) with a pacing indication for AV conduction disorders were enrolled. Patients underwent baseline echocardiographic examination. LBBAP was achieved by means of stylet-driven leads advanced transeptally (right ventricle (RV) to LV) via dedicated delivery systems, with continuous monitoring of 12-lead electrocardiographic morphology and impedance until a typical QRS morphology in V1 was obtained (usually rSr’ or Sr’). Standard measures for left bundle (LB) capture were used (stimulus to peak R in V6 – S-RV6, V6-V1 interpeak interval, presence of transition in these measures during threshold testing, presence of fascicular signal during spontaneous QRS). Results Between January 2022 and June 2023, among 63 patients undergoing LBBAP, 7 patients (11%) had CA, 2 AL (28%) and 5 (72%) wtATTR. Patients were prevalently old (78±7 y) males (6, 85%); LV mean septal thickness was 17±2 mm (min 16, max 20 mm) and mean LV ejection fraction (LVEF) was 45±6%. Indications were PR prolongation in 3, bradycardic atrial fibrillation and LB branch block (LBBB) in 2, primary LBBB in 1 and chronic RV pacing in 1. Baseline QRS duration was 145±47 ms (QRS<120 ms: 97±15 ms, QRS>120 ms: 182±13 ms). LBBAP success was 100%. Fascicular electrograms were observed in ¾ of patients without LBBB; S-RV6 interval was 74 ±11 ms (³70 ms in 3), RV6-RV1 interpeak interval was 47±9 ms (³ 30 ms in 6 patients). DQRS in baseline broad QRS was -52 ms and +32 ms in narrow. No complications were observed. Over a short follow up of 6 months, an increase in average LVEF was observed (LVEF at 6 months: 51±3%, p<0.05). Conclusions In patients with CA, LBBAP is easily achievable with stylet-driven systems with frequent selective engagement of conduction system. QRS narrowing in baseline broad QRS is significant while QRS broadening in baseline narrow QRS is limited. Early results regarding follow-up of surrogate endpoint such as LVEF are promising.

Conduction latency in left bundle branch pacing in heart failure patient

Since the introduction of left bundle branch pacing (LBBP), a search for precise parameters confirming successful capture of conduction system was conducted. Most of the proposed electrocardiographic criteria refer to patients with narrow QRS complexes. We present a patient with heart failure in whom cardiac resynchronization was achieved using conduction system pacing. While measuring left ventricular activation time, an isoelectric interval of 74 ms between stimulus and R-wave appeared resulting in prolongation of V6 RWPT to 124 ms. Considering the immediate narrowing of QRS complexes following LBBP, the observed latency most probably reflects prolonged conduction time through the His-Purkinje system.

Perioperative management of patients with cardiac implantable electronic devices.

The use of cardiac implantable electronic devices (CIEDs) has increased significantly in recent years. Consequently, more patients with CIEDs will undergo surgery during their lifetime, and thus the involvement of anesthesiologists in the perioperative management of CIEDs is increasing. With ongoing advancements in technology, many types of CIEDs have been developed, including permanent pacemakers, leadless pacemakers, implantable cardioverter defibrillators, cardiac resynchronization therapy-pacemakers/defibrillators, and implantable loop recorders. The functioning of CIEDs exposed to an electromagnetic field can be affected by electromagnetic interference, potential sources of which can be found in the operating room. Thus, to prevent potential adverse events caused by electromagnetic interference in the operating room, anesthesiologists must have knowledge of CIEDs and be able to identify each type. This review focuses on the perioperative management of patients with CIEDs, including indications for CIED implantation to determine the baseline cardiovascular status of patients; concerns associated with CIEDs before and during surgery; perioperative management of CIEDs, including magnet application and device reprogramming; and additional perioperative provisions for patients with CIEDs. As issues such as variations in programming capabilities and responses to magnet application according to device can be challenging, this review provides essential information for the safe perioperative management of patients with CIEDs.

Ten years of subcutaneous defibrillator therapy: Consolidated clinical evidence and future perspectives.

The subcutaneous implantable cardioverter defibrillator (S-ICD) was developed as an alternative to the traditional transvenous implantable cardioverter defibrillator (TV-ICD), aiming to provide easier implantation, simplified detection algorithm of malignant ventricular arrhythmias and prevention from placing components in the cardiovascular system. The S-ICD is implanted subcutaneously or intramuscularly with the generator placed in the left midaxillary line and the lead tunneled subcutaneously in the left para-sternal region. Preimplant electrocardiogram screening is recommended to prevent implantation in patients at high risk of T wave over-sensing. Currently, the S-ICD is unsuitable for patients requiring pacing or cardiac resynchronization. Since the beginning, the S-ICD underwent extensive preclinical investigation until the first prospective multicentre trial demonstrating high efficacy and safety led to market release. While earlier studies focused on younger patients with higher ejection fraction, more recent studies showed favorable outcomes even in patients with comorbidities similar to those typically observed in patients receiving TV-ICD. The development of second and third generation devices has contributed to reduce inappropriate shocks and overcome previous limitations. The aim of this paper is to review the evidence in the literature over the past decade supporting S-ICD as a valid alternative to TV-ICD in terms of safety and efficacy, highlighting the improvements in technology, as well as outcomes.

Physical rehabilitation in heart failure with reduced ejection fraction: are the cardiac implantable devices a barrier?

The development of implantable cardiac devices brought a spectacular improvement in the prognosis of patients with heart failure with reduced ejection fraction, reducing the risk of sudden cardiac death by implanting a cardiac defibrillator, improving ventricular remodeling through cardiac resynchronization and, at the same time, increasing the pa-tient's functional capacity, reducing decompensation episodes and hospitalization. Phys-ical training at moderate exercise intensity is safe and effective in patients with heart fail-ure and cardiac implantable devices; even if they have a severely impaired effort capacity and device-related issues, the assessment of the disease status and of the device parame-ters before the enrollment in the training program warrants the improvement of physical performance and disease outcomes without notable adverse events.

Optimization of atrioventricular delay using Doppler ultrasound and left ventricular catheterization in patients implanted with His bundle pacing devices

Background: Currently, there is a lack of guidance on selecting the optimal method for optimizing the AV interval. Objective: To evaluate the technical characteristics of His bundle pacing and compare relation optimal ventricular conduction intervals using cardiac catheterization and echocardiogram. Method: Interventional prospective study. Result: A total of 56 patients underwent His bundle pacing (HBP) with a success rate of 78.5%. The average age was 57.8 ± 19.25, and 68.1% (30 cases) were female. Selective His pacing and non-selective respectively was successfully achieved in 22 out of 44 cases (50%) and 95.4% with pacing threshold was measured at an average of 0.82 ± 0.38 volts and 1.37 ± 0.83 volts with a pulse width of 1ms. The accuracy comparing AV optimization varied in the following order: VTImitral valve > VTIaortic valve > DFTmitral valve for AVsense optimization and VTImitral valve > DFTmitral valve > VTIaortic valve for AVpace optimization. After AV optimization, myocardial contractility increased by an additional 18.6% for AVsense and 26% for AVpace. Conclusion: His bundle pacing procedure success rate of 78.5%. AV optimization results enhancement in left ventricular contractility from 18.6 to 26%. Key words: His bundle pacing, cardiac resynchronization, heart failure, pacemaker, conduction disease, AV optimization, AV coupling.

Impact of atrial fibrillation ablation in heart failure with reduced ejection fraction

Abstract Introduction Atrial fibrillation (AF) is the most common supraventricular arrhythmia in patients with heart failure (HF) and is associated with a significant increase in morbidity and mortality. Some studies have shown evidence in favor of ablation over pharmacological treatment in patients with AF and reduced ejection fraction (HFrEF). However, little is known about the generalizability of the trial results to routine clinical practice, particularly in a low- and middle-income country. Objective To evaluate whether catheter ablation (CA) of AF reduces morbidity and mortality compared to medical therapy alone in patients with HFrEF and AF in a real-word contemporary cohort from Argentina. Methods We consecutively identified patients with HF with ejection fraction less than 40% associated with paroxysmal or persistent AF who presented to our hospital, either as outpatients or inpatients, between February 2018 and June 2020. Baseline characteristics and outcomes were compared among patients undergoing CA or medical therapy alone. The primary outcome was all-cause mortality and first HF hospitalization until completing a 3-year follow-up. Propensity score overlap weighting was used to balance ablated and drug-treated patients on sex, age, body mass index, hypertension, diabetes, dyslipidemia, smoking, previous atrial fibrillation ablation, use of antiarrhythmic drugs, cardiac resynchronization, cardiac defibrillator, left ventricular ejection fraction, cardiovascular surgery, infarction, stroke, peripheral vascular disease, etiology of heart failure, respiratory disease and renal disease baseline characteristics. Results Data from 6297 patients with AF were analyzed, of whom 430 had ejection fraction ≤ 40%. We excluded 20 patients who were ablated for atrial flutter. 53 patients in the ablation and 357 patients in the medical therapy group were identified. After PS matching, the primary outcome occurred in 9 patients (23,7%) in the ablation group and in 19 patients (50%) in the control group. Catheter ablation was associated with a statistically significant reduction of the primary outcome in a 3-year follow up (Hazard ratio [HR] 0.33 [95%CI, 0.12-0.93]). Conclusion Catheter ablation for atrial fibrillation in patients with HFrEF was associated with decreased risk of mortality and heart failure hospitalisations relative to medical therapy.Kaplan-Meier survival estimates

Level of education and mortality in the vulnerable period following an acute heart failure hospitalization

Abstract Introduction Patients hospitalized for acute heart failure (HF) are at increased risk of death in the early post-discharge period, so-called the "vulnerable period" (1). Post-discharge treatment strategies can help improve outcomes, but the role of the patient's level of education on this regard is unclear. Purpose To analyse the association between level of education and 180-day mortality after discharge from acute HF hospitalization. Methods We performed a prospective cohort study of patients who were discharged alive following hospitalization for acute HF in 26 hospitals in Brazil from February 2016 and September 2021. Patients were classified according to the International Standard Classification of Education 2011 into four groups: Less than Basic, Basic, Intermediate and Advanced. We analysed all-cause mortality in the 180 days following hospital discharge using Cox regression. Results We evaluated 2724 patients (mean age 61±15 years; 42% women) hospitalized for acute HF, who were divided according to education level: less than basic (n = 280, 10%), basic (n = 1503, 55%), intermediate (n = 716, 26%) and advanced (n = 225, 8%). Patients with lower education levels were older (68±12 vs 62±14 vs 56±16 vs 58±15 years, p-for-trend<0.001), more frequently women (47% vs 43% vs 40% vs 37%, p-for-trend = 0.005) and non-whites (77% vs 66% vs 65% vs 53%, p-for-trend<0.001), compared with those with higher education levels. At discharge, a prescription of both angiotensin-converting enzyme inhibitors /angiotensin receptor blockers, beta-blocker and mineralocorticoid receptor antagonists (41% vs 45% vs 49% vs 53%, p-for-trend = 0.001), vaccine counselling (52% vs 50% vs 55% vs 62%, p-for-trend = 0.002) and weigh management counselling (72% vs 69% vs 72% vs 81%, p-for-trend = 0.007) were less frequently provided for patients with lower education. Education level was inversely associated with the risk of death in the follow-up period (Hazard ratio (HR) 0.71, 95%CI 0.61 – 0.84, p = <0.001; Figure). This association remained significant after adjusting for baseline characteristics (age, sex, race, left-ventricle ejection fraction, previous HF, HF aetiology, cardiac resynchronization therapy/implantable cardiac defibrillator use, chronic kidney disease and income) and prescription of disease-modifying drugs, vaccine and weight management counselling at discharge (adjusted HR 0.78, 95% CI 0.64 – 0.95, p = 0.011). Conclusion In this large cohort of patients discharged after hospitalization for acute HF, lower education levels were independently associated with higher mortality rates in the vulnerable period.

Abstract 16146: A Scoping Review of Adverse Outcomes Associated With Cardiac Resynchronization Therapy Device Implantation: Implications for Informed Consent

Background/Objectives: Cardiac Resynchronization Therapy (CRT) is a treatment option for many adults with heart failure with reduced ejection fraction (HFrEF). While the benefits of CRT are well-established, the downstream implications of adverse events are not well-characterized. We sought to better understand the ramifications of CRT-related adverse events on length of hospital stay (LOS) and mortality—information relevant for patients and clinicians to make informed decisions about pursuing CRT. Design: Scoping Review Methods: We conducted an initial PubMed search using terms including “Congestive Heart Failure” or “Heart Failure” and "Cardiac resynchronization" or "Cardiac re-synchronization" or "Biventricular pacing.” We reviewed resulting articles that were written in English, studied CRT devices, and outlined adverse events related to CRT device placement. We separately searched PubMed for additional articles outlining individual adverse events identified using search terms “event name,” “mortality,” and “hospital stay.” We read articles and summarized data regarding the impact of reported adverse events on hospital LOS and mortality. Results: Our search identified 18 full length articles with relevant data. The most common adverse events included device implant failure/non-response, lead dislodgment, coronary sinus dissection, and pocket hematoma. The LOS and mortality rates of each event are shown in Table 1. Of note, LOS for implantation in the ambulatory setting is up to 1 day; LOS for uncomplicated implantation during hospitalization is 4.6 days. Implantation during hospitalization with complication is mean 13.6 days. Conclusion: While absolute risks for adverse events associated with CRT implantation are low, several have important implications on hospital LOS and mortality. These findings warrant inclusion in discussion regarding the risks of CRT when clinicians and patients engage in informed decision making related to CRT.

Abstract 13067: Conduction System Pacing to Achieve Cardiac Resynchronization Therapy: Is There a Sex Difference in Response Rates?

Background: It is well established that in patients with dyssynchronous heart failure related to left bundle branch block (LBBB) and reduced left ventricular ejection fraction (LVEF), females show higher response rates than males when cardiac resynchronization (CRT) is achieved by conventional biventricular (BiV) pacing. Whether this sex difference is also true when CRT is achieved via conduction system pacing is unknown. Hypothesis: There is no difference between women and men in response rates when CRT is achieved by conduction system pacing (CSP), either by His bundle pacing (HBP) or by left bundle area pacing (LBAP). Methods: Patients who underwent CSP with a baseline LVEF ≤40% and a QRS duration ≥140 milliseconds (ms) were retrospectively selected from a CSP database maintained at our institution. 52 patients were included: 17 females and 35 males. Baseline clinical, electrocardiographic, echocardiographic, and follow up data were gathered and analyzed. Electrocardiograms and echocardiograms closest to the dates of implant and at last known follow up were used. Super-response was defined as absolute EF improvement ≥15%. Results: At baseline, there were no statistically significant differences in clinical, electrocardiographic, and echocardiographic characteristics between females and males except for higher prevalence of coronary disease in men, and higher percentage use of guideline directed medical therapy in men (Table 1). At median follow up of 113 days, there were no differences in electrocardiographic or echocardiographic response, number of super-responders, and mortality between females and males (Table 1). Conclusions: Unlike conventional CRT where females show superior response rates, CRT with CSP seems to provide comparable benefits in females and males. If confirmed in larger data sets, this may represent an important advantage of CSP over conventional CRT.

Abstract 14047: Comparison of Left Bundle Branch Area Pacing and Biventricular Pacing in Patients With Left Ventricular Systolic Failure: A Systematic Review and Meta-Analysis

Introduction: There is limited data comparing the effectiveness of Left Bundle Branch Area Pacing (LBBAP) and traditional Biventricular Pacing (BiVP) in patients with left ventricular systolic failure. The aim of this study was to assess the electromechanical and clinical outcomes of both cardiac resynchronization (CRT) techniques. Hypothesis: LBBAP offers comparable or superior clinical outcomes compared to BiVP in patients with systolic left ventricular failure Methods: We conducted a systematic review of PubMed (MEDLINE), Embase, Google Scholar, Scopus, and Cochrane Central Register of Control Trials (CENTRAL) for studies comparing LBBAP with BiVP from inception till May 22, 2023. To evaluate categorical and continuous outcomes, risk ratios (RRs) and standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs) were calculated using RevMan version 5.4 software. Results: We selected 12 studies involving 3,004 patients (LBBP=1,242; BiVP=1,762) for our meta-analysis. The pooled results demonstrated significant improvements with LBBAP in left ventricular ejection fraction (LVEF) (SMD=0.40, 95%CI[0.25, 0.54], P<0.00001), NYHA functional class (SMD=-0.44, 95%CI[-0.65, -0.23], P<0.0001), reduction in QRS duration (SMD=-0.90, 95%CI[-1.14, -0.66], P<0.00001), fewer heart failure hospitalizations (RR=0.72, 95%CI [0.62, 0.85], P<0.0001), and improved survival (RR=0.73, 95%CI [0.58, 0.92], P=0.007). Additionally, LBBAP was associated with a lower pacing threshold at implantation (SMD=-1.03, 95%CI[-1.32, -0.74], P<0.00001) as compared to BiVP. Conclusions: LBBAP was associated with significant improvements in both electromechanical and clinical outcomes, including LVEF, reduction in QRS duration, NYHA class, heart failure hospitalizations, and all-cause mortality in patients with systolic left ventricular failure.

Rationale and study protocol for the BRITISH randomized trial (Using cardiovascular magnetic resonance identified scar as the benchmark risk indication tool for implantable cardioverter defibrillators in patients with nonischemic cardiomyopathy and severe systolic heart failure)

BackgroundFor patients with nonischemic cardiomyopathy (NICM), current guidelines recommend implantable cardioverter defibrillators (ICD) when left ventricular ejection fraction (LVEF) is ≤35%, but the DANISH trial failed to confirm that ICDs reduced all-cause mortality for such patients. Circumstantial evidence suggests that scar on CMR is predictive of sudden and arrhythmic death in this population. The presence of myocardial scar identified by cardiac magnetic resonance imaging (CMR) in patients with NICM and an LVEF ≤35% might identify patients at higher risk of sudden arrhythmic death, for whom an ICD is more likely to reduce all-cause mortality. Methods/DesignThe BRITISH trial is a prospective, multicenter, randomized controlled trial aiming to enrol 1,252 patients with NICM and an LVEF ≤35%. Patients with a nonischemic scar on CMR will be randomized to either: (1) ICD, with or without cardiac resynchronization (CRT-D), or (2) implantable loop recorder (ILR) or cardiac resynchronization (CRT-P). Patients who are screened for the trial but are found not to be eligible, predominantly due to an absence of scar or those who decline to be randomized will be enrolled in an observational registry. The primary endpoint is all-cause mortality, which we plan to assess at 3 years after the last participant is randomized. Secondary endpoints include clinical outcomes, appropriate and inappropriate device therapies, symptom severity and well-being, device-related complications, and analysis of the primary endpoint by subgroups with other risk markers. ConclusionThe BRITISH trial will assess whether the use of CMR-defined scar to direct ICD implantation in patients with NICM and an LVEF ≤35% is associated with a reduction in mortality.

Current and novel percutaneous epicardial access techniques for electrophysiological interventions: A comparison of procedural success and safety.

Accessing the pericardial space safely and efficiently is an important skill for interventional cardiac electrophysiologist. With the increased recognition of the complexity of the 3-dimensional arrhythmogenic substrate due to advances in imaging and mapping technologies there has been an expansion of epicardial procedures in recent years. Equally, minimally invasive implantation of epicardial pacing, cardiac resynchronization, or defibrillation leads is expanding in specific patients where transvenous systems are contraindicated or their long term sequelae should be ideally avoided. Selective delivery of intrapericardial pharmacological antiarrhythmic therapy is yet another potential indication, albeit still investigational. The expanding indications for percutaneous epicardial procedures is contrasted by the still substantial risk and challenges associated with accessing the pericardial space. Myocardial perforation, coronary artery laceration, and damage to the surrounding organs are all recognized and feared complications. A number of innovative epicardial access techniques have been proposed to overcome the difficulties and risks of traditional dry subxiphoid punctures and may allow for more widespread use of epicardial access in the future. We review 10 different established and novel subxiphoidal epicardial access techniques describing procedural success rates, safety profile and overall experience. The technical aspects as well as access times and costs for extra equipment will be reviewed. Finally, an outlook of reported preclinical techniques awaiting in-human feasibility studies is provided.

Septal scar as a barrier to left bundle branch area pacing.

The use of left bundle branch area pacing (LBBAP) for bradycardia pacing and cardiac resynchronization is increasing, but implants are not always successful. We prospectively studied consecutive patients to determine whether septal scar contributes to implant failure. Patients scheduled for bradycardia pacing or cardiac resynchronization therapy were prospectively enrolled. Recruited patients underwent preprocedural scar assessment by cardiac MRI with late gadolinium enhancement imaging. LBBAP was attempted using a lumenless lead (Medtronic 3830) via a transeptal approach. Thirty-five patients were recruited: 29 male, mean age 68years, 10 ischemic, and 16 non-ischemic cardiomyopathy. Pacing indication was bradycardia in 26% and cardiac resynchronization in 74%. The lead was successfully deployed to the left ventricular septum in 30/35 (86%) and unsuccessful in the remaining 5/35 (14%). Septal late gadolinium enhancement was significantly less extensive in patients where left septal lead deployment was successful, compared those where it was unsuccessful (median 8%, IQR 2%-18% vs. median 54%, IQR 53%-57%, p<.001). The presence of septal scar appears to make it more challenging to deploy a lead to the left ventricular septum via the transeptal route. Additional implant tools or alternative approaches may be required in patients with extensive septal scar.

Cardiac Resynchronization in the Acute Phase of Decompensated Heart Failure in a Young Patient with Systemic Sclerosis

Abstract Cardiac resynchronization therapy is an essential tool for treating patients with heart failure in different types of dilatative cardiomyopathy with bundle branch block. This technique is wildly used with significant benefits in terms of quality of life and effort tolerability along with optimized medical therapy. In spite of its benefits, several factors may influence its efficacy such as etiology, lead position, or device settings. In some cases, the anatomical variance of the coronary sinus could create technical difficulties for advancing the left ventricular lead. This case report describes a female patient presenting with decompensated heart failure, known with complicated sclerosis multiplex and a fibrous tissue in the coronary sinus, which created a critical obstruction leading to impossibility to advance the left ventricular lead. This case underlines the importance of appropriate imaging investigation for optimal interventional approach in these difficult cases.

Automatic subcutaneous defibrillator screening in patients with intracardiac devices: comparative study depending on the point of pacing

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Subcutaneous defibrillator (S-ICD) has been shown to be effective in the prevention of sudden cardiac death with the advantage of avoiding intravascular access. Although it should not be indicated when pacing indications exists, the need for pacing may arise in the course of underlying heart disease. Before implantation, it is necessary to screen the surface electrocardiogram (ECG) to avoid inappropriate shocks due to overdetection. Published studies so far show a drastic reduction in the percentage of patients eligible for screening with conventional pacing techniques (right ventricular apex, right ventricular outflow tract or resynchronisation with coronary sinus pacing). Purpose The change in screening signal produced by cardiac pacing during is unknown. So far, no studies have been published comparing the outcome of S-ICD screening between different pacing sites, including conduction system pacing (CSP, his and left bundle branch pacing). Our aim is to analyse the success rate of screening and its predictors in patients with cardiac pacing according to the pacing point. Methods A total of 102 patients were screened for S-ICD and divided into 5 groups according to pacing type: His bundle pacing (HBP), left bundle pacing (LBP), right ventricular apex (RVA), right ventricular outflow tract (RVOT) and biventricular cardiac resynchronisation (CRT). There were no significant differences in any variable between the HBP and LBP group, so they were unified as the CSP group. We used a control group of 10 healthy patients with no implantable devices or ECG abnormalities. All patients underwent automatic screening with paced rhythm using the automatic algorithm (Boston Scientific). We considered a suitable screening when at least one vector (primary, secondary or alternative) was positive in both decubitus and standing position, in left or right parasternal position. Results Baseline characteristics by group are summarised in table1. Paced QRS width was lower in the CSP group (135 [120-160] vs 120 [106-120] p=0,001). All healthy controls passed the screening (100%). 39 (97.5%) CSP patients passed the screening, compared to 15 (71.4%) CRT, 14 (70%) RVOT and 4 (19%) RVA. The differences were statistically significant, p &amp;lt; 0.001 (image 1 A &amp; B). In multivariate analysis, only pacing type was shown to be a predictor of positive screening (p 0.001), independent of paced QRS width. Conclusions In our experience, the probability of obtaining a positive screening of the S-ICD is higher with conduction system stimulation than with the other pacing points (AVD, RVOT or CRT).

The Challenges of Cardiac Resynchronization Therapy in Patients with Dilated Cardiomyopathy and Persistent Left Superior Vena Cava: A Case Report and Concise Literature Review

Heart failure with reduced ejection fraction (HFrEF) is a chronic and debilitating disease, which requires extensive diagnostic and treatment resources in order to achieve an acceptable quality of life for the patient. While optimal medical treatment remains at the core of the disease's management, interventional cardiology also plays a very important role. However, in very rare situations, interventionists might find cases especially challenging due to the presence of venous anomalies, such as persistent left superior vena cava (PLSVC), anomalies that may go undiscovered during the patient's lifetime until venous cannulation is necessary. While these types of malformations also pose challenges in regards to standard pacemaker implantation, cardiac resynchronization (CRT) devices pose several additional challenges due to the complexity of the device and the necessity of finding an optimal position for the coronary sinus (CS) lead. We present the case of a 55-year-old male patient with advanced heart failure due to dilated cardiomyopathy (DCM) and LBBB who was a candidate for CRT-D therapy, describing the investigations that led to the discovery of the PLSVC as well as the technique and results of the intervention, while comparing our case to similar cases found in recent literature.

Cardiac resynchronization in heart failure: Recent advances and their practical implications.

Cardiac resynchronisation (CRT) improves survival and reduces heart failure hospitalisations, in symptomatic patients with heart failure (HF) with reduced ejection fraction with wide QRS despite guidelines indicated medical therapy. In patients with mild HF symptoms (New York Heart Association [NYHA], class II) CRT delays or reverses disease progression. Still, CRT is largely underused. The results of CRT Survey II indicates wide adoption of class I indications in European Society of Cardiology guidelines but with important national differences. As an example more patients in Poland had ischemic HF etiology and in NYHA III than in the overall CRT cohort. Similar patterns were seen in other countries suggesting that some patients such as those in NYHA II and with non-ischemic etiology may be especially underserved by CRT. But the Survey results also shows wide use in areas with week scientific evidence such in atrial fibrillation (AF) and when upgrading from ongoing implantable cardioverter defibrillator or right ventricular pacing to CRT. This practise may imply the belief of the physcian than CRT may but also highlights the need of randomised studies to elucidate CRT effects in such patients. Besides, gaps of evidence the review further discusses reasons for obstacles for CRT implementation and the challenges with the traditional responder definition which may deter the clinician from offering CRT therapy. Finally, the importance of sex and body size for electrical selection criteria for CRT are discussed. A person with small body size and/or female sex may may derive CRT benefit at shorter QRS durations than a bigger individual indicating the need ato shift to personalized medicine.