Indications For Permanent Pacemaker Implantation Research Articles

Incidence and Risk Factors for Permanent Pacemaker Implantation After Tricuspid Valve Repair

BackgroundAlthough the likelihood of needing a permanent pacemaker (PPM) after tricuspid valve (TV) repair has been thought to be low compared with TV replacement, the incidence and determinants are controversial. This study aimed to evaluate the incidence and risk factors for PPM implantation after TV repair. MethodsA total of 1237 consecutive patients undergoing TV repair from 1997 to 2019 were reviewed using a prospectively maintained database, and 1058 patients were enrolled. ResultsIncidence of PPM implantation was 10.3% (n = 109). Median time to PPM implantation was 7 (range, 6-9) days. Indications for PPM implantation were heart block (n = 62, 56.9%), junctional or sinus bradycardia (n = 21, 19.3%), and ventricular arrhythmia (n = 17, 15.6%). Likelihood of PPM varied with concurrent procedures: left ventricular assist device (3.4%), mitral repair (11.2%), mitral valve replacement (13.7%), aortic and mitral valve replacement (19.2%), and isolated tricuspid repair (6.5%). Older age (odds ratio [OR], 1.020; 95% CI, 1.003-1.036), prior mediastinal radiation (OR, 4.106; 95% CI, 1.598-10.554), and concomitant mitral and aortic valve replacement (OR, 1.963; 95% CI, 1.046-3.683) were risk factors, and concomitant left ventricular assist device implantation (OR, 0.325; 95% CI, 0.139-0.759) was a protective factor for PPM implantation. PPM implantation did not affect the early outcomes, overall survival (P =.287), or cumulative incidence of recurrent moderate or greater tricuspid regurgitation (P =.890) or TV reoperation (P =.602). ConclusionsThe likelihood of PPM implantation after TV repair is relatively high, but PPM implantation does not affect the early and long-term clinical outcomes. Older age, prior mediastinal radiation, and concomitant mitral and aortic valve replacement are risk factors, and concomitant left ventricular assist device implantation is a protective factor for PPM implantation after TV repair.

Investigation of the Prevalence and Clinical Characteristics of Early Complication of Electrode Dislodgement in Patients has Indications for Permanent Pacemaker Implantation.

To investigate the prevalence and reopen the drive procedure of early complications of electrode dislodgement in patients with an indication for permanent pacemaker implantation at the Vietnam National Heart Institute. This is a study on patients who received permanent pacemaker implantation at the Vietnam National Heart Institute during the period from August 1, 2019 to March 30, 2020. In all cases with complications of electrode dislodgement after implantation indicated to reopen the machine to handle complications, the results of handling complications are safe and stable. There is a positive relationship between the events of electrode dislodgement on the pacemaker and the degree of tricuspid valve regurgitation with a statistically significant difference (P < 0.01, OR = 8.2; 95% CI: 1.6-42.9).

Permanent pacemaker reduction using temporary-permanent pacemaker as a 1-month bridge after transcatheter aortic valve replacement: a prospective, multicentre, single-arm, observational study

The permanent pacemaker (PPM) implantation and pacemaker dependency rates after transcatheter aortic valve replacement (TAVR) are highly variable as some of the conduction disturbances are reversible. It remains poorly investigated how to optimise temporary pacing in these patients. This study aimed to explore the potential reduction in the PPM implantation rate using temporary-permanent pacemaker (TPPM) as a 1-month bridge. This is a prospective, multicentre, single-arm, observational study. Consecutive patients undergoing TAVR from March 1, 2022 to March 1, 2023 in 13 tertiary hospitals in China were screened. Patients who developed high-degree atrioventricular block, complete heart block, or first-degree atrioventricular block plus new onset left bundle branch block during the TAVR procedure or within 1 month after TAVR were included to receive TPPM. Patients with pre-existing PPM implantation or indications for PPM implantation before the TAVR procedure were excluded. Patients with TPPM were monitored to determine whether the conduction disturbances persisted or recovered. The primary endpoint was the rate of freedom from indications for PPM implantation 1 month after TAVR. This study is registered with ChiCTR, ChiCTR2200057931. Of 688 patients who have undergone TAVR, 71 developed conduction disturbance and met the inclusion criteria, 1 patient withdrew due to noncompliance, 70 patients received TPPM and completed follow-up. There were 41 (58.6%) men and 29 (41.4%) women in the study, with a mean age of 74.3±7.3 years. At 1 month follow-up, 75.7% (53/70) of the patients with TPPM did not require PPM implantation. For 688 patients who have undergone TAVR, the rate of PPM implantation at 1 month was 2.47% (17/688, 95% CI 1.55%-3.92%), representing a significant reduction in self-comparison with the rate at 48 h after TPPM (2.47% vs. 8.28% [95% CI 6.45%-10.58%], P<0.0001). Similar results were obtained in the subgroup analysis of patients with HAVB/CHB. Multivariate analysis revealed the baseline PR interval, difference between the membranous septum length and implantation depth, and timing of postprocedural conduction disturbance occurrence were independent predictors of freedom from indications for PPM implantation at 1 month after TAVR. Using TPPM as a 1-month bridge allows for a buffer period to distinguish whether conduction disturbances are reversible or persistent, resulting in a significant reduction in the PPM implantation rate after TAVR when compared with the current strategy. However, this is an observational study, the results need to be confirmed in a randomized trial. Beijing Science and Technology Plan 2022 from Beijing Municipal Science & Technology Commission.

His Bundle Pacing: Predicting Mortality and Major Complications in Mid-Term Follow-Up.

Introduction: His bundle pacing (HBP) is suitable for 80% of patients with any indication for permanent pacemaker implantation, with a clinical benefit compared to right ventricular pacing (RVP). Although complications and mortality related to RVP are widely reported in the literature, data on HBP are limited. This study aimed to analyze HBP complications and outcomes in the short-term (up to 30 days) and long-term (up to the following 24 months) follow-up (F/U). Materials and Methods: The study includes 373 patients aged ≥ 18, enrolled from October 2015 to May 2019 in a single-center HBP prospective registry conducted in the Department of Electrocardiology, Upper Silesian Medical Centre of the Medical University of Silesia in Katowice, Poland. Mortality and HBP complications were used as end-points: during hospitalization and up to 30 days (short-term F/U), and for each F/U point-six months, 12 months, and 24 months after the procedure (long-term F/U). Results: Successful HBP was achieved in 252 patients (68%), with an increasing success rate during consecutive years: 57% in 2015-2016 and 73% in 2017-2019. Complications were found in 8.4% of patients (21/252) in short-term F/U and 5.8% (13/224), 5.5% (11/201), and 6.9% (12/174) at six months, 12 months, and 24 months, respectively. There were no deaths during the first 30 days. However, 26 patients (10.3%) died within 24 months. A left ventricular ejection fraction (LVEF) ≤ 34% was the only independent predictor of all-cause mortality or any major complication in the 24-month F/U. Conclusions: This single-center study reported a low risk of mortality and complications associated with HBP at the short-term F/U. However, during the long-term F/U, we observed a higher but acceptable risk of major complications, with a lower LVEF being an independent predictor of the composite end-point of all-cause mortality or any major complication.

Pacemaker implantation after cardiac surgery: a contemporary analysis

Abstract Background Cardiac surgery entails an increased risk for bradyarrhythmias. Currently known rates for permanent pacemaker (PPM) implantation after cardiac surgery are derived from non-contemporary studies. Purpose We sought to explore the one-year incidence and indications for PPM implantation after different cardiac surgical procedures in the modern era. Methods All patients in Sweden from 2006 to 2020 who underwent first-time cardiac surgery without previous PPM or implantable cardioverter-defibrillator (ICD) were included in this nationwide population-based study using data from three national registries (SWEDEHEART, National Patient Registry and Swedish ICD &amp; Pacemaker Registry). Patients who received an ICD (n=1,714) and patients undergoing heart transplantation (n=376) were excluded. Sex- and age-matched controls from the general population were used for comparison. Results A total number of 83,484 patients and 82,921 controls were included. Median follow-up was 6.3 years (range 0-15 years). A PPM was implanted in 8.0% (n= 6,707) of the patients, out of these 46.2% (n= 3,101) had pacemaker implanted during the first postoperative year. Atrioventricular block was the main indication in 1,988 (64.1%) of the patients and 1,113 (35.9%) received a PPM due to sinoatrial disease. The incidence rate per 100 patient-years for PPM implantation during the first postoperative year was 1.4 (95% confidence interval 1.3-1.5) for those who underwent coronary artery bypass grafting (CABG), 15.8 (14.6-18.4) following mitral valve surgery, 7.0 (6.6-7.5) after aortic valve surgery and 9.6 (8.6-10.3) for those with combined CABG and valve surgery. The median time from surgery to PPM implantation was 10 days (IQR 7 – 28, Figure 1A and Figure 1B). Compared to the control population, the risk for PPM implantation after cardiac surgery was higher even beyond the first post-operative year. Conclusions The need for PPM after cardiac surgery is highest during the first 30 postoperative days and mostly due to atrioventricular block. The incidence rate for PPM implantation after mitral valve surgery was higher than that following CABG, aortic valve, or combined CABG and/or valvular surgery.Figure 1AFigure 1B

Prognostic impact of new permanent pacemaker implantation following transcatheter aortic valve replacement.

Conduction disturbances requiring permanent pacemaker implantation (PPI) are common following transcatheter aortic valve replacement (TAVR). There were conflicting data regarding the impact of new PPI on clinical outcomes after TAVR. The study sought to evaluate the impact of new PPI on clinical outcomes in patients undergoing TAVR. This study was a retrospective analysis of prospectively collected data. Data were from 210 consecutive patients without prior PPI who underwent TAVR due to severe symptomatic aortic stenosis at our center between June 2018 and July 2020. Clinical, echocardiographic, and pacing data were assessed at 30-day, 1- and 2-year follow-up. New PPI was required in 35 (16.7%) patients within 30 days after TAVR. The median time from TAVR to PPI was 3 days. The most common indication for PPI was high-degree or complete atrioventricular block. The median follow-up was 798.0 (interquartile range, 669.0-1115.0) days. There were no differences in all-cause mortality (adjusted hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 0.85-2.36; p = 0.415) and cardiovascular mortality (adjusted HR: 0.92; 95% CI: 0.57-1.89; p = 0.609) between groups. However, PPI group had a higher risk of heart failure (HF) rehospitalization (adjusted HR: 1.53; 95% CI: 1.26-2.28; p = 0.027). Echocardiography showed no significant improvement of LVEF over time in patients with PPI. At the latest follow-up, 31.3% of patients exhibited low (≤10%) pacing burdens, whereas 28.1% of patients had near constant (>90%) right ventricular pacing. New PPI within 30 days following TAVR was not associated with an increased risk of all-cause or cardiovascular mortality. However, patients with PPI had a higher risk of HF rehospitalization and lack of LVEF improvement.

The prevalence of permanent pacemaker implantation after open-heart surgeries; eight years of experience in Tehran heart center

BackgroundWe aimed to evaluate the prevalence of permanent pacemaker implantation (PPI) among open-heart surgery patients.MethodsWe reviewed data from 23 461 patients undergoing open-heart surgeries between 2009 and 2016 in our heart center in Iran. A total of 18 070 patients (77%) had coronary artery bypass grafting (CABG), 3 598 (15.3%) valvular surgeries, and 1 793 (7.6%) congenital repair procedures. Finally, 125 patients who received PPI following open-heart surgeries were enrolled in our study. We defined the demographic and clinical characteristics of all these patients.ResultsPPI was required in 125 (0.53%) patients with an average age of 58 ± 15.3 years. The average hospitalization time after surgery and waiting time for PPI were 19.7 ± 10.2 and 11.4 ± 6.5 days, respectively. Atrial fibrillation was the dominant pre-operative cardiac conduction abnormality (29.6%). Also, the primary indication for PPI was complete heart block in 72 patients (57.6%). Patients in the CABG group were significantly older (P = 0.002) and were more likely to be male (P = 0.030). The valvular group longer bypass and cross-clamp times and had more left atrial abnormalities. In addition, the congenital defect group was younger and had longer ICU stay times.ConclusionsBased on our study findings, PPI was required in 0.53% of patients following open-heart surgery due to damage to the cardiac conduction system. The current study paves the way for future investigations to identify possible predictors of PPI in patients undergoing open-heart surgeries.

Reevaluation of indications for permanent pacemaker implantation after cardioneuroablation.

Reevaluation of indications for permanent pacemaker implantation after cardioneuroablation.

Left bundle branch area pacing in patients with baseline narrow, left, or right bundle branch block QRS patterns: insights into electrocardiographic and echocardiographic features.

Left bundle branch area pacing (LBBAP) is a recent technique aiming at preservation of physiological ventricular electrical activation. Our goal was to assess mechanical synchrony parameters in relation to electrocardiographic features during LBBAP performed in routine practice. From June 2020 to August 2021, all patients of our institution with permanent pacemaker implantation indication were eligible for LBBAP. A 'qR' pattern in V1 and a delay from pacing spike to the peak of the R-wave in V6 < 80 ms defined a successful LBBAP. Electrocardiogram and echocardiography were performed during spontaneous rhythm and LBBAP: left ventricular mechanical synchrony (LVMS) parameters using 2D Speckle tracking and interventricular mechanical delay (IVMD) were collected. LBBAP was attempted with success in 134/163 patients (82.2%). During LBBAP, the mean QRS width was 104 ± 12 ms. In patients with left bundle branch block (n = 47), LBBAP provided a significant decrease of QRS width from 139 ± 16 to 105 ± 12 ms (P < 0.001) with reduction of LVMS (53 ± 21 vs. 90 ± 46 ms, P = 0.009), and IVMD (14 ± 13 vs. 49 ± 18 ms, P < 0.001). In patients with right bundle branch block (n = 38), LBBAP led to a significant decrease of QRS width from 134 ± 14 to 106 ± 13 ms (P < 0.001) with no effect on LVMS and a reduction of IVMD (17 ± 14 vs. 50 ± 16 ms, P < 0.001). LBBAP in routine practice preserved intra-ventricular mechanical synchrony in patients with narrow and RBBB QRS and improved asynchrony parameters in patients with LBBB.

Monitoring conduction disturbances following TAVR: Feasibility study of early discharge using a novel telemetry patch

IntroductionDespite the technological advances and increasing operator experience, the rate of permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) has not decreased over time. With a continuous downward trend in post-TAVR length of stay, prolonged home-monitoring may have a key role in detecting potentially serious conduction abnormalities after TAVR discharge. MethodsIn this study, the ZioPatch-AT monitor was used to detect conduction abnormalities after TAVR discharge. The cardiac monitoring device was systematically provided to all patients having pre-existing right bundle branch block or developing intra−/peri-procedural conduction disturbances, in the absence of guideline indication for PPI at discharge. ResultsFrom a total of 75 patients at high-risk of conduction disturbances, 8 (11%) of them underwent PPI and most of them (6/8) were detected before symptoms' occurrence. Paired analysis between baseline and discharge electrocardiograms detected a significant widening of the QRS in all patients; on the contrary, PR length was significantly increased only in the group experiencing HAVB after discharge (p < 0.01). ConclusionsIn an early post-TAVR discharge era, 30-day outpatient cardiac rhythm monitoring is potentially a safe solution to allow timely recognition of new conduction disturbances requiring PPI.

Patients Characteristic, Indications, and Complications of Permanent Pacemaker Implantation

Background: Permanent pacemaker implantation is a relatively safe procedure that significantly improves morbidity and mortality among patients with bradyarrhythmias. This study was conducted to determine the patients’ characteristics, indications, and complications of pacemaker implantation. Materials and Methods: This was a single-center, prospective study conducted in Azadi Heart Center, Duhok, Iraq between March 2013 and March 2020. All patients who had indications for permanent pacemaker implantation according to the current guidelines (AHA/ACC) were included and followed up for at least 1 year. Results: The study included 396 patients (242 males [61%] and 154 females [39%]) with a mean age of 65 ± 16 years. The most common presenting symptom was dizziness (63%). Atrioventricular block was the most common indication for pacing in 249 cases (63%), followed by sick sinus syndrome (SSS) in 138 patients (34.8%). The most common mode of pacing was DDD in 234 patients (59%). Among all patients undergoing permanent pacemaker implantation, 17 patients (4.25%) developed early and late complications. The most common early complication was pocket hematoma seen in four patients (1%), followed by pneumothorax in three patients (0.75%). Among late complications, painful shoulder was the most common affecting four patients (1%). Conclusions: Pacemaker implantation is a relatively safe procedure with a low complication rate. Elderly males were the most common group receiving permanent pacemaker. Dual-chamber (DDD) pacing mode was the most commonly used mode.

Evaluation of early results of patients with permanent peacemakers implantation at Bai Chay Hospital from 2016 to 2020

Objectives: Review the results of pacing and some early complications of patients Who implanted pacemaker at Bai Chay Hospital from 2016 to 2020. Subjects and research methods: A descriptively prospective study longitudinal follow-up study on 31 bradyarrhythmia patients who were permanently paced at Bai Chay Hospital from 2016 to October 2020. Results: After implantation of pacemaker, the rate of symptoms improved markedly, the change was statistically significant with p = 0.0001. Medium heart rate before and after implantation (47.84 ± 7.712 with 65.61 ± 4.425, 95%CI: 17.77 ± 7.173, p = 0.000). Change in QRS width after implantation (153.52 ± 11,963ms vs 91.81 ± 10,882ms, 95%CI 61.71 ± 12,947, p = 0.000). Pacing threshold changed after 6 months (0.68 ± 0.146V; 0.73 ± 0.149; p=0.001). Received R wave and electrode wire impedance did not changing after 6 months of follow-up. The rate of complications right after the procedure accounted for a total of 6.45%. The rate of complications after 6 months of follow-up accounted for 6.45%. Complications were all minor complications and were well managed. The successful rate of the procedure reached 100%, the pacing parameter was assessed as good, accounting for 70.97%. Conclusion: The method is considered effectively in the symptom improvement, safety, low complication rate and should be applied and deployed for patients with bradyarrhythmias with indications for permanent pacemaker implantation.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary.

Impact of transcatheter aortic valve implantations on temporal trends of pacemaker implantations among French octogenarians: a nation-wide cohort study over the period 2008–2018

Abstract Background The indications for permanent pacemaker implantation (PPMI) are strongly associated with age, with the highest rates for octogenarians (&amp;gt;80 years old). Over the last decade, impact of aging on temporal trends in PPMI rates among octogenarians is questionable. In the 2010's, transcatheter aortic valve implantation (TAVI) has emerged for inoperable or high-risk patients, mainly octogenarians, with an exponential increase over years. PPMI is a common short-term complication after TAVI procedure. Many studies have explored these post-TAVI PPMI in terms of incidence, timing and outcomes of PPMI following TAVI, but there are no data on the impact of TAVI on PPMI temporal trend at a nationwide scale. Purpose To evaluate whether PPMI in octogenarians have increased during the last decade, independently from age and sex, on a nationwide scale. Eventually, to estimate the potential contribution of TAVI in PPMI increase in this setting. Methods Our study was based on octogenarians from the Echantillon Généraliste de Bénéficiaires, the 1/97 random sample of the French nationwide health insurance claims database. Between 2008 and 2018, we identified de novo PPMI and TAVI with medical procedures codes in the French Common Classification of Medical Procedures (CCAM). Annual incidence rates of PPMI were evaluated between 2008 and 2012 (preTAVI-period). The number of observed PPMI cases, O, in the period 2013–2018 (TAVI-period) was compared with the expected number of PPMI cases, E, calculated by using 2008–2012 incidence rates with age and sex standardization. We then computed the standardized incidence ratio (SIR) of the observed number of PPMI to the expected number of PPMI (O/E), with 95% confidence intervals (CIs). Thereafter, we evaluated the contribution of post-TAVI PPMI in the number of excess cases of PPMI (O-E) for the period 2013–2018. Results The population of octogenarians increased from 23,822 in 2008 to 33,752 in 2018. In 2008, 130 PPMI were observed (546/100,000 inhabitants) reaching 228 PPMI (676/100,000) in 2018 with a marked increase in rates from the year 2012. During the period 2013–2018, for all octogenarians, 1242 cases of PPMI were observed, compared with 1171.3 expected cases of PPMI, corresponding to a significant SIR=1.06 (95% CI: 1.01–1.12). For the subpopulation of octogenarians without TAVI, no excess risk was observed with a SIR=1.01 (95% CI: 0.95–1.06). Among the excess cases of PPMI observed in 2013–2018 in all octogenarians, 72% were post-TAVI PPMI. Conclusion Based on our study, the number of observed PPMI in octogenarians in period 2013–2018 is 6% higher than the number we would expect. Nearly three-quarter of these excess cases are attributable to TAVI complication. Funding Acknowledgement Type of funding sources: None.

Stability of pacemaker parameters in cardiac amyloidosis patients

Abstract Cardiac amyloidosis is a rare disease due to the deposition of amyloid fibrils in the heart. Clinical manifestation of the heart includes restrictive heart failure and arrhythmia, when myocardium and conduction system are involved respectively. Arrhythmia can present as atrioventricular block (AVB), and sick sinus syndrome (SSS), therefore cardiac amyloidosis may require permanent pacemaker implantation. However, the stability of pacemaker parameters in cardiac amyloidosis patients remains unknown. We conducted an observational retrospective study of patients diagnosed with cardiac amyloidosis who underwent permanent pacemaker implantation from January 1, 2011 to December 31, 2019. Base-line data were obtained via Medical Record System. Data of pacemaker parameters were obtained via pacemaker programming at the time of implantation and last follow-up at the clinic. A total of 10 patients were included in our study, among which 5 patients underwent cardiac biopsy and showed positive result, 4 patients showed positive biopsy result of other tissue and characteristic echocardiography result of restrictive diastolic dysfunction, 1 patient was diagnosed with primary systematic amyloidosis (AL) involving kidney and advanced atrioventricular block. Amyloidosis type of the 10 patients were primary systemic amyloidosis (AL). Among the 10 patients, 3 were female (30.0%), and the mean age was 61.3±3.9. All patients met the indication for permanent pacemaker implantation, including 9 SSS and 1 advanced AVB. 9 patients were implanted with DDD, and 1 with VVI. The middle survival time was 446 (331, 728) days from the time of implantation to last follow-up (June 30, 2020). Two patients died due to disease progression. As for the 7 patients whose baseline and follow-up data were both obtained, pacemaker parameters at baseline were as followed: Atrial Impedance 477.8±115.0 Ω, Atrial P Wave 1.30±0.70 mV, Atrial Threshold 0.75±0.16 V@0.4ms, Ventricular Impedance 551.3±233.4 Ω, Ventricular R Wave 7.99±4.66 mV, Ventricular Threshold 0.76±0.15 V@0.4ms. Pacemaker parameters at follow-up were as followed: Atrial Impedance 426.2±93.2 Ω, Atrial P Wave 1.34±0.71 mV, Atrial Threshold 1.59±1.51 V@0.4ms, Ventricular Impedance 405.8±41.6 Ω, Ventricular R Wave 10.69±6.53 mV, Ventricular Threshold 1.80±1.88 V@0.4ms. Most patients relieved from cardiac symptoms and severe cardiac complications. A relatively short-term follow-up indicated elevation of Ventricular Threshold (P=0.028), and analysis of other parameters showed insignificant results. Elevation of Ventricular Threshold may be explained by the progression of amyloid fibrils deposition in the heart. Ventricular Threshold of one patient significantly increased from 1.0 V to 6.0 V at 3-month follow-up. Since all patients underwent chemotherapy for the primary amyloidosis, stability of pacemaker parameters may be another way for evaluation. Long-term follow-up is needed for further evaluation. Funding Acknowledgement Type of funding sources: None.

Angiography-guided mid/high septal implantation of ventricular leads in patients with congenital heart disease.

BackgroundConduction system pacing prevents pacing‐induced cardiomyopathy, but it can be challenging to perform in patients with congenital heart disease (CHD), and mid/high septal lead implantation is an alternative. This study aimed to assess intraprocedural angiography's utility as a guide for mid/high‐septal lead implantation in CHD patients.MethodsThe study subjects were CHD patients with Class I/IIa indications for permanent pacemaker implantation. To guide septal lead implantation, we performed an intraprocedural right ventricular angiogram in anteroposterior, 40° left anterior oblique, and 30° right anterior oblique. The primary endpoint was the lead tip in the mid/high septum on computed tomography (CT). The secondary endpoints were complications and systemic ventricular function on follow‐up.ResultsFrom January 2008 to December 2018, we enrolled 27 patients (mean age: 30 ± 20 years; M:F 17:10) with CHD (unoperated: 20, operated: 7). The mean paced QRS duration was 131.7 ± 5.8 ms, and CT done in 22/27 patients confirmed the lead tip in the mid‐septum in 16, high septum in 5, and apical septum in 1 patient. There were no procedural complications, and during a mean follow‐up of 58 ± 35.2 months, there was no significant change in the systemic ventricular ejection fraction (56.4 ± 8.3% vs 53.9 + 5.9%, P = .08). Two patients with Eisenmenger syndrome died because of refractory heart failure.ConclusionsIntraprocedural angiography is safe and useful to guide mid/high‐septal lead implantation in CHD patients. Mid/high septal lead position preserves systemic ventricular function in patients with CHD during medium‐term follow‐up.

Effect of a restrictive pacemaker implantation strategy on mortality after transcatheter aortic valve implantation

AbstractObjectivesWe sought to assess the safety of a restrictive permanent pacemaker implantation (PPI) strategy after transcatheter aortic valve implantation (TAVI) as compared to a liberal strategy.BackgroundConduction disturbances resulting in PPI are common after TAVI. However, conduction disturbances may be transient and PPI may be superfluous in some patients.MethodsUntil August 2015, we performed PPI in all patients with new complete left bundle branch block (LBBB, QRS &gt; 120 milliseconds) or higher degree atrioventricular (AV) blocks (liberal strategy). From September 2015 onwards, LBBB established an indication for PPI only in the presence of new‐onset AV block (PQ &gt; 200 milliseconds) (restrictive strategy). We analyzed the impact of the restrictive strategy on pacemaker implantation rate, duration of hospital stay, and 1‐year mortality.ResultsBetween January 2014 and December 2016, 383 consecutive, pacemaker‐naive patients underwent TAVI with the liberal PPI strategy and subsequently 384 with the restrictive strategy. The restrictive strategy significantly reduced the percentage of patients undergoing PPI before discharge (17.2% vs. 38.1%, p &lt; .001) and length of hospital stay (intensive care unit 52 ± 55 vs. 60 ± 52 hours, p &lt; .001; general ward 10.6 ± 5.7 vs. 11.5 ± 5.7 days, p = .001). One‐year all‐cause mortality was not significantly different between groups (14.1% vs. 11.7%, log‐rank p = .28). However, sudden death was more frequent in the restrictive group (3.4% vs. 1.3%, log‐rank p = .049).ConclusionsAs compared to a liberal indication for PPI, a restrictive indication reduced PPI rate and length of hospital stay without significantly affecting all‐cause mortality. The observed increase in the risk of sudden death with the restrictive PPI indication deserves further investigation.

Incidence, Predictors, and Implications of Permanent Pacemaker Requirement After Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) is a safe and feasible alternative to surgery in patients with symptomatic severe aortic stenosis regardless of the surgical risk. Conduction abnormalities requiring permanent pacemaker (PPM) implantation remain a common finding after TAVR due to the close proximity of the atrioventricular conduction system to the aortic root. High-grade atrioventricular block and new onset left bundle branch block (LBBB) are the most commonly reported conduction abnormalities after TAVR. The overall rate of PPM implantation after TAVR varies and is related to pre-procedural and intraprocedural factors. The available literature regarding the impact of conduction abnormalities and PPM requirement on morbidity and mortality is still conflicting. Pre-procedural conduction abnormalities such as right bundle branch block and LBBB have been linked with increased PPM implantation and mortality after TAVR. When screening patients for TAVR, heart teams should be aware of various anatomical and pathophysiological conditions that make patients more susceptible to increased risk of conduction abnormalities and PPM requirement after the procedure. This is particularly important as TAVR has been recently approved for patients with low surgical risk. Thepurpose of this review is to discuss the incidence, predictors, impact, and management of the various conduction abnormalities requiring PPM implantation in patients undergoing TAVR.

Clinical Characteristics and Complications in Patients Undergoing Permanent Pacemaker Implantation

Abstract Background: Pacemakers are electronic impulse generators that are implanted to restore a regular heart rhythm in patients with symptomatic bradycardia. A large body of epidemiological data on permanent pacemaker implantation (PPI) originates from developed countries with minimal data from developing regions, especially sub-Saharan Africa. This study aims to describe patient demographics, clinical indications, short-term and long-term complications in patients undergoing PPI at the Charlotte Maxeke Johannesburg Academic Hospital, which is a large urban public teaching hospital in Johannesburg, South Africa. Methods: We retrospectively reviewed in-patient and out-patient medical records of consecutive patients who underwent index PPI over ten years (January 2009 to November 2018). Results: The study cohort comprised of 565 patients, of which 325 (57.52%) were female. The median age at first PPI was 71.8 [interquartile range: 61.7–78.8] years. The indications for pacemaker implantation were atrioventricular (AV) block in 417 (73.81%) and sinus node dysfunction in 114 (20.18%). A total of 40 (7.08%) patients experienced PPI-related complications. Lead dislodgement was the most common complication occurring in 16 (3.05%) patients. Females were 3.8 times more likely to experience a complication [odds ratio (OR): 3.80; 95% CI: 1.40–10.32, P = 0.009]. Conclusion: In this study, AV block was the most common indication for PPI, and the complication rate was found to be 7.08%. Furthermore, the risk of developing a complication was significantly higher in females.

Indications and predictors for pacemaker implantation after isolated aortic valve replacement with bioprostheses: the CAREAVR study.

We sought to study the indications, long-term occurrence, and predictors of permanent pacemaker implantation (PPI) after isolated surgical aortic valve replacement with bioprostheses. The CAREAVR study included 704 patients (385 females, 54.7%) without a preoperative PPI (mean ± standard deviation age 75 ± 7 years) undergoing isolated surgical aortic valve replacement at 4 Finnish hospitals between 2002 and 2014. Data were extracted from electronic patient records. The follow-up was median 4.7 years (range 1 day to 12.3 years). Altogether 56 patients received PPI postoperatively, with the median 507 days from the operation (range 6 days to 10.0 years). The PPI indications were atrioventricular block (31 patients, 55%) and sick sinus syndrome (21 patients, 37.5%). For 4 patients, the PPI indication remained unknown. A competing risks regression analysis (Fine-Gray method), adjusted with age, sex, diabetes, coronary artery disease, preoperative atrial fibrillation (AF), left ventricular ejection fraction, New York Heart Association class, AF at discharge and urgency of operation, was used to assess risk factors for PPI. Only AF at discharge (subdistribution hazard ratio 4.34, 95% confidence interval 2.34-8.03) was a predictor for a PPI. Though atrioventricular block is the major indication for PPI after surgical aortic valve replacement, >30% of PPIs are implanted due to sick sinus syndrome during both short-term follow-up and long-term follow-up. Postoperative AF versus sinus rhythm conveys >4-fold risk of PPI. clinicaltrials.gov Identifier: NCT02626871.