Need For Permanent Pacing Research Articles

Feasibility and safety of physiologic pacing post-TAVR

Abstract Introduction His-Purkinje conduction system pacing (HPCSP) is an increasingly used technique due to its benefits. The transcatheter aortic valve replacement (TAVR) has in turn been growing and surpasses the number of procedures than surgical aortic valve replacement, however, the main disadvantage with respect to the surgical technique is a greater risk of atrioventricular block and the need for permanent pacing. Purpose Assess the feasibility of HPCSP in patients after TAVR, the success rates and the pacing thresholds. Methods We present a series of consecutive patients (undergoing TAVI in a single center with need for subsequent ventricular stimulation (n=58), from March 2019 to July 2023, performing HPCSP as the first stimulation option. Results We achieved HPCSP in 49 of 58 patients (84.5%). Patients had a mean age of 81.5 years, 60.3% men, mean LVEF 53.82 ± 12.4%. His bundle pacing (HBP) was successful as first option in 41.4% of cases, and left bundle branch area (LBBAP) in 43,1 % of cases (73.5% of the remaining 58.6%) , while the other 9 patients (15.5%) were pace conventionally at right ventricle, septal or wireless. HBP thresholds and R-wave amplitudes at implantation were 0.99 ± 0.72 at 0.5 ms, 4.59 ± 3.67 mV), remaining stable at follow-up at 1 month (1.16 ± 0.92 at 0.5 ms, 4.17 ± 3.97 mV),. Average QRS width was40.8 ± 21.3 ms pre and 122.43 ± 15.2 ms post). LBBAP pacing thresholds and R-wave amplitudes were(0.89 ± 0.45 at 0.5 ms, 6.145 ± 5.3 mV)at implant, and were stable at follow-up at 1 month (0.75 ± 0.3 at 0.5 ms, 8.41 ± 5.8 mV), with no improvements on QRS (129.75 ± 21.01 ms pre, 134.13 ± 17.34 ms post). During a mean follow-up of 23 months. There has been no acute elevation of thresholds or need for reintervention. Only 6 patients have died (10.3%), 2 of them (33%) from cardiovascular causes. Conclusions HPCSP is feasible as a routine techniquein patients after TAVR who need a pacemaker implantation, with low pacing thresholds, which remained stable on the follow-up.

Novel approaches for leadless pacemaker implantation in the extra-cardiac Fontan cohort: Options to avoid leaded systems or epicardial pacing.

Fontan surgery, a palliative procedure for single ventricle patients, often leads to the need for permanent pacing. Epicardial pacing has limitations, while transvenous pacing carries risks in the Fontan circulation. This case series introduces a novel approach of leadless pacemaker implantation in the extra-cardiac Fontan (ECF) cohort to overcome these limitations. The study includes four cases of leadless pacemaker (Micra™) implantation in patients with ECF. Procedures were performed under general anesthesia with guidance from trans-esophageal echocardiography. Various access routes were used, including trans-carotid and trans-fenestration approaches. Procedural details, parameters, and follow-up data were collected. All leadless pacemaker implantations were successful, with satisfactory electrical parameters and stable pacing postprocedural outcomes during short-term follow-up. One patient required closure of their fenestration for symptomatic desaturation post procedurally. Leadless pacemaker implantation via trans-carotid and trans-fenestration approaches appears to be a feasible back up option for pacing in Fontan patients where other options have been exhausted or there is a patient choice to avoid surgery. These techniques provide an option to avoid leaded systems or epicardial pacing, reducing the need for multiple thoracotomies and addressing challenges associated with surgical pacing leads. Further studies are needed to evaluate long-term outcomes and assess the broader application of leadless pacemakers in the Fontan population.

IN-HOSPITAL OUTCOME OF PATIENTS REQUIRING TEMPORARY TRANSVENOUS PACEMAKER AFTER ST ELEVATION MYOCARDIAL INFARCTION

Objectives: Bradyarrhythmias and Electrical conduction defects are common sequelae of acute myocardial ischemia (AMI). Many of these arrhythmias are symptomless and do not require urgent intervention while others are life threatening. Of all other potential causes myocardial ischemia is the commonest and important causative agent of acute and potentially dangerous conduction defect. This study will upgrade various aspects of patients’ care with Acute MI who need TPM which will improve outcome and make the cause of death along with long term sequelae clear in such patients in our local population. To determine the in hospital outcomes of patients requiring temporary transvenous pacemaker after ST elevation MI.
 Methodology: This cross-sectional descriptive study was conducted at cardiology Department, MTI-KTH, Peshawar from 25 Jan, 2020 to 25 Jun, 2020. All temporary pacemakers were implanted in our Coronary Care Unit procedures and were done in an exploration room. All procedures performed by consultant cardiologists and trainee registrars. Pacemaker malfunction was described as capture failure, failure to sense, or both. Death secondary to cardiac tamponade, a systole or ventricular arrhythmias as well as improvement and need for permanent pacing was also be documented as mentioned above in operational definitions. Data was obtained after performing the procedure and during stay of patient in the coronary care unit, as determined by set protocol. The electrocatheter used was 110 cm bipolardevices of caliber 6F. Cardiac catheterization was generally via the right subclavian or internal jugular by the Seldinger’s wire technique, with insertion in the apical region of the right ventricle under aseptic measures. A sensing threshold values for pacing of 0.5=2 mV were set. Pacing was initially deployed at values double the threshold voltages, using the TPM in WI mode.
 Results: As per in-hospital outcomes, death occurred in 14 (9.7%) died, 49 (34.0%) patients had malfunction, 10 (6.9%) patients had hematoma, 26 (18.1%) patients had fever, 27 (18.8%) patients experienced improvement while 18 (12.5%) required permanent pacing.
 Conclusion: In-hospital adverse outcomes were observed in a significant number of patients.

Does Pacemaker Implantation After Surgical Aortic Valve Replacement Impact Long-Term Morbidity and Mortality? A Focused Review.

Permanent pacing remains a serious complication that can occur in the postoperative period of surgical aortic valve replacement. The reported incidence is variable, and there are many perioperative factors that have been linked with a greater need for permanent pacing. Permanent pacing can also be associated with late lead-related and cardiac complications that can affect late outcome. However, the degree of late dependence on pacemakers is varied, and some studies have shown that a substantial proportion of patients do not need long-term pacing. Some groups have found that permanent pacing was associated with a negative impact on long-term survival in these patients. A common finding among these studies is that the groups of patients with pacemakers had higher preoperative surgical risk and comorbidity status. This makes it difficult to establish whether permanent pacing on its own represents a risk factor for late mortality or whether it is simply a marker that reflects the higher complexity and comorbidities in this group of patients.

Early and Late Outcomes of the Warden and Modified Warden Procedure

BackgroundOperative repair of partial anomalous pulmonary venous connection (PAPVC) remains challenging due to risks of sinus node dysfunction, baffle obstruction, and superior vena cava (SVC) obstruction. MethodsTraditional or modified Warden procedures were performed in 75 of 318 consecutive patients (24%) with PAPVC repaired surgically at our institution during 1993 to 2021. Clinical characteristics, echocardiography data, operative details, and early and late outcomes were collected. Cumulative incidence of reintervention and Kaplan-Meier survival analysis are reported. ResultsMedian age was 39 years (interquartile range, 21-57 years). Fifty-nine (79%) had normal sinus rhythm preoperatively. Seventeen (23%) had intact atrial septa. Traditional and modified Warden procedures were performed in 15 (20%) and 60 (80%), respectively. Frequent concomitant procedures included 15 (20%) tricuspid valve repairs and 12 (16%) atrial fibrillation procedures. There were no early deaths. Postoperative complications included atrial fibrillation in 17 (23%), sinus node dysfunction in 15 (20%), pneumothorax in 3 (4%), pleural effusion in 2 (3%), and pacemaker implantation in 1 (1%). At hospital discharge, sinus node dysfunction persisted in 8 (11%). Over a median follow-up of 6 years (interquartile range, 4-10 years), baffle obstruction developed in 1 patient and SVC obstruction developed in 7. None required reoperation and 6 were treated with SVC stents. At 1, 5, and 10 years, the cumulative incidence of reintervention was 5%, 7%, and 14%, and survival was 99%, 94%, and 94%, respectively. ConclusionsTraditional and modified Warden procedures can be performed with satisfactory early and late survival. Persistent sinus node dysfunction and need for permanent pacing are low. Late SVC obstruction is uncommon and can often be managed nonoperatively.

Characteristics of bradyarrhythmia in patients with COVID-19: Systematic scoping review.

COVID‐19 has recently been associated with the development of bradyarrhythmias, although its mechanism is still unclear. We aim to summarize the existing evidence regarding bradyarrhythmia in COVID‐19 and provide future directions for research. Following the PRISMA Extension for Scoping Reviews, we searched MEDLINE and EMBASE for all peer‐reviewed articles using keywords including“Bradycardia,” “atrioventricular block,” and “COVID‐19″ from their inception to October 13, 2021. Forty‐three articles, including 11 observational studies and 59 cases from case reports and series, were included in the systematic review. Although some observational studies reported increased mortality in those with bradyarrhythmia and COVID‐19, the lack of comparative groups and small sample sizes hinder the ability to draw definitive conclusions. Among 59 COVID‐19 patients with bradycardia from case reports and series, bradycardia most often occurred in those with severe or critical COVID‐19, and complete heart block occurred in the majority of cases despite preserved LVEF (55.9%). Pacemaker insertion was required in 76.3% of the patients, most of which were permanent implants (45.8%). This systematic review summarizes the current evidence and characteristics of bradyarrhythmia in patients with COVID‐19. Further studies are critical to assess the reversibility of bradyarrhythmia in COVID‐19 patients and to clarify potential therapeutic targets including the need for permanent pacing.

Association between fragmented QRS and post-procedural rhythm disturbances in patients who underwent transcatheter aortic valve implantation with CoreValve system

Abstract Background Transcatheter aortic valve implantation (TAVI) is a less invasive and safe therapeutic alternative in patients who are at very high surgical risk or in whom there are contraindications to open surgery (1,2).On the other hand, life threatening complications including stroke, paravalvular leak, and rhythm disturbances that require permanent pacing still persist (3).Fragmented QRS (fQRS) is defined as RSR' pattern with different morphologies of QRS complexes with or without the Q wave on a resting 12-lead electrocardiogram (ECG) (4). Purpose In this study, we examined association between fQRS and post-procedural rhythm disturbances and the need for permanent pacing in patients who underwent TAVI with CoreValve system. Methods We analysed standard 12-lead electrocardiographic recordings of 124 consecutive patients in whom a CoreValve prosthesis (MedronicInc; Minneapolis; USA) was implanted. Patients having bundle branch block or QRS duration ≥120 ms in baseline ECG recordings and patients with prior history of permanent pacing were excluded from the study. We examined 12-lead ECGs before and after procedure along with one month and six month follow up. We documented QRS fragmentation and post-procedural rhythm disturbances. Results Based on our data, 39 out of 71 patients (54.9%) with fQRS developed temporary rhythm disturbances. However, only 4 out of 29 patients (13.7%) without fQRS developed temporary rhythm disturbances.The difference between two groups in terms of temporary rhythm disturbances was statistically significant (59.4% vs 13.7%, p=0.002). Furthermore, 28 out of 71 patients (39.4%) with fQRS and 1 out of 29 patients (3.4%) without fQRS developed permanent rhythm disturbances, (39.4% vs 3.4%, p<0.001).The difference in permanent rhythm disturbances was also maintained in 1st month and 6th-month follow-ups (37.1% vs 0%, p<0.0001, and 38.7% vs 0%; p<0.0001). According to our data, presence of QRS in anterior derivations was the only independent factor associated with development of post-procedural rhythm disturbances (p<0.05). Conclusion Our data showed an increased risk for development of new-onset LBBB and AV blocks following TAVI in patients whose baseline ECG recordings demonstrated fQRS. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Ankara Ataturk Training and Research Hospital

401 Conventional Aortic Valves Versus Rapidly Deployed Valves in The Elderly Population. A Comparative Study in A Single Centre Experience

Abstract Aim Current recommendations favour TAVI over Surgical Aortic valve replacement (SAVR) for patients aged>75 years. However, in current practice a significant proportion of patients in this group are offered SAVR. Rapidly deployed valves are of increasing popularity among surgeons as they shorten the procedure time, but their benefits are yet to be investigated. Method Patients aged >75 years undergoing Aortic valve replacement with or without any concomitant procedure were included between January 2014 and January 2020 (total: 597). Patients were divided into two groups: Group A (495 patients) conventional Aortic valve and Group2 (102 patients) rapidly deployed valve. Results Preoperative variables including mean age, EuroScore II, and body mass index were of no statistical significance between the two groups. More females and Octogenarians were in the rapidly deployed valve group versus the conventional valve group, respectively. Bypass time and Cross-clamp times were shorter in rapidly deployed group. However, the length of ICU and hospital stay was not significant between the two groups. Early post-operative pacemaker implantation (Conventional 2% Vs RDV 7%) (P < 0.05) differed significantly between groups. At follow up echocardiography, pressure gradients were comparable between groups. Thirty-day mortality and valve-related complications were insignificant. Conclusions RDVs show comparable early and medium-term outcomes and valve hemodynamics. RDVs are associated with shortened operative time and cross-clamp time but may carry an increased risk of need for permanent pacing.

Association between fragmented QRS and postprocedural rhythm disturbances in patients who underwent transcatheter aortic valve implantation.

According to recent studies, the rate of atrioventricular block requiring permanent pacing in patients following transcatheter aortic valve implantation varied between 5.7% and 42.5%. Fragmented QRS is a useful marker of myocardial scar and can predict adverse cardiac events. In this study, we examined association between f ragmented QRS and postprocedural rhythm disturbances and the need for permanent pacing in patients who underwent transcatheter aortic valve implantation. In this study, we examined association between fragmented QRS and postprocedural rhythm disturbances and the need for permanent pacing in patients who underwent transcatheter aortic valve implantation' sentence is enough for it. We retrospectively analyzed standard 12-lead electrocardiographic recordings of 124 consecutive patients in whom a CoreValve prosthesis was implanted. We examined 12-lead electrocardiogram before and after procedure along with one- and six-month follow-up. We documented QRS fragmentation and postprocedural rhythm disturbances. There was a significant increase in the frequency of left bundle branch block, (21.1 versus 0%, p<0.05) and the incidence of atrioventricular blocks requiring permanent pacing (21.1 versus 0%, p<0.05) following transcatheter aortic valve implantation in patients whose preprocedural electrocardiogram recordings revealed fragmented QRS compared to those without fragmented QRS. Based our collected data, the presence of QRS fragmentation in anterior derivations was the only independent factor associated with postprocedural rhythm disturbances (B-value 0.217; OR 0.805; 95%CI 0.136-4.78; p=0.004). Our data showed an increased risk for the development of new-onset left bundle branch block and atrioventricular blocks following transcatheter aortic valve implantation in patients whose baseline electrocardiogram recordings demonstrated QRS fragmentation.

Iatrogenic bradyarrhythmia: previous conduction disturbances predicted need for permanent pacing

Abstract Funding Acknowledgements Type of funding sources: None. Background In bradyarrhythmia due to negative chronotropic medication, the need for permanent pacing after drug discontinuation is not always straightforward. Purpose Evaluate prevalence and predictors of the need of permanent pacing in patients with symptomatic bradyarrhythmia under negative chronotropic drugs. Methods We retrospectively studied patients admitted to the emergency room between January 2012 and December 2018 with symptomatic bradyarrhythmia who were under negative chronotropic drugs. We analysed patient demographic factors, previous medical history or electrocardiographic abnormalities and concomitant drugs. We evaluated the laboratory results, electrocardiographic and echocardiographic parameters at admission. During follow-up we analysed mortality, re-hospitalizations and device implantation. We used cox regression to assess the predictors of device implantation. Results 85 patients, were admitted to the emergency room, 47% male, median age 81 (76-87) years. The majority of patients (39, 46%) were admitted with syncope/presyncope and presented with complete AV block (62 patients, 73%). 54% had previous bundle branch block and most (69%) were taking beta blockers. Of note, 17 (20%) presented with ionic disturbances. 17 (20%) patients needed temporary pacing and 60 (71%) patients needed permanent pacing, implanted during index-hospitalization in 78 (92%) patients. Intra-hospital mortality was 5%. During a median follow-up of 66 months, 31 (36%) patients were re-hospitalized and 7 (8%) needed device implantation. Global mortality was 26%. In univariate analysis, previous bundle branch block predicted the need for permanent pacing, while presence of atrial fibrillation, antipsychotic/antidepressant use, acute kidney failure and hypo/hyperkalaemia precluded its requirement. In multivariate analysis, previous bundle branch block was the only independent predictor of the need for permanent pacing. Conclusion In this group of patients with iatrogenic symptomatic bradyarrhythmia, the need for permanent pacing was independently associated with the presence of previous conduction disturbances. Univariate analysisHR (95% CI), p-valueMultivariate analysisHR (95% CI), p-valueAge in years0.987 (0.959-1.016), 0.3330.988 (0.955-1.024), 0.514Previous bundle branch block2.197 (1.137-4.246), 0.0192.081 (1.042-4.156), 0.038Previous atrial fibrillation0.559 (0.321-0.974), 0.0400.903 (0.491-1.662), 0.743Use of antipsychotic/antidepressant drugs0.429 (0.202-0.908), 0.0270.717, (0.276-1860), 0.494Acute kidney failure0.500 (0.281-0.889), 0.0180.950, (0.455-1.984), 0.891Hypo/hyperkalaemia0.359 (0.163-0.792), 0.0110.470, (0.172-1.288), 0.142

Long-term outcomes of sinus node modification in patients with severely symptomatic drug-refractory inappropriate sinus tachycardia: a single-center experience.

The purpose of the study was to evaluate the long-term outcomes of sinus node modification (SNM) in treating patients with severely symptomatic drug-refractory inappropriate sinus tachycardia (IST). The study included 39 patients with symptomatic drug-refractory IST who have undergone SNM at Saint Louis University Hospital. Data was reviewed retrospectively. Recurrence of symptoms was assessed at 3-6-month follow-up intervals. The mean age of our cohort was 31.5 ± 11. The mean HR at diagnosis was 135 ± 25.4 beats per minute (BPM). Thirty-seven of 39 (94.8%) patients had complete resolution of symptoms. Of these 37 patients, 16 required 1 SNM, 17 patients required 2 SNM, and 4 patients required 3 SNM in order to achieve complete symptom resolution. Mean HR post-procedure was 78.6 ± 12.3 BPM. Thirteen of 39 patients required rate control medication post-procedure, all of whom were prescribed beta-blockers. Patients were followed every 3 to 6months with a mean follow-up duration of 62.3 ± 42.9months from the patient's last SNM procedure. Thirteen of those 37 patients (35.1%) developed intermittent symptomatic bradycardia requiring permanent pacemaker implantation. Two of the 39 patients had phrenic nerve injury, and 6 patients had post-procedure pericarditis. This study provides additional information to the limited dataset available in the literature and shows that SNM might provide patients with long-term symptomatic relief bearing in mind the potential increased risk for the need for permanent pacing.

Ventricular tachycardia in patients with type 1 myotonic dystrophy: a case series.

BackgroundType 1 myotonic dystrophy (DM1) is associated with a variety of cardiac conduction abnormalities and the frequent need for permanent pacing. However, the role of ventricular tachycardia (VT) and the implied risk of sudden cardiac death (SCD) is poorly understood.Case summaryThis study examined a 56-patient DM1 cohort of men and women, and identified five patients (two females and three males) with ventricular arrhythmias (8.9%). Patients were reviewed on a case-by-case basis, with their clinical presentation and management of VT and the associated cardiomyopathy indicated. Patient cardiac function was determined by 12-lead electrocardiogram, 48-h Holter monitor, and transthoracic echocardiography. These patients were therefore suitable candidates for implantable cardioverter-defibrillator implantation and received these devices; four of the five patients also received cardiac resynchronization therapy. Medical therapies included angiotensin converting enzyme inhibition, mineralocorticoid receptor antagonist, and following device implantation, beta-blocker therapy was initiated.DiscussionOur case series demonstrates the prevalence of VT in patients with DM1 highlighting the associated risks of SCD in this patient population. The burden of ventricular arrhythmias, advanced conduction disease, and cardiomyopathy are best treated with a combination of device and medical therapies.

A Higher Need for Permanent Pacing after Orthotopic Heart Transplantation Due to Increased Donor Age

Purpose Extreme shortage in donors in the Netherlands has led to increasingly aging donors in heart transplantations (HT). The aim of the study was to evaluate the relationship between donor age and the need for a permanent pacemaker (PPM) implantation after HT. Methods All HTs in our centre between 1984 and august 2018 were retrospectively analysed. Retransplantation within 30 days (n=2) and patients who died within 30 days after HT (n=53) were excluded from the study. In this study 664 HTs were included. Based on the donor age, the HTs were divided into three groups: Group I ( 50 years, n=96). Primary outcome was the implantation of a PPM post-HT, either early (≤ 90 days) or late (> 90 days). Results The biatrial technique was performed in 659 HTs and only 5 using the bicaval technique. Before 2000 (the moment of immunosuppressive regime switch from cyclosporine- to tacrolimus-based therapy), the median donor age was 26 [IQR 20-35] and after 2000 42 [IQR 25-51] (P 90 days (median 7.6 years [IQR 3.4-13.4]) post-HT. The early PPM rate was 1.5% before 2000 vs 11% late PPM rate, while after 2000 the rates were 10.6% and 5.9% respectively. Indications for PPM implantation were sinus node dysfunction in 52.1% and atrioventricular block in 47.9%. Total PPM rates were 10% (Group I), 18% (Group II) and 25% (Group III) (P Conclusion The need for an early PPM is statistically higher in HTs with a donor age > 50 years. However, the long-term survival was non-inferior in patients with a PPM.

Pacemakers are associated with a higher risk of late death and transplantation in the Fontan population

BackgroundThe need for permanent pacing has been identified as a predictor of poor outcomes in the late survivors of Fontan surgery. However, it is not clear if the need for a pacemaker is a surrogate marker of a declining Fontan state, or if pacing is deleterious to the Fontan circulation. ObjectivesWe sought to compare the long-term outcomes of propensity-matched Fontan patients with and without a permanent pacemaker. MethodsPatients who have survived Fontan completion with a documented history of cardiac arrhythmia were identified from the Australia and New Zealand Fontan Registry. Pacemaker insertion details, cardiac function and electrophysiological data were obtained for the patients with a permanent pacemaker. Survival analysis was performed with propensity score matching to compare late survival and outcomes in patients with versus without a pacemaker. ResultsThere was a total of 310 patients with a history of cardiac arrhythmia, of which 126 (41%) had a permanent pacemaker. After propensity-score matching, 99 pairs were generated (n = 198). Patients with a permanent pacemaker had a higher risk of death (HR 3.32 95% CI 1.60–6.90, p = 0.001) and death or transplantation (HR 3.55 95% CI 1.87–6.73, p < 0.001). Patients who were only paced atrially were not at a significantly increased risk of death or transplantation. However, patients who were ventricular paced >50% of the time were much more likely to encounter late death or transplantation (HR 3.82 95% CI 1.64–8.95, p = 0.002). ConclusionsHaving a permanent pacemaker and needing ventricular pacing is likely associated with an increased risk of death and transplantation in patients with a Fontan circulation.

Analysis of electrocardiographic intervals before and after transcatheter aortic valve implantation to predict the need for permanent pacing

Transcatheter aortic valve implantation (TAVI) is growing in utilization in the USA, and atrioventricular heart block is a common complication of the procedure. In patients with conduction system changes following TAVI, there are no clear guidelines for permanent pacing, leading to difficult clinical decisions on how long to leave temporary transvenous pacemakers in place. The aim of our study was to determine whether changes in electrocardiogram characteristics could predict the need for permanent pacing. A retrospective analysis was conducted of 209 consecutive TAVI patients seen from January 2012 to December 2015 at Baylor Heart and Vascular Hospital, Dallas. The baseline characteristics were similar between those who received a permanent pacemaker (PPM) within 7 days of the procedure (21.1%) and those who did not (78.9%); of those who did receive a PPM, 79.5% were implanted for complete heart block. The median (range) percentage change in the sum of QRS and PR was significantly higher in those who received a PPM (20.2%) than those who did not (7.1%) (P = 0.004). Using the percentage change in the sum of QRS and PR to predict PPM, the area under the curve was found to be 0.69. The optimal cutpoint was found to be 18.9% (sensitivity = 0.63, specificity = 0.73). Our study suggests that delay in the conduction system immediately following TAVI predicts the need for permanent pacing.

Transcatheter versus surgical aortic valve replacement in severe, symptomatic aortic stenosis.

Aortic stenosis (AS) is the most common type of valvular heart disease in the elderly. Surgical aortic valve replacement (SAVR) has been the standard practice for treating severe, symptomatic AS, but recently new treatment options have emerged. Transcatheter aortic valve replacement (TAVR) is now an established treatment option in patients at high surgical risk. In this review, we focus on recent developments and compare the two treatment methods in specific populations in terms of efficacy and safety (e.g., in patients with history of prior thoracic surgery, type of anesthesia employed, access site used or need for permanent pacing). The impact of comorbidities (pulmonary hypertension, arterial hypertension and obesity paradox), the cost-effectiveness of TAVR vs. SAVR and advances in transcatheter valve technology as well as issues that merit further investigation are further discussed. Moreover, outcomes and complications of TAVR in patients of different risk category (extremely high, high, intermediate and low risk) are analyzed. We strongly believe that during the following years, TAVR may evolve as the treatment of choice in a broader group of patients with symptomatic AS and beyond those with intermediate and high-risk features.

Permanent nonselective His bundle pacing in an adult with L-transposition of the great arteries and complete AV block.

We report the placement of a permanent transvenous nonselective His bundle pacing lead in conjunction with a transvenous pacemaker/implantable cardioverter-defibrillator in an adult with Levo-Transposition of the Great Arteries (L-TGA) and a stenotic coronary sinus (CS) ostium, which would not accommodate a transvenous left ventricular (LV) pacing lead. Nonselective His bundle pacing provided a nearly identical ventricular activation pattern in this previously unpaced patient. Many L-TGA patients will have an eventual need for permanent pacing and, given the challenges of CS cannulation, His bundle pacing may represent a preferred modality rather than pure morphologic LV pacing or surgical systemic ventricular lead placement to achieve optimal electrical synchrony.

Need for a Permanent Pacemaker after Transcatheter Aortic Valve Implantation

A permanent pacemaker is commonly required in patients undergoing transcatheter aortic valve implantation (TAVI) at ranges up to 30-50%. In general, the incidence is higher with the self- vs balloon-expandable valves. Several risk factors have been identified. Importantly, pacemaker implantation does not seem to improve prognosis and this needs to be further explored. Finally, new generation valves appear to increase the complication of AV block and need for permanent pacing. These issues are herein briefly reviewed. Rhythmos 2016;11(4):87-89.

Prediction of Sinus Node Dysfunction in Patients with Paroxysmal Atrial Fibrillation and Sinus Pause

Background and Objectives: Sinus pause association of paroxysmal atrial fibrillation (PAP) is generally considered a sinus node dysfunction (SND) known as tachycardia-bradycardia syndrome (TBS). Cure of tachyarrhythmias in some patients with prolonged pauses on termination of tachyarrhythmia resulted in an improvement in sinus node function and/or a return to normal ranges thus avoiding the need for permanent pacing. The purpose of this study was to investigate the electrophysiological and clinical characteristics as well as their sinus node function in patients with prolonged pauses and PAP. Methods and Results: Of 1266 PAP patients undergoing radiofrequency catheter ablation (RFCA), 122 patients with pauses (>2 s) were studied. The mean maximum symptomatic prolonged pause on termination of tachycardias was 2.67 ± 1.4 s (2.0–12.6 s). SND developed in 32 patients. There was no difference between the patients with and without SND in terms of the age and sex. Patients were divided into two groups based on the intracardiac electrophysiology study after the RFCA procedure. Eleven patients (8 men, 3 women; age 30–72 years, mean 48.2 ± 9.3 years) were placed in a normal sinus node function (NSF) group, and 17 patients (12 men, 5 women; age 37–75 years, mean 62.2 ± 7.5 years) were in an SND group. There was no significant difference in gender, left atrial dimension, left ventricular ejection fraction, blood pressure, or the longest pause between the two groups. RFCA was successful in 28 patients. Electrophysiological data show that corrected sinus node recovery time (CSNRT) was 409 ± 152 ms in NSF group patients and 558 ± 178 ms in SND group before the ablation procedure (P 2 cycle lengths in 12 patients. In the multivariate analysis, prolonged pauses on termination of tachyarrhythmia, frequency of pauses, and mean heart rate after ablation were independent predictors of SND. Conclusions: (1) Catheter ablation of atrial fibrillation (AF) is effective in treating paroxysmal AF-related TBS; (2) in some patients, there is progressive improvement of sinus node function after elimination of AF, an indication that these sinus pauses may be a manifestation of tachycardia-mediated remodeling of the sinus node, and that permanent pacemaker implantation is unnecessary; (3) among the extrinsic and intrinsic causes of SND, intrinsic causes are seldom reversible and some causes of extrinsic SND may be reversible; and (4) prolonged pauses on termination of PAF, frequency of pauses (>2.0 s), and mean heart rate after ablation were independent predictive factors of SND.

Local Versus General Anesthesia in Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is conventionally performed under general anesthesia (GA) allowing intraoperative transoesophageal echocardiogram imaging. We present our experience in patients having the procedure under local anesthesia (LA), who were subsequently transferred to a low dependency unit postprocedure, to assess safety and length of hospital stay. We retrospectively assessed all the transfemoral TAVR procedures conducted at our center from January 03, 2011. Of 216 patients, 145 had the procedure under GA and 71 under LA. Both groups were similar with respect to age, co-morbidities, Euro Score, and the severity of the aortic stenosis. The procedure time was significantly shorter in the LA group measured from time in room to skin closure (108 vs 143minutes, p <0.001). Skin open to skin closure time were the same in both groups (78 vs 79.4minutes, p= 0.57). There was no difference in 30days: aortic regurgitation > mild (2.1% in GA and 2.8% in LA, p= 0.67), need for permanent pacing (3.4% in GA and 1.4% in LA, p= 0.32), and disabling cerebrovascular accidents (1.4% and 1.4%, p= 1.0). The 30-day survival was not significantly different (95.9% in GA and 100% in LA, p= 0.17), whereas the median number of days in hospital was shorter in the LA group (4 in GA and 2 in LA, p <0.001). No emergency conversions to GA were performed in the LA group and only 1 patient needed admission to a high dependency (HD) unit. In conclusion, performing a TAVR under LA is at least as safe as GA. In addition, there is a reduced procedural time and length of hospital stay. LA is a safe and cost-effective alternative to GA and patients can be safely transferred to a low dependency unit.