Pacemaker Patients Research Articles

Treatment of pacemaker-induced superior vena cava syndrome by venoplasty with a coronary balloon.

Venous thrombosis or stenosis frequently occurs after implanting transvenous pacemaker leads, and it is usually asymptomatic. The reported incidence is 30%–64%. The mandatory treatments are balloon angioplasty, stenting, thrombolytic, mechanical thrombectomy, and venous grafting. We present a case with the special cooperation of an electrophysiologist and a coronary interventionist in Ha Noi Heart Hospital, Vietnam, to treat an implanted pacemaker patient with fracture ventricular lead and superior vena cava syndrome.

Safety, feasibility and prognostic value of stress perfusion CMR in patients with pacemaker

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND Several studies have shown the excellent prognostic value of stress cardiovascular magnetic resonance (CMR). However, its prognostic value in patients with pacemaker (PM) remains unknown because most studies excluded PM patients. PURPOSE This study aimed to assess the prognostic value of vasodilator stress perfusion CMR in patients with PM. METHODS Consecutive patients with MR-conditional pacemakers referred for stress perfusion CMR at 1.5 T were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. Cox regressions analyses were performed to determine the prognostic value of CMR-parameters. The quality of CMR was rated by two observers blinded to clinical details. Data on pacemaker and leads were collected pre- and post-CMR. RESULTS Of 224 patients who completed the stress CMR protocol, 2 patients had inconclusive stress CMR due to artefact and 203 patients (72.9% male, mean age 71.4 ± 8.7 years) completed the follow-up (median [interquartile range], 7.0 [5.2-7.3] years). Among those, 23 experienced a MACE (11.3%). Stress CMR was well tolerated with no major adverse events. All scans were completed successfully with no significant change in lead thresholds or pacing parameters. Overall, the image quality was rated good or excellent in 84.1% of segments. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 11.80 [95% CI, 4.63-30.30]; and HR: 6.74 [95% CI, 2.47-18.40], both p < 0.001; respectively). In multivariable Cox regression, inducible ischemia and LGE were independent predictors of a higher incidence of MACE (HR: 5.24 [95% CI, 2.61-14.40]; and HR: 2.98 [95% CI, 2.25-4.02]; both p < 0.001; respectively). In patients with ischemia, CMR-related coronary revascularization showed no benefit in reducing MACE (p = 0.25). CONCLUSION Stress CMR is safe, feasible and has a good discriminative prognostic value in consecutive patients with PM.

Myths and misperceptions in pacemaker patients: a quasi experimental study to assess effect of an educational intervention

BackgroundMisconceptions regarding activities after pacemaker implantation can result in restrictions in daily life. This study aims at measuring the correction of misconceptions following an educational intervention utilizing a picture based brochure and personal counseling.MethodsOne hundred and twenty-eight patients were enrolled in a quasi experimental study on the day after pacemaker implantation. Patients’ perceptions about safety of various daily activities, medical procedures, and usage of appliances, in the presence of pacemaker was assessed using a questionnaire before and ten days after an educational intervention using a pictorial brochure. The number of correct responses before and after the intervention was compared to assess the change in patients’ perception.ResultsA total of 128 patients were interviewed at baseline, of which 115 followed-up at 10 days. Mean age of patients was 60.31 ± 12.81 years. In total, 76 (59.4%) were male and 61(47.7%) were illiterate. Mean correct responses increased from 64.47 ± 29.48% to 92.29 ± 14.42% (p < 0.001). Percent of questions answered correctly improved in all three categories after the intervention. Correct answers increased from 74.57 ± 24.94% to 95.65 ± 11.48% (p < 0.001) for routine daily activities, 51.09 ± 33.9% to 84.78 ± 20.86% (p < 0.001) for medical procedures and 64.03 ± 37.36% to 92.57 ± 18.79% (p < 0.001) for domestic appliance usage.ConclusionMisconception that can adversely affect pacemaker patient’s quality of life can be corrected by counseling with pictorial based brochures regardless of the patient’s baseline knowledge or education.

Atrial Fibrillation Burden Detected by Dual-Chamber Pacemakers as a Predictor for Cardiac Outcomes: A Retrospective Single-Center Cohort Study.

Background: Atrial fibrillation (AF) might lead to adverse cardiac consequences. The association between AF burden and cardiac prognosis is unknown.Methods and Results: This retrospective cohort study enrolled 204 patients (117 males; age 74.5 ± 11.5 years) who underwent dual-chamber pacemaker implantation in our center from October 2003 to May 2017. During a median follow-up of 66.5 months, AF could be detected in 153 (75%) of the 204 pacemaker patients. Primary endpoint events (composite cardiac readmission, stroke or systemic embolism, and all-cause death) occurred in 83 cases (40.7%). In logistic regression analysis, AF detection was associated with increased risks of composite endpoints [odds ratio (OR) = 2.9, 95% confidence interval (CI): 1.3–6.2, p = 0.007], and the hazard was mainly driven by increased cardiac readmission (OR = 2.2, 95% CI: 1.1–4.7, p = 0.034). No significantly elevated risk for new-onset stroke, systemic embolism, or deaths were found in patients with AF detected than those without AF recorded. AF duration grade of more than 6 min suggested progressively increased composite endpoints (OR = 1.8, 95% CI: 1.2–2.7, p for trend = 0.005), cardiac readmission (OR = 1.8, 95% CI: 1.2–2.7, p for trend = 0.005), especially heart failure or acute coronary syndrome-associated readmission (OR = 1.8, 95% CI: 1.2–2.9, p for trend = 0.010), than those with shorter (<6 min) or no AF episodes. Kaplan–Meier analyses and Cox regression also suggested that episodes of AF more than 6 min predicted future cardiac events.Conclusions: AF detected by pacemakers were common. Higher AF burden predicted more adverse cardiac outcomes and might suggest the intervention of rhythm control in these population.

Safety, feasibility and prognostic value of stress perfusion CMR in patients with pacemaker

Several studies have shown the excellent prognostic value of stress cardiovascular magnetic resonance (CMR). However, its prognostic value in patients with pacemaker (PM) remains unknown because most studies excluded PM patients. This study aimed to assess the prognostic value of vasodilator stress perfusion CMR in patients with PM. Consecutive patients with MR-conditional pacemakers referred for stress perfusion CMR at 1.5 T were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. Cox regressions analyses were performed to determine the prognostic value of CMR-parameters. The quality of CMR was rated by two observers blinded to clinical details. Data on pacemaker and leads were collected pre- and post-CMR. Of 224 patients who completed the stress CMR protocol, 2 patients had inconclusive stress CMR due to artefact and 203 patients (72.9% male, mean age 71.4 ± 8.7 years) completed the follow-up [median (interquartile range), 7.0 (5.2–7.3) years]. Among those, 23 experienced a MACE (11.3%). Stress CMR was well tolerated with no major adverse events. Overall, the image quality was rated good or excellent in 84.1% of segments. Using Kaplan–Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (HR: 11.80 [95%CI, 4.63–30.30]; and HR: 6.74 [95%CI, 2.47–18.40], both P < 0.001; respectively). In multivariable Cox regression, inducible ischemia and LGE were independent predictors of a higher incidence of MACE [HR: 5.24 (95%CI, 2.61–14.40); and HR: 2.98 (95%CI, 2.25–4.02); both P < 0.001; respectively]. In patients with ischemia, CMR-related coronary revascularization showed no benefit in reducing MACE ( P = 0.25) ( Fig. 1 ). Stress CMR is safe, feasible and has a good discriminative prognostic value in consecutive patients with PM.

The use of laser lead extraction sheath in the presence of supra-cardiac occlusion of the central veins for cardiac implantable electronic device lead upgrade or revision

The implantation of cardiac implantable electronic devices (CIED) has increased in the last decades with improvement in the quality of life of patients with cardiac rhythm disorders. The presence of bilateral subclavian, innominate or superior vena cava obstruction is a major limitation to device revision and/or upgrade. This is retrospective study of patients who underwent laser-assisted lead extraction (LLE) (GlideLight laser sheath, Spectranetics Corporation, Colorado Springs, USA) with lead revision or upgrade using the laser sheath as a guide rail. Patients with known occlusion, severe stenosis or functional obstruction of the venous access vessels with indwelling leads were included in this study. 106 patients underwent percutaneous LLE with lead revision and/or upgrade. Preoperative known complete occlusion or severe stenosis of access veins was present in 23 patients (21.5%). More patients with implantable cardioverter-defibrillator (ICD) underwent LLE (64.1%) than patients with CRT-Ds (24.5%) and pacemaker patients (11.3%). In total 172 leads were extracted: 79 (45.9%) single-coil defibrillator leads, 35 (20.3%) dual-coil defibrillator leads, 31 (18.0%) right atrial leads, 24 (13.9%) right ventricular leads and three (1.7%) malfunctional coronary sinus left ventricular pacing leads. The mean age of leads was 99.2±65.6 months. The implantation of new leads after crossing the venous stenosis/obstruction was successful in 98 (92.4%) cases. Postoperative complications were pocket hematoma in two cases and wound infection in one case. No peri-operative and no immediate postoperative death was recorded. One intraoperative superior vena cava tear was treated by immediate thoracotomy and surgical repair. In a single-center study on LLE in the presence of supra-cardiac occlusion of the central veins for CIED lead upgrade and revision we could demonstrate a low procedural complication rate with no procedural deaths. Most of the leads could be completely extracted to revise or upgrade the system. Our study showed a low complication rate, with acceptable mortality rates.

Respiratory Induced Modulation in f-Wave Characteristics During Atrial Fibrillation.

The autonomic nervous system (ANS) is an important factor in cardiac arrhythmia, and information about ANS activity during atrial fibrillation (AF) may contribute to personalized treatment. In this study we aim to quantify respiratory modulation in the f-wave frequency trend from resting ECG. First, an f-wave signal is extracted from the ECG by QRST cancelation. Second, an f-wave model is fitted to the f-wave signal to obtain a high resolution f-wave frequency trend and an index for signal quality control (). Third, respiratory modulation in the f-wave frequency trend is extracted by applying a narrow band-pass filter. The center frequency of the band-pass filter is determined by the respiration rate. Respiration rate is estimated from a surrogate respiration signal, obtained from the ECG using homomorphic filtering. Peak conditioned spectral averaging, where spectra of sufficient quality from different leads are averaged, is employed to obtain a robust estimate of the respiration rate. The envelope of the filtered f-wave frequency trend is used to quantify the magnitude of respiratory induced f-wave frequency modulation. The proposed methodology is evaluated using simulated f-wave signals obtained using a sinusoidal harmonic model. Results from simulated signals show that the magnitude of the respiratory modulation is accurately estimated, quantified by an error below 0.01 Hz, if the signal quality is sufficient (). The proposed method was applied to analyze ECG data from eight pacemaker patients with permanent AF recorded at baseline, during controlled respiration, and during controlled respiration after injection of atropine, respectively. The magnitude of the respiratory induce f-wave frequency modulation was 0.15 ± 0.01, 0.18 ± 0.02, and 0.17 ± 0.03 Hz during baseline, controlled respiration, and post-atropine, respectively. Our results suggest that parasympathetic regulation affects the magnitude of respiratory induced f-wave frequency modulation.

Heart rate score, a measure related to chronotropic incompetence in pacemaker patients.

BackgroundHeart rate score (HrSc) ≥70% in cardiac resynchronization therapy defibrillator and implantable cardioverter-defibrillator subjects predicts 5-year mortality risk. A high HrSc suggests few sensed cardiac cycles above the programmed lower rate.ObjectiveTo determine if HrSc is related to chronotropic incompetence (CI) in pacemaker (PM) subjects.MethodsHrSc is the percentage of all atrial-paced and sensed events in the single tallest 10 beats/min histogram bin programmed to DDD 60/min. The prospective LIFE study of PM subjects examined multiple treadmill-based measures of CI. The 1-month postimplant DDD 60/min PM rate histogram prior to treadmill was retrospectively analyzed for HrSc. Measures of CI were applied to submaximal treadmill data in the DDD mode. HrSc was compared to these CI measures and to clinical indications for PM.ResultsThe 1-month histogram demonstrated HrSc ≥70% in 43% of subjects. HrSc ≥70% correlated with a clinical diagnosis of sick sinus syndrome (P < .001). CI was present in 34%–88% of subjects by treadmill-based measures. Agreement between treadmill-based measures for CI was poor and varied from 39% to 83%. HrSc ≥70%, as a measure of CI, was most highly correlated with unpaced heart rate <70% of age-predicted maximum heart rate (67%) (odds ratio 3.7, P < .001).ConclusionsHrSc ≥70% correlates with treadmill measures of CI and clinical sick sinus syndrome. HrSc ≥70% is a measure of CI in PM subjects that is inexpensive, repeatable, and quantitative.

Subclinical Atrial Fibrillation Burden and Adverse Clinical Outcomes in Patients With Permanent Pacemakers.

Unlike clinical atrial fibrillation (AF), the significance of subclinical AF (SCAF) burden in patients with permanent pacemakers has not been fully evaluated. We investigated whether the SCAF burden was associated with increased risks of composite adverse outcomes, including progression to clinical AF, ischemic stroke, myocardial infarction, heart failure-related hospitalization, or cardiac death, in patients without previous AF. To quantify the 6-month SCAF burden, the total cumulative time spent in SCAF during every 6-month follow-up was summed. During the median 5.2-year follow-up, 496 consecutive permanent pacemaker patients were classified into the no SCAF (no SCAF episode in any device analysis; n=152), low-burden SCAF (6-month SCAF <24 hours in at least one device analysis; n=287), or high-burden SCAF (6-month SCAF ≥24 hours in at least 1 device analysis; n=57) groups. The risk of composite adverse outcomes was greatest in the high-burden SCAF group (P<0.001) and was primarily driven by progression to clinical AF (P<0.001) and ischemic stroke (P<0.001). The presence of high-burden SCAF, which always preceded ischemic stroke events, was independently associated with composite adverse outcomes (odds ratio=20.1 [95% CI, 7.60-52.7], P<0.001) and progression to clinical AF (odds ratio, 36.2 [95% CI, 15.9-87.8], P<0.001). In permanent pacemaker patients without preexisting AF, the presence of high-burden SCAF was closely associated with increased risks of composite adverse outcomes, particularly progression to clinical AF and ischemic stroke. Therefore, prospective studies deserve to be performed on the optimal anticoagulation therapy for permanent pacemaker patients with both high-burden SCAF and high stroke risk.

Thoughts on Future Trends in Cardiology

Thoughts on Future Trends in Cardiology

Assessment of Biventricular Function by Echocardiography in Patients with Right Ventricular Apical Pacing

Introduction: Artificial cardiac pacing is a consolidated, safe, and effective treatment strategy that has been evolving for 60 years. In a normal heart, the left ventricle (LV) contracts in a fast and synchronized manner. Stimulation anywhere in the right ventricle (RV) alters the natural pattern of activation and as a consequence the ventricular contraction. This may lead to the induction of asynchrony with potential risk for the development of ventricular dysfunction. The majority of studies have looked into left ventricular dysfunction, while effects on the RV have not been studied. Furthermore, there are little data on the chronology of events that occur in pacemaker patients. We, therefore, aimed to evaluate diastolic and systolic functions of LV and RV in consecutive patients undergoing Ventricle is paced, sensed, and the pulse generator inhibits pacing output in response to a sensed ventricular event (VVI) permanent pacemaker implantation over 6 months using trans-thoracic echocardiography. Materials and Methods: This was a hospital-based observational study from October 2017 to April 2019. Conclusion: Diastolic abnormalities are first to appear which are followed by appearance of systolic abnormalities of the respective ventricles. The right ventricular dysfunction (tricuspid annular plane systolic excursion &lt;17 mm) developed in 28% at 1 month and in 62% at the end of 6 months. The left ventricular dysfunction (ejection fraction&lt; 50%) occurs later, LV dysfunction developed in 14%, and worsening of LV function developed in 16% of the study population at the end of study, that is, 6 months.

Long-Term Safety and Feasibility of Left Bundle Branch Pacing in a Large Single-Center Study.

Left bundle branch pacing (LBBP) is a novel pacing method and has been observed to have low and stable pacing thresholds in prior small short-term studies. The objective of this study was to evaluate the feasibility and safety of LBBP in a large consecutive diverse group of patients with long-term follow-up. This study prospectively enrolled 632 consecutive pacemaker patients with attempted LBBP from April 2017 to July 2019. Pacing parameters, complications, ECG, and echocardiographic measurements were assessed at implant and during follow-up of 1, 6, 12, and 24 months. LBBP was successful in 618/632 (97.8%) patients according to strict criteria for LBB capture. Mean follow-up time was 18.6±6.7 months. Two hundred thirty-one patients had follow-up over 2 years. LBB capture threshold at implant was 0.65±0.27 mV at 0.5 ms and 0.69±0.24 mV at 0.5 ms at 2-year follow-up. A significant decrease in QRS duration was observed in patients with left bundle branch block (167.22±18.99 versus 124.02±24.15 ms, P<0.001). Postimplantation left ventricular ejection fraction improved in patients with QRS≥120 ms (48.82±17.78% versus 58.12±13.04%, P<0.001). The number of patients with moderate and severe tricuspid regurgitation decreased at 1 year. Permanent right bundle branch injury occurred in 55 (8.9%) patients. LBB capture threshold increased to >3 V or loss of bundle capture in 6 patients (1%), 2 patients of them had a loss of conduction system capture. Two patients required lead revision due to dislodgement. This large observational study suggests that LBBP is feasible with high success rates and low complication rates during long-term follow-up. Therefore, LBBP appears to be a reliable method for physiological pacing for patients with either a bradycardia or heart failure pacing indication.

Syncope in Patients with Cardiac Pacemakers.

IntroductionIt is challenging to diagnose syncope in patients with pacemakers. Because these patients have increased morbidity and mortality risks, they require immediate attention to determine the causes in order to provide appropriate treatment. This study aimed to investigate the causes and predictive factors of syncope as well as the methods used to diagnose syncope in cardiac pacemaker patients.MethodsPatients with pacemakers implanted owing to sinus node disease or atrioventricular block were evaluated with standardized questionnaires, endocavitary electrograms, and other tests based on the suspected causes of syncope. Mann-Whitney U tests were used to analyze continuous variables and Chi-squared or Fisher’s exact tests were used for categorical variables. Logistic regression was used for multivariate analyses. Statistical significance was P<0.05.ResultsThe study included 95 patients with pacemakers: 47 experienced syncope in the last 12 months and 48 did not. Of the 100 documented episodes of syncope, 48.9% were vasovagal syncopes, 17% had cardiac-related causes, 10.6% had unknown causes, and 8.5% had pacemaker failure. The multivariate analysis showed that a New York Heart Association (NYHA) Functional Class II was a significant factor for developing syncope (P<0.01).ConclusionWhile the most common type of syncope in pacemaker patients was neurally mediated, it is important to perform detailed evaluations in this population as the causes of syncope can be life-threatening. The best diagnostic methods were stored electrogram analysis and the tilt table test. NYHA Functional Class II patients were found to have a higher risk for syncope.

Optimal Pacing Mode in Dual Chamber Pacing with Long AV-Intervals:A Pressure Volume Loop Study

Objectives: This study aimed to assess if dual chamber pacemaker patients with prolonged atrioventricular (AV-) intervals at rest and maintained LV function will benefit from spontaneous AV-conduction compared to AV synchronous pacing at optimized AV-intervals (DDD-OPT). Background: AV-hysteresis and mode change algorithms allow very long AV-intervals to avoid right ventricular pacing, however, the optimal long AV interval remains undefined. Methods: LV pressure volume loops were obtained via a conductance catheter in 19 dual chamber pacemakers patients with resting AV-intervals >250 ms. Hemodynamic data were recorded during atrial pacing at 70/min (AAI) and DDD-OPT. The optimal AV-interval was defined by the largest consequent stroke work. Results: Mean AV-interval during atrial pacing was 302{±}32 ms. Systolic parameters were not different between pacing modes with the exception of +dp/dt max (AAI: 1398{±}393 mmHg/s; DDD-OPT 1319{±}377 mmHg/s; p=0.006). Stroke work was higher in 9/19 patients with AAI and in 10/19 with DDD-OPT. The diastolic parameters tau (DDD-OPT: 38{±}8 ms; AAI: 35{±}8 ms; p=0.002) and peak filling rate (DDD-OPT: 832{±}450 ml/s; AAI: 627{±}231 ml/s; p=0.001) showed superior results for DDD-OPT. Differential values between the two modes for stroke work and +dp/dtmax correlated significantly with the resting AV-interval ( 320 ms favored DDD-OPT whereas AV-intervals <280ms favored AAI. Conclusion: In dual chamber pacemaker patients with long resting AV-intervals there is a trade-off between pacing-induced LV systolic dysfunction and impaired diastolic filling. Maintaining spontaneous AV-conduction at all cost might not be the preferred option in this patient group.

Device-Detected Atrial Fibrillation Before and After Hospitalisation for Noncardiac Surgery or Medical Illness: Insights From ASSERT

BackgroundAtrial fibrillation (AF) is often detected during hospitalisation for surgery or medical illness and is often assumed to be due to the acute condition. MethodsThe Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial (ASSERT) study enrolled patients ≥ 65 years old without AF. Pacemakers or implantable cardioverter-defibrillators recorded device-detected AF. We identified participants who were hospitalised and compared the prevalence of AF before and after hospitalisation. ResultsAmong 2580 participants, 436 (16.9%) had a surgical or medical hospitalisation. In the 30 days following a first hospitalisation, 43 participants (9.9%, 95% confidence interval [CI] 7.2%-13.1%) had > 6 minutes of device-detected AF; 20 (4.6%, 95% CI 2.8%-7.0%) had > 6 hours. More participants had AF > 6 minutes in the 30 days following hospitalisation compared with the period 30-60 days before hospitalisation (9.9% vs 4.4%; P < 0.001). Similar results were observed for episodes > 6 hours (4.6% vs 2.3%, P = 0.03). Roughly half of participants with device-detected AF in the 30 days following hospitalisation had at least 1 episode of the same duration in the 6 months before (50% [95% CI 31.3%-68.7%] for > 6 min; 68.8% [95% CI 41.3%-89.0%] for > 6 h). Those with AF in the 30 days following hospitalisation were more likely to have had AF in the past (adjusted odds ratio [OR] 7.2, 95% CI 3.2-15.8 for > 6 min; adjusted OR 32.6, 95% CI 10.3-103.4 for > 6 h). ConclusionsThe prevalence of device-detected AF increases around the time of hospitalisation for noncardiac surgery or medical illness. About half of patients with AF around the time of hospitalisation previously had similar episodes.

Prevention of long-lasting atrial fibrillation through antitachycardia pacing in DDDR pacemakers.

The MINERVA trial showed that in pacemaker patients with atrial fibrillation (AF) history, DDDRP pacing combining three algorithms - (a) atrial antitachycardia pacing with Reactive ATP enabled, (b) atrial preventive pacing and (c) managed ventricular pacing (MVP)-may effectively delay progression to persistent/permanent AF compared with standard DDDR pacing. We performed a comparative non-randomised evaluation to evaluate if Reactive ATP can be the main driver of persistent/permanent AF reduction independently on preventive pacing. Thirty-one centres included consecutive dual-chamber pacemaker patients with AF history. Reactive ATP was programmed in all patients while preventive atrial pacing was not enabled. These patients were compared with the three groups of MINERVA randomised trial (Control DDDR, MVP, and DDDRP). The main endpoint was the incidence of AF longer than 7 consecutive days. A total of 146 patients (73years old, 54% male) were included and followed for a median observation period of 31months. The 2-year incidence of AF>7days was 12% in the Reactive ATP group, very similar to that found in the DDDRP arm of the MINERVA trial (13.8%, P=.732) and significantly lower than AF incidence found in the MINERVA Control DDDR arm (25.8%, P=.012) and in the MINERVA MVP arm (25.9%, P=.025). In a real-world population of dual-chamber pacemaker patients with AF history, the use of Reactive ATP is associated with a low incidence of persistent AF, highlighting that the positive results of the MINERVA trial were related to the effectiveness of Reactive ATP rather than to preventive pacing.

Prevention of long-lasting atrial fibrillation through antitachycardia pacing in 584 dual-chamber pacemaker patients

Abstract Background Atrial fibrillation (AF) is a frequent arrhythmia in pacemaker patients and is associated with poor quality of life and increased risks of heart failure, dementia, stroke, and death. The MINERVA trial has shown that the combination of 3 pacing algorithms – 1) atrial antitachycardia pacing (aATP), 2) atrial preventive pacing and 3) managed ventricular pacing (MVP) - delays progression to persistent and permanent AF, compared with standard DDDR pacing mode and with MVP mode, in pacemaker patients with AF history. Purpose We performed a comparative non randomized evaluation to confirm the hypothesis that aATP is the main driver of persistent/permanent AF reduction independently on the effect of preventive atrial pacing. Methods Thirty-one Italian and Japanese Cardiology centers included consecutive dual-chamber pacemaker patients with AF history. aATP was programmed in all patients while preventive atrial pacing was not enabled. Comparison was made with all the 3 groups in MINERVA randomized trial. The main endpoint was incidence of AF longer than 7 consecutive days, as detected by device diagnostics. Results A total of 146 patients (73 years old, 54% male) were included and followed for a median observation period of 31 months. The 2-year incidence of AF&amp;gt;7 days was 12% in the aATP group, very similar to that found in the arm of the MINERVA trial with aATP enabled (13.8%, p=0.732) and significantly lower than AF incidence found in the MINERVA Control DDDR arm (25.8%, p=0.012) and in the MINERVA MVP arm (25.9%, p=0.025). Conclusions In a real-world population of dual-chamber pacemaker patients with AF history, use of aATP was associated with low incidence of persistent AF during follow up, highlighting that the positive results of the MINERVA trial are related to the effectiveness of aATP rather than to the effects of preventive atrial pacing. Funding Acknowledgement Type of funding source: None

Clinic time required to manage cardiac implantable electronic device patients: a time and motion workflow evaluation

Abstract Background The population with cardiac implantable electronic devices (CIEDs) is growing, creating workload for device clinics to manage these patients. However, the CIED follow-up workflow is poorly understood. This study sought to characterize the workflow and staff time for CIED patient management. Methods A time and motion workflow evaluation was performed in 6 U.S. CIED clinics, which manage an average of 4,217 patients. Each task involved in CIED management was repeatedly timed, including all manufacturers, during 1 business week at each clinic. Mean staff time for a remote transmission and an in-person visit were calculated, including all clinical and administrative (e.g: scheduling, documentation) activities related to the encounter. Annual staff time for follow-up of 1 patient was modeled using CIED transmission data for the 6 clinics, guidelines for CIED follow-up, and published literature. Results 124 clinic visits and 1,374 remote monitoring activities were observed. Staff time required per remote transmission ranged from 12.1–13.4 minutes (depending on the CIED type), and time per visit was 43.4–51.0 minutes. Including all remote and in-person follow-ups, the estimated total staff time per year to manage one pacemaker, ICD, CRT, and ICM patient was 2.3, 2.4, 2.4, and 9.3 hours, respectively (Table 1). Conclusion CIED clinic workflow is complex and requires significant staff time. Remote monitoring is an efficient complement to in-office visits, allowing for continuous follow-up of patients. Future research should examine heterogeneity in clinic processes to identify the most efficient workflow. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Medtronic

Impact of Pacemakers and Implantable Cardioverter Defibrillators on the Psychosocial Functioning of Paediatric Patients.

Although implanted cardiac devices improve patients' physical health, long-term psychosocial effects especially in the paediatric population are still unknown. The aim of this study was to evaluate the psychosocial effects of cardiac devices in a paediatric population.Pediatric Quality of Life Questionnaire (PedsQoL) was used to evaluate life quality, Connor-Davidson Resilience Scale was used to evaluate resilience and Brief Symptom Inventory was used to evaluate psychiatric symptoms in a paediatric population with cardiac devices.Seventy-one patients were enrolled in the study. Fifty of them (70.5%) had a cardiac pacemaker and 21 of them (29.5%) had implantable cardioverter defibrillator. When compared to the control group both implantable cardioverter defibrillator and pacemaker using patients had lower quality of life (79.5 ± 12.4 versus 86.7 ± 12.1, p = 0.001) but no difference was observed in resilience and psychological pathologies. Age, gender, family size, and education level had no effect on quality of life. Implantable cardioverter defibrillator bearing patients had higher levels of anxiety than pacemaker patients (0.58 versus 0.30 p = 0.045), and implantable cardioverter defibrillator patients who had received shock in the last year had higher levels of somatisation than the group that did not receive device shock (0.17 versus 0.44 p = 0.022).In conclusion study showed that cardiac devices have negative effects on the psychosocial health of children. Cardiologist working with these patients should be aware of these pathologies and monitor not only physical health but also psychosocial health too.

An approach towards individualized lower rate settings for pacemakers.

Author(s): Infeld, Margaret; Avram, Robert; Wahlberg, Kramer; Silverman, Daniel N; Habel, Nicole; Lustgarten, Daniel L; Pletcher, Mark J; Olgin, Jeffrey E; Marcus, Gregory M; Meyer, Markus