Utilisation of cardiac pacemakers over a 20-year period: Results from a nationwide pacemaker registry

The impact of smoking on third-degree atrioventricular block outcomes: A propensity-matched analysis

Background

Third-degree atrioventricular (AV) blocks are rare but cause significant symptoms and require immediate intervention. Coronary artery disease (CAD) is felt to be the most common etiology. Although smoking is a prominent risk factor for CAD, there is a paucity of data assessing the direct effect of smoking on third-degree AV block.

Methods

We performed a retrospective cohort study on adult-weighted admissions in 2019-2020 with a primary diagnosis of third-degree AV block and a history of smoking using the National Inpatient Sample (NIS) database. In-hospital mortality, rates of pacemaker insertion, cardiogenic shock, cardiac arrest, acute kidney injury (AKI), stroke, tracheal intubation, mechanical ventilation, mechanical circulatory support, vasopressor use, length of stay (LOS), and total hospitalization costs were analyzed using regression analysis. We performed a secondary analysis using propensity score matching to confirm the results.

Results

A total of 77,650 admissions met inclusion criteria (33,625 females [43.3 %], 58,315. Caucasians [75 %], 7030 African American [9 %], 6155 Hispanic [7.9 %]; mean [SD] age 75.4.[10.2] years) before propensity matching. A total of 29,380 (37.8 %) patients with AV block were smokers.A total of 5560 patients with and without a history of smoking were matched for the analysis. Smokers had.decreased odds of mortality (aOR, 0.59; CI, 0.44-0.78; p < 0.001), cardiogenic shock, cardiac arrest, tracheal intubation, mechanical ventilation, shorter LOS, and lower total hospital costs in both the multivariable regression and propensity-matched analyses.

Conclusion

Third-degree AV block had lower in-hospital mortality, cardiogenic shock, cardiac arrest, LOS, and total hospitalization cost in patients with smoking history.

Downregulation of SIRT1 and GADD45G genes and left atrial fibrosis induced by right ventricular dependent pacing in a complete atrioventricular block pig model

The molecular and genetic mechanisms underlying left atrial (LA) enlargement and atrial fibrosis following right ventricular (RV) dependent pacing remain unclear. Our objective was to investigate genetic expressions in the LA of pigs subjected to RV pacing for atrioventricular block (AVB), as well as to identify the differential gene expressions affected by biventricular (BiV) pacing. We established an AVB pig model and divided the subjects into three groups: a sham control group, an RV pacing group, and a BiV pacing group. Differential expression genes (DEGs) analyses conducted through next-generation sequencing (NGS) and enrichment analyses were employed to identify genes with altered expression in the LA myocardium. The RV pacing group showed a significant increase in extracellular fibrosis in the LA myocardium compared to the control group. NGS analysis revealed suppressed expression of the sirtuin signaling pathway in the RV pacing group. Among the DEGs within this pathway, GADD45G was found to be downregulated in the RV pacing group and upregulated in the BiV pacing group. Remarkably, the BiV pacing group exhibited elevated levels of GADD45G protein. In our study, we observed significant downregulation of SIRT1 and GADD45G genes, which are associated with the sirtuin signaling pathway, in the LA myocardium of the RV pacing group when compared to the control group. Moreover, these genes, which were downregulated in the RV pacing group, displayed a noteworthy upregulation in the BiV pacing group when compared to the RV pacing group.

Development and Validation of a Novel Risk Score for All-Cause Mortality Risk Stratification Prior to Permanent Pacemaker Implantation in Octogenarians or Older

Background and Objectives: The demand for permanent pacemaker (PPM) implantation for extremely old patients is increasing. Prior to implanting PPMs, life expectancy evaluation is essential but difficult. We aimed to develop and validate a scoring system for all-cause mortality risk stratification prior to PPM implantation in patients aged ≥80. Materials and Methods: A total of 210 patients aged ≥80 who received PPM implantation were included. Multivariable analysis was performed to assess the effects of different variables on all-cause mortality in a derivation cohort (n = 100). We developed the MELODY score for stratifying all-cause mortality prior to PPM implantation and tested the scoring system in a validation cohort (n = 102). Results: After 4.0 ± 2.7 years of follow-up, 54 patients (54%) had died. The 0.5-, 1- and 2-year all-cause mortality rates were 7%, 10% and 24%, respectively. The MELODY score based on body mass index <21 kg/m2 (HR: 2.21, 95% CI: 1.06-4.61), estimated glomerular filtration rate <30 mL/min/1.73 m2 (3.35, 1.77-6.35), length of hospitalization before PPM implantation >7 days (1.87, 1.02-3.43) and dyspnea as the major presenting symptom (1.90, 1.03-3.50) successfully distinguished patients at high risk of mortality. Patients with MELODY scores ≥3 had a higher risk of mortality compared to those with MELODY scores <3 (8.49, 4.24-17.00). The areas under the receiver operating characteristic curves in predicting 0.5, 1 and 2 years mortality rates were 0.86, 0.81 and 0.74, respectively. The predictive value of the model was confirmed in a validation cohort. Conclusions: The novel scoring system is a simple and effective tool for all-cause mortality risk stratification prior to PPM implantation in patients aged ≥80.

Prevalence of depression and its association with quality of life in patients after pacemaker implantation during the COVID-19 pandemic: A network analysis

Background

This study was designed to investigate the prevalence and predictors of depression in patients after pacemaker implantation during the COVID-19 pandemic in addition to identifying specific depressive symptoms associated with quality of life (QOL) using network analysis (NA).

Methods

This cross-sectional, observational study was conducted in China between July 1, 2021, and May 17, 2022. Descriptive analysis was used to calculate depression prevalence. Univariate analyses were used to compare differences in demographic and clinical characteristics between depressed and non-depressed patients following pacemaker implantation. Binary logistic regression analysis was used to assess factors independently associated with depression. Network analysis “expected influence,” and flow function indexes were used to identify symptoms central to the depression network of the sample and depressive symptoms that were directly associated with QOL, respectively. Network stability was examined using a case-dropping bootstrap procedure.

Results

In total, 206 patients implanted with a pacemaker met the study entry criteria and completed the assessment. The overall prevalence of depression (PHQ-9 total score ≥ 5) was 39.92% [95% confidence interval (CI) = 29.37−42.47%]. A binary logistic regression analysis revealed that patients with depression were more likely to report a poor health status (p = 0.031), severe anxiety symptoms (p &lt; 0.001), and fatigue (p &lt; 0.001). In the network model for depression, “Sad mood,” “Poor Energy,” and “Guilt” were the most influential symptoms. “Fatigue” had the strongest negative association with QOL, followed by “Sad mood” and “Appetite”.

Conclusion

Depression is common among patients having undergone pacemaker implantation during the COVID-19 pandemic. Anxiety, central symptoms of depression (i.e., “Sad mood”, “Poor Energy”, and “Guilt”) and depressive symptoms linked to QOL (i.e., “Sad mood”, “Appetite”, and “Fatigue”) identified in this study are promising targets for interventions and preventive measures for depression in patients who have undergone pacemaker implants.

Long-Term Implications of Pacemaker Insertion in Younger Adults: A Single Centre Experience

BACKGROUND

The long-term implications of pacemaker insertion in younger adults are poorly described in the literature.

METHODS

We performed a retrospective analysis of consecutive younger adult patients (18-50 yrs) undergoing pacemaker implantation at a quaternary hospital between 1986-2020. Defibrillators and cardiac resynchronisation therapy devices were excluded. All clinical records, pacemaker checks and echocardiograms were reviewed.

RESULTS

Eighty-one (81) patients (median age 41.0 yrs IQR=35-47.0, 53% male) underwent pacemaker implantation. Indications were complete heart block (41%), sinus node dysfunction (33%), high grade AV block (11%) and tachycardia-bradycardia syndrome (7%). During a median 7.9 (IQR=1.1-14.9) years follow-up, nine patients (11%) developed 13 late device-related complications (generator or lead malfunction requiring reoperation [n=11], device infection [n=1] and pocket revision [n=1]). Five (5) of these patients were <40 years old at time of pacemaker insertion. At long-term follow-up, a further nine patients (11%) experienced pacemaker-related morbidity from inadequate lead performance managed with device reprogramming. Sustained ventricular tachycardia was detected in two patients (2%). Deterioration in ventricular function (LVEF decline >10%) was observed in 14 patients (17%) and seven of these patients required subsequent biventricular upgrade. Furthermore, four patients (5%) developed new tricuspid regurgitation (>moderate-severe). Of 69 patients with available long-term pacing data, minimal pacemaker utilisation (pacing <5% at all checks) was observed in 13 (19%) patients.

CONCLUSIONS

Pacemaker insertion in younger adults has significant long-term implications. Clinicians should carefully consider pacemaker insertion in this cohort given risk of device-related complications, potential for device under-utilisation and issues related to lead longevity. In addition, patients require close follow-up for development of structural abnormalities and arrhythmias.

Clinical electrophysiology of the aging heart

INTRODUCTION

Advancements in medical and consumer-grade technologies have made it easier than ever to monitor a patient's heart rhythm and to diagnose arrhythmias. Octogenarians with symptomatic arrhythmias have unique management challenges due to their frailty, complex drug interactions, cognitive impairment, and competing comorbidities. The management decisions are further complicated by the lack of randomized evidence to guide treatment.

AREAS COVERED

A comprehensive literature review was undertaken to outline various tachyarrhythmias and bradyarrhythmias and their management, the role of cardiac implantable electronic devices, cardiac ablations, and specific geriatric arrhythmia considerations as recommended in international guidelines.

EXPERT OPINION

Atrial fibrillation (AF) is arguably the most important arrhythmia in the elderly and is associated with significant morbidity and mortality. Early diagnosis of AF, potentially with smart devices (wearables), has the potential to reduce the incidence of stroke, systemic emboli, and the risk of dementia. Bradyarrhythmias have a high incidence in the elderly as well, often requiring implantation of a permanent pacemaker. Leadless pacemakers implanted directly into the right ventricle are great options for gaining traction in elderly patients.

Periprocedural complications of cardiac implantable electronic device implantation in very elderly patients with cognitive impairment: A prospective study

Very elderly people (over 80 years) with cardiac implantable electronic devices (CIEDs) indications often have a higher prevalence of aging comorbidity, among which cognitive impairment is not uncommon. This study aimed to investigate periprocedural complications of CIED implantation among very elderly patients with and without cognitive impairment. One hundred eighty patients ≥80 years of age indicated for CIED implantation were included in our study. During hospitalization, the cognitive evaluation was performed according to the Diagnostic and Statistical Manual of Mental Disorders (fifth edition). According to the cognitive test results, patients were divided into 2 groups (90 patients with normal cognitive function and 90 patients with cognitive impairment). Meanwhile, their physical parameters and laboratory measurements were completed. The procedural data and periprocedural complications were collected from both groups. The association between cognitive impairment and periprocedural complications was analyzed using univariate and multiple logistic regression analyses. During a one-month follow-up, the most frequent periprocedural complications in very elderly patients were pocket hematoma and thrombosis events. Cognitively impaired patients had a higher incidence of complications than normal cognitive patients. Multivariate regression analysis showed that cognitive impairment was positively correlated with periprocedural complications in very elderly patients. Cognitive impairment is associated with increased periprocedural complications of CIED implantation in very elderly patients.

Utilization and perception of same-day discharge in electrophysiological procedures and device implantations: an EHRA survey

The aim of this European Heart Rhythm Association (EHRA) survey was to assess the utilization of same-day discharge (SDD) in electrophysiology (EP). An online-based questionnaire was shared with the EHRA community between 12 and 30 June 2020 and recorded institutional information, complication assessment, recent experiences, and opinions regarding possible advantages or concerns with SDD. In total, 218 responses from 49 countries provided information on current SDD management. Overall, SDD was implemented in 77.5%, whereas this proportion was significantly higher in tertiary and high-volume centres (83.8% and 85.3%, both P < 0.01). The concept of SDD was most commonly used following implantations of cardiac event recorders (97%), diagnostic EP procedures (72.2%), and implantations of pacemakers with one or two intracardiac leads (50%), while the lowest SDD utilization was observed after catheter ablations of left atrial or ventricular arrhythmias. Within SDD-experienced centres, ∼90% respondents stated that this discharge concept is recommendable or highly recommendable and reported that rates of increased rehospitalization and complication rates were low. Most respondents assumed a better utilization of hospital resources (78.2%), better cost effectiveness (77.3%), and an improved patients' comfort but were concerned about possible impairment of detection (72.5%) and management (78.7%) of late complications. In conclusion, >75% of respondents already implement SDD following EP interventions with a large heterogeneity with regard to specific procedures. Further research is needed to confirm or disprove existing and expected benefits and obstacles.

Arrhythmia Perception and Quality of Life in Bradyarrhythmia Patients Following Permanent Pacemaker Implantation

Although studies have evaluated the quality of life (QoL) of patients undergoing permanent pacemaker (PPM) placement, their results are inconsistent. To assess arrhythmia perceptions and QoL in bradyarrhythmia patients following PPM implantation, 137 patients completed demographic, arrhythmia perception, and QoL questionnaires before and six months after implantation. Before implantation, they reported fatigue (74.1%), dizziness (72.9%), dyspnea (64.7%), chest pain (62.4%), and heart fluttering (54.1%). After implantation, arrhythmia perceptions and QoL showed significant improvement (p < .05), except vitality (p > .05). However, patients with arrhythmia for more than three years, three or more PPM implants, two or more comorbidities, or were 41-50 years showed no significant QoL improvement. Doctors and hospital educators, rather than nurses, provided the most PPM information to patients. Since nurses provide primary in-hospital care to PPM patients, they should impart more patient education while considering individual characteristics in caring situations to enhance patients' QoL.

Arrhythmias in Patients ≥80 Years of Age: Pathophysiology, Management, and Outcomes

Advances in medical care have led to an increase in the number of octogenarians and even older patients, forming an important and unique patient subgroup. It is clear that advancing age is an independent risk factor for the development of most arrhythmias, causing substantial morbidity and mortality. Patients ≥80 years of age have significant structural and electrical remodeling of cardiac tissue; accrue competing comorbidities; react differently to drug therapy; and may experience falls, frailty, and cognitive impairment, presenting significant therapeutic challenges. Unfortunately, very old patients are under-represented in clinical trials, leading to critical gaps in evidence to guide effective and safe treatment of arrhythmias. In this state-of-the-art review, we examine the pathophysiology of aging and arrhythmias and then present the available evidence on age-specific management of the most common arrhythmias, including drugs, catheter ablation, and cardiac implantable electronic devices.

Post-pacemaker implant QRS duration and heart failure admission in patients with sick sinus syndrome and complete atrioventricular block

AIMS

High demand right ventricular pacing may elicit left ventricular systolic dysfunction known as pacing-induced cardiomyopathy, increasing the risks of heart failure (HF) hospitalization. Percentage of demand ventricular pacing is different between patients with sick sinus syndrome (SSS) and those with complete atrioventricular block (CAVB). This study aims to compare the incidence of HF admission and pacing-induced cardiomyopathy between patients with SSS and CAVB.

METHODS AND RESULTS

A total of 824 patients who received single ventricular or dual-chamber pacemaker implantation at our hospital between January 2003 and December 2012 were recruited for the study. Patients with HF, those without complete cardiac echocardiography, and those with significant coronary artery disease were excluded. Finally, 315 patients with SSS and 289 patients with CAVB were enrolled in this study. The CAVB group had a higher pacing percentage (39.37 ± 9.17% vs. 83.82 ± 33.06%; P < 0.001), longer pacing QRS duration (142.56 ± 33.02 ms vs. 156.63 ± 25.18 ms; P < 0.001), and higher prevalence of follow-up left ventricular ejection fraction ≤40% (1.3% vs. 4.2%; P = 0.040). However, the incidence of HF admission was similar between the two groups (log-rank P = 0.647). Age [hazard ratio (HR), 95% confidence interval (CI): 1.121, 1.054-1.193], diabetes mellitus (HR, 95% CI: 2.667, 1.159-6.136), pacing QRS duration ≥163 ms (HR, 95% CI: 3.506, 1.491-8.247), and left atrial size (HR, 95% CI: 1.070, 1.012-1.131) were independent predictors of HF admission. The Kaplan-Meier curve showed a significant difference in HF admission over a 3.5 year follow-up period (3.5 years: P value = 0.004; 5 years: P value = 0.002) between patients with pacing QRS duration ≥163 and <163 ms.

CONCLUSIONS

There was no difference in HF admission between patients with SSS and CAVB, although the CAVB group had a higher pacing percentage. Post-pacemaker implant pacing QRS duration ≥163 ms was the most important predictor of HF admission.

Complete Atrioventricular Block with Intact Retrograde Conduction in Cardiac Rhythm Management Devices: Implications of the Phenomenon

Intact retrograde ventriculoatrial (VA) conduction in the presence of complete atrioventricular (AV) heart block has been well-documented in the past. We sought to describe the prevalence and clinical significance of intact VA conduction accompanied by complete antegrade AV block in patients with implanted cardiac rhythm management (CRM) devices. During routine follow-up of CRM devices in our device clinic, 42 patients were found to be in a state of complete heart block. All patients presented in sinus rhythm. The patients' underlying rhythms were tested with the inhibition of pacing and documented AV dissociation. Subsequently, retrograde VA conduction was tested with ventricular pacing. In the 42 patients with complete heart block as the underlying rhythm, five patients demonstrated retrograde VA conduction. In conclusion, the prevalence of intact of VA conduction was 11.9% in our study. The implications of this phenomenon can have noteworthy clinical significance. The occurrence of pacemaker-mediated tachycardia and repetitive nonreentrant VA synchrony are discussed herein. All patients, even those with a device indication of complete heart block, should be tested for retrograde conduction at implantation and during routine follow-up.

Trends in replacement of pacemaker leads in the Netherlands: A long-term nationwide follow-up study

BACKGROUND

Our objective was to investigate trends over time in longevity and reasons for replacement with or without extraction of pacemaker leads after first implantation.

METHODS

Data collected between 1984 and 2006 in the national Dutch pacemaker registry were used. This registry covered 84% of sold leads. First lead replacement with or without extraction of one or more leads implanted with a first pacemaker generator was the endpoint of interest. The time interval of and reason for first replacement were analyzed. A 7-year follow-up interval after first implantation was used to analyze changes over time.

RESULTS

During 22 years of data collection, 138,225 leads were implanted with a first pacemaker generator. Within a mean 5.5 (SD 4.4) years for 7,377 patients one or more leads were extracted for the first time. In total, 8,849 leads (6.4%) were replaced or extracted. The main reasons for first replacement of leads with or without extraction were insulation failures (14.6%), infection (8.8%), displacement (7.6%), or for elective reasons (10.0%). The number of insulation failures peaked during 1991-1995.

CONCLUSIONS

Despite improvements in pacing techniques and experience with cardiac devices, we found that insulation and conductor failures, and complications such as infections, did not diminish over the 20 years of the registry. Continuing attention in clinical practice for the evaluation of these adverse outcomes and maintaining quality registries is warranted, whereas manufacturers should use this information to further improve their devices.

Trends in service time of pacemakers in the Netherlands: a long-term nationwide follow-up study

AIMS

After decades of experience and strongly improved technology, service time of pacemaker generators is expected to increase. To test this hypothesis, we conducted a retrospective review of a large cohort of patients with a pacemaker.

METHODS

We reviewed data collected between 1984 and 2006 in the first national Dutch pacemaker registry. This registry covered 96% of all generators implanted. We analysed the time of and reason for explantation of pacemaker generators. A 7-year follow-up interval after first implantation and following replacements was used to analyse changes over time.

RESULTS

During 22 years of data collection, nearly 97,000 first pacemaker generators were implanted. A total of 27,937 (22.4%) generators were explanted within a mean of 6.3 (standard deviation 3.3) years. Reasons for approximately 60% of these explantations were 'end of life' of the pacemaker generator or elective system change. Complications or failures such as infections and recalls accounted for approximately 20% of the explantations. For the remaining 20%, the reasons for explantation had not been registered.

CONCLUSION

Despite progress in technology, a substantial proportion of pacemaker generators is explanted before its expected service time, with one in five generators being replaced due to technical failures, infections or other complications. Furthermore, the time interval between pacemaker implantation and explantation due to normal 'end of life' (battery EOL) decreased. Infections continue to rank highly as a cause for pacing system replacement, despite all current preventive measures.