Time Of Pacemaker Implantation Research Articles

Clinical characteristics of patients with better ejection fraction recovery after upgrading to cardiac resynchronization therapy

Abstract Background Chronic right ventricular (RV) pacing can cause cardiac systolic dysfunction and heart failure (HF), increased risk of HF hospitalization and adverse outcomes. In these patients upgrading to cardiac resynchronization therapy (CRT) may improve left ventricular function. Purpose We aimed to identify the profile of patients (their clinical, electrical and echocardiographic characteristics) who are more likely to make a significant change in left ventricular ejection fraction (LVEF) one year after revision of the RV pacing system to CRT. Methods This was a retrospective, observational, single-center study. We included patients with a permanent antibradycardia pacemaker who had no systolic dysfunction and HF symptoms at the time of pacemaker implantation and who experienced a drop in LVEF below 35% during follow-up, with development of HF symptoms and with at least 20% of ventricular pacing. In all patient's revision to CRT was performed at our center between January 2014 and December 2019. We excluded patients who were indicated for a system upgrade regardless of the percentage of ventricular pacing and those in whom the drop in LVEF is due to a new coronary event. We used patients’ medical records to collect data on baseline characteristics. LVEF was measured pre-revision and 12 months after upgrade. To examine the difference in LVEF change between specified subgroups of patients we used a t-test. Results During the defined period, 82 upgrade procedures from conventional pacemaker to CRT were done in our center. We excluded 12 patients with left bundle branch block (LBBB) QRS morphology, 4 with non-LBBB QRS morphology but with QRS duration over 150ms and 4 patients who died within a year after revision to CRT. Therefore, we analyzed 62 patients (20.9% female, mean age 66.9 ± 11.2 years, mean LVEF 25.9 ± 6.8). After 12 months, 58.1% of patients had an increase in EF above 5%, and the mean change in LVEF (ΔLVEF) was 7.8 ± 11.8. Compared to those with non-ischemic cardiomyopathy (NICMP), patients with ischemic etiology had statistically significantly less improvement in LVEF (ΔLVEF 1.8 ± 6.8 vs 13.1 ± 12.7, p < 0.01), as well as patients with an RV apical pacing compared to those with a septal lead position (ΔLVEF 5.1 ± 9.1 vs 14.1 ± 14.7, p = 0.021). Patients with narrower paced QRS complex (<150ms) before upgrade had a significantly greater improvement in LVEF compared to those with a wider paced QRS complex (≥150ms) (ΔLVEF 10.9 ± 12.2 vs 4.8 ± 10.7, p = 0.04), and those with post-revision paced QRS width above 150ms had significantly lower change in LVEF compared to those with a narrower paced QRS (ΔLVEF 4.6 ± 9.8 vs 11.1 ± 12.8, p = 0.028). Conclusion Patients with NICMP and with width of the paced QRS complex before and after revision to CRT below 150ms had significantly greater improvement in LVEF 12 months after the upgrade. The position of RV lead significantly affects the success of the upgrade procedure.

Survival predictors after pacemaker implantation in a very elderly population

Abstract Background Electrophysiological studies and ablation procedures are the most prevalent activities in electrophysiology. However, device implantation represents a great deal of the daily activity. In several European regions, aging populations are becoming a big concern, not only increasing the number of pacemakers implantations but also raising the age threshold for implantation. Purpose Assessment of survival rates after device implantations on patients over ninety years of age. Are there any markers that could help us infer survival rates? How prevalent are complications? What key performance indicators should be paying attention to? Methods Observational retrospective study of a cohort of 903 patients referred to the arrhythmia unit of our institution for pacemaker implantation, during the period from 2016 to 2019. Cox regression analysis performed over that cohort. Hazard-ratio (HR) and confidence intervals (CI 95%)calculated. Survival curves represented with Kaplan-Meier method and statistical significance estimated with log-rank test. Results Out of the 903 patients, 82 (9.1%) are nonagenarians. Follow-up was 3.97 ± 4.98 years. The mean age at the time of pacemaker implantation was 78.94 ± 10.11 years. Some complications were observed in 9.9% of patients under 90 years of age, compared to 4.9% in those over that age. At the time of the follow-up, 82.5% of the patients were alive. In the univariate analysis, the following predictors of mortality were identified: age; atrial fibrillation (AF); renal function; anemia; comorbidity, estimated by Charlson score; underlying heart disease; type of pacemaker implanted; and, whether the patient was institutionalized. In the multivariate analysis, the following were independent predictors of mortality: age (HR 1.129; 95% CI 1.1-1.159; p<0.001), comorbidity reflected as a Charlson score ≥ 5 (HR 4.116; 95% CI 2.349 -7.212; p<0.001); heart disease (HR 2.496; 95% CI 1.725-3.612; p<0.001); institutionalization of the patient (HR 2.794; 95% CI 1.632-4.783; p<0.001); and the single-chamber pacemaker (HR 2.201; 95% CI 1.455-3.329; p<0.001). In the group of nonagenarian patients, the univariate analysis showed the following variables as predictors of lower survival: age; serum creatinine; comorbidity, estimated by the Charlson score; and, underlying heart disease. In the multivariate analysis, the following were identified as independent predictors of mortality: comorbidity, reflected as a Charlson score ≥ 5 (HR 7.299; 95% CI 2.468-21.589; p<0.001); age (HR: 1.193; 95% CI 1.063- 1.339; p 0.003) and institutionalization of the patient (HR 3.033; 95% CI 1.237- 7.439; p 0.015). Conclusions Comorbility estimated by Charlson score is the most powerful survival predictor after pacemaker implantation, both in the general population and in those over 90 years of age. Being institutionalized is an independent survival predictor in both groups. Nonagenarian patients do not show a higher complication rate.Baseline characteristics >90 y.o.Survival curves K-M

Intrinsic Sinus Node/Atrioventricular Node Dysfunction Requiring Pacemaker Implantation: Role of Former Professional Sport Activity.

Sinus bradycardia and first degree or second degree Mobitz type I atrioventricular (AV) block in an athlete are considered adaptive and reversible phenomena; however, some evidence suggests that they may persist after detraining and become pathological. The aim of the study was to investigate the characteristics of a group of former professional athletes who required pacemaker (PM) implantation for intrinsic (idiopathic) sinus node (SN) dysfunction or AV block in comparison to control groups of sedentary individuals. We included all patients who underwent PM implantation during 2022. Three groups were compared: group 1 including 18 former professional athletes who received a PM for SN dysfunction/AV block in the absence of heart disease; group 2 including the first 20 sedentary individuals without heart disease who underwent PM implantation; and group 3 including all other 323 patients who received PM, the majority with underlying heart diseases. Compared to the non-athlete control group 2, the mean age at diagnosis and at the time of PM implantation of former professional athletes did not show statistically significant differences. However, subgroup analysis revealed significant differences depending on the type of sports discipline: the age at diagnosis and at PM implantation was significantly lower in former endurance athletes than former strength/mixed athletes, control non-athletes, and all other patients. Moreover, former endurance professional athletes exhibited a higher prevalence of second or third degree AV block (78%) as the reason for PM implantation compared to power/mixed athletes (44%). The other clinical characteristics, including echocardiographic parameters, did not differ between former athletes and non-athletes. Former professional endurance athletes with idiopathic SN dysfunction/AV block manifested the disease earlier in the life course compared to former power/mixed athletes and non-athletes. This suggests that bradycardia/AV block caused by intense and prolonged endurance sports may not always be benign and adaptive phenomena.

Correlation of ventricular pacing burden and left ventricular function in patients with heart failure with reduced ejection fraction.

Pacemaker-induced cardiomyopathy is a well described phenomenon in patients with preserved ejection fraction at the time of permanent pacemaker implant. One of the identified risk factors for pacemaker-induced cardiomyopathy is the degree of ventricular pacing burden. However, it is unclear how a high right ventricular pacing burden affects patients with depressed left ventricular function at the time of pacemaker implantation. We sought to assess the relationship between right ventricular pacing and change in left ventricular function over time. We conducted an analysis of all patients who had received either a single or dual lead cardiac implantable electronic devices, excluding biventricular devices, and had a prior transthoracic echocardiogram demonstrating an ejection fraction of less than 50%. The primary end-point was the correlation between the percentage of ventricular pacing and the change in LV ejection fraction. Fifty eight patients with preceding heart failure had pacemakers implanted and had follow up echocardiograms. There was no correlation between the degree of ventricular pacing and the absolute change in LV function (r = .04, p = .979). None of the previously identified risk factors for pacemaker induced cardiomyopathy were predictive of a significant fall in ejection fraction. The degree of RV pacing and other established risk factors for pacemaker-induced cardiomyopathy in patients with normal left ventricular function at the time of implantation do not appear to carry the same risk in patients with pre-existing heart failure who receive either single or dual lead pacemakers.

COMPARATIVE ANALYSIS OF LONG-TERM OUTCOMES FOLLOWING THE STIMULATION OF CARDIAC CONDUCTION SYSTEM AND RIGHT VENTRICULAR PACING IN PATIENTS WITH BRADYARRHYTHMIAS

Introduction. Right ventricular myocardial pacing induces asynchronous ventricular contraction, potentially resulting in pacing-induced cardiomyopathy and adverse long-term clinical outcomes. Conduction system pacing is a physiological alternative to right ventricular myocardial pacing. The objective of this study is to analyze the long-term outcomes of the conduction system pacing in comparison with right ventricular myocardial pacing in patients requiring permanent ventricular pacing and who have preserved initial left ventricular ejection fraction (≥ 50%). Materials and methods. 48 patients with indications for permanent ventricular pacing were selected for comparative analysis. Of these, 18 patients had cardiac conduction system pacing and 30 patients had right ventricular myocardial pacing. Permanent pacemaker implantation in both groups of this study was performed from 2012 to 2022. Patients in both groups had to meet the following selection criteria for this study: 1) preserved systolic function of the left ventricle at the time of pacemaker implantation (≥ 50%); 2) total percentage of ventricular pacing from the time of implantation had to be not less than 90%.
 Results. The observation period was 35.3 ± 37 months in the conduction system pacing group and 46 ± 28.73 months in the right ventricular pacing group. Since the time of pacemaker implantation, pacing-induced cardiomyopathy occurred in 7 (23%) patients in the right ventricular pacing group and in none in the conduction system pacing group. The mean left ventricular ejection fraction at the control visit was significantly lower in the right ventricular pacing group (51.59 ± 8.55 vs. 58.64 ± 4.58%, p =.004). A significant reduction in global longitudinal strain was observed in the right ventricular pacing group compared to the conduction system pacing group (14.22 ± 3.66 vs. 18.49 ± 2.5%, p = <.001). Paced QRS width was significantly greater in the right ventricular pacing group (152.32 ± 18.13 vs. 119.12 ± 8.8 ms, p <.001). Conclusions. Applying new physiological methods of cardiac pacing enables to avoid the negative consequences of an asynchronous pattern of ventricular activation during conventional right ventricular pacing.

Pacemaker Implantation in the Pediatric Population: Bosnian and Herzegovinian Experience

Introduction: The development of pediatric arrhythmology, as a segment of pediatric cardiology, is conditioned by surgical correction of congenital heart diseases (CHD). The beginning of pediatric cardiosurgery is also the time of pacemaker implantation. The aim of this article is to present indications and results of pacemaker implantation in children in our conditions from April 1997 to April 2020 in the Clinical Center University of Sarajevo (CCUS). Patients and Methods: The article is descriptive and includes the period from April 1997 to April 2020. The data were extracted from the official medical documentation of patients hospitalized at the Paediatric Clinic, CCUS (protocol of operated CHD in children, register of continuous electrocardiogram [ECG] Holter monitoring, register of implanted pacemakers in children). Results: During this period, 46 pacemakers were implanted, 29 (63%) in male patients, of which 13 (28%) were due to congenital atrioventricular (AV) block, and 33 (71.7%) were mostly in children with a postoperative block. Postoperative block occurred in 28 children (84.8%). Given that 771 children with CHD were operated on in the same period, a complication of postoperative complete heart block arose in 3.6% of children, which had to be tackled immediately after surgery in seven patients (21.2%), and later in 26 patients (78.8%). In regard to the age of pacemaker implantation, the interval was between 7 days and 18 years. The local team implanted 37 (80.4%) pacemakers. Reimplantation was done in four patients (8.7%). In April 2020, we followed 42 patients, four of whom died (three after surgery and one child due to congenital heart block). With the help of continuous ECG Holter monitoring (5,839 registrations and analysis), we recognized second- or third-degree or high-degree AV block, which was the indication for pacemaker implantation in 8.2% of all performed ECG Holter monitorings, with a respective indication for control of implanted pacemaker in 3.2% of ECG Holters. Conclusion: Children with implanted pacemakers require close monitoring, frequent medical examinations, recognition of the right time for generator exchange, as well as reimplantation of the pacemaker. This can be achieved principally with the help of continuous ECG Holter monitoring, with an adequately developed pediatric cardiology/cardiosurgery.

Role of genetic testing in young patients with idiopathic atrioventricular conduction disease.

To investigate the role of genetic testing in patients with idiopathic atrioventricular conduction disease requiring pacemaker (PM) implantation before the age of 50 years. All consecutive PM implantations in Southern Switzerland between 2010 and 2019 were evaluated. Inclusion criteria were: (i) age at the time of PM implantation: < 50 years; (ii) atrioventricular block (AVB) of unknown aetiology. Study population was investigated by ajmaline challenge and echocardiographic assessment over time. Genetic testing was performed using next-generation sequencing panel, containing 174 genes associated to inherited cardiac diseases, and Sanger sequencing confirmation of suspected variants with clinical implication. Of 2510 patients who underwent PM implantation, 15 (0.6%) were young adults (median age: 44 years, male predominance) presenting with advanced AVB of unknown origin. The average incidence of idiopathic AVB computed over the 2010-2019 time window was 0.7 per 100 000 persons per year (95% CI 0.4-1.2). Most of patients (67%) presented with specific genetic findings (pathogenic variant) or variants of uncertain significance (VUS). A pathogenic variant of PKP2 gene was found in one patient (6.7%) with no overt structural cardiac abnormalities. A VUS of TRPM4, MYBPC3, SCN5A, KCNE1, LMNA, GJA5 genes was found in other nine cases (60%). Of these, three unrelated patients (20%) presented the same heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene. Diagnostic re-assessment over time led to a diagnosis of Brugada syndrome and long-QT syndrome in two patients (13%). No cardiac events occurred during a median follow-up of 72 months. Idiopathic AVB in adults younger than 50 years is a very rare condition with an incidence of 0.7 per 100 000 persons/year. Systematic investigations, including genetic testing and ajmaline challenge, can lead to the achievement of a specific diagnosis in up to 20% of patients. Heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene was found in an additional 20% of unrelated patients, suggesting possible association of the variant with the disease.

The role of pacemaker algorithms in preventing atrial fibrillation progression

Background: Unnecessaryright ventricular (RV) pacing leads to cardiac dyssynchrony and increases the risk of developing permanent atrial fibrillation. Minimizing RV pacing by specefic algorithms decreases the AF risk. Aim and objectives: Our objective was to study the effect of pacemaker algorithms on atrial fibrillation progression. Subjects and Methods: Patients with dual chamber (group A) and single chamber (group B)pacemakers were included in the study. Patients with history of AF at the time of pacemaker implantation were not included in the study. The relation between pacemaker parameters and AF development was monitored. Result: Group A showed that RV pacing percentage had high significance for developing AF with P value P &lt;0.001, also A pacing had high significance for developing AF with P value &lt;0.001 and VIP mode OFF there was high significance of developing AF with P value &lt;0.001.As regards group B RV pacing (%) had high significant risk for developing AF with p value&lt;0.001,Also hysteresis off had high significant risk for developing AF with p value&lt;0.005. Conclusion: Reducing unnecessary RV pacing in single and dual chamber pacemakers is assossiated with decreasing the risk of AF.

Diagnostic Yield of Genetic Testing in Young Patients With Atrioventricular Block of Unknown Cause.

BackgroundThe cause of atrioventricular block (AVB) remains unknown in approximately half of young patients with the diagnosis. Although variants in several genes associated with cardiac conduction diseases have been identified, the contribution of genetic variants in younger patients with AVB is unknown.Methods and ResultsUsing the Danish Pacemaker and Implantable Cardioverter Defibrillator (ICD) Registry, we identified all patients younger than 50 years receiving a pacemaker because of AVB in Denmark in the period from January 1, 1996 to December 31, 2015. From medical records, we identified patients with unknown cause of AVB at time of pacemaker implantation. These patients were invited to a genetic screening using a panel of 102 genes associated with inherited cardiac diseases. We identified 471 living patients with AVB of unknown cause, of whom 226 (48%) accepted participation. Median age at the time of pacemaker implantation was 39 years (interquartile range, 32–45 years), and 123 (54%) were men. We found pathogenic or likely pathogenic variants in genes associated with or possibly associated with AVB in 12 patients (5%). Most variants were found in the LMNA gene (n=5). LMNA variant carriers all had a family history of either AVB and/or sudden cardiac death.ConclusionsIn young patients with AVB of unknown cause, we found a possible genetic cause in 1 out of 20 participating patients. Variants in the LMNA gene were most common and associated with a family history of AVB and/or sudden cardiac death, suggesting that genetic testing should be a part of the diagnostic workup in these patients to stratify risk and screen family members.

Familial risk of atrioventricular block in first-degree relatives

ObjectiveRare cases of genetically inherited atrioventricular block (AVB) have been reported; however, the heredity of AVB remains unknown. We aimed to assess the heredity of AVB.Design, setting and participantsUsing data...

Pulmonary hypertension associated with auto-immune complete heart block in neonates: Unrecognized manifestation of neonatal lupus

Auto-immune complete heart block (CHB) is a well-defined consequence of antenatal exposure to maternal anti-SSA/Ro and/or anti-SSB/La antibodies. After birth, the persistence of maternal anti-SSA and/or anti-SSB antibodies passively transferred to the foetus can cause skin rash, vascular, hepatic or neurologic manifestations. Pulmonary involvement is infrequent in a such condition in neonates while pulmonary hypertension (PH) is a common complication of systemic lupus erythematosus (SLE) in adulthood. We report a series of 4 neonates referred to our institution for prenatal diagnosis of auto-immune CHB who developed pulmonary hypertension after birth. Two patients were paced at the time of PH diagnosis and 2 patients weren’t. PH was suspected by transthoracic echocardiography after a PH-free interval ranging from 10 days to 3 months. PH was confirmed by right heart cath (RHC) in all, all had a lung CT-pulmonary angiography and one patient had a pulmonary biopsy at the time of pacemaker implantation. At the RHC all the patients presented a pre-capillary PH (PAPm > 25 mmHg, PWAP < 15 mmHg). All our patients presented a vasoreactivity at the O 2 /NO test performed during the RHC. Lung CT showed ground glass opacities in all patients. The one biopsy showed medial hypertrophy without intimal proliferation. Clinical, hemodynamical, CT scan and even pulmonary biopsy findings were consistent with a lung disease cause for PH. Based on the adult management of PH in SLE patients, immunosuppression therapy with intravenous immunoglobulin and with corticosteroids has been proposed to all but one patient. In 2 cases, it has been necessary to add a treatment with pulmonary vasodilator. By 6 months PH normalized in all patients. This series demonstrated the potential pulmonary involvement in neonatal lupus. The prognostic of PH associated with auto-immune CHB in paediatrics patients seams good if adequately diagnosed and treated.

Early Versus Delayed Pacemaker for Heart Block After Valve Surgery: A Cost-Effectiveness Analysis

BackgroundA significant percentage of patients who acutely develop high-grade atrioventricular block after valve surgery will ultimately recover, yet the ability to predict recovery is limited. The purpose of this analysis was to evaluate the cost-effectiveness of two different management strategies for the timing of permanent pacemaker implantation for new heart block after valve surgery. MethodsA cost-effectiveness model was developed using costs and probabilities of short- and long-term complications of pacemaker placement, short-term atrioventricular node recovery, intensive care unit stays, and long-term follow-up. We aggregated the total expected cost and utility of each option over a 20-y period. Quality-adjusted survival with a pacemaker was estimated from the literature and institutional patient-reported outcomes. Primary decision analysis was based on an expected recovery rate of 36.7% at 12 d with timing of pacemaker implantation: early placement (5 d) versus watchful waiting for 12 d. ResultsA strategy of watchful waiting was more costly ($171,798 ± $45,695 versus $165,436 ± $52,923; P < 0.0001) but had a higher utility (9.05 ± 1.36 versus 8.55 ± 1.33 quality-adjusted life years; P < 0.0001) than an early pacemaker implantation strategy. The incremental cost-effectiveness ratio of watchful waiting was $12,724 per quality-adjusted life year. The results are sensitive to differences in quality-adjusted survival and rates of recovery of atrioventricular node function. ConclusionsWatchful waiting for pacemaker insertion is a cost-effective management strategy compared with early placement for acute atrioventricular block after valve surgery. Although this is cost-effective from a population perspective, clinical risk scores predicting recovery will aid in personalized decision-making.

Abstract 16603: Appropriate Timing of Pacemaker Implantation in Patients With Wild-Type and Variant Amyloidogenic Transthyretin Cardiac Amyloidosis

Background and Objectives: It has been shown that cardiac conduction disorders can be seen in patients with wild-type amyloidogenic transthyretin (ATTRwt) and variant ATTR (ATTRv) cardiac amyloidosis. However, its appropriate timing of pacemaker implantation has not been clarified yet. Methods and Results: The consecutive 100 patients with ATTRwt cardiac amyloidosis who diagnosed by myocardium biopsy and/or technetium-99m-pyrophosphate scintigraphy and 62 patients with ATTRv cardiac amyloidosis who diagnosed by means of genetic screening were included in this study. In patients with ATTRwt cardiac amyloidosis, 21 patients have normal conduction at the time of diagnosis. However, conduction disorder had seen in only 5 patient (first degree atrioventricular block (AVB); 4 patients, complete AVB; 1 patients) and only one patient underwent cardiac implantable electric device (CIED) implantation during follow-up period. On the other hand, in patients with ATTRv cardiac amyloidosis, 36 patients have normal conduction at the time of diagnosis. However, conduction disorder had seen in 13 patient (first degree AVB; 8 patients, second degree AVB; 3 patients, trifascicular block; 1 patients, complete AVB; 1 patients) (5/21 vs 13/36, p=0.335) and 6 patients underwent CIED implantation during follow-up period (1/21 vs 6/36, p=0.186). Furthermore, in ATTRwt cardiac amyloidosis, 10 patients (first degree AVB; 2 patients, second degree AVB; 1 patient, trifascicular block; 7 patients) had underwent CIED implantation because of cardiac conduction disorders and/or prevention of sudden cardiac death. However, only 4 patients with trifascicular block progressed to complete AVB.On the other hand, In ATTRv cardiac amyloidosis, 14 patients (first degree AVB; 2 patients, second degree AVB; 4 patient, trifascicular block; 8 patients) had underwent CIED implantation for same reason. However, only 3 patients with trifascicular block progressed to complete AVB. Conclusions: Patients with ATTRv cardiac amyloidosis were more likely to progress conduction disorders than those with ATTRwt cardiac amyloidosis. However, prophylactic pacemaker implantation might had not need in both ATTRwt and ATTRv patients with first or second degree AVB.

Transthoracic implantation of dual-chamber pacemaker for synchronous treatment of cardiac dysfunction due to idiopathic complete left bundle branch block in children

Objective: To investigate the efficacy and feasibility of transthoracic implantation of permanent left atrial and left ventricular dual-chamber pacemaker for synchronous treatment of cardiac dysfunction due to idiopathic complete left bundle branch block (CLBBB) in children. Methods: The clinical data of five children with cardiac dysfunction due to idiopathic CLBBB and accepting implantation of permanent left atrial and left ventricular epicardial dual chamber pacemaker from January 2015 to July 2019 at the Pediatric Cardiologic Department of the First Hospital of Tsinghua University were analyzed retrospectively. The effects of pacemaker implantation on patients' cardiac function and cardiac synchrony were evaluated by echocardiogram. Results: Among 5 patients, 2 were males and 3 females. At the time of pacemaker implantation, the age of these patients was 0.5-5.7 years, the left ventricle ejection fraction (LVEF) was 29%-46%, the left ventricle end stage of diastolic diameter was 30-53 mm and the mean Z score was 4.0-34.0. Pacemaker was successfully implanted for all the patients. After the implantation, medications that can suppress atrioventricular node conduction were used and sensed atrioventricular delay (SAV) parameters were modulated until patients' QRS duration became shortest and the percentage of left ventricular pacing increased to and maintained at 97% to 100%. Patients' QRS duration was 120-160 ms before implantation and 90-120 ms after implantation. Patients' cardiac function began to improve 1 day to 1 month after implantation. Patients' cardiac function normalized after a mean of 1-12 months. LVEF increased from 29%-46% to 55%-67%. During the follow-up, interventricular mechanical delay, septal-to-posterior wall motion delay, and left ventricular systolic dyssynchrony index decreased significantly: IVMD decreased from 31-62 ms to 26-50 ms; SPWMD decreased from 40-63 ms to 10-50 ms and Ts-SD decreased from 34.3-50.3 ms to 16.3-31.4 ms. The global longitudinal strain of left ventricle decreased from -7.7%--13.8% to -13.5%--20.3%. Conclusion: Cardiac dysfunction due to CLBBB in children can be treated with transthoracic implantation of permanent epicardial left atrial and left ventricular dual chamber pacemaker which can substitute three chamber pacemaker to achieve the effects of synchronous therapy that lead to reversion and normalization of cardiac function.

Implantation percutanée de valve aortique et troubles conductifs

Transcatheter aortic valve implantation (TAVI) is currently becoming the treatment of choice for patients with calcific aortic stenosis. Despite several technical improvements, the incidence of conduction disturbances has not diminished and remains TAVI's major complication. These disturbances include the occurrence of left bundle branch block and/or high-grade atrioventricular block often requiring pacemaker implantation. The proximity of the aortic valve to the conduction system (conduction pathways) accounts for the occurrence of these complications. Several factors have been identified as carrying a high risk of conduction disturbances like the presence of pre-existing right bundle branch block, the type of valve implanted, the volume of aortic and mitral calcifications, the size of the annulus and the depth of valve implantation. Left bundle branch block is the most frequent post TAVI conduction disturbance. Whereas the therapeutic strategy for persistent complete atrioventricular block is simple, it becomes complex in the presence of fluctuating changes in PR interval and left bundle branch block duration. The QRS width threshold value (150-160 ms) indicative of the need for pacemaker implantation is still being debated. Although there are currently no recommendations regarding the management of these conduction disturbances, the extension of TAVI indications to patient at low surgical risk calls for a standardization of our practice. However, a decision algorithm was recently proposed by a group of experts composed of interventional cardiologists, electrophysiologists and cardiac surgeons. There are still uncertainties about the appropriate timing of pacemaker implantation and the management of new onset left bundle branch block.

6118Mid- and long-term percentage of ventricular pacing in patients implanted with a pacemaker after a transcatheter aortic valve replacement procedure: potential clinical implications

Abstract Background Cardiac conduction disturbances frequently occur following transcatheter aortic valve replacement (TAVR). As this procedure is getting more and more common, more research efforts should focus on post procedural rhythm disturbances and their evolution over time Purpose To evaluate the percentage of pacing in patients who underwent a TAVR procedure and developed a conduction disturbance requiring a transvenous pacemaker (PM) implantation Methods We considered all the patients who underwent a TAVR procedure between march 2009 and november 2018 in our centre. Patients implanted with a PM or an ICD before the TAVR procedure or 30 days after the TAVR were not considered eligible for our analysis, because likely not related to TAVR. The percentage of effective right ventricular pacing was assessed both at mid- and long-term follow-up Results 265 patients underwent TAVR in the study period (45% males, 81±6 years). 20 patients already had a PM and were excluded. 39 of the 245 patients (16%) were implanted with a PM after TAVR, 26 of them were implanted within 30 days (median time TAVR-PM implant: 8±7 days). The rate of PM implant within 30 days after TAVR was 8% (20/246) for patients implanted with an Edward Sapien valve, 25% (4/16) for patients with an Evolute Pro valve and 66% (2/3) in patients with a Lotus Edge valve. The indication for PM implant was a permanent 3rd degree A-V block in 12 patients, a paroxysmal A-V block in 4, a bifascicular A-V block with an infra-hisian disease in 5, a II degree Mobitz II A-V block in 2, an atrial fibrillation with slow A-V conduction in 2 and a 2:1 A-V block with infra-hisian disease in 1. The first follow-up after the PM implantation was available in 24 patients (mean 78±87 days after PM implant) and the second in 15 patients (372±267 days after PM implant). The patients were divided into two groups based on the presence/absence of permanent 3rd degree AV block at the time of implantation. At the first follow-up the percentage of pacing was significantly higher in patients implanted with vs. without a permanent 3rd degree AV block (98.5% vs 11%, p&lt;0.001). Notably, in none of the patients without a permanent 3rd AV block at baseline conduction disturbances progressed toward a permanent AV block during long-term follow-up. Accordingly, at the second follow-up patients without permanent 3rd AV block at baseline showed a significantly lower percentage of pacing (1% vs 100%; p&lt;0.01) Conclusion Patients implanted with a PM after TAVR in the absence of a permanent 3rd AV block have a very low likelihood of progression to a permanent AV conduction disturbance and show a negligible percentage of pacing during follow-up. Our results may impact the choice of the correct timing of PM implantation after TAVR and the potential indication for a leadless PM.

Investigating the Manifestation of Coronary Artery Disease and Determining the Role of Effective Factors in the Need for Pacemaker Insertion in These Patients.

BACKGROUND:Many patients who are candidates for a pacemaker are also at the same time risk factors for coronary artery disease such as high blood pressure, hypertension, diabetes, and hyperlipidemia, and therefore the probability of having coronary artery disease is significant. Effective diagnostic measures can be taken to prove the factors affecting the incidence of CAD in patients undergoing pacemakers at high-risk, including angiography. Therefore, it can prevent complications during and after pacemaker implantation, which leads to an increase in the quality of treatment in patients requiring pacemaker implantation.AIM:Therefore, the purpose of this study was to determine the predictive factors of significant coronary artery disease in patients with pacemaker implantation to identify patients in need of coronary angiography at the time of pacemaker implantation.METHODS:This retrospective study was carried out to examine the patients’ files that were placed at the heart of Imam Reza Hospital during the period between March 2017 and September 2017. Demographic data, risk factors, echocardiography findings, and angiography, were collected and then recorded using a checklist. Statistical analysis was performed using SPSS software version 22 and Chi-square, and Mann-Whitney tests were used for determining significates variables.RESULTS:A group of 102 patients who had undergone a permanent cardiac pacemaker insertion due to an atrioventricular (AV) Block were included in the study, and also coronary anatomy was determined coronary angiography. Based on the results, 13.7% of patients with cardiac pacemaker had obstructive coronary artery disease (stenosis > 70%). Factors affecting coronary artery stenosis on angiography include gender, chest pain, history of myocardial infarction, angioplasty, diabetes, smoking, history of aspirin intake, calcium blocker and Plavix, high hematocrit, ST elevation and ST depression in the ECG, and severe mitral regurgitation.CONCLUSION:It seems that in most patients requiring permanent pacemaker insertion because of the atrioventricular (AV) Block, angiography does not change the patient’s fate, and so can be ignored. However, in patients who have several risk factors from the listed above, coronary angiography is recommended during admission.

Contemporary practice pattern of permanent pacing for conduction disorders in inferior ST-elevation myocardial infarction.

BackgroundCurrently, there is no clear consensus regarding the optimal waiting period before permanent pacemaker implantation in patients with conduction disorders following an inferior myocardial infarction.HypothesisWe aimed to elucidate the contemporary practice pattern of pacing, especially the timing of pacemaker implantation, for sinoatrial node and atrioventricular (AV) conduction disorders following an inferior ST‐elevation myocardial infarction (STEMI).MethodsUsing the National Inpatient Sample database from 2010 to 2014, we identified patients with a primary diagnosis of inferior STEMI. Primary conduction disorders were classified into: (a) high‐degree AV block (HDAVB) consisting of complete AV block or Mobitz‐type II second‐degree AV block, (b) sinoatrial node dysfunction (SND), and (c) no major conduction disorders.ResultsAmong 66 961 patients, 2706 patients (4.0%) had HDAVB, which mostly consisted of complete AV block (2594 patients). SND was observed in 393 patients (0.6%). Among the 2706 patients with HDAVB, 267 patients (9.9%) underwent permanent pacemaker. In patients with HDAVB, more than one‐third (34.9%) of permanent pacemakers were placed within 72 hours after admission. The median interval from admission to permanent pacemaker implantation was 3 days (interquartile range; 2‐5 days) for HDAVB vs 4 days (3‐6 days) for SND (P < .001). HDAVB was associated with increased in‐hospital mortality, whereas SND was not.ConclusionsIn patients who developed HDAVB following an inferior STEMI, only one in 10 patients underwent permanent pacemaker implantation. Despite its highly reversible nature, permanent pacemakers were implanted relatively early.

Clinically oriented device programming in bradycardia patients: part 1 (sinus node disease). Proposals from AIAC (Italian Association of Arrhythmology and Cardiac Pacing).

: Modern pacemakers have an increasing number of programable parameters and specific algorithms designed to optimize pacing therapy in relation to the individual characteristics of patients. When choosing the most appropriate pacemaker type and programing, the following variables must be taken into account: the type of bradyarrhythmia at the time of pacemaker implantation; the cardiac chamber requiring pacing, and the percentage of pacing actually needed to correct the rhythm disorder; the possible association of multiple rhythm disturbances and conduction diseases; the evolution of conduction disorders during follow-up. The goals of device programing are to preserve or restore the heart rate response to metabolic and hemodynamic demands; to maintain physiological conduction; to maximize device longevity; to detect, prevent, and treat atrial arrhythmia. In patients with sinus node disease, the optimal pacing mode is DDDR. Based on all the available evidence, in this setting, we consider appropriate the activation of the following algorithms: rate responsive function in patients with chronotropic incompetence; algorithms to maximize intrinsic atrioventricular conduction in the absence of atrioventricular blocks; mode-switch algorithms; algorithms for autoadaptive management of the atrial pacing output; algorithms for the prevention and treatment of atrial tachyarrhythmias in the subgroup of patients with atrial tachyarrhythmias/atrial fibrillation. The purpose of this two-part consensus document is to provide specific suggestions (based on an extensive literature review) on appropriate pacemaker setting in relation to patients' clinical features.

Prognosis of super-elderly healthy Japanese patients after pacemaker implantation for bradycardia

BackgroundThe prognosis of super-elderly patients (age≥85 years) who undergo bradycardia pacemaker (PM) implantation remains unknown. MethodsWe retrospectively enrolled 868 patients (men 49.0%, 76.6±10.6 years) who could walk unassisted and whose expected life expectancy was more than 1 year, receiving their first bradycardia PM implantation between January 1, 2006, and June 30, 2013. Clinical outcomes were compared between super-elderly patients (n=201, mean age 88.6±3.2 years) and younger patients (n=667, 73.0±9.3 years). ResultsAt the end of a median 1285-day follow-up, 128 patients (14.7%) died, of which 54 were cardiac deaths (42.2%). Mortality rates were similar between the groups (16.4% vs. 14.2%, log-rank p=0.56) and across different indications for implantation (atrio-ventricular conduction disturbance or sick sinus syndrome, p=0.59), initial rhythms (sinus rhythm or persistent atrial fibrillation, p=0.62), pacing modes (dual chamber pacing or VVI pacing, p=0.26), and ventricular lead positions (septum or apex, p=0.52). On Cox proportional hazard model analysis, hypertension [hazard ratio (HR)=1.74, 95% confidence interval (CI)=1.19–2.54, p=0.004], diabetes mellitus (HR=2.18, 95% CI=1.51–3.14, p<0.001), history of myocardial infarction (HR=3.59, 95% CI=2.49–5.16, p<0.001), and history of stroke (HR=2.26, 95% CI=1.51–3.37, p<0.001) were independent predictors for mortality. ConclusionsThe mortality rate of super-elderly patients who had no critical illnesses and were healthy enough to walk unassisted at the time of PM implantation was not inferior to that of younger patients. Prognosis was determined by comorbidities, but not by age, PM indication, initial rhythm, pacing leads, or mode.