Patients Undergoing Pacemaker Implantation Research Articles

Clinical significance and prognostic value of right bundle branch block in permanent pacemaker patients.

In patients undergoing pacemaker implantation with no prior history of heart failure (HF), the presence of left bundle branch block (LBBB) has been identified as an independent predictor of HF-related death or hospitalization, while the prognostic significance of right bundle branch block (RBBB) remains uncertain. We aimed to assess the long-term risk of all-cause mortality in patients with a standard indication for permanent pacing and normal or moderately depressed left ventricular function when RBBB is detected at the time of implantation. We retrospectively enrolled 1348 consecutive patients who had undergone single- or dual-chamber pacemaker implantation at the study center, from January 1990 to December 2022. Patients with a left ventricular ejection fraction ≤35% or a prior diagnosis of HF were excluded. The baseline 12-lead electrocardiogram revealed an RBBB in 241 (18%) and an LBBB in 98 (7%) patients. During a median follow-up of 65 [25th-75th percentile: 32-117] months, 704 (52%) patients died. The combined endpoint of cardiovascular death or HF hospitalization was reached by 173 (13%) patients. On multivariate analysis, RBBB was confirmed as an independent predictor of death [hazard ratio, 1.33; 95% confidence interval (CI), 1.09-1.63; P = 0.005]. However, when considering the combined endpoint of cardiovascular death and HF hospitalization, this endpoint was independently associated with LBBB (hazard ratio, 2.13; 95% CI, 1.38-3.29; P < 0.001), but not with RBBB. In patients with standard pacemaker indications and normal or moderately depressed left ventricular function, the presence of basal RBBB was an independent predictor of mortality. However, it was not associated with the combined endpoint of cardiovascular death and HF hospitalization.

Clinical significance and prognostic value of right bundle branch block in permanent pacemaker patients

Abstract Aim In patients undergoing pacemaker implantation with no prior history of heart failure (HF), the presence of left bundle branch block (LBBB) has been identified as an independent predictor of HF-related death or hospitalization, while the prognostic significance of right bundle branch block (RBBB) remains uncertain. We aimed to assess the long-term risk of all-cause mortality in patients with a standard indication for permanent pacing and normal or moderately depressed left ventricular function when RBBB is detected at the time of implantation. Methods We retrospectively enrolled 1348 consecutive patients who had undergone single- or dual-chamber pacemaker implantation at the study center, from January 1990 to December 2022. Patients with a left ventricular ejection fraction ≤35% or a prior diagnosis of HF were excluded. Results The baseline 12-lead electrocardiogram revealed an RBBB in 241 (18%) and an LBBB in 98 (7%) patients. During a median follow-up of 65 [25th-75th percentile: 32-117] months, 704 (52%) patients died. The combined endpoint of cardiovascular death or HF hospitalization was reached by 173 (13%) patients. On multivariate analysis, RBBB was confirmed as independent predictor of death (Hazard Ratio, 1.33; 95% CI, 1.09–1.63; P=0.005). However, when considering the combined endpoint of cardiovascular death and HF hospitalization, this endpoint was independently associated with LBBB (Hazard Ratio, 2.13; 95% CI, 1.38–3.29; P&amp;lt;0.001), but not with RBBB. Conclusions In patients with standard pacemaker indications and normal or moderately depressed LV function the presence of basal RBBB was an independent predictor of mortality. However, it was not associated with the combined endpoint of cardiovascular death and HF hospitalization.Time to event

HYPERTROPHIC CARDIOMYOPATHY AND MYBPC3 VARIANT - A CLINICAL CASE

Abstract Introduction Hypertrophic cardiomyopathy is a primary pathology of the cardiac muscle. Sarcomeric forms of hypertrophic cardiomyopathy (HCM) often have autosomal dominant transmission. A pathogenetic or likely pathogenetic mutation affecting genes encoding sarcomeric proteins is present in 30-60% of cases. In this study, we present a case of a family affected by hypertrophic cardiomyopathy with a mutation classified as of uncertain significance in the MYBPC3 gene. Clinical Case Mr. AA, 74 years old, attended the cardiomyopathy outpatient clinic of our hospital in June 2021 due to worsening heart failure with an hypertrophic phenotype. His medical history reported an increase in the thickness of the interventricular septum (IVS) since 1985. In 2015, the patient underwent pacemaker implantation for symptomatic 2:1 atrioventricular block associated with syncope and complete left bundle branch block. Since 2016, he had paroxysmal atrial fibrillation complicated by an ischemic stroke in 2019 with subtherapeutic INR. Cardiac magnetic resonance imaging (MRI) or genetic evaluation had never been performed. During the visit, the patient reported that his sister (AG, 73 years old) had undergone tests due to diffuse negative T waves findings in a previous ECG, revealing the presence of a long myocardial bridge of the left anterior descending artery (LAD). No family history of sudden cardiac death was reported. The echocardiogram of AA showed LV hypertrophy (septal wall thickness/posterior wall thickness 18/15 mm, respectively) with an ejection fraction of 36%. Suspecting sarcomeric HCM, a genetic test (TruSight One Expanded Illumina) was performed, revealing two variants of uncertain significance in heterozygosity in the CACNA1C - Calcium Voltage-Gated Channel Subunit Alpha1 C gene (c.2460G&amp;gt;C p.(Lys820Asn)) and MYBPC3 gene (c.2030C&amp;gt;T p.(Pro677Leu)). After a few months, AG presented MRI results suggestive of HCM apical variant (Figure 1). The genetic consultant recommended family screening, and the pedigree is shown in Figure 2. All carriers of the CACNA1C mutation had a negative phenotype. AG's son, IF, 56 years old, carriers of MYBPC3 mutation, presented an MRI compatible with early-stage HCM (Figure 3). His son, carriers of MYBPC3 mutation as well, is now awaiting a cardiac MRI. Conclusions In the family presented here, the MYBPC3 variant (c.2030C&amp;gt;T p.(Pro677Leu)) appears to be correlated with the development of sarcomeric hypertrophic cardiomyopathy. Registry studies with a large sample size are desirable to accurately classify variants of uncertain significance, which are becoming more common due to the widespread use of genetic tests.

10 Years of Pacemaker Implantation in Port Harcourt, Rivers State: Our Experience and Matters Arising

Abstract Background: There has been an increasing growth in the number of pacemaker implantations in Nigeria. This study is aimed at reviewing the pattern and occurrence of pacemaker implantation and also mode of pacemaker over a 10-year period. Methods: We retrospectively reviewed patients who underwent pacemaker implantation over a 10 year period between September 2012 and December 2023. Results: During the study period, 41 patients underwent pacemaker implantation. There were more males (51.2%) than females with a general mean age 66.8 ±10.6. The most common indication was Complete heart block (CHB) (60.98%) followed by second degree atrioventrivcular block (27.27%). There was an increasing trend in the rate of pacemaker implantation over the 10 years in review. There was no significance difference in the rate of complication between the genders. Conclusion: Pacemaker implantation in Port Harcourt south-south, Nigeria started in September 2012. The major reason for pacemaker implantation were complete heart block (CHB) and second degree Atrioventicular block (2nd degree AVB) being the second reason. Sick sinus syndrome (SSS) was rare in our population as opposed to the western world. Pacemaker implantation is being widely accepted in our society and it is lifesaving procedure associated with very low risk. Keywords: Pacemaker, Pacemaker implantation, heart block, Port Harcourt

Incidental Arrhythmias During Atrial Fibrillation Screening With Repeat 7-Day Holter ECGs in a Hospital-Based Patient Population.

Screening for atrial fibrillation (AF) may reveal incidental arrhythmias of relevance. The aim of this study was to describe incidental arrhythmias detected during screening for AF in the STAR-FIB (Predicting SilenT AtRial FIBrillation in Patients at High Thrombembolic Risk) cohort study. In the STAR-FIB cohort study, we screened hospitalized patients for AF with 3 repeat 7-day Holter ECGs. We analyzed all Holter ECGs for the presence of the following incidental arrhythmias: (1) sinus node dysfunction, defined as sinus pause of ≥3 seconds' duration; (2) second-degree (including Wenckebach) or higher-degree atrioventricular block (AVB); (3) sustained supraventricular tachycardia of ≥30 seconds' duration; and (4) sustained ventricular tachycardia of ≥30 seconds' duration. We furthermore report treatment decisions because of incidental arrhythmias. A total of 2077 Holter ECGs were performed in 794 patients (mean age, 74.7 years; 49% women), resulting in a mean cumulative duration of analyzable ECG signal of 414±136 hours/patient. We found incidental arrhythmias in 94 patients (11.8%). Among these were sinus node dysfunction in 14 patients (1.8%), AVB in 41 (5.2%), supraventricular tachycardia in 42 (5.3%), and ventricular tachycardia in 2 (0.3%). Second-degree AVB was found in 23 patients (2.9%), 2:1 AVB in 10 (1.3%), and complete AVB in 8 (1%). Subsequently, 8 patients underwent pacemaker implantation, 1 for sinus node dysfunction (post-AF conversion pause of 9 seconds) and 7 for advanced AVB. One patient had an implantable cardioverter-defibrillator implanted for syncopal ventricular tachycardia. Incidental arrhythmias were frequently detected during screening for AF in the STAR-FIB study and resulted in device therapy in 1.1% of our cohort patients.

Heart transplantation from COVID-positive donors with 6-month follow-up: A case series.

Data on long term outcomes in heart transplant recipients from Coronavirus disease 2019 (COVID-19) positive donors are limited. We present a series of nine patients who underwent heart transplants from COVID-19 PCR-positive donors between November 2021 to August 2022 with mean follow-up of 12.12±3 months. All the recipients received two doses of COVID-19 vaccine and had at least 6 months follow-up. Eight recipients had acceptable long-term outcomes; one patient died during index admission from primary graft dysfunction. Details regarding donor and recipient characteristics, management and outcomes are provided. Two patients developed deep vein thrombosis, and one patient underwent pacemaker implantation for sinus node dysfunction. Among the surviving eight patients, none developed COVID-19 infection during follow-up period. There was no significant difference in outcome parameters when compared to patients who received hearts from donors who tested negative for COVID-19 during the same time period at our center. Keeping in mind the significant waitlist mortality in patients awaiting heart transplantation, COVID-19-positive donors should be considered for heart transplantation to help expand the donor pool and potentially reduce waitlist mortality.

Short- and long-term survival in patients over 90 years old undergoing pacemaker implantation.

In Italy, 12-month survival in the general population between 90 and 94 years old is 26%. In very old patients, the benefit of pacemaker implantation in terms of quality and duration of life is unclear. The aim of our study was to analyse clinical characteristics, outcome and factors associated with survival in patients at least 90 years old at the time of the first pacemaker implant. Clinical parameters, device characteristics, survival and predictors of outcome in patients at least 90 years old treated with a pacemaker in our centre in 2019-2020 were evaluated. Among the 554 patients undergoing pacemaker implantation in our centre during the study interval, 69 (12%) were at least 90 years old; a complete/advanced atrioventricular block was present in 65%. A cardiological comorbidity (excluding atrial fibrillation) was present in 22 patients (32%). Oncological, pulmonary and neurological comorbidities were present in 12 (17%), 19 (28%) and 32 (46%), respectively. Renal impairment was present in 25 patients (36%). After pacemaker implantation, a pneumothorax developed in two patients and lead dislodgment in one. During follow-up (median 17 months, interquartile range: 13-24), 32 patients died (46%), with a 12-month mortality probability of 24.6%. At multivariate analysis, the presence of oncological (hazard ratio (HR) 5.31; P < 0.001) and neurological (HR 6.44; P < 0.001) comorbidities was associated with mortality. Truncating the outcome at 6 months, renal impairment (HR 8.01; P = 0.003), anticoagulant therapy (HR 8.14; P = 0.003), oncological comorbidities (HR 14.1; P < 0.001) and left ventricular function (5% increase of left ventricular ejection fraction: HR 0.66; P < 0.001) were significantly associated with outcome. At our centre, patients at least 90 years old underwent pacemaker implantation mainly for advanced atrioventricular block. One-year survival was excellent, even better than expected in the general population.

Diffusion-weighted whole-body magnetic resonance imaging with background body signal suppression was useful in a patient with isolated myocardial abscess confined to the right atrial wall: a case report

BackgroundMyocardial abscess is often associated with infective endocarditis (IE), and isolated myocardial abscess without IE is rare. Echocardiography and computed tomography (CT) are often used to diagnose myocardial abscess; however, to the best of our knowledge, diffusion-weighted whole-body magnetic resonance imaging with background body signal suppression (DWIBS) has not been used. Here, we present a case of myocardial abscess without IE that was diagnosed using DWIBS.Case presentation: A 72-year-old Japanese man with a history of hypertension, dyslipidemia, and retinitis pigmentosa presented to our hospital with malaise and a fever lasting 10 days. Blood test results showed elevated inflammatory marker levels (white blood cell count 18,700/µL and C-reactive protein level 23.0 mg/dL). Infection was suspected; however, the source of the infection could not be identified. DWIBS, which was performed on day 7 of admission to determine the source of infection, showed a high signal surrounding the right wall, suggesting inflammation. Contrast-enhanced CT performed on day 1 of hospitalization revealed a low-density area in the same region; however, the pathological implications of this finding could not be determined. Based on DWIBS findings, we concluded that the condition presented as a myocardial abscess that was confined specifically to the right atrial wall. Three sets of blood cultures revealed negative findings, and echocardiography showed no vegetation or valve regurgitation. Therefore, the patient was diagnosed with an isolated myocardial abscess uncomplicated with IE. An electrocardiogram on admission showed no P waves, and the patient had a junctional rhythm. However, on day 20 of hospitalization, he developed a complete atrioventricular block. After complete myocardial abscess healing following antibiotic treatment was confirmed, the patient underwent pacemaker implantation. Ten months after surgery, the patient had no signs of infection recurrence.ConclusionsBased on history and physical examination alone, diagnosis of an isolated myocardial abscess can be challenging. In addition to CT and echocardiography, DWIBS might be helpful for the diagnosis of myocardial abscesses.

Role of periprocedural HV interval assessment to determine the risk of atrioventricular block after transcatheter aortic valve replacement

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Fondation vaudoise de cardiologie interventionnelle. Background The identification of patients at risk of post-procedural high-grade atrio-ventricular block (HAVB) is one of the major unmet challenges in transcatheter aortic valve replacement (TAVR). Some studies have suggested that periprocedural electrophysiological (EP) testing might help to identify patients at risk, but its role is controversial. Purpose To determine whether the immediate postvalve deployment HV and the Delta-HV interval (difference between post- and prevalve deployment HV interval) are predictive of HAVB and pacemaker (PM) need over 1 year follow-up. Methods We prospectively analysed consecutive patients undergoing TAVR between August 2019 and October 2021, and without prior PM implantation. ECG and standardized HV interval measurements were performed pre- and postvalve deployment with the quadripolar catheter used for rapid pacing. The primary outcome was either documented HAVB beyond 24h after TAVR or ventricular pacing &amp;gt;1% in patients who underwent prophylactic PM implantation because of abnormal EP testing in the days following TAVR. Minimal follow-up was 12 months. Results 97 patients were included. The primary outcome occurred in 8 patients (8.3%): HAVB occurred in 7 patients (5 during hospitalisation and 2 within one month of follow-up), and 1 patient underwent PM implantation because of abnormal EP testing (HV interval≥70 ms) with ventricular pacing up to 11% despite an algorithm to minimize pacing. Among ECG and EP findings, univariate predictors of the primary outcome were the pre- and postvalve deployment PR interval and both the postvalve deployment HV and Delta-HV interval (Table 1). By ROC analysis, a Delta-HV interval ≥18ms predicted HAVB with 50% sensitivity and 90% specificity (AUC=0.708, PPV 31%), and an HV interval ≥ 60ms after TAVR predicted HAVB with 63% sensitivity and 79% specificity (AUC=0.681, PPV 21%) (Figure 1). Conclusion The yield of the periprocedural HV interval assessment alone is limited in ruling out the risk of HAVB since about half of the patients at risk fail to be identified. However, abnormal postvalve deployment HV or Delta-HV interval may identify a subgroup at particularly higher risk, with up to one third of HAVB during follow-up.

Catheter ablation (CA) for atrial fibrillation and atrial tachycardia in the elderly: Results from a large single center study in 293 patients over 80 years old

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The increasing incidence of atrial arrhythmias in the elderly is mostly adjudicated to the age-dependent development of arhythmic substrate. In recent years, CA has become a standard approach in treating atrial fibrillation (AF) and left and right atrial flutter (AFlut). Data regarding safety and efficacy of CA in patients over 80 years old remains scarce. This study aims to report on our high-volume center experience regarding the safety and efficacy of CA in a large cohort of patients &amp;gt;80 years of age. Methods All patients &amp;gt;80 years undergoing de-novo-CA for AF or AFlut (parox. AF n=85, 29%; pers. AF n=146, 49.8%; left-/right- AFlut n=62, 21.2%) in our institution between 01/2016 and 12/2020 were included (n=293; mean age 82.3 ± 2.27 years). For safety analysis, all complications requiring intervention or causing sequels occurring during or up to 30 days after CA were collected. For efficacy, AF/Aflut-free survival was analysed after a blanking period (3 months) using 7-day Holter ECGs. Results Baseline characteristics are shown in table 1. Most patients suffered from multiple cardiovascular co-morbidities (CHA2DS2-VASc-score 4.45 ± 1.15), &amp;gt;30% were on reduced OAC. Isolation of all pulmonary veins (PV) and/or termination of AFlut with demonstration of bidirectional block across the ablation line was achieved in all patients (procedure success 100%). During a follow-up of 400 ± 446 days, 61.4% of patients remained in stable sinus rhythm after 1.56 ± 0.81 ablations (Figure 1). Single procedure outcome was significantly higher in paroxysmal AF compared to persistent AF (p = 0.03, s. Figure 1b). 32 patients (10.9%) were lost to follow-up. In 17 patients (5.8%) complications occurred: 1 case of pericardial tamponade during PVI and CA of PVCs (LA and CS). 2 patients suffered a stroke within a week after CA of persistent AF and left AFlut, 1 TIA occurred after CA of persistent AF. All patients had been under uninterrupted full-dose OAC. Major groin complications occurred in 13 patients (4.4%). 3 arterial bleeds treated by covered stent implant, 7 pseudoaneurysms needing thrombin injections, 2 infections of the puncture site and 1 patient requiring surgical treatment for a large hematoma. 9 patients underwent pacemaker implantation shortly after CA due to underlying symptomatic sick-sinus-syndrome or higher degree AV-blocks demasked in sinus rhythm, none were procedure-related. Conclusion De novo catheter ablation of AF and AFlut in very old patients is safe and effective. In paroxysmal AF, ablation success rates seem to be similar to those in younger patients and are significantly higher than for persistent AF. After 1.56 ablation procedures, &amp;gt;60% of patients were free of arrhythmia, suggesting that the supposed atrial remodelling does not preclude an interventional treatment approach.

Reduction of left ventricular global longitudinal strain in patients with permanent pacemakers as a predictor of heart failure and mortality outcomes.

Frequent right ventricular (RV) pacing is associated with cardiomyopathy. The impact of RV pacing on left ventricular (LV) global longitudinal strain (GLS) and clinical outcomes is unclear. We analyzed GLS via two-dimensional speckle tracking and LV ejection fraction (EF) on pre- and post-implantation transthoracic echocardiograms of patients undergoing dual chamber pacemaker implantation. We collected long-term data on strain, LVEF, and clinical outcomes. One hundred and ten patients (mean age 76±12years; 59 [54%] female) were followed for mean 23±17months. Mean baseline LVEF was 58±11% and mean GLS was -17±4%. Twenty-four (22%) patients had an absolute decrease in LVEF>10% and 43 (39%) patients had a relative reduction of GLS>15%. Among patients with a reduction of GLS, a larger proportion of patients had RV pacing burden ≥20% (67% vs. 46%; p=.048). Compared to patients without GLS reduction, more patients with a reduction in GLS reached a composite endpoint of HF hospitalization, CRT upgrade or death (47% vs. 16%; p=.001). Reduction in LV GLS was seen in nearly four in 10 patients undergoing pacemaker implantation and was significantly associated with increased RV pacing burden. LV GLS reduction was associated with increased risk of adverse outcomes. LV GLS may have utility in predicting outcomes among patients with RV pacing.

Rate and nature of complications of conduction system pacing compared with right ventricular pacing: Results of a propensity score–matched analysis from a multicenter registry

Conduction system pacing (CSP) using His bundle pacing (HBP) or left bundle branch area pacing (LBBAP) has emerged as an alternative to right ventricular pacing (RVP). Comparative data on the risk of complications between CSP and RVP are lacking. This prospective, multicenter, observational study aimed to compare the long-term risk of device-related complications between CSP and RVP. A total of 1029 consecutive patients undergoing pacemaker implantation with CSP (including HBP and LBBAP) or RVP were enrolled. Propensity score matching for baseline characteristics yielded 201 matched pairs. The rate and nature of device-related complications occurring during follow-up were prospectively collected and compared between the 2 groups. During a mean follow-up duration of 18 months, device-related complications were observed in 19 patients: 7 in RVP (3.5%) and 12 in CSP (6.0%) (P = .240). On dividing the matched cohort into 3 groups with similar baseline characteristics according to pacing modality (RVP, n = 201; HBP, n = 128; LBBAP, n = 73), patients with HBP showed a significantly higher rate of device-related complications than did patients with RVP (8.6% vs 3.5%; P = .047) and patients with LBBAP (8.6% vs 1.3%; P = .034). Patients with LBBAP showed a rate of device-related complications similar to that of patients with RVP (1.3% vs 3.5%; P = .358). Most of the complications observed in patients with HBP (63.6%) were lead related. Globally, CSP was associated with a risk of complications similar to that of RVP. Considering HBP and LBBAP separately, HBP showed a significantly higher risk of complications than did both RVP and LBBAP whereas LBBAP showed a risk of complications similar to that of RVP.

Permanent pacing versus cardioneuroablation for cardioinhibitory vasovagal syncope.

We compared the efficacy and safety of cardioneuroablation (CNA) vs. permanent pacing (PM) for recurrent cardioinhibitory vasovagal syncope (CI-VVS). One hundred sixty-two patients (CNA = 61, PM = 101), age 36 + 11years) with syncope frequency of 6.7 ± 3.9/year were included in this multicenter study. All patients with CNA were provided by a single center, while patients with PM were provided by 4 other centers. In the CNA arm, an electroanatomic mapping guided approach was used to detect and ablate ganglionated plexus sites. Dual chamber rate drop response (RDR) or close loop stimulation (CLS) transvenous and leadless pacemakers were implanted using standard technique. The primary endpoint was freedom from syncope. Of 101 patients in the PM group, 39 received dual-chamber pacemaker implants with the CLS algorithm, 38 received dual-chamber pacemakers with the RDR algorithm, and 24 received a leadless pacemaker. At 1-year follow-up, 97% and 89% in the CNA and PM group met the primary endpoint (adjusted HR = 0.27, 95% CI 0.06-1.24, p = 0.09). No significant differences in adverse events were noted between groups. There was no significant association between age (HR:1.01, 95% CI 0.96-1.06, p = 0.655), sex (HR:1.15, 95% CI 0.38-3.51, p = 0.809), and syncope frequency in the past year (HR:1.10, 95% CI 0.97-1.25, p = 0.122) and the primary outcome in univariable analyses. After adjustment for patient characteristics, the medium-term syncope recurrence risk of CI-VVS patients who underwent CNA was similar to that of a population of patients undergoing pacemaker implantation with a similar safety profile.

621 TRANSVENOUS LEAD ADVANCEMENT IN PAEDIATRIC PACING TO OVERCOME GROWTH STRETCHING

Abstract Background One of the main complications of transvenous leads implanted in paediatric patients is the stretching of the lead caused by the somatic growth. It may cause pacing and sensing defects and lead dislodgement or even fracture. Absorbable lead ligature and atrial loop may reduce this risk. However, the loop may induce traction or may unroll too early and therefore impair lead function. Lead extraction and replacement is another solution, although it has some procedural risks in young patients. Lead advancement through pushing it from the pocket may solve growth-induced traction and spare the electrode throughout childhood until post-puberty. Objective of the study is the retrospective analysis of the outcome of the transvenous lead advancement in children with a pacemaker (PM) in a single tertiary paediatric center. Methods consecutive patients with a VVIR PM implanted for isolated congenital complete atrioventricular block (no structural heart disease) in alternative right ventricular (RV) pacing sites, with lead stretching underwent a trial of lead advancement during general anaesthesia, cefuroxime antibiotic profilaxis, from 2014 to 2021. After venous angiography showed venous patency, the PM pocket was opened, the lead was released from subcutaneous adherences and with a stylet was gently advanced to create a semi-loop in the atrium without dislodging the tip. Lead data (threshold, sensing, impedance) were compared before and after the procedure. Data are expressed as median (25th-75th centiles). Results 8 patients underwent PM implantation at 6.8 (5.8-8.0) years of age, 20 (18-21) kg, 116 (106-120) cm, with the lead positioned at parahisian(3)/mid-septum (5 pts) sites. During a follow-up of 3 (1-5) years, advancement procedures were 1.5 (1.0-4.3) per patient. Between procedures, delta age was 16 (12-20) months, height 8 (7-11) cm and weight 5 (3-7) kg. All leads were successfully advanced without any procedural complications. Procedure time (skin to skin) was 96 (73-108) minutes, fluoroscopy was 0.5 (0.2-1.4) mGy, 16 (10-46) microGy/m2. Electrical lead parameters did not showed significant differences between consecutive control times. Conclusion the advancement of transvenous leads in children is a safe and effective procedure, with low fluoroscopy exposure, without significant acute and chronic complications. This procedure seems to preserve transvenous leads until growth has completed.

RECURRENT SINUS ARREST DURING LAPAROSCOPIC SACRAL COLPOPEXY IN PATIENTS WITH SICK SINUS SYNDROME : A CASE REPORT

Sick sinus syndrome (SSS) is a disease in which the SA node fails to perform the function of pacemaking. ECG shows various rhythms including sinus arrest. We report recurrent sinus arrest during laparoscopic sacral colpopexy in a 77-year-old female patient with SSS. The patient was diagnosed with SSS, but as there were no symptoms, the operation was performed without pacemaker implantation. After induction of anesthesia, vital signs were stable, but sinus arrest repeatedly appeared due to elevated vagal tone during uterine traction. After operation, the patient underwent pacemaker implantation, and to this day, she is doing well without any symptoms. The anesthesiologist should pay close attention to the progress of the operation through much communication with operator during the surgery. Also, we recommend to considering temporary pacemaker implantation for patients with SSS who undergo surgery that can increase vagal tone.

Medium term survival in patients over ninety years-old undergoing pacemaker implantation

Abstract Background According to the Italian National Statistical Institute, the 12-month probability of survival in the general population between 90 and 94 years-old is 26%. Pacemaker (PM) implantation is often an urgent and necessary intervention, but in these patients the benefit in terms of quality and duration of life is unclear. Purpose To analyze characteristics, outcome and factors associated with survival in patients who had turned 90 at the time of PM implant. Methods All the PM implants performed in patients ≥90 from 1/1/2019 to 12/31/2020 were analyzed. Clinical parameters, device characteristics and follow-up data were extrapolated from the SuitEstensa Ebit reporting system; the exitus was verified by analyzing data from the Regional Health System. Results During the study interval, among the 554 patients undergoing PM implantation in our Center, 69 (12%) were ≥90 years-old (mean age 92±2 years, 46% male; complete/advanced AV block in 76%). Twenty-six (38%) patients had history of atrial fibrillation and 19 (28%) ischemic heart disease. A cardiological co-morbidity (excluding AF) was present in 23 patients (33%). Oncological, pneumological and neurological comorbidities were present in 12 (18%), 19 (28%) and 32 (46%) respectively. Renal impairment was present in 25 patients (36%). In 47 patients (68%) there were at least 2 co-morbidities. After implantation (single-chamber in 36, dual-chamber in 25 and VDD single-lead dual-chamber in 8 patients) complications occurred in 3 patients (2 pneumothorax and 1 lead dislodgment). Remote monitoring was activated in 57 patients (83%). Within August 31st 2021 (mean follow-up 288±193 days) 24 patients died (35%, 219±241 days after implant). Five patients (19% of patients implanted in 2019) died within 12 months. No patients died for device malfunction. Three patients died because of COVID-19 pneumonia. Renal dysfunction (Hazard Ratio-HR 8.05, p=0.002) and the presence of 2 or more co-morbidities (HR 6.03; p=0.015) were associated with a higher risk of death at univariate analysis; other significant variables were diabetes (HR 2.34; p=0.038), left ventricular ejection fraction (LVEF) (HR 0.70 for 5% variation; p=0.005), walking impairment (HR 2.99, p=0.006), the presence of oncological (HR 2.21; p=0.003), pneumological (HR 2.55; p=0.024) and neurological (HR 1.90, p=0.007) comorbidities. At multivariable analysis the only significant parameter associated with survival was LVEF (0.76 for 5% difference; p=0.043) Conclusions At our Center, patients ≥90 years-old undergo PM implantation mainly for advanced AVB. The good survival in the medium term, even better than expected in the general population, does not justify a too conservative attitude especially, but exclusively, in patients with less comorbidities. Funding Acknowledgement Type of funding sources: None.

Intracardiac echocardiographically guided permanent pacemaker implantation is a feasible imaging tool with comparable procedural efficacy and safety

Abstract Background Amongst cardiovascular interventions, pacemaker implantation procedure is one of the most hazardous in terms of radiation exposure due to its proximity and unprotected radiation exposure. In order to reduce radiation hazards, alternative imaging tool to guide pacemaker implantation should be sought. The aim of this study is to investigate the feasibility, efficacy, and safety of intracardiac echocardiographically (ICE) guided pacemaker implantation. Methods We retrospectively investigated pacemaker implantation with ICE guidance. ICE catheter was placed in right atrium (RA). Right ventricular (RV) lead was placed in RV apex within home view (low RA, 2-4 O'clock). Then RA lead was placed in RA appendage within mid RA 1-2 O'clock view. Fluoroscopy was used only for verifying lead redundancy (2 or 3 second duration before pocket closure). Other procedure steps were similarly performed as in conventional fluoroscopic method. Radiation dosage, patient safety, total procedure time, and lead parameters were assessed and compared. Results From June 2013 to March 2021, a total of 270 patients underwent pacemaker implantation either with ICE or with fluoroscopy. Amongst them, ICE guided implantation was attempted in 35 patients. In order to exclude potential bias caused by the operator's learning curve, we excluded early 5 cases out of ICE group. Radiation exposure was markedly decreased within ICE group (2.3±4.4 Gy cm2 in ICE group vs. 27.2±50.5 Gy cm2 in fluoroscopy group, P&amp;lt;0.001). The total procedure time and complication rate showed no significant difference between groups. In ICE group, atrial lead parameters were better than those of fluoroscopy group (impedance 454±57 Ω vs. 533±125 Ω, P&amp;lt;0.001). Conclusion In 30 patients with ICE guided pacemaker implantation, radiation exposure was markedly decreased without any trade-offs in terms of patients' safety and procedural success. Furthermore, operation team members' physical stress reduction also might be potentially guaranteed. Funding Acknowledgement Type of funding sources: None.

Risk of pacemaker implantation after femur fracture in patients with and without a history syncope: a Danish nationwide registry-based follow-up study.

It has previously been described that fall-associated injuries including fractures are commonly observed among patients with bradyarrhythmia. However, knowledge on the risk of pacemaker implantation after admission due to femur fracture from large population-based epidemiologic data is lacking. Therefore, we investigated the risk of pacemaker implantation following femur fracture in patients with and without a history of previous syncope. All patients with femur fracture between 2005-2017 were identified using the Danish Nationwide Patient Registry. Among these, patients already having a pacemaker were excluded. Primary outcome was one-year risk of pacemaker implantation and secondary outcome was one-year all-cause mortality. Multivariable logistic regression was used to obtain absolute and relative risks of the study endpoint in relation to patients with versus without history of syncope and standardized to the age, sex, selected comorbidity and pharmacotherapy distribution of all patients. Of 93,093 patients with femur fracture, 5508 (5.9%) had a history of syncope within five years. Patients with prior syncope were slightly older (84 vs. 83 years), more often male (33.6% vs. 29.4%), and had more often comorbidities relative to those without history of syncope. All-cause mortality was significantly higher among those with previous history of syncope compared to those without previous syncope (29.9% vs. 28.6%, P = 0.021). The relative mortality risk was 1.05 (95% CI: 1.01-1.09, P = 0.021). A total of 695 (0.8%) patients underwent pacemaker implantation within 5 years following femur fracture, and a significantly higher proportion of patients with syncope had a pacemaker implanted within one year (1.6% vs. 0.7%, P < 0.001; relative risk, 2.01 [95% CI: 1.55-2.46]). In patients with femur fracture, a history of syncope was significantly associated with a higher one-year risk of pacemaker implantation.

Trend in Age at the Initial Pacemaker Implantation in Patients With Bradyarrhythmia - A 50-Year Analysis (1970-2019) in Japan.

This study investigated whether the age of patients undergoing pacemaker implantation is increasing.Methods and Results: This study retrospectively reviewed the consecutive cases of 3,582 patients who underwent an initial pacemaker implantation at our hospitals because of symptomatic bradyarrhythmias between 1970 and 2019. The exclusion criteria were: patients with AV block due to cardiac surgery or AV junction ablation, and patients aged <20 years. The patients were divided into 5×10-year groups: those treated in the 1970s (1970-1979), 1980s (1980-1989), 1990s (1990-1999), 2000s (2000-2009), and 2010s (2010-2019). A total of 3,395 patients satisfied the study criteria. The average age at which the patients underwent a first pacemaker implantation increased across the 10-year periods: 63.7±13.2 years in the 1970s, 66.2±12.6 years (1980s), 69.1±12.4 years (1990s), 72.0±11.1 years (2000s), and 75.8±10.0 years (2010s) and advanced significantly in the 1990s, 2000s, and 2010s compared to the 1970s (all P<0.001). The ratio of patients aged ≥80 and ≥90 years increased from 10.6% and 0% in the 1970 s to 38.2% (P<0.001) and 5.2% (P= 0.017) in the 2010s, respectively. The average age at initial pacemaker implantation increased by 12.1 years over the last 50 years in Japan. In particular, the ratios of ≥80 and ≥90 years as the patients age increased significantly.

Carpal Tunnel Syndrome in Patients Who Underwent Pacemaker Implantation and Relation to Amyloidosis, Heart Failure, and Mortality

Advances in treatment warrant earlier diagnosis of cardiac amyloidosis (CA). Common cardiac and extracardiac manifestations of CA, such as pacemaker implantation and carpal tunnel syndrome (CTS), might provide screening opportunities for CA. However the association between CTS and CA in patients undergoing pacemaker implantation has not been well studied. This study examined the association between previous CTS surgery and adverse cardiovascular outcomes in patients who underwent pacemaker implantation. Using Danish nationwide registries, we identified all patients ≥50 years who underwent first-time pacemaker implantation during 2000 to 2018, examining the association between previous CTS surgery and adverse cardiovascular outcomes 5 years after pacemaker implantation. Cumulative incidence functions and Cox proportional hazard models were used to assess the differences. Among 57,315 patients who underwent pacemaker implantation, 2.2% (n=1,266) had previous CTS surgery. Patients in the CTS cohort were older, more often female, and had more co-morbidities than patients without CTS. The cumulative 5-year mortality was higher among patients with CTS (44.6% [41.1% to 47.9%] versus 40.2% [39.7% to 40.6%], p=0.04). In the adjusted models, previous CTS surgery was not associated with increased 5-year mortality, but it was associated with an increased rate of hospitalization for new-onset heart failure, (hazard ratio 1.32 [1.11 to 1.57], p=0.002) and a higher risk of amyloidosis diagnosis after pacemaker implantation (hazard ratio 7.72 [2.96 to 20.10], p <0.0001), compared with no previous CTS surgery. In patients who underwent pacemaker implantation, adjusted models showed that previous CTS surgery was associated with a higher incidence of hospitalization for new-onset heart failure and amyloidosis diagnosis after pacemaker implantation. Screening for CA may be considered in patients undergoing pacemaker implantation.