Right Ventricular Lead Research Articles

303 IMPACT OF LEAD POSITION IN THE TRICUSPID ANULUS ON THE DEVELOPMENT OF CARDIAC IMPLANTABLE ELECTRONIC DEVICES RELATED TRICUSPID REGURGITATION

Abstract Introduction Originally considered as the “forgotten valve disease”, tricuspid regurgitation (TR) has recently been shown to correlate with consistent morbidity and mortality, suggesting the need for a deeper understanding of its natural course. Direct injury from Cardiac Implantable Electrical Device (CIED) leads is one of the most common causes of primary TR, with a prevalence up to 40%. The aim of the present proof-of-concept study was to evaluate the effect of CIED right ventricular (RV) lead position within the tricuspid anulus on TR development. Methods Consecutive patients undergoing CIED implantation at our institution (Humanitas Research Horpital IRCCS, Milan, Italy) were included, as long as they had been performed pre- and post- transthoracic echocardiogram (TTE) and a chest CT scan after the implantation. TTE and CT images were retrospectively reviewed. TR severity was graded using a pre-specified 4-class grading scheme: mild, moderate, severe and massive. CIED RV lead position was defined as postero-septal, antero-septal or antero-posterior, based on the commissure in which the lead was observed on a cross-sectional view of the tricuspid anulus at CT scan. Results 64 patients undergoing CIED implantation from January 2015 to December 2021 were included. All CT scans were non-ECG gated. TR was detected in 42 patients (65.62%) at pre-implantation TTE. The RV lead was implanted across the postero-septal, antero-posterior and antero-septal commissures in 35 (54.7%), 16 (25%) and 13 (20.3%) patients respectively. After the implantation, 12 individuals (18.75%) had new-onset or worsening TR, with CIED lead contributing to TR in 46.88% of cases (30/64), and 26 (40.63%) had worse RV function. At logistic regression analysis, the absence of atrial fibrillation was the only independent predictor of new-onset or worsening TR (OR: 0.17, 95% CI: 0.03-0.86, p=0.032), while CIED RV lead in the postero-septal commissure was associated with a numerically lower risk as compared to other sites (OR: 0.34, 95% CI: 0.09-1.27, p=0.108). Consistently, the degree of increase in TR severity was numerically lower in patients with a lead in the postero-septal commissure (Δ = 0.38±0.10 vs. 0.63±0.13, p=0.07). Conclusions CIED implantation is associated with increasing TR severity and worsening RV function. Positioning a lead across the postero-septal commissure of the tricuspid anulus might have a lower impact on TR development and worsening, thus representing a feasible option to prevent CIED-related TR.

Outcomes of leadless pacemaker implantation following transvenous lead extraction in high-volume referral centers: Real-world data from a large international registry

Limited data on the real-world safety and efficacy of leadless pacemakers (LPMs) post-transvenous lead extraction (TLE) are available. The purpose of this study was to assess the long-term safety and effectiveness of LPMs following TLE in comparison with LPMs de novo implantation. Consecutive patients who underwent LPM implantation in 12 European centers joining the International LEAdless PacemakEr Registry were enrolled. The primary end point was the comparison of LPM-related complication rate at implantation and during follow-up (FU) between groups. Differences in electrical performance were deemed secondary outcomes. Of the 1179 patients enrolled, 15.6% underwent a previous TLE. During a median FU of 33 (interquartile range 24-47) months, LPM-related major complications and all-cause mortality did not differ between groups (TLE group: 1.6% and 5.4% vs de novo group: 2.2% and 7.8%; P = .785 and P = .288, respectively). Pacing threshold (PT) was higher in the TLE group at implantation and during FU, with very high PT (>2 V@0.24 ms) patients being more represented than in the de novo implantation group (5.4% vs 1.6 %; P = .004). When the LPM was deployed at a different right ventricular (RV) location than the one wherethe previous transvenous RV lead was extracted, a lower proportion of high PT (>1-2 V@0.24 ms) patients at implantation, 1-month FU, and 12-month FU (5.9% vs 18.2%, P = .012; 3.4% vs 12.9%, P = .026; and 4.3% vs 14.5%, P = .037, respectively) was found. LPMs showed a satisfactory safety and efficacy profile after TLE. Better electrical parameters were obtained when LPMs were implanted at a different RV location than the one where the previous transvenous RV lead was extracted.

Risk of Pacing-Induced Cardiomyopathy in Patients with High-Degree Atrioventricular Block-Impact of Right Ventricular Lead Position Confirmed by Computed Tomography.

Prospective studies applying fluoroscopy for assessment of right ventricular (RV) lead position have failed to show clear benefits from RV septal pacing. We investigated the impact of different RV lead positions verified by computed tomography (CT) on the risk of pacing-induced cardiomyopathy (PICM). We retrospectively included 153 patients who underwent routine fluoroscopy-guided pacemaker implantation between March 2012 and May 2020. All patients had normal pre-implant left ventricular ejection fraction (LVEF). Patients attended a follow-up visit including contrast-enhanced cardiac CT and transthoracic echocardiography. Patients were classified as septal or non-septal based on CT analysis. The primary endpoint was PICM (LVEF < 50% with ≥10% decrease after implantation). Based on CT, 48 (31.4%) leads were septal and 105 (68.6%) were non-septal. Over a median follow-up of 3.1 years, 16 patients (33.3%) in the septal group developed PICM compared to 31 (29.5%) in the non-septal group (p = 0.6). Overall, 13.1% deteriorated to LVEF ≤ 40%, 5.9% were upgraded to cardiac resynchronization therapy device, and 14.4% developed new-onset atrial fibrillation, with no significant differences between the groups. This study demonstrated a high risk of PICM despite normal pre-implant left ventricular systolic function with no significant difference between CT-verified RV septal or non-septal lead position.

Impact of right ventricular lead position on left ventricular functions and early remodeling in permanent single- and dual-chamber pacemakers.

Right ventricular (RV) apical pacing can induce both interventricular dyssynchrony and intraventricular dyssynchrony. Mechanical dyssynchrony after long-term RV apical pacing is associated with reduced left ventricular (LV) systolic function and deterioration in functional capacity. We aimed to identify the short-term effects of the pacemaker RV lead position on remodeling of LV systolic functions. The study included 30patients who presented with an indication of permanent pacing and who underwent permanent single- or dual-chamber pacemaker insertion: 15patients with RV apical pacing (RV apex), and 15patients with non-apical pacing (mid-septal). The two-dimensional (2D)speckle tracking imaging technique was used for quantification of global longitudinal function of the left ventricle and dyssynchrony evaluation before pacemaker implantation and after a3-month follow-up. At the 3‑month follow-up, post-pacing 2Dspeckle tracking echocardiography revealed impairment of global longitudinal strain in all patients and intraventricular dyssynchrony was significantly increased in the apical location compared with the non-apical location (radial dyssynchrony: 108.67 ± 11.68 ms vs. 80.53 ± 8.17 ms, p < 0.001) with a greater difference (50.53 ± 13.30 ms) in the apical location than in the non-apical location (29.87 ± 6.64 ms, p < 0.001). In the short-term follow-up, 2Dspeckle tracking echocardiography showed more radial dyssynchrony in the apical location than in the non-apical location of RV lead. The RV septal pacing is abetter alternative in terms of less dyssynchrony compared to RV apical pacing. Older age, higher percentage of pacing, and device type are prognostic factors for development of pacemaker-induced cardiomyopathy.

Right ventricular lead sensing latency in pacemaker therapy.

BackgroundPacemaker implantation involves intraoperative testing of ventricular sensing using a device called a pacing system analyzer (PSA). The value obtained is expected to correspond to those taken by the pacemaker after its implantation. This study determined the latency period for sensing intracardiac electrogram (EGM) by the right ventricular (RV) lead.MethodsPatients without significant heart disease and underlying intrinsic atrioventricular (AV) conduction underwent Medtronic or Abbott dual‐chamber pacemaker implantation with the RV lead positioned on the mid‐septum. Real‐time sensing data were obtained through PSA and after pacemaker implantation to evaluate latency as the time interval Q‐VS between the onset of QRS on surface electrocardiogram and the sensed EGM by the RV lead.ResultsOf 157 patients, 105 had narrow QRS (<120 ms) and 52 had wide QRS of complete right bundle branch block (RBBB). Both narrow‐QRS and RBBB patients had longer sensing latency through PSA (50.9 ± 24.2 and 67.8 ± 32.9 ms, respectively) than through pacemaker (18.2 ± 12.8 and 31.2 ± 14.8 ms, respectively, both p < 0.001). RBBB patients had longer sensing latency compared with narrow QRS patients, either through PSA or through pacemaker (p < 0.001). The sensing latency of Medtronic recipients was longer than those of Abbott in narrow‐QRS (p < 0.05), but not in RBBB.ConclusionWe demonstrated longer RV lead sensing latency (1) through PSA than through pacemaker, (2) in RBBB than in narrow‐QRS, and (3) in Medtronic pacemakers compared with Abbott pacemakers. Knowledge of sensing latency helps the optimization of the AV delay.

Individualised left anterior oblique projection for lead implantation into interventricular septum

ObjectiveWe sought to investigate whether it is possible to obtain individualised left anterior oblique (LAO) by preprocedural electrocardiographic parameters and, if so, whether these parameters can help to improve the...

Right ventricular lead sensing latency in pacemaker therapy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Pacemaker’s ventricular sensing function relies on the analysis of the intracardiac electrogram (EGM) including the timing of the intrinsic detection. The phenomenon of ventricular sensing latency refers to the gap of time by which the intrinsic signal gets delayed to be detected compared with the surface electrogram (ECG). A pacing system analyzer (PSA) unit is needed to record the EGM during pacemaker operation, which is expected to correspond to those taken following implantation. Purpose We sought to determine the latency period for sensing EGM by the right ventricular (RV) lead, either through the PSA or through the implanted pacemaker on the same patient. Methods Patients without significant heart disease and intrinsic atrioventricular conduction underwent conventional dual-chamber Medtronic or Abbott pacemaker implantation with the RV lead positioned on mid-septum. Real time sensing data was obtained through PSA and after pacemaker implantation. The RV lead sensing latency was defined as the time interval Q-VS measured from the beginning of QRS on ECG to the released ventricular sensed (VS) event marker on either device. Results Of 157 patients, 105 had narrow QRS (&amp;lt;120 ms) and 52 had wide QRS (≥120 ms) of right bundle branch block (RBBB). Both narrow QRS and RBBB patients had longer sensing latency through PSA (50.9 ± 24.2 ms and 67.8 ± 32.9 ms, respectively) than through pacemaker (18.2 ± 12.8 ms and 31.2 ± 14.8 ms, respectively, both p&amp;lt;0.001). RBBB patients had longer sensing latency compared with narrow QRS patients, either through PSA or through pacemaker (p&amp;lt;0.001). The sensing latency of Medtronic recipients was longer than those of Abbott in narrow QRS, but not in RBBB (p=0.03 and p=0.08, respectively). Conclusion We demonstrated longer RV lead sensing latency (1) through PSA than through the implanted pacemaker, (2) in RBBB than in narrow QRS, (3) in Medtronic pacemakers compared with Abbott pacemakers. Knowledge of the RV lead sensing latency helps optimization of atrioventricular delay and reduces unnecessary ventricular pacing.

Cardiac computed tomography-verified right ventricular lead position and outcomes in cardiac resynchronization therapy.

To evaluate the association between different right ventricular (RV) lead positions as assessed by cardiac computed tomography (CT) and echocardiographic and clinical outcomes in patients receiving cardiac resynchronization therapy (CRT). We reviewed patient records of all 278 patients included in two randomized controlled trials (ImagingCRT and ElectroCRT) for occurrence of heart failure (HF) hospitalization or all-cause death (primary endpoint) during long-term follow-up. Outcomes were compared between RV lead positions using adjusted Cox regression analysis. Six months after CRT implantation, we estimated left ventricular (LV) reverse remodeling by measuring LV end-systolic and end-diastolic volumes by echocardiography. Changes from baseline to 6months follow-up were compared between RV lead positions. Device-related complications were recorded at 6-month follow-up. During median (interquartile range) follow-up of 4.7 (2.9-7.1) years, the risk of meeting the primary endpoint was similar for patients with non-apical vs. apical RV lead position (adjusted hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.54-1.12, p = 0.17) and free wall vs. septal RV lead position (adjusted HR 1.03, 95% CI 0.72-1.47, p = 0.86). Changes in LV ejection fraction and dimensions were similar with the different RV lead positions. We observed no differences in device-related complications relative to the RV lead position. In patients receiving CRT, the risk of HF hospitalization or all-cause death during long-term follow-up, and LV remodeling and incidence of device-related complications after 6months are not associated with different anatomical RV lead position as assessed by cardiac CT.

Multi-lead pacing for cardiac resynchronization therapy in heart failure: a meta-analysis of randomized controlled trials.

AimsMulti-lead pacing is a potential therapy to improve response to cardiac resynchronization therapy (CRT) by providing rapid activation of the myocardium from multiple sites. Here, we perform a meta-analysis of randomized controlled trials to assess the efficacy of multi-lead pacing.Methods and resultsA literature search was performed which identified 251 unique records. After screening, 6 studies were found to meet inclusion criteria, with 415 patients included in the meta-analysis. Four studies performed multi-lead pacing with two left ventricular (LV) leads and one right ventricular (RV) lead. One study used two RV leads and one LV lead, and one study used both configurations. There was no difference between multi-lead pacing and conventional CRT in LV end-systolic volume [mean difference (MD) −0.54 mL, P = 0.93] or LV ejection fraction (MD 1.42%, P = 0.40). There was a borderline significant improvement in Minnesota Living With Heart Failure Questionnaire score for multi-lead pacing vs. conventional CRT (MD −4.46, P = 0.05), but the difference was not significant when only patients receiving LV-only multi-lead pacing were included (MD −3.59, P = 0.25). There was also no difference between groups for 6-min walk test (MD 15.06 m, P = 0.38) or New York Heart Association class at follow-up [odds ratio (OR) 1.49, P = 0.24]. There was no difference in mortality between groups (OR 1.11, P = 0.77).ConclusionThis meta-analysis does not support the use of multi-lead pacing for CRT delivery. However, significant variation between studies was noted, and therefore a benefit for multi-lead pacing in select patients cannot be excluded, and further investigation may be warranted.

Predictors of worsening TR severity after right ventricular lead placement: any added value by post-procedural fluoroscopy versus three \u2013dimensional echocardiography?

BackgroundThe effect of right ventricular (RV) leads on tricuspid valve has been already raised concerns, especially in terms of prognostic implication. For such assessment, three-dimensional transthoracic echocardiography (3D-TTE) has been used previously but there was no data on the use of post-procedural fluoroscopy in the literature.MethodsWe prospectively enrolled 59 patients who underwent clinically indicated placement of pacemaker or implantable cardioverter defibrillator (ICD). Vena contracta (VC) and tricuspid regurgitation (TR) severity were measured using two-dimensional transthoracic echocardiography (2D-TTE) at baseline. Follow up 3D-TTE was performed 6 months after device implantation to assess TR severity and RV lead location.ResultsLead placement position in TV was defined in 51 cases.TR VC was increased after the lead placement, compared to the baseline study (VC: 3.86 ± 2.32 vs 3.18 ± 2.39; p = 0.005), with one grade worsening in TR in 25.4% of cases. The mean changes in VC levels were 1.14 ± 0.67 mm. Among all investigated parameters, VC changes were predicted based on lead placement position only in 3D-TTE (p < 0.001) while the other variables including fluoroscopy parameters were not informative.ConclusionThe RV Lead location examined by 3D-TTE seems to be a valuable parameter to predict the changes in the severity of the tricuspid regurgitation. Fluoroscopy findings did not improve the predictive performance, at least in short term follow up.

Biventricular Pacing Versus RightVentricular Pacing in Patients Supported With LVAD.

This study sought to evaluate the effects of right ventricular (RV) pacing versus biventricular (BiV) pacing on quality of life, functional status, and arrhythmias in LVAD patients. Cardiac resynchronization therapy (CRT) and left ventricular assist devices (LVADs) independently improve outcomes in heart failure patients, but the effects of combining these therapies remains unknown. We present the first prospective randomized study evaluating the effects of RV versus BiV pacing on quality of life, functional status, and arrhythmias in LVAD patients. In this prospective randomized crossover study, LVAD patients with prior CRT devices were alternated on RV and BiV pacing for planned 7-14-day periods. Ambulatory step count, 6-minute walk test distance, Kansas City Cardiomyopathy Questionnaire scores, arrhythmia burden, CRT lead function, and echocardiographic data were collected with each pacing mode. Thirty patients were enrolled, with a median age of 65 years, 67% male, and mean duration of LVAD support of 309days. Compared with BiV pacing, RV-only pacing resulted in 29% higher mean daily step count, 11% higher 6-minute walk test distance, and 7% improved KCCQ-12 score (all p<0.03). LV end-diastolic volume was significantly lower with RV pacing (220 vs. 250mL; p=0.03). Fewer patients had ventricular tachyarrhythmia episodes during RV pacing (p=0.03). RV lead impedance was lower with RV pacing (p=0.047), but no significant differences were observed in impedance across other CRT leads. In the first prospective randomized study comparing variable pacing in LVAD patients, RV pacing was associated with significantly improved functional status, quality of life, fewer ventricular tachyarrhythmias, and stable lead impedance compared with BiV pacing. This study supports turning off LV lead pacing in LVAD patients with CRT.

Impact of pacing configuration and right ventricular lead location on dynamic atrioventricular delay optimization

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Abbott Introduction Automatic adjustment of atrioventricular delay (AVD) with SyncAV has been shown to improve electrical synchronization. However, the effect of pacing configuration and right ventricular (RV) lead location on SyncAV programming is unknown. Purpose Evaluate the effect of pacing configuration and lead location on SyncAV optimization during biventricular (BiV) and LV-only pacing, with and without MultiPoint Pacing (MPP). Methods Patients with LBBB and QRS duration (QRSd) ≥ 150 ms scheduled for CRT-P/D device implantation with quadripolar LV lead were enrolled in this prospective study. RV lead location was classified at implant by the operator via fluoroscopy. QRSd was measured post-implant from 12-lead surface ECG by blinded experts during the following pacing modes: intrinsic conduction, BiV (BiV = RV + LV1), MPP (MPP = RV + LV1 + LV2), LV-only single-site (LVSS = LV1 only), and LV-only MPP (LVMPP = LV1 + LV2). For each mode, SyncAV was enabled (e.g. BiV + SyncAV) with the patient-tailored SyncAV offset that minimized QRSd. For BiV and LVSS, LV1 was the latest activating LV cathode; for MPP and LVMPP, LV1 + LV2 were the two LV cathodes with the widest possible separation (≥30mm). All modes used minimal RV-LV and LV1-LV2 delays. Results Fifty-three patients (68% male, 36% ischemic, 26% ejection fraction, 169 ms intrinsic QRSd) completed device implant and QRSd assessment. RV leads were implanted in either the septum (48%) or apex (52%), according to implanting physician preference. Relative to intrinsic conduction, BiV + SyncAV and MPP + SyncAV reduced QRSd by 23% and 27%, respectively (p &amp;lt; 0.01). LVSS + SyncAV reduced QRSd by 22% (p &amp;lt; 0.01 vs BiV + SyncAV), and LVMPP + SyncAV reduced QRSd by 25% (p &amp;lt; 0.05 vs MPP + SyncAV). RV apex or septum lead location did not have a significant impact on QRS reduction for each pacing configuration. As a percent of PR interval, optimal SyncAV offsets were similar for BiV + SyncAV and MPP + SyncAV (16% vs 13%, p = 0.05), and for LVSS + SyncAV and LVMPP + SyncAV (18% vs 21%, p = 0.46), but were significantly higher for LV-only settings vs. corresponding BiV/MPP settings (p &amp;lt; 0.05 for both pairs). For BiV + SyncAV, apical vs septal RV leads required greater SyncAV offsets (22% vs 11%, p &amp;lt; 0.05). SyncAV offsets also tended to be higher in apical vs septal RV leads for MPP (21% vs 11%), LVSS (20% vs 15%), and LVMPP (25% vs 16%), but without statistical significance. Conclusion SyncAV improves acute electrical synchronization in CRT patients with LBBB, particularly with patient-specific SyncAV programming. Pacing configuration (RV + LV or LV only, with or without MPP) and RV lead location (apex or septum) could potentially influence optimal SyncAV programming. Abstract Figure.

Standard stylet-driven Abbott Tendril compared to non-stylet driven Medtronic 3830 in left bundle branch area pacing: procedural duration and acute outcome measures

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Maatschap cardiologie Isala Zwolle Right ventricular apical pacing (RVAP) is associated with an increased incidence of heart failure, caused by dyssynchronous activation. Left bundle branch area pacing (LBBAP) is an alternative physiological pacing technique. However, evidence on LBBAP is limited. Moreover, most LBBAP has been performed with the lumenless, bipolar, permanent pacing lead, with a fixed helix. Although several case reports described the successful use of a standard stylet-driven lead, only one trial compared a stylet-driven active fixation lead to the Medtronic 3830 lead. The aim of this analysis was to compare the non-stylet driven Medtronic 3830 (MDT) to a standard stylet-driven active fixation lead in terms of pacing parameters, success and complication rates. In this ongoing observational study, 84 patients received a LBBAP in the period of December 2019 until December 2020. The majority received a right ventricular (RV) lead as back-up. A subgroup of 80 patients was selected, including all patients who received the MDT (41.3%) or Tendril lead (58.8%) and had at least a 2-week follow-up period. In both groups 1 LBBAP lead positioning was not successful; 2.1% (Tendril) versus 3.0% (MDT). One patient had a Tendril lead dislocation (2.1%) and therefore switched to the back-up RV lead. The success rate of LBBAP lead performance was comparable, p = 0.632. Complication rate was comparable in both groups, p = 0.441. Mean number of deployments, lead implantation and procedural time did not differ significantly, for Tendril respectively 2.8 ± 2.5 deployments, 47 ± 26 and 107 ± 32 minutes. MDT showed 3.8 ± 3.3 deployments, 48 ± 36 and 123 ± 47 minutes, p-values 0.058, 0.399 and 0.172. Mean sensing amplitude (mV) and pacing threshold (V) were comparable, although Tendril pacing impedance was significantly lower; 439 ± 207 Ohm versus 594 ± 202 Ohm with MDT, p = 0.001. There was no learning effect in the MDT group, comparing the first ten and last ten implantations in implantation time, success rate, number of deployments and complications. The Tendril group showed significantly shorter lead implantation time in the last ten implantations compared to the first ten: 28 ± 15 versus 63 ± 34 minutes, p = 0.002. The last ten Tendril leads were implanted significantly faster than the last ten MDT leads, p = 0.035, with mean lead implantation time for MDT 45 ± 22 minutes. This analysis demonstrates that there are no differences in complications, lead implantation time and number of deployments in LBBAP implantation between MDT and Tendril, although Tendril showed a significant learning effect in lead implantation time. Moreover, success rate did not differ significantly. Pacing impedance was significantly lower in the Tendril group, however this did not result in clinically relevant outcomes. Further research should focus on long-term differences between these leads in terms of pacing parameters and lead failure.

Predictors of Cardiac Implantable Electronic Device Artifact on Cardiac MRI: The Utility of a Device Related Score

Cardiac magnetic resonance imaging (CMR) image quality can be degraded by artifact in patients with cardiac implantable electronic devices (CIED). We aimed to establish a clinical risk score, so patient selection for diagnostic CMR could be optimised. In this retrospective cohort study, CMRs performed for clinical use in subjects with CIED from January 2016 to May 2019 were reviewed. Subject anthropometry, CIED generator/lead specifications and pre-scan chest X-ray (CXR) measurements were collected. Generator-related artifact size was measured on axial steady state free precession images. Interpretability of late gadolinium enhancement (LGE) imaging was performed based on a three-grade visual score attributed to each of 17 myocardial segments. Fifty-seven (57) patients (59±16 years, 74% male) fitted the inclusion criteria. Artifact precluded left ventricle (LV) evaluation (≥5 segments) in 17 (30%). Artifact was more common with implantable cardioverter-defibrillators, related to generator volume, mass, height, width, thickness, and area, along with right ventricular (RV) lead length and diameter (all p<0.05). Artifact was associated with distance from generator to LV apex, generator to RV lead tip and shortest distance from generator to heart on CXR (all p<0.05). On multivariable regression modelling, RV lead diameter (OR 5.861, 95% CI 1.866-18.407, p=0.002) and distance from generator to LV apex (OR 0.693, 95% CI 0.511-0.940, p=0.019) were independent predictors of artifact. Multivariable predictors were used to develop Device Related CMR Artifact Prediction Score (DR-CAPS), where all patients with DR-CAPS=0 had fully interpretable LGE imaging. Simple, readily available measures, such as lead characteristics and pre-scan CXR measures, can stratify patients via an artifact prediction score to optimise selection for diagnostic CMR.

Localization of right ventricular non-apical lead position: comparison of three-dimensional echocardiography, computed tomography, and fluoroscopic imaging.

ObjectiveRight ventricular (RV) septal pacing is considered a better pacing procedure compared with traditional apical pacing. This study aimed to investigate agreement among computed tomography (CT), three-dimensional echocardiography (3D-echo), and fluoroscopy for evaluating the tip of the RV pacing lead in the non-apical position in patients with permanent pacemaker implantation.MethodsFifty-four patients were prospectively enrolled. Data on patients’ characteristics and imaging findings were analyzed. The agreement rate in distinguishing the RV septal lead position among the three imaging modalities was determined.ResultsThirty-three (61%) patients were men and the median age was 76 years. Overall, the agreement rate among the three imaging modalities was 87% (47/54; Kappa ratio: 0.734). The agreement of 3D-echo compared with thoracic CT (Kappa ratio: 0.893) was better than that for thoracic CT and fluoroscopy (Kappa ratio: 0.658). Agreement between fluoroscopy and 3D-echo was lowest (Kappa ratio: 0.632).ConclusionsAgreement in evaluating the position of the septal lead between thoracic CT and 3D-echo is better than that between other imaging modalities. Our findings indicate that 3D-echo imaging might be the best imaging tool for defining the tip of the RV non-apical lead position and be useful for guiding positioning of the RV lead.

Diastolic dyssynchrony in patients with LV only fusion pacing CRT without RV lead

Abstract Funding Acknowledgements Type of funding sources: None. Background CRT improves both systolic and diastolic function, thus increasing cardiac output. However, less data is available concerning diastolic dyssynchrony and fusion pacing CRT. The aim of our study was to assess the outcome of LV diastolic asynchrony in a population of fusion pacing CRT without right ventricular (RV) lead. Methods Prospective data were collected from a cohort of patients (pts) with right atrium/left ventricle leads (RA/LV CRT). Baseline and every 6 months follow-up included standard ETT and classical dyssynchrony parameter measurements. Diastolic dyssynchrony was done by offline speckle-tracking derived TDI timing assesment of the simultaneity of E" and A" basal septal and lateral wall 4 chamber view. New parameters were introduced: E" and respectively A" time (E"T / A"T) as the time difference between E" (respectively A" ) peaks septal and lateral wall. Exercise tests, drugs optimization and device individual programmimg were systematically performed in order to maintain constant fusion and improve CRT response. Patients were divided in three groups: super-responders (SR), responders (R) and non responders (NR). Results Sixty-two pts (35 male) aged 62 ± 11 y.o. with idiopathic DCM implanted with a RA/LV CRT were analyzed: 34%SR / 61%R / 5%NR. Baseline initial characteristics: QRS 164 ± 18 ms; EF 27 ± 5.2; 29% had type III diastolic dysfunction (DD), 63% type II DD, 8% type I DD. Average follow-up was 45 ± 19 months; mean LVEF at the last follow-up was 37 ± 7.9%. The E"T decreased from 90 ± 20 ms to 25 ± 10 ms in SR with significant LV reverse remodelling (LV end-diastolic volume 193.7 ± 81 vs 243.2 ± 82 ml at baseline, p &amp;lt; 0.0028) and lower LV filling pressures (E/E" 13.2 ± 4.6 vs 11.4 ± 4.5, p =0.0295). DD profile improved in 65% of R with a reduction in E/A ratio (1.46 ± 5.3 vs. 0.82 ± 3.9 at baseline, p= 0.4453). Non-sudden cardiac death occurred in 3 NR pts (2%) with type III DD, severe LA volume and larger E" T /A"T (E"T&amp;gt; 85 msec A"T &amp;gt; 30 msec). Significant cut off value calculated by ROC curve for LV diastolic dyssynchrony is E"T &amp;gt; 80 ms and A"T of &amp;gt; 25 msec. Conclusions Fusion pacing CRT without RV lead showed a positive outcome; improving LV diastolic dyssynchrony in responders and super-responders patients is obvious. Larger randomized studies are needed to define the role of diastolic asynchronism as a predictor of favorable response in fusion pacing. Abstract Figure. Typical TDI patterns in LV fusion pacing

An Unusual Cause of Pacemaker Lead Displacement: 'Reverse Ratchet' Syndrome.

Lead displacement is a common complication of pacemaker device implantation, often resulting in prolonged hospital stays and increased costs. The frequency of long-term lead displacement ranges between 1.8% and 8.0%. In our case, the patient did not present any symptoms and the lead displacement was seen at a relatively late stage. During a routine pacemaker follow up, it was noted that the right ventricular (RV) threshold had increased and deteriorated over time. The pacemaker box had rotated anticlockwise and the RV lead had developed a loop that eventually led to its retraction from the RV implantation position into the pulmonary artery. The patient was asymptomatic; however, he underwent RV lead revision. Patient education, opening an appropriate pocket for the size of the generator, fixing the sleeves to an appropriate tightness and securing the battery with a strong suture all can be used to avoid lead displacement.

Pacemaker lead-induced progression of primary vs. secondary tricuspid regurgitation

Abstract Background Currently no data are available whether the implantation of right ventricular (RV) pacemaker (PM) lead worsens preexisting primary or secondary (functional due to RV dilatation, RVD) tricuspid regurgitation (TR). Purpose The aim of the present retrospective analysis was to assess TR after PM implantation with a RV lead. Methods Patients with PM implantation (n=990) were enrolled if they had routine echocardiography including assessment of TR before first implantation and immediately after. RVD and severity of TR were characterized visually. Based on RVD in baseline echocardiography, patients were divided into 2 groups: with primary TR (without preexisting RVD, n=743) or secondary TR (with preexisting RVD, n=243). Results Lead-induced worsening of TR was present in both groups (Table 1). Progression from mild/moderate to severe TR was observed in 6.7% of patients with primary TR, compared to 25.6% of patients with secondary TR (P=0.001). Using an ordinal regression model, the probability to progress to severe TR with primary TR was 14.8% (95% CI 11.0%-19.7%), compared to 41.6% (95% CI 40.3%-42.8%) with secondary TR (P&amp;lt;0.001). Conclusion Preexisting secondary TR was associated with higher rates of lead-induced progression to severe TR compared to primary TR. Leadless pacing or tricuspid valve clipping post-PM implantation could be an option for patients with preexisting secondary TR and indication for a PM. Table 1. Patient characteristics. Funding Acknowledgement Type of funding source: Public grant(s) – EU funding. Main funding source(s): This study was supported by the European Union's Horizon 2020 Future and Emerging Technologies Programme [Grant number 732170].

Can QRS morphology be used to differentiate between true septal vs. apparently septal lead placement? An analysis of ECG of real mid-septal, apparent mid-septal, and apical pacing.

The location of the pacemaker lead is based on the shape of the lead on fluoroscopy only, typically in the left and right anterior oblique positions. However, these fluoroscopy criteria are insufficient and many leads apparently considered to be in septum are in fact anchored in anterior wall. Periprocedural ECG could determine the correct lead location. The aim of the current analysis is to characterize ECG criteria associated with a correct position of the right ventricular (RV) lead in the mid-septum. Patients with indications for a pacemaker had the RV lead implanted in the apex (Group A) or mid-septum using the standard fluoroscopic criteria. The exact position of the RV lead was verified using computed tomography. Based on the findings, the mid-septal group was divided into two subgroups: (i) true septum, i.e. lead was found in the mid-septum, and (ii) false septum, i.e. lead was in the adjacent areas (anterior wall, anteroseptal groove). Paced ECGs were acquired from all patients and multiple criteria were analysed. Paced ECGs from 106 patients were analysed (27 in A, 36 in true septum, and 43 in false septum group). Group A had a significantly wider QRS, more left-deviated axis and later transition zone compared with the true septum and false septum groups. There were no differences in presence of q in lead I, or notching in inferior or lateral leads between the three groups. QRS patterns of true septum and false septum groups were similar with only one exception of the transition zone. In the multivariate model, the only ECG parameters associated with correct lead placement in the septum was an earlier transition zone (odds ratio (OR) 2.53, P = 0.001). ECGs can be easily used to differentiate apical pacing from septal or septum-close pacing. The only ECG characteristic that could help to identify true septum lead position was the transition zone in the precordial leads. ClinicalTrials.gov identifier: NCT02412176.

Direct left ventricular wire pacing during transcatheter aortic valve implantation.

Rapid ventricular pacing is used during balloon aortic valvuloplasty, balloon‑expandable transcatheter aortic valve implantation (TAVI), and for postdilatation. Right ventricular (RV) lead pacing has been regarded as a gold standard. Direct left ventricular (LV) wire pacing has recently been considered safe and effective in TAVI interventions. This study aimed to analyze procedural outcomes of direct LV pacing compared with RV stimulation in unselected patients undergoing TAVI. Direct LV wire pacing was provided via available preshaped guidewires and used only when no predictors of atrioventricular block were present. The primary study objective was the assessment of the efficacy of direct LV wire pacing. The secondary objectives included the evaluation of procedure duration and safety in comparison with the conventional method. A combined endpoint (major adverse cardiovascular event) was defined as the occurrence of death, stroke, venous puncture-related complications, and cardiac tamponade. In 2017 and 2018, 143 patients underwent transfemoral TAVI. Of these, 114 (79.7%) had self‑ ‑expandable valves implanted. Direct LV wire pacing was the dominant method of pacing (82 patients [57.3%]), and its efficacy reached 97.6%. The median (interquartile range) procedure time was shorter in the direct LV wire pacing group (80 [70-90] min vs 85 [70-95] min; P = 0.02). Major adverse cardiovascular events were more frequent in the RV lead pacing group (11.5% vs 4.9%), but no statistical significance was achieved (P = 0.13). Direct LV wire pacing during TAVI is a simple, reproducible, and safe technique, which provides reliable, sustained stimulation with a low complication rate and potential reduction of procedural time.