Generator Replacement Research Articles

Rural–urban migration and urban identity differentiation in China

ABSTRACT Previous studies on the social identity of rural-urban migrants in China have often neglected the fact that migration is highly selective. Consequently, the findings generally suffer from survival bias. To overcome this problem, we construct an analytical framework to differentiate six subgroups: rural residents with no migration experience, returned migrants, rural-urban migrants, new urban residents through elite approaches, new urban residents through policy dividends, and urban natives. Employing logistic regression, propensity score matching, and propensity score-based marginal mean weighting through stratification, this study analyzes the 2013 Chinese General Social Survey data and confirms that the urban identity of rural residents, rural-urban migrants, new urban residents, and urban natives changed from weak to strong. The sources of urban identity can be ascribed to three aspects: urban experience, hukou conversion, and generational replacement, among which hukou conversion is the most important. The findings indicate that incorporating rural-urban migrants whose identity status may have changed into the analysis helps overcome the problem of survival bias. This method can be further used to reveal other issues related to rural-urban migration in urbanizing China. Moreover, theories concerning international migrants in western countries should be critically appraised before being applied to explain the social integration of internal migrants in different social contexts.

Outcome and safety of intraoperative defibrillation testing during device replacement: the Simpler trial.

Intraoperative defibrillation testing (DT) during implant or replacement of implantable cardioverter-defibrillators (ICDs) has been a matter of debate for many years. This debate was put to rest by the Simple and Nordic ICD trials, and the practice of testing during new implantations has essentially been almost abandoned. Old registries demonstrated an increased incidence of significant findings in DT during replacements. The aim of the present study was to evaluate frequency of significant findings and safety of DT in subjects undergoing device replacement. A prospective observational multi-centre study included consecutive patients undergoing ICD generator replacement. The primary outcome was a failure to terminate induced ventricular fibrillation (VF) with a single shock 10 J below the maximal capacity of the device. Secondary outcomes included complications of DT. Patients were followed-up at 1- and 6-months post-procedure. A total of 92 patients were eligible, and consented to the study, of which 84 underwent DT during battery replacement. The median age was 68 years and 79.8% were males. Induction of VF was successful in 84 patients as was a successful conversion on the first attempt in all. There were no procedure-related complications. During follow up one patient had two appropriate ICD shock events. In four patients, ICD programming was changed. None suffered inappropriate shock. There was no evidence of lead malfunction. Two deaths occurred, none of which was related to arrhythmia. The present study found DT was not associated with complications in patients undergoing ICD generator replacement but produced no clinically important information.

ПОШУК НОВИХ ДЖЕРЕЛ СТВОРЕННЯ ВАРТОСТІ ТА СУСПІЛЬНОЇ ЦІННОСТІ У КОНТЕКСТІ СТАЛОГО РОЗВИТКУ ПРОМИСЛОВОГО РИНКУ

Since the beginning of the 21st century, scientific discussions on the issues of sustainable economic development and socially responsible investing have intensified. This is explained by the lack of a direct correlation between GDP growth and environmental sustainability, which harms the natural environment and has a weak impact on the quality of society's life. The global business practice demonstrates new trends in the development of high-tech markets, the increased intensity of processes of market capitalization of innovative companies, and the multiplication of consumer capital of their clients, leading not only to a redistribution of power among global players in industrial and consumer markets but also creating new barriers to access to raw material resources. In the era of society's informatization and the accelerated replacement of technology generations, the processes of functioning and development of socio-economic systems are carried out in close interaction of all factors of production and various mechanisms of distribution of production, logistics, and marketing opportunities. Liberalization of foreign economic activity has affected the target orientation of the development of domestic markets, where the state increasingly relies on market mechanisms and introduces new incentives for private initiatives and industrial privatization, removing restrictions on trade and distribution activities. The openness of the country's national economy poses urgent tasks for redirecting capital flows (both public and private), attracting investors to environmentally friendly choices of innovative investment projects, and ensuring more sustainable entrepreneurial activities. The efficiency of using all factors of production in the conditions of deepening energy and socio-ecological crisis will depend on the holistic vision of top managers of the future perspective in the development of "producer-consumer" relations, as well as the argumentation of socially oriented policies with concrete results of multiplying social value. Global economic challenges require an adequate response from production and consumption management, as well as a functional reboot of the content of "producer-consumer" relations, redistribution of risks associated with the adoption of new eco-technologies, their commercialization for long-term perspective purposes – improving the quality of life and the growth of the social value of goods.

The Removal, Excision, Sterilization, and Quarantine (RESQ) Method is a Feasible Alternative Treatment for Cardiac Implantable Electronic Device Infections.

Current guidelines recommend that all infected cardiac implantable electronic devices (CIEDs) should be removed. However, financial or anatomical concerns can lead to management of infection with simple debridement, as opposed to complete removal. In this observational study, we report the outcomes of our modified procedure for this real-world dilemma. The Quarantine (RESQ) method is characterized as follows: the removal (R) of all non-essential foreign materials, including old sutures and leads; the excision (E) of all non-viable, chronically inflamed, granulation, or scar tissue; the sterilization (S) of the remaining generator; and the quarantine (Q) of a new pocket in the sub-muscular layer for reimplantation. From a review of electronic medical records, 30 patients were selected and divided into three groups according to the intervention used: RESQ (n = 9) in group A, simple debridement (n = 16) in group B, and guideline-recommended replacement (n = 5) in group C. Patient baseline characteristics were similar between the groups. After analyzing the proportion of patients that were free from infection one year following their respective interventions, we found that group A performed better than group B (100% and 31.2% infection-free, respectively, p = 0.001), and was comparable to group C (both 100% infection-free, p = not applicable). The RESQ method is a feasible and beneficial alternative for selected patients with CIED infections who are unable to receive a generator replacement according to the recommended guideline.

Demographic Challenges in Poland Understanding Low Fertility

Research background: The phenomenon of low fertility in Poland is a vital subject of demographic analysis. In recent years, not only have there been changes in procreative and family models, but also in the age structure of society. This is particularly significant in the context of population ageing, which is becoming increasingly evident and brings numerous challenges such as increased burden on healthcare systems, a decrease in the active workforce, and the need to secure adequate retirement funds. Despite the desire to have children, many individuals refrain from making such a decision, and the reasons for this choice are diverse. Therefore, it was essential to conduct an analysis of the factors determining fertility in Poland, considering both the economic and social aspects. Understanding how the economic situation, labour market conditions, and changes in social structure impact on the decision-making process regarding childbearing is essential. Purpose of the paper: The objective of this article was to analyse fertility rates in Poland for the period 2004-2020. The conducted research identified the factors influencing the observed state of low generational replacement and determining their intensity. Methodology/Methods/Data sources: The data used in this article were sourced from the Central Statistical Office and covered the years 2004-2020. The study was based on literature concerning demography and econometrics. Three statistical methods were applied in the analysis of fertility in Poland: the Classical Method of Least Squares (CMLS) model, the Fixed Effects (FE) estimator, and the Random Effects (RE) estimator. Fertility analysis was conducted at regional level by dividing Poland into 16 administrative units (voivodeships). A panel model was employed for the analysis, and the results were subjected to Wald, Breusch-Pagan, and Hausman tests to compare the outcomes obtained from different models. Findings: The results of the analysis indicate that the economic situation and the labour market significantly influence the decision to have children in Poland. The trend of low fertility, although showing some increase, is still characteristic of the country compared to other EU nations. The analysis of the factors determining fertility is vital for understanding the decisions of young generations of Poles regarding parenthood.

PERSPECTIVES OVER THE ECONOMIC TRANSITION AND DEMOGRAPHIC AGING IN EASTERN EUROPE

The countries of Eastern Europe represent a particular case from the demographic and economic point of view, as their demographic transition overlapped the economic development process. This represents a major challenge for the sustainability of their health and pension systems and has resulted in reforms and measures to support economic growth and increase the birth rate. Two categories of countries from Eastern Europe were analysed, Romania and Poland as representatives of the ex-Communist countries that joined the European Union and the Russian Federation as representative of the former Soviet Union. The Russian Federation experienced the most profound changes after 1990, being the only country in the Eastern bloc that is close to the generational replacement threshold, the only country with a positive migration balance, but also the only country with the lowest life expectancy.

668 TWO CATHETERS (DDD) OR ONE (VDD) FOR ATRIO-VENTRICULAR BLOCK? COMPLICATION RATES OVER A MORE THAN 20 YEARS EXPERIENCE

Abstract Background in patients with atrio-ventricular block and spared sinus node function dual chamber (DDD) pacing or ventricular (VDD) pacing are considered as an alternative in clinical practice. Literature lacks validated data on the best treatment choice in this situation. Decision should be made balancing risk and benefit ratio of a single or dual lead procedure. Aims to compare complication rates of DDD and VDD implants in a single center experience. Methods data from consecutive patients who underwent DDD or VDD implantation in our institution between January 2000 and December 2021 were included in the analysis. Complications consisted of catheter dislodgements (i.e. dislodgements needing a repositioning procedure), catheter related problems (i.e. lead problems needing a substitution) and infections (i.e. pocket infections or lead infections needing antibiotic therapy or extraction). The need of an upgrading procedure in VDD recipients was not considered as a complication but as a further procedure. The rate of generator replacement and its longevity was also recorded. Results we performed 2499 pacemaker implantations, among them 1435 (57,4%) were DDD and 1064 (42,6%) were VDD. The majority of DDD and VDD recipients were male (836 patients, 58,3% and 609 patients, 57,2% respectively). The VDD population was significantly older (77,7 years old vs 75,5 years old, p<0,01) at the time of implant. Complications occurred more often in the DDD than in the VDD group, without reaching statistical significance (7,3% vs 5,7% p=0,13). No statistical difference was found in catheter displacement rate between DDD and VDD cohorts (4,9% vs 3,8%, p=0,21). In the first group, dislodgements were more frequent for the atrial catheter (41) than the ventricular (29). Catheter-related problems occurred in 25 (1,7%) with a DDD and in 5 (0,5%) patients implanted with a VDD (p<0,01). Infections were also more frequent in patients with dual-chamber pacemakers (1,5%, 22 patients) than in those with single-chamber pacemakers (1,3%, 14 patients) (p=0,67). Twenty (1,9%) VDD recipients needed upgrading to DDD mode during the follow-up due to chronotropic incompetence, whereas a single patient with a DDD underwent a CRT upgrading to relieve the symptoms of heart failure. During the study period, we changed 121 DDD and 140 VDD generators. Mean device duration was similar in both groups: 91,3 months and 93,3 months (p=0,43). Conclusions VDD implantation was the more frequent choice for elderly patients. No significant complications difference occurred in in patients implanted with DDD and with VDD pacemakers, although catheter-related problems occur more frequently in the former population. A small proportion of VDD recipients needed to upgrade the device to DDD. Both pacing choices are equally effective in atrio-ventricular block.

Predictive nomogram for deep brain stimulation-related infections.

Infection is one of the important and frequent complications following implantable pulse generator and deep brain stimulation (DBS) electrode insertion. The goal of this study was to retrospectively evaluate and identify potential risk factors for DBS infections. From January 2015 to January 2021 in Qingdao municipal hospital (training cohort) and The First Affiliated Hospital of the University of Science and Technology of China (validation cohort), the authors enrolled patients with Parkinson disease who had undergone primary DBS placement or implantable pulse generator replacement. The cases were divided into infection or no-infection groups according to the 6-month follow-up. The authors used the logistic regression models to determine the association between the variables and DBS infection. Depending on the results of logistic regression, the authors established a nomogram. The calibration curves, receiver operating characteristic curve analysis, and decision curves were used to evaluate the reliability of the nomogram. There were 191 cases enrolled in the no-infection group and 20 cases in the infection group in the training cohort. The univariate logistic regression showed that BMI, blood glucose, and albumin were all significant predictors of infection after DBS surgery (OR 0.832 [p = 0.009], OR 1.735 [p < 0.001], and OR 0.823 [p = 0.001], respectively). In the crude, adjust I, and adjust II models, the three variables stated above were all considered to be significant predictors of infection after DBS surgery. The calibration curves in both training and validation cohorts showed that the predicted outcome fitted well to the observed outcome (p > 0.05). The decision curves showed that the nomogram had more benefits than the "All or None" scheme. The areas under the curve were 0.93 and 0.83 in the training and validation cohorts, respectively. The nomogram included BMI, blood glucose, and albumin, which were significant predictors of infection in patients with DBS surgery. The nomogram was reliable for clinical application.

Abstract 11940: Does Mixing Matter? Is This the Final Device Hurdle for Mri Patients?

Introduction: Over the last decade substantial efforts have been aimed at improving acceptability of pacemakers and ICDs in the MRI. Many labs have evaluated the construction, safety, efficacy, reproducibility and more recently, clinical impact value in such legacy devices. In parallel, there has been extensive effort by major vendors to develop safe MRI compatible devices. To date, there remains few reasons for hesitation in universal use of any PM/ICD in the MRI bore. However, mixing vendor leads and generators remains a major hurdle limiting MRI usage. Hypothesis: Mixed leads and generators has no distinct safety signal from common devices; whether CIED or non-CIED. Methods: We undertook a retrospective DB analysis to determine safety signals in those pts possessing mixed vendor leads and devices. Comparisons of impedance, amplitude, threshold and battery voltage and patient safety etc. were performed. Results: Pts from 5/2010 to 5/2022, representing 1739 pts with CIED (81%) and non-CIED (19%) underwent an MRI in a dedicated CMR Lab. The majority of the mixed cohort were obtained from the non-CIED population (&gt;98%), not having need for generator replacement. Accordingly, 11% of these underwent an MRI to include: 73% neurologic, 8% orthopedic and 19% cardiac indications. In comparison of safety signals between standard and mixed lead/generator implants, there were no differences in any implant parameters either pre-MRI study or post-interrogation (p=NS). Similarly, there were no peri-MRI pt events or reported in the 30d and 180d post-MRI scan (p=NS). Importantly, especially for EP considerations, there were no added complications to interrogations. Moreover, utilizing a similar approach to manipulation of MRI parameters for maximum safety intrinsic to dependent/non-dependent PM status was employed regardless of lead/generator configuration yielding no complications. Conclusions: Employing a similar approach to MRI scanning in those pts with mixed vendor lead/generator configurations yielded no difference in a multitude of safety, interrogation, devices and efficacy parameters. This reassurance suggests, despite inherent incompatibility concerns between vendors while in the magnetic field, no such fears are truly warranted.

The Artisanal Fishing Sector in the Spanish Mediterranean: A Sector with a Long History and an Uncertain Future

The fishing sector is facing major economic and environmental challenges worldwide. However, at least in developed countries, it is also undergoing a major social crisis. This research has tried to quantify and validate this subjective feeling of deep crisis, based on objective and quantitative data referring to the Spanish Mediterranean. Indeed, the results show alarming data. Different scattered databases have been analyzed and it has been exposed that in only 15 years the number of vessels, power and tonnage has decreased by about 40%; as for fishermen, their number has decreased by about 30%, also revealing a serious problem of generational replacement, since in only 10 years, the average age of fishermen has increased by 3 years. A simple linear regression model shows that this downward trend in the number of boats and fishermen will continue at least in the short term. The data obtained invite a deep reflection on the future or even the very survival of fishing in the Spanish Mediterranean in the medium term. This reflection is not limited to this specific area but can be extrapolated to many other fishing areas.

Generic synthetic inertia scheme for voltage source inverters

System kinetic inertia is declining due to the rapid replacement of synchronous generators (SG) by renewable power generations (RPG). To maintain grid inertia, this paper proposes a generic synthetic inertia (GSI) scheme for RPGs, enabling inertial response by a supercapacitor (SC) bank integrated with a voltage source inverter (VSI) DC link via a DC/DC converter. A GSI control loop is developed for the DC/DC converter controller to vary the SC voltage along with the grid frequency for power exchange following the SG swing equation. The GSI scheme realizes plug-and-play advantage without modifying the RPG original system. Small-signal stability analysis is carried out to optimize the GSI controller parameters. The performance of the GSI scheme is evaluated using a modified IEEE 39-bus test system.

Long-term risk of replacement of cardiovascular implantable electronic devices following external cardioversion

Abstract Introduction External cardioversion (ECV) with transthoracic shock is a recommended and important part of the rhythm control strategy regardless of cardiovascular implantable electronic devices (CIED). Studies and case reports have demonstrated rare, but serious CIED malfunctions related to the ECV procedure. However, follow-up data on contemporary CIEDs undergoing ECV procedures are limited. The aim of this study is to investigate the long-term risk of generator replacements following an ECV procedure. Methods All CIED implants and surgical re-interventions in Denmark were identified in the Danish Pacemaker and ICD Register from January 2005 to April 2021. The ECV procedures were identified in the Danish National Patient Registry from January 2010 to February 2019. For each patient undergoing ECV, five matched (age, sex, and type of CIED) controls without previous ECV were identified. Time to generator replacement was estimated using competing risk analyses, with death, extraction and up-/down-grade being competing events. Risks were estimated by the pseudo-observation method. Results We identified in total 3,924 ECV-events in 2,610 CIED patients with 74.4% male. Mean age of patients at first ECV-procedure were 68.6±11.7 years, and median implant time was 1.5 year. The type of CIED included 50% of pacemakers, 28% of Implantable Cardioverter Defibrillators, and 22% of Cardiac Resynchronization Therapy-systems. During the first 5 years of follow-up, 451 (17.3%) of the shock-exposed devices were replaced vs. 2,000 (15.2%) of the unexposed devices. The relative risks (RR) of device replacement were 1.43 (95% CI: 0.5; 2.4) after 12 months, 1.44 (95% CI: 0.1; 2.8) after 24 months, and −0.53 (95% CI: −2.8; 1.7) after 5 years. The cumulated incidence of first endpoint: Replacement, death, extraction, and up-/down-grade are illustrated in Figure 1. A larger proportion of patients died in the shock-exposed group with n=427 (16.4%) compared to n=1,588 (12.2%) in the unexposed group during 5-years of follow-up with RR=3.2 (95% CI: 1.2; 5.3) of dead before other events. Conclusion Contemporary CIEDs do not indicate different risk of generator replacement following external cardioversion with transthoracic shocks. Shock-exposed device patients were more prone for extraction and death. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): This is work was financed by Department of Cardiology, Aalborg University Hospital and supported by Karl G. Andersen foundation.

Clinical impact of “minimal” right ventricular pacing on atrial arrhythmias: results from the prospective multi-center worldwide EMERALD study

Abstract Background/Introduction Unnecessary right ventricular pacing (RVP), typically the result of pacing forced by the atrio-ventricular delay (AVD), can have deleterious effects such as atrial arrhythmias (AA) and heart failure (HF). Previous studies have shown that these increased risks occur when unnecessary RVP exceeds 40%, leading to the development of pacing modes to reduce the amount of unnecessary RVP and minimize these risks. Purpose The EMERALD (AssEssment of CoMorbiditiEs &amp; Atrial ArRhythmiA Burden In DuaL-Chamber PaceD Patients) Study was a real-world registry designed to assess the impact of RVP burden on the risk of developing AA. The primary endpoint was the difference in incidence of persistent/permanent AA in subjects with high (&amp;gt;40%) and low (&amp;lt;40%) RVP. Methods EMERALD was a non-interventional, prospective, observational, multi-center registry conducted at 186 centers in 12 countries. The study enrolled subjects without a previous history of persistent or permanent AA implanted with a dual-chamber (DR) pacemaker according to ESC or ACC/AHA/HRS guidelines. Devices could be implanted as de-novo therapy, generator replacement or an upgrade in therapy. All implanted devices were approved for commercial use by local regulatory authorities. Programming was left to the investigators' discretion. Subjects were followed for at least 24 months. Persistent/permanent AA was defined as: a) &amp;gt;22 hours/day of AA for &amp;gt;7 consecutive days; b) permanent/persistent AA diagnosed during any follow-up visit; c) an AA-related ablation carried-out; d) a cardioversion performed during any follow-up visit. Results Eligible follow-up data were available for n=3477 subjects with a RVP value. The population was nearly evenly split between High RVP (47.7%) and Low RVP (52.3%). In the High RVP group, 11.7% fulfilled at least one criterion for persistent/permanent AA versus 9.1% in the Low RVP group (p=0.006). The primary endpoint was met. A reanalysis of the data was performed first looking at quartiles of %RVP. Based on this, the threshold of RVP was changed from 40% to 1% (High RVP&amp;gt;1%; Low RVP&amp;lt;1%). Using this new RVP threshold, 13.1% of patients in the High RVP group fulfilled at least 1 criterion for persistent/permanent AA versus 3.4% in the Low RVP group (p&amp;lt;0.0001). Conclusions The EMERALD Study confirmed the results of previous studies showing that limiting unnecessary RVP to &amp;lt;40% is beneficial in reducing the risk of AA in unselected DR pacemaker patients. Moreover, it showed for the first time that even small amounts of unnecessary RVP (&amp;gt;1%) significantly increases the risk of AAs, underlining the need to target very low RVP with efficient modes to reduce RVP. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): MicroPort CRM (Clamart, France)

Left bundle branch area pacing as a first line pacing strategy, which patients should we consider?

Abstract Background A higher right ventricular (RV) pacing burden in those with permanent pacemakers results in accelerated pacing induced cardiomyopathy, in addition to increased incidence of heart failure and mortality [1–3]. This process may necessitate upgrade to a biventricular system in time, as the cardiomyopathy progresses. Physiological conduction system pacing targets such as His-bundle pacing (HBP) or Left Bundle Branch Area Pacing (LBBAP) have been shown to generate comparatively narrower QRS complexes and thus mitigate this cardiomyopathy development [4,5]. The 2021 ESC guidelines have a class 2b indication for consideration of HBP as an alternative to RV pacing in those with AV block and left ventricular ejection fraction &amp;gt;40%, who are anticipated to have &amp;gt;20% ventricular pacing burden [6]. Purpose To retrospectively identify ECG, echocardiographic, permanent pacemaker (PPM) setting and patient factors associated with high RV pacing burden that may aid selection of those who may benefit from conduction system pacing (CSP). Methods We retrospectively identified 300 consecutive patients who underwent cardiac implantable electronic device insertion in our Electrophysiology Lab from the years 2017–2018. We excluded patients who underwent generator replacements, in addition to those who had biventricular devices or implantable cardioverter defibrillators inserted. We collated ECG, echo, past medical history and pacing data for each patient over a three-year follow up period. Data were analysed using SPSS v.26. Results 160 patients met inclusion criteria. Those with an RV pacing burden &amp;gt;20% were categorised group one (n=85) and those with &amp;lt;20% in group two (n=75). Baseline characteristics of these two groups are compared in Table 1 and Table 2. Our analysis showed that significant differences between these groups included a lower mean HR (Table 1) (55.1±17.8 vs 57.63±17.4) with a more prolonged PR interval (225.7ms ± 8.34 vs. 188.6ms ± 6.62) or atrial fibrillation/flutter (AF/AFL) on admission ECG. There were more males with a greater mean age (High Ventricular Paced (VP) = 76.6 years ± 8.4 vs Low VP = 71.23 years ± 12.3) in the higher VP group, and they demonstrated more incidence of dilated RA/RV on echo (Enlarged RA = 30.5%; Enlarged RV = 23.6% vs 10% and 8.4% respectively). There were significant differences in PPM indications and setting between groups (Table 2), with the higher VP groups having PPM inserted for persistent high-grade AV block (CHB = 31.5% vs 4.9% and Mobitz 2 = 9.6% vs 0%) and had less MVP mode activated (Mode switch algorithm = 13.3% vs 71%). Conclusion Our data suggests that those with persistent high grade AV block such as Mobitz 2 or CHB should be considered for CSP. Other considerations include older age, male sex, dilated RV/RA, prolonged PR, lower intrinsic HR or AF/AFL on admission ECG. PPM mode switching settings to reduce RV pacing burden should be utilised where possible. Funding Acknowledgement Type of funding sources: None.

Left ventricular dysfunction, heart failure, and mortality risk factors in de novo pacemaker recipients and those requiring pacemaker generator replacement

Abstract Background Pacing the right ventricle (RV) can lead to adverse remodelling of the left ventricle (LV), LV dysfunction, increased risk of heart failure hospitalisation (HFH) and mortality. Despite RV pacing avoidance programming becoming commonplace, pacemaker patients remain at risk of pacing-induced cardiomyopathy. New pacing strategies and cardiac resynchronisation therapy are available therapeutic options, but it is unclear which patients should be targeted, and when. Purpose This study examined the effects of RV pacing on LV function, the risk of heart failure requiring hospitalisation and all-cause mortality in patients during the first 12 months of pacemaker therapy, compared to those at pacemaker generator replacement (PGR). Methods Data were obtained from a cohort of patients who underwent de novo pacemaker implantation between 2014 and 2017, and patients requiring PGR between 2008 and 2011 at a single tertiary UK hospital, with follow-up from 12 months. Clinical, echocardiographic, and pacemaker variables, medication, and past medical history data were collected. Predictors of a combined endpoint of all-cause mortality or HFH were assessed using cox-regression analysis, with predictors of impaired LV function analysed using multivariable regression analysis. Results 514 newly implanted (NI) patients (mean age, 75 years; 66% male) were recruited, and 491 patients (mean age, 76 years; 56% male) requiring PGR. After a mean follow up of 887 days, 79 NI patients (16%) were deceased (n=27) or had been hospitalised for HF (n=52), whereas after a mean follow up of 668 days, 56 patients after PGR (12%) were deceased (n=34) or had been hospitalised (n=22) for HF. After 12 months of pacemaker therapy, 182 (35%) NI patients had a LV ejection fraction (LVEF) &amp;lt;50%, which had a higher incidence at PGR of 197 (40%). Age was the only significant predictor of mortality or HFH for both NI and PGR (hazard ratio (HR), 1.068; 95% confidence interval (CI), 1.039 to 1.098; p&amp;lt;0.001 vs 1.035; 95% CI, 1.007 to 1.064; p=0.014), respectively). Univariate analysis revealed baseline LVEF (2.439; 95 percent CI, 1.279 to 4.659; p=0.007), RV pacing burden, medication and blood chemistry were significant predictors of the combined outcome at PGR but not at NI (Table 2). Multivariable analysis of predictors of LV impairment (&amp;lt;50% LVEF) showed history of MI (odds ratio (OR), 0.47; 95% CI, 0.29 to 0.78; p=0.003), RV pacing burden (1.01; 95% CI, 1.01 to 1.02; p&amp;lt;0.001) and creatinine (1.06; 95% CI, 1.02 to 1.10; p=0.004) were independently associated in both cohorts. Conclusions Our data suggest that there remains a similar subgroup of people from initial implantation to PGR at risk of LV impairment that might benefit from medication optimisation or novel pacing strategies. Further research is required to better identifying these people to direct more complex therapies to those with the most to gain. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The research is supported by a National Institute for Health Research (NIHR) clinician scientist fellowship (NIHRCS-2012-032). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. This research was supported by the NIHR Leeds Clinical Research Facility.

A novel simple and safe approach to frozen pacemaker leads

Elective pulse generator replacement remains a mainstay procedure in any contemporary electrophysiology laboratory. Frozen pacemaker leads, where the leads fail to disengage from the pacemaker resulting in lead entrapment within the header, have been well described. We report on 2 cases where the pacemaker (IS-1) bipolar lead failed to detach from the device header and describe a novel solution to this unique and old problem involving the use of a procedural glove to effectively release a frozen lead and avoid the need for mechanical and electrical devices.

Religious Decline as a Population Dynamic: Generational Replacement and Religious Attendance in Europe

AbstractNothing puzzles sociologists of religion more than the reasons and the patterns behind religious change. In the literature on secularization processes, it is broadly accepted that ongoing modernization has undermined many of the pillars of institutional religions, leading to widespread religious decline. While a considerable body of research investigates the “why(s)” of this decline, the main focus of this paper is on the “how.” Drawing on CARPE, a harmonized dataset concerning church attendance with almost 2 million observations spanning over 40 years in 39 European countries, this article disentangles the contributions of period change and cohort replacement to the general religious decline. It shows that this decline reflects a real population dynamic based on generational replacement. It is not historical events or developments affecting everyone that undermine religion: new and less religious cohorts are replacing old and more religious ones. Like many other population dynamics, this process is described by an S-shaped curve and applies—with different speeds and levels—to almost all the European countries considered herein. These findings suggest that the effects of the processes of modernization on the mechanisms of religious socialization should be scrutinized more carefully when studying the reasons behind religious decline.

Predictors of late arrhythmic events after generator replacement in Brugada syndrome treated with prophylactic ICD.

IntroductionPredictors of late life-threatening arrhythmic events in Brugada syndrome (BrS) patients who received a prophylactic ICD implantation remain to be evaluated. The aim of the present long-term multicenter study was to assess the incidence and clinical-electrocardiographic predictors of late life-threatening arrhythmic events in BrS patients with a prophylactic implantable cardioverter defibrillator (ICD) and undergoing generator replacement (GR).MethodsThe study population included 105 patients (75% males; mean age 45 ± 14years) who received a prophylactic ICD and had no arrhythmic event up to first GR.ResultsThe median period from first ICD implantation to last follow-up was 155 (128–181) months and from first ICD Implantation to the GR was 84 (61–102) months. During a median follow-up of 57 (38–102) months after GR, 10 patients (9%) received successful appropriate ICD intervention (1.6%/year). ICD interventions included shock on ventricular fibrillation (n = 8 patients), shock on ventricular tachycardia (n = 1 patient), and antitachycardia pacing on ventricular tachycardia (n = 1 patient). At survival analysis, history of atrial fibrillation (log-rank test; P = 0.02), conduction disturbances (log-rank test; P < 0.01), S wave in lead I (log-rank test; P = 0.01) and first-degree atrioventricular block (log-rank test; P = 0.04) were significantly associated with the occurrence of late appropriate ICD intervention. At Cox-regression multivariate analysis, S-wave in lead I was the only independent predictor of late appropriate ICD intervention (HR: 9.17; 95%CI: 1.15–73.07; P = 0.03).ConclusionsThe present study indicates that BrS patient receiving a prophylactic ICD may experience late appropriate intervention after GR in a clinically relevant proportion of cases. S-wave in lead I at the time of first clinical evaluation was the only independent predictor of persistent risk of life-threatening arrhythmic events. These findings support the need for GR at the end of service regardless of previous appropriate intervention, mostly in BrS patients with conduction abnormalities.

Evaluation of Sagittal Spinopelvic Balance in Spinal Cord Stimulator Patients

ObjectiveSpinal cord stimulation (SCS) has become a popular nonopioid pain intervention. However, the treatment failure rate for SCS remains significantly high and many of these patients have poor sagittal spinopelvic balance, which has been found to correlate with increased pain and decreased quality of life. The purpose of this study was to determine if poor sagittal alignment is correlated with SCS treatment failure. Materials and MethodsComparative retrospective analysis was performed between two cohorts of patients who had undergone SCS placement, those who had either subsequent removal of their SCS system (representing a treatment failure cohort) and those that underwent generator replacement (representing a successful treatment cohort). The electronic medical record was used to collect demographic and surgical characteristics, which included radiographic measurements of lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). Also included were data on pain medication usage including opioid and nonopioid therapies. ResultsEighty-one patients met inclusion criteria, 31 had complete removal, and 50 had generator replacements. Measurement of sagittal balance parameters demonstrated that many patients had poor alignment, with 34 outside normal range for LL (10 vs 24 in removal and replacement cohorts, respectively), 30 for PI (12 [38.7%] vs 18 [36.0%]), 46 for PT (18 [58.1%] vs 28 [56.0%]), 38 for SS (18 [58.1%] vs 20 [40.0%]), and 39 for PI-LL mismatch (14 [45.2%] vs 25 [50.0%]). There were no significant differences in sagittal alignment parameters between the two cohorts. ConclusionsThis retrospective cohort analysis of SCS patients did not demonstrate any relationship between poor sagittal alignment and failure of SCS therapy. Further studies of larger databases should be performed to determine how many patients ultimately go on to have additional structural spinal surgery after failure of SCS and whether or not those patients go on to have positive outcomes.

Defibrillator generator replacements in patients with left ventricular assist device support: The risks of hematoma and infection.

The majority (89%) of left ventricular assist device (LVAD) patients have an implantable cardioverter-defibrillator (ICD) in place. Due to the advances of modern-day LVAD therapy, more patients are on support for longer. This inevitably leads to more LVAD patients facing ICD generator battery depletion. Until now, there are insufficient data regarding periprocedural risks of generator replacements in a high-risk group like the LVAD cohort. A retrospective, single-center analysis of pocket-related outcomes of all ICD generator replacements in LVAD and Non-LVAD patients between January 2014 and December 2018. The primary outcome was the combined endpoint of clinically significant pocket hematoma and/or cardiac implantable electronic device (CIED) infection in the first 6 months after ICD generator exchange. The clinically significant hematoma was defined as hematoma requiring reoperation, prolongation of hospitalization, or interruption of anticoagulation. The cumulative incidence function was calculated for the primary endpoint. Two hundred seventy-seven patients underwent ICD generator exchange in our clinic in this time. Of these, 251 patients had a complete 6-month follow-up regarding clinically significant pocket hematomas and pocket infections. One hundred ninety patients had no LVAD, and 61 patients were on LVAD support. The rate of the primary combined endpoint clinically significant pocket hematoma and/or CIED infection was 3.5 times higher in LVAD patients compared to the non-LVAD cohort (event rate 39.14 vs 11.07 per 100 patient-years, p=0.048). Clinically significant pocket hematomas necessitating revision occurred nearly 4 times more often in the LVAD group (p=0.042). Pocket device infection rates were around 16 times higher in LVAD patients compared to non-LVAD patients (p=0.002). Compared to Non-LVAD patients, LVAD patients exhibit a relevant higher rate of clinically significant pocket hematoma and CIED infection after ICD generator exchange. This information should additionally be considered in the decision-making process regarding the indication for ICD generator exchange.