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Breeman KTN, Knops RE, van der Stoel MD, Boersma LVA, Yap SC, van Erven L, van Dijk VF, Maass AH, Wilde AAM, Tjong FVY. Trends in adoption of extravascular cardiac implantable electronic devices: the Dutch cohort. Neth Heart J 2024:10.1007/s12471-024-01892-6. [PMID: 39158682 DOI: 10.1007/s12471-024-01892-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 08/20/2024] Open
Abstract
INTRODUCTION Conventional implantable cardioverter-defibrillators (ICDs) and pacemakers carry a risk of pocket- and lead-related complications in particular. To avoid these complications, extravascular devices (EVDs) have been developed, such as the subcutaneous ICD (S-ICD) and leadless pacemaker (LP). However, data on patient or centre characteristics related to the actual adoption of EVDs are lacking. OBJECTIVE To assess real-world nationwide trends in EVD adoption in the Netherlands. METHODS Using the Netherlands Heart Registration, all consecutive patients with a de novo S‑ICD or conventional single-chamber ICD implantation between 2012-2020, or de novo LP or conventional single-chamber pacemaker implantation between 2014-2020 were included. Trends in adoption are described for various patient and centre characteristics. RESULT From 2012-2020, 2190 S‑ICDs and 10,683 conventional ICDs were implanted; from 2014-2020, 712 LPs and 11,103 conventional pacemakers were implanted. The general use has increased (S-ICDs 8 to 21%; LPs 1 to 8%), but this increase seems to have reached a plateau. S‑ICD recipients were younger than conventional ICD recipients (p < 0.001) and more often female (p < 0.001); LP recipients were younger than conventional pacemaker recipients (p < 0.001) and more often male (p = 0.03). Both S‑ICDs and LPs were mainly implanted in high-volume centres with cardiothoracic surgery on-site, although over time S‑ICDs were increasingly implanted in centres without cardiothoracic surgery (p < 0.001). CONCLUSION This nationwide study demonstrated a relatively quick adoption of innovative EVDs with a plateau after approximately 4 years. S‑ICD use is especially high in younger patients. EVDs are mainly implanted in high-volume centres with cardiothoracic surgery back-up, but S‑ICD use is expanding beyond those centres.
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Affiliation(s)
- Karel T N Breeman
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands.
- Heart Failure & Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
| | - Reinoud E Knops
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | | | - Lucas V A Boersma
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thorax Center, Rotterdam, The Netherlands
| | - Lieselot van Erven
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vincent F van Dijk
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Alexander H Maass
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Arthur A M Wilde
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Fleur V Y Tjong
- Department of Cardiology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
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Singh JP, Rinaldi CA, Sanders P, Kubo SH, James S, Niazi IK, Betts T, Butter C, Okabe T, Cunnane R, Aziz E, Biffi M, Zaidi A, Alison J, Defaye P, Aurrichio A, Gold MR, Lindenfeld J, Rogers T, Walsh MN. Leadless Ultrasound-Based Cardiac Resynchronization System in Heart Failure. JAMA Cardiol 2024:2821182. [PMID: 39083254 PMCID: PMC11292567 DOI: 10.1001/jamacardio.2024.2050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 04/04/2024] [Indexed: 08/03/2024]
Abstract
Importance Approximately 40% of patients with heart failure (HF) who are eligible for cardiac resynchronization therapy (CRT) either fail to respond or are untreatable due to anatomical constraints. Objective To assess the safety and efficacy of a novel, leadless, left ventricular (LV) endocardial pacing system for patients at high risk for a CRT upgrade or whose coronary sinus (CS) lead placement/pacing with a conventional CRT system failed. Design, Setting, and Participants The SOLVE-CRT study was a prospective multicenter trial, enrolling January 2018 through September 2022, with follow-up in March 2023. Data were analyzed from DATE MONTH, YEAR, through DATE MONTH, YEAR. The trial combined data from an initial randomized, double-blind study (n = 108) and a subsequent single-arm part (n = 75). It took place at 36 centers across Australia, Europe, and the US. Participants were nonresponders, previously untreatable (PU), or high-risk upgrades (HRU). All participants contributed to the safety analysis. The primary efficacy analysis (n = 100) included 75 PU-HRU patients from the single-arm part and 25 PU-HRU patients from the randomized treatment arm. Interventions Patients were implanted with the WiSE CRT System (EBR Systems) consisting of a leadless LV endocardial pacing electrode stimulated with ultrasound energy delivered by a subcutaneously implanted transmitter and battery. Main Outcomes and Measures The primary safety end point was freedom from type I complications. The primary efficacy end point was a reduction in mean LV end systolic volume (LVESV). Results The study included 183 participants; mean age was 68.1 (SD, 10.3) years and 141 were male (77%). The trial was terminated at an interim analysis for meeting prespecified stopping criteria. In the safety population, patients were either New York Heart Association Class II (34.6%) or III (65.4%). The primary efficacy end point was met with a 16.4% (95% CI, -21.0% to -11.7%) reduction in mean LVESV (P = .003). The primary safety end point was met with an 80.9% rate of freedom from type I complications (P < .001), which included 12 study device system events (6.6%), 5 vascular events (2.7%), 3 strokes (1.6%), and 7 cardiac perforations which mostly occurred early in the study (3.8%). Conclusions and Relevance The SOLVE-CRT study has demonstrated that leadless LV endocardial pacing with the WiSE CRT system is associated with a reduction in LVESV in patients with HF. This novel system may represent an alternative to conventional CRT implants in some HF patient populations. Trial Registration ClinicalTrials.gov Identifier: NCT0292203.
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Affiliation(s)
- Jagmeet P. Singh
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher A. Rinaldi
- St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- Kings College London, London, United Kingdom
| | - Prashanthan Sanders
- University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Simon James
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
| | | | - Timothy Betts
- Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Christian Butter
- Immanuel Klinikum Bernau Herzzentrum Brandenburg, Bernau, Germany
| | - Toshimasa Okabe
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Emad Aziz
- Rutgers-New Jersey Medical School, New Jersey
| | - Mauro Biffi
- Policlinico S. Orsola, Malpighi Bologna, Italy
| | - Amir Zaidi
- Manchester Heart Centre, Manchester, United Kingdom
| | | | - Pascal Defaye
- University Hospital and University Grenoble Alpes, Grenoble, France
| | - Angelo Aurrichio
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Michael R. Gold
- Cardiology Division, Medical University of South Carolina, Charleston, South Carolina
| | - JoAnn Lindenfeld
- Section of Heart Failure and Cardiac Transplantation, Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
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Xu F, Meng L, Lin H, Xu W, Guo H, Peng F. Systematic review of leadless pacemaker. Acta Cardiol 2024; 79:284-294. [PMID: 37961771 DOI: 10.1080/00015385.2023.2276537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023]
Abstract
Conventional pacing systems consist of a pacemaker and one or more leads threaded from the device pocket through veins into the heart conducting the pacing therapy to the desired pacing site. Although these devices are effective, approximately one in eight patients treated with these traditional pacing systems experiences a complication attributed to the pacemaker pocket or leads. With the technological advances in electronics, leadless pacemakers that small enough to implant within the heart were introduced. Leadless pacemakers have been developed to overcome many of the challenges of transvenous pacing including complications related to leads or pacemaker pockets. This review aims to provide an overview of advantages of leadless pacemaker, complications and limitations of leadless pacemaker, leadless pacemaker candidate, and future directions of this promising technology.
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Affiliation(s)
- Fukang Xu
- Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Liping Meng
- Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Hui Lin
- Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Weiyuan Xu
- Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Hangyuan Guo
- Shaoxing Wen li Medical College, Shaoxing, China
| | - Fang Peng
- Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
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Beccarino N, Saleh M, Epstein LM. Leadless pacemakers: Where are we? Trends Cardiovasc Med 2024:S1050-1738(24)00018-5. [PMID: 38522582 DOI: 10.1016/j.tcm.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 03/10/2024] [Accepted: 03/10/2024] [Indexed: 03/26/2024]
Abstract
Pacemakers have been the cornerstone of brady-arrhythmia management since the mid-20th century. Despite the widespread use and success of traditional transvenous pacemakers, they are associated with an estimated 15 % complication rate at three years. Driven by the advantages over traditional transvenous pacemakers including a lack of transvenous leads, resistance to infection, and ease of implantation, the number of leadless pacemakers placed annually in the United States has dramatically increased since their initial approval. While current iterations of leadless pacemakers lack the versatility offered by transvenous devices, recent advances in leadless pacing offer an increasingly diverse range of therapeutic options. This review will discuss the past, present, and future emerging technologies, and strategies in leadless pacing.
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Affiliation(s)
- Nicholas Beccarino
- Department of Cardiology/Cardiac Surgery, Northwell Health. Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset 11030, NY, United States.
| | - Moussa Saleh
- Department of Cardiology/Cardiac Surgery, Northwell Health. Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset 11030, NY, United States
| | - Laurence M Epstein
- Department of Cardiology/Cardiac Surgery, Northwell Health. Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset 11030, NY, United States
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5
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Tang JE, Awad H, Essandoh MK, Iyer MH. Dual-Chamber Leadless Pacing: The Future is Wireless. J Cardiothorac Vasc Anesth 2024; 38:1-3. [PMID: 38016818 DOI: 10.1053/j.jvca.2023.08.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 11/30/2023]
Affiliation(s)
- Jonathan E Tang
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, OH.
| | - Hamdy Awad
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael K Essandoh
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, OH
| | - Manoj H Iyer
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, OH
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6
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Wijesuriya N, Mehta V, Vere FD, Howell S, Behar JM, Shute A, Lee M, Bosco P, Niederer SA, Rinaldi CA. Cost-effectiveness analysis of leadless cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2023; 34:2590-2598. [PMID: 37814470 PMCID: PMC10946454 DOI: 10.1111/jce.16102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/11/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND The Wireless Stimulation Endocardially for CRT (WiSE-CRT) system is a novel technology used to treat patients with dyssynchronous heart failure (HF) by providing leadless cardiac resynchronization therapy (CRT). Observational studies have demonstrated its safety and efficacy profile, however, the treatment cost-effectiveness has not previously been examined. METHODS A cost-effectiveness evaluation of the WiSE-CRT System was performed using a cohort-based economic model adopting a "proportion in state" structure. In addition to the primary analysis, scenario analyses and sensitivity analyses were performed to test for uncertainty in input parameters. Outcomes were quantified in terms of quality-adjusted life year (QALY) differences. RESULTS The primary analysis demonstrated that treatment with the WiSE-CRT system is likely to be cost-effective over a lifetime horizon at a QALY reimbursement threshold of £20 000, with a net monetary benefit (NMB) of £3781 per QALY. Cost-effectiveness declines at time horizons shorter than 10 years. Sensitivity analyses demonstrated that average system battery life had the largest impact on potential cost-effectiveness. CONCLUSION Within the model limitations, these findings support the use of WiSE-CRT in indicated patients from an economic standpoint. However, improving battery technology should be prioritized to maximize cost-effectiveness in times when health services are under significant financial pressures.
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Affiliation(s)
- Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Felicity De Vere
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Sandra Howell
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Jonathan M. Behar
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | | | | | - Paolo Bosco
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- National Heart and Lung InstituteImperial CollegeLondonUK
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
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7
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Toon LT, Roberts PR. The Micra Transcatheter Pacing System: past, present and the future. Future Cardiol 2023; 19:735-746. [PMID: 38059460 DOI: 10.2217/fca-2023-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/13/2023] [Indexed: 12/08/2023] Open
Abstract
Leadless permanent pacemakers represent an important innovation in cardiac device developments. Although transvenous permanent pacemakers have become indispensable in managing bradyarrhythmia and saving numerous lives, the use of transvenous systems comes with notable risks tied to intravascular leads and subcutaneous pockets. This drawback has spurred the creation of leadless cardiac pacemakers. Within this analysis, we compile existing clinical literature and proceed to evaluate the efficacy and safety of the Micra Transcatheter Pacing System. We also delve into the protocols for addressing a malfunctioning or end-of-life Micra as well as device extraction. Lastly, we explore prospects in this domain, such as the emergence of entirely leadless cardiac resynchronization therapy-defibrillator devices.
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Affiliation(s)
- Lin-Thiri Toon
- Cardiac Rhythm Management, University Hospital Southampton NHS Trust, Southampton, SO16 6YD, UK
- Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK
| | - Paul R Roberts
- Cardiac Rhythm Management, University Hospital Southampton NHS Trust, Southampton, SO16 6YD, UK
- Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK
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8
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Nair V, Dalrymple AN, Yu Z, Balakrishnan G, Bettinger CJ, Weber DJ, Yang K, Robinson JT. Miniature battery-free bioelectronics. Science 2023; 382:eabn4732. [PMID: 37943926 DOI: 10.1126/science.abn4732] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/28/2023] [Indexed: 11/12/2023]
Abstract
Miniature wireless bioelectronic implants that can operate for extended periods of time can transform how we treat disorders by acting rapidly on precise nerves and organs in a way that drugs cannot. To reach this goal, materials and methods are needed to wirelessly transfer energy through the body or harvest energy from the body itself. We review some of the capabilities of emerging energy transfer methods to identify the performance envelope for existing technology and discover where opportunities lie to improve how much-and how efficiently-we can deliver energy to the tiny bioelectronic implants that can support emerging medical technologies.
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Affiliation(s)
- Vishnu Nair
- Rice Neuroengineering Initiative, Rice University, Houston, TX, USA
| | - Ashley N Dalrymple
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Zhanghao Yu
- Department of Electrical and Computer Engineering, Rice University, Houston, TX, USA
| | - Gaurav Balakrishnan
- Department of Materials Science & Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Christopher J Bettinger
- Department of Materials Science & Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Douglas J Weber
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA, USA
- Center for Neural Basis of Cognition, Pittsburgh, PA, USA
| | - Kaiyuan Yang
- Department of Electrical and Computer Engineering, Rice University, Houston, TX, USA
| | - Jacob T Robinson
- Rice Neuroengineering Initiative, Rice University, Houston, TX, USA
- Department of Electrical and Computer Engineering, Rice University, Houston, TX, USA
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Alnaimat S, Doyle M, Krishnan K, Biederman RWW. Worsening tricuspid regurgitation associated with permanent pacemaker and implantable cardioverter-defibrillator implantation: A systematic review and meta-analysis of more than 66,000 subjects. Heart Rhythm 2023; 20:1491-1501. [PMID: 37506990 DOI: 10.1016/j.hrthm.2023.07.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Worsening tricuspid regurgitation (TR) after either permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) implantation is an emerging clinical challenge. Early recognition of this entity is essential in guiding treatment. OBJECTIVE This meta-analysis was designed to identify the overall incidence and patient-specific predictors of TR post-device implantation. METHODS We searched electronic databases from inception to January 2023 for published studies that reported the incidence of TR worsening post-device implantation. The log odds ratio (OR) was used to summarize group differences. RESULTS Our analysis included 29 studies with 66,590 participants. Patients who underwent device implantation (n = 1008) were significantly more likely to develop worsening TR than controls who did not undergo device implantation (n = 58,605) (OR 3.18; P < .01). In a total of 7777 patients, the pooled incidence of at least 1-grade worsening of TR post-device implantation was 24%. Worsening TR post-device implantation significantly increases mortality (hazard ratio 1.42; P = .02). Larger right atrial area (OR 1.11; P < .01) is significantly associated with an increased risk of worsening TR post-device implantation, while male patients are less likely to develop this complication than female patients (OR 0.74; P < .01). Importantly, there is no statistically significant difference between the type of implanted device (ICD vs PPM) and post-device implantation TR. Further, right ventricular dysfunction, pulmonary artery pressure, baseline mitral regurgitation, left ventricular ejection fraction, baseline atrial fibrillation, and age have no association with worsening TR post-device implantation. CONCLUSION A substantial number of patients undergoing PPM or ICD implantation are at an increased risk of worsening TR. Importantly, in this largest review to date incorporating more than 66,000 subjects, worsening TR significantly increases mortality by greater than 140%, accordingly deserving more recognition and clinical attention in the current era.
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Affiliation(s)
- Saed Alnaimat
- Center of Cardiovascular MRI, Allegheny General Hospital, Pittsburgh, Pennsylvania.
| | - Mark Doyle
- Center of Cardiovascular MRI, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Kousik Krishnan
- Division of Electrophysiology, Midwest Cardiovascular Institute, Naperville, Illinois
| | - Robert W W Biederman
- Center of Cardiovascular MRI, Allegheny General Hospital, Pittsburgh, Pennsylvania; West Virginia University School of Medicine, Morgantown, West Virginia; Roper Hospital/Medical University of South Carolina, College of Medicine, Charleston, South Carolina
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Jiwani S, Akhavan D, Reddy M, Noheria A. Cardiac stereotactic radiotherapy for refractory ventricular tachycardia in a patient with wireless left ventricular endocardial stimulation system. HeartRhythm Case Rep 2023; 9:818-822. [PMID: 38023677 PMCID: PMC10667127 DOI: 10.1016/j.hrcr.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Affiliation(s)
- Sania Jiwani
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas
| | - David Akhavan
- Department of Radiation Oncology, The University of Kansas Medical Center, Kansas City, Kansas
| | - Madhu Reddy
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas
| | - Amit Noheria
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas
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11
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Friedman DJ, Qin L, Freeman JV, Singh JP, Curtis JP, Piccini JP, Al-Khatib SM, Jackson KP. Left ventricular lead implantation failure in an unselected nationwide cohort. Heart Rhythm 2023; 20:1420-1428. [PMID: 37406870 DOI: 10.1016/j.hrthm.2023.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Left ventricular (LV) lead implantation is often the most challenging aspect of cardiac resynchronization therapy (CRT) procedures; early studies reported implant failure rates in ∼10% of cases. OBJECTIVE The purpose of this study was to define rates, reasons for, and factors independently associated with LV lead implant failure. METHODS We studied patients with left bundle branch block and ejection fraction ≤ 35% who underwent planned de novo transvenous CRT implantation (2010-2016) and were reported to the National Cardiovascular Data Registry ICD Registry. Independent predictors of LV lead implant failure were determined using logistic regression; age, sex, and variables with a univariable P value of <.15 were considered for inclusion in the model. RESULTS Of the 111,802 patients who underwent a planned CRT procedure, 3.6% of patients (n = 3979) had LV lead implant failure. Reasons for implant failure included venous access (7.5%), coronary sinus access (64.3%), tributary vein access (13.5%), coronary sinus dissection (7.6%), unacceptable threshold (4.4%), and diaphragmatic stimulation (1.7%). Significant independent predictors of LV lead implant failure included younger age (odds ratio [OR] 1.01; 95% confidence interval [CI] 0.1.01-1.02), female sex (OR 1.38; 95% CI 1.29-1.47), black race (vs white, OR 1.44; 95% CI 1.32-1.57), Hispanic ethnicity (OR 1.23; 95% CI 1.08-1.40), QRS duration (OR 1.055 per 10 ms; 95% CI 1.038-1.072 per 10 ms), obstructive sleep apnea (OR 1.14; 95% CI 1.04-1.24), and implantation by a physician without specialized training (vs electrophysiology trained, OR 1.53; 95% CI 1.34-1.76). CONCLUSION LV lead implant failure is uncommon in the current era and is most commonly due to coronary sinus access failure. Predictors of LV lead implant failure included younger age, female sex, black race, Hispanic ethnicity, increased QRS duration, sleep apnea, and absence of electrophysiology training.
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Affiliation(s)
- Daniel J Friedman
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Li Qin
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - James V Freeman
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - Jonathan P Piccini
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Sana M Al-Khatib
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Kevin P Jackson
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina
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12
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Vouliotis AI, Roberts PR, Dilaveris P, Gatzoulis K, Yue A, Tsioufis K. Leadless Pacemakers: Current Achievements and Future Perspectives. Eur Cardiol 2023; 18:e49. [PMID: 37655133 PMCID: PMC10466270 DOI: 10.15420/ecr.2022.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/18/2022] [Indexed: 09/02/2023] Open
Abstract
Despite the technological advances in pacemaker technology, the transvenous implanted leads are still considered the Achilles' heel of this rhythm-control therapy. The leadless permanent pacemaker system was developed as an option to bypass the weakness of the transvenous approach. Advances in battery technology and deep miniaturisation of electronics now offer the opportunity to implant the whole pacemaker system into the right ventricle. This review aims to provide a comprehensive report on the advent of leadless pacemakers, their clinical usefulness and the future perspectives of this disruptive and promising technology. Further research is required before some of these technologies are safely and routinely used in clinical practice.
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Affiliation(s)
- Apostolos Ilias Vouliotis
- Cardiology Department, University Hospital SouthamptonSouthampton, UK
- First University Department of Cardiology, School of Medicine, National and Kapodistrian University of AthensAthens, Greece
| | - Paul R Roberts
- Cardiology Department, University Hospital SouthamptonSouthampton, UK
| | - Polychronis Dilaveris
- First University Department of Cardiology, School of Medicine, National and Kapodistrian University of AthensAthens, Greece
| | - Konstantinos Gatzoulis
- First University Department of Cardiology, School of Medicine, National and Kapodistrian University of AthensAthens, Greece
| | - Arthur Yue
- Cardiology Department, University Hospital SouthamptonSouthampton, UK
| | - Konstantinos Tsioufis
- First University Department of Cardiology, School of Medicine, National and Kapodistrian University of AthensAthens, Greece
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13
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Ballantyne BA, Chew DS, Vandenberk B. Paradigm Shifts in Cardiac Pacing: Where Have We Been and What Lies Ahead? J Clin Med 2023; 12:jcm12082938. [PMID: 37109274 PMCID: PMC10146747 DOI: 10.3390/jcm12082938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/07/2023] [Accepted: 04/09/2023] [Indexed: 04/29/2023] Open
Abstract
The history of cardiac pacing dates back to the 1930s with externalized pacing and has evolved to incorporate transvenous, multi-lead, or even leadless devices. Annual implantation rates of cardiac implantable electronic devices have increased since the introduction of the implantable system, likely related to expanding indications, and increasing global life expectancy and aging demographics. Here, we summarize the relevant literature on cardiac pacing to demonstrate the enormous impact it has had within the field of cardiology. Further, we look forward to the future of cardiac pacing, including conduction system pacing and leadless pacing strategies.
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Affiliation(s)
- Brennan A Ballantyne
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Bert Vandenberk
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
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14
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Wijesuriya N, De Vere F, Mehta V, Niederer S, Rinaldi CA, Behar JM. Leadless Pacing: Therapy, Challenges and Novelties. Arrhythm Electrophysiol Rev 2023; 12:e09. [PMID: 37427300 PMCID: PMC10326662 DOI: 10.15420/aer.2022.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/15/2023] [Indexed: 07/11/2023] Open
Abstract
Leadless pacing is a rapidly growing field. Initially designed to provide right ventricular pacing for those who were contraindicated for conventional devices, the technology is growing to explore the potential benefit of avoiding long-term transvenous leads in any patient who requires pacing. In this review, we first examine the safety and performance of leadless pacing devices. We then review the evidence for their use in special populations, such as patients with high risk of device infection, patients on haemodialysis, and patients with vasovagal syncope who represent a younger population who may wish to avoid transvenous pacing. We also summarise the evidence for leadless cardiac resynchronisation therapy and conduction system pacing and discuss the challenges of managing issues, such as system revisions, end of battery life and extractions. Finally, we discuss future directions in the field, such as completely leadless cardiac resynchronisation therapy-defibrillator devices and whether leadless pacing has the potential to become a first-line therapy in the near future.
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Affiliation(s)
- Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Felicity De Vere
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Jonathan M Behar
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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15
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Tong F, Sun Z. Strategies for Safe Implantation and Effective Performance of Single-Chamber and Dual-Chamber Leadless Pacemakers. J Clin Med 2023; 12:jcm12072454. [PMID: 37048538 PMCID: PMC10094832 DOI: 10.3390/jcm12072454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/02/2023] [Accepted: 03/14/2023] [Indexed: 04/14/2023] Open
Abstract
Leadless pacemakers (LPMs) have emerged as an alternative to conventional transvenous pacemakers to eliminate the complications associated with leads and subcutaneous pockets. However, LPMs still present with complications, such as cardiac perforation, dislodgment, vascular complications, infection, and tricuspid valve regurgitation. Furthermore, the efficacy of the leadless VDD LPMs is influenced by the unachievable 100% atrioventricular synchrony. In this article, we review the available data on the strategy selection, including appropriate patient selection, procedure techniques, device design, and post-implant programming, to minimize the complication rate and maximize the efficacy, and we summarize the clinical settings in which a choice must be made between VVI LPMs, VDD LPMs, or conventional transvenous pacemakers. In addition, we provide an outlook for the technology for the realization of true dual-chamber leadless and battery-less pacemakers.
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Affiliation(s)
- Fei Tong
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Zhijun Sun
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang 110004, China
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16
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Frazer M, Phan F, Dalouk K, Zarraga IG, Raitt M, Jessel PM. A Case of Leadless-to-Leadless Pacemaker Interaction. HeartRhythm Case Rep 2023. [DOI: 10.1016/j.hrcr.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
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17
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Malaczynska-Rajpold K, Elliot M, Wijesuriya N, Mehta V, Wong T, Rinaldi CA, Behar JM. Leadless Cardiac Pacing: New Horizons. Cardiol Ther 2023; 12:21-33. [PMID: 36417178 PMCID: PMC9986180 DOI: 10.1007/s40119-022-00288-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/31/2022] [Indexed: 11/25/2022] Open
Abstract
Since the introduction of transvenous cardiac pacing leads, pacemaker system design has remained similar for several decades. Progressive miniaturisation of electronic circuitry and batteries has enabled a smaller, single pacing unit comprising the intracardiac electrodes, generator and computer. This review explores the development of leadless pacing, the clinical trials comparing leadless to transvenous pacing in addition to the future developments of multi-chamber leadless pacing.
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Affiliation(s)
- Katarzyna Malaczynska-Rajpold
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1, UK
| | - Mark Elliot
- St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- Imaging Sciences and Biomedical Engineering, Kings College London, London, UK
| | - Nadeev Wijesuriya
- St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- Imaging Sciences and Biomedical Engineering, Kings College London, London, UK
| | - Vishal Mehta
- St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- Imaging Sciences and Biomedical Engineering, Kings College London, London, UK
| | - Tom Wong
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1, UK
| | - Christopher Aldo Rinaldi
- St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- Imaging Sciences and Biomedical Engineering, Kings College London, London, UK
| | - Jonathan M Behar
- Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1, UK.
- St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK.
- Imaging Sciences and Biomedical Engineering, Kings College London, London, UK.
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18
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Anderson C, Olshansky B. The LEADR ICD lead study: Is thinner better? J Cardiovasc Electrophysiol 2023; 34:268-269. [PMID: 36378785 DOI: 10.1111/jce.15750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Christian Anderson
- Cardiology, The University of Iowa Hospitals and Clinics, Iowa, Iowa City, USA
| | - Brian Olshansky
- Cardiology, The University of Iowa Hospitals and Clinics, Iowa, Iowa City, USA
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19
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Elliott MK, Strocchi M, Sieniewicz BJ, Sidhu B, Mehta V, Wijesuriya N, Behar JM, Thorpe A, Martic D, Wong T, Niederer S, Rinaldi CA. Biventricular endocardial pacing and left bundle branch area pacing for cardiac resynchronization: Mechanistic insights from electrocardiographic imaging, acute hemodynamic response, and magnetic resonance imaging. Heart Rhythm 2023; 20:207-216. [PMID: 36575808 DOI: 10.1016/j.hrthm.2022.10.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/13/2022] [Accepted: 10/21/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Biventricular endocardial pacing (BiV-endo) has demonstrated superior cardiac resynchronization compared to conventional biventricular epicardial pacing (BiV-epi). Left bundle branch area pacing (LBBAP) may also achieve effective cardiac resynchronization therapy (CRT). OBJECTIVE The purpose of this study was to compare the acute electrical and hemodynamic effects of BiV-epi, BiV-endo, and LBBAP delivered from the LV endocardium and to assess how myocardial scar affects response. METHODS Eleven patients with heart failure and indications for CRT underwent a temporary pacing study with electrocardiographic imaging (ECGi) and hemodynamic assessment. BiV-endo was delivered by stimulation of the left ventricular (LV) lateral wall, and LBBAP was delivered by stimulation of the LV septum, at the site of a Purkinje potential. LV activation time (LVAT-95), LV dyssynchrony index (LVDI), biventricular activation time (BIVAT-90), and biventricular dyssynchrony index (BIVDI) were calculated. Myocardial scar was assessed using magnetic resonance imaging (MRI). RESULTS The protocol was completed in 10 patients. Compared to BiV-epi (LVAT-95: 79.2 ± 13.1 ms; LVDI: 26.6 ± 3.4 ms) LV resynchronization was superior during BiV-endo (LVAT-95: 48.5 ± 14.9 ms; P = .001; LVDI: 16.6 ± 6.4 ms; P = .002) and LBBAP (LVAT-95: 48.9 ± 12.5 ms; P = .001; LVDI: 15.3 ± 3.4 ms; P = .001). Biventricular resynchronization was similarly superior during BiV-endo and LBBAP vs BiV-epi (BIVAT-90 and BIVDI; P <.05). The rate of acute hemodynamic responders was higher during BiV-endo (90%) and LBBAP (70%) vs BiV-epi (50%). The benefits of LBBAP (but not BiV-endo) on LV resynchronization were attenuated when septal scar was present in a subset of 8 patients who underwent MRI. CONCLUSION Our findings suggest superior electrical resynchronization and a higher proportion of acute hemodynamic responders during BiV-endo and LBBAP compared to BiV-epi. Electrical resynchronization was similar between BiV-endo and LBBAP; however, septal scar seemed to attenuate response to LBBAP.
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Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Benjamin J Sieniewicz
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Baldeep Sidhu
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jonathan M Behar
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Andrew Thorpe
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Dejana Martic
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Tom Wong
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College School of Medicine, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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20
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Wijesuriya N, Elliott MK, Mehta V, De Vere F, Strocchi M, Behar JM, Niederer SA, Rinaldi CA. Pacing interventions in non-responders to cardiac resynchronization therapy. Front Physiol 2023; 14:1054095. [PMID: 36776979 PMCID: PMC9909021 DOI: 10.3389/fphys.2023.1054095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/17/2023] [Indexed: 01/28/2023] Open
Abstract
Non-responders to Cardiac Resynchronization Therapy (CRT) represent a high-risk, and difficult to treat population of heart failure patients. Studies have shown that these patients have a lower quality of life and reduced life expectancy compared to those who respond to CRT. Whilst the first-line treatment for dyssynchronous heart failure is "conventional" biventricular epicardial CRT, a range of novel pacing interventions have emerged as potential alternatives. This has raised the question whether these new treatments may be useful as a second-line pacing intervention for treating non-responders, or indeed, whether some patients may benefit from these as a first-line option. In this review, we will examine the current evidence for four pacing interventions in the context of treatment of conventional CRT non-responders: CRT optimization; multisite left ventricular pacing; left ventricular endocardial pacing and conduction system pacing.
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Affiliation(s)
- Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom,*Correspondence: Nadeev Wijesuriya,
| | - Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Felicity De Vere
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Jonathan M. Behar
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom,Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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21
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Blank EA, El-Chami MF, Wenger NK. Leadless Pacemakers: State of the Art and Selection of the Ideal Candidate. Curr Cardiol Rev 2023; 19:43-50. [PMID: 36999695 PMCID: PMC10518884 DOI: 10.2174/1573403x19666230331094647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 01/17/2023] [Accepted: 01/24/2023] [Indexed: 04/01/2023] Open
Abstract
The field of cardiac pacing has been defined by constant development to provide efficacious, safe, and reliable therapy. Traditional pacing utilizes transvenous leads, which dwell in the venous system and place patients at risk for complications, including pneumothorax, bleeding, infection, vascular obstruction, and valvular compromise. Leadless pacemakers have been developed to overcome many of the challenges of transvenous pacing while providing safe and effective pacing therapy for an increasing population of patients. The Medtronic Micra transcatheter pacing system was approved by the FDA in April of 2016 and the Abbott Aveir pacemaker was approved in April of 2022. Several additional leadless pacemakers are in various stages of development and testing. There exists limited guidance on the selection of the ideal candidate for leadless pacemakers. Advantages of leadless pacemakers include decreased infection risk, overcoming limited vascular access, and avoidance of interaction with the tricuspid valve apparatus. Disadvantages of leadless pacemakers include right ventricular-only pacing, unclear lifecycle management, cost, perforation risk, and lack of integration with defibrillator systems. This review aims to provide an overview of the current state of the art of leadless pacemakers, currently approved systems, clinical trials and real-world evidence, considerations for patient selection, and future directions of this promising technology.
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Affiliation(s)
- Evan A. Blank
- Division of Cardiology, Section of Electrophysiology, Emory University School of Medicine, Atlanta, Georgia
| | - Mikhael F. El-Chami
- Division of Cardiology, Section of Electrophysiology, Emory University School of Medicine, Atlanta, Georgia
| | - Nanette K. Wenger
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
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22
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Hua J, Kong Q, Chen Q. Alternative pacing strategies for optimal cardiac resynchronization therapy. Front Cardiovasc Med 2022; 9:923394. [PMID: 36237907 PMCID: PMC9551024 DOI: 10.3389/fcvm.2022.923394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/06/2022] [Indexed: 12/02/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) via biventricular pacing (BVP) improves morbidity, mortality, and quality of life, especially in subsets of patients with impaired cardiac function and wide QRS. However, the rate of unsuccessful or complicated left ventricular (LV) lead placement through coronary sinus is 5–7%, and the rate of “CRT non-response” is approximately 30%. These reasons have pushed physicians and engineers to collaborate to overcome the challenges of LV lead implantation. Thus, various alternatives to BVP have been proposed to improve CRT effectiveness. His bundle pacing (HBP) has been increasingly used by activating the His–Purkinje system but is constrained by challenging implantation, low success rates, high and often unstable thresholds, and low perception. Therefore, the concept of pacing a specialized conduction system distal to the His bundle to bypass the block region was proposed. Multiple clinical studies have demonstrated that left bundle branch area pacing (LBBAP) has comparable electrical resynchronization with HBP but is superior in terms of simpler operation, higher success rates, lower and stable capture thresholds, and higher perception. Despite their well-demonstrated effectiveness, the transvenous lead-related complications remain major limitations. Recently, leadless LV pacing has been developed and demonstrated effective for these challenging patient cohorts. This article focuses on the current state and latest progress in HBP, LBBAP, and leadless LV pacing as alternatives for failed or non-responsive conventional CRT as well as their limits and prospects.
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23
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Vijayaraman P, Herweg B, Verma A, Sharma PS, Batul SA, Ponnusamy SS, Schaller RD, Cano O, Molina-Lerma M, Curila K, Huybrechts W, Wilson DR, Rademakers LM, Sreekumar P, Upadhyay G, Vernooy K, Subzposh FA, Huang W, Jastrzebski M, Ellenbogen KA. Rescue left bundle branch area pacing in coronary venous lead failure or nonresponse to biventricular pacing: Results from International LBBAP Collaborative Study Group. Heart Rhythm 2022; 19:1272-1280. [PMID: 35504539 DOI: 10.1016/j.hrthm.2022.04.024] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/18/2022] [Accepted: 04/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) using biventricular pacing (BVP) is effective in patients with heart failure, left bundle branch block (LBBB), and reduced left ventricular function. Left bundle branch area pacing (LBBAP) has been reported as an alternative option for CRT. OBJECTIVE The purpose of this study was to assess the feasibility and outcomes of LBBAP in patients who failed conventional BVP because of coronary venous (CV) lead complications or who were nonresponders to BVP. METHODS At 16 international centers, LBBAP was attempted in patients with conventional CRT indication who failed BVP because of CV lead complications or lack of therapeutic response to BVP. Heart failure hospitalization (HFH) and death, echocardiographic outcomes, procedural data, pacing parameters, and lead complications including CV lead failure are reported. RESULTS LBBAP was successfully performed in 200 patients (CV lead failures 156; nonresponders 44) (age 68 ± 11 years; female 35%; LBBB 55%; right ventricular pacing 23%; ischemic cardiomyopathy 28%; nonischemic cardiomyopathy 63%; left ventricular ejection fraction [LVEF] ≤35% in 80%). Procedural duration was 119.5 ± 59.6 minutes, and fluoroscopy duration was 25.7 ± 18.5 minutes. LBBAP threshold and R-wave amplitudes were 0.68 ± 0.35 V @ 0.45 ms and 10.4 ± 5 mV at implant, respectively, and remained stable during mean follow-up of 12 ± 10.1 months. LBBAP resulted in significant QRS narrowing from 170 ± 28 ms to 139 ± 25 ms (P <.001) with V6 R-wave peak times of 85 ± 17 ms. LVEF improved from 29% ± 10% at baseline to 40% ± 12% (P <.001) during follow-up. The risk of death or HFH was lower in those with CV lead failure than in nonresponders (hazard ratio 0.357; 95% confidence interval 0.168-0.756; P = .007) CONCLUSION: LBBAP is a viable alternative to CRT in patients who failed conventional BVP due to CV lead failure or who were nonresponders.
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Affiliation(s)
| | - Bengt Herweg
- Division of Cardiology, University of South Florida, Tampa, Florida
| | - Atul Verma
- South Lake Regional Health Center, University of Toronto, Toronto, Canada
| | | | | | - Shunmuga Sundaram Ponnusamy
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Velammal Village, Madurai, Tamil Nadu, India
| | - Robert D Schaller
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Oscar Cano
- Hospital Universitari i Politècnic La Fe, Valencia, Spain, and Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV)
| | | | - Karol Curila
- Cardiocenter, University Hospital Kralovske Vinohrady and 3rd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Wim Huybrechts
- Department of Cardiology, University Hospital Antwerp, Belgium
| | - David R Wilson
- Division of Cardiology, University of South Florida, Tampa, Florida
| | | | - Praveen Sreekumar
- Electrophysiology Unit, Department of Cardiology Aster Medcity, Kochi, Kerala, India
| | | | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | | | - Weijian Huang
- Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, and The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Marek Jastrzebski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
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24
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Wijesuriya N, Elliott MK, Mehta V, Sidhu BS, Behar JM, Niederer S, Rinaldi CA. Leadless left ventricular endocardial pacing for cardiac resynchronization therapy: A systematic review and meta-analysis. Heart Rhythm 2022; 19:1176-1183. [PMID: 35189383 DOI: 10.1016/j.hrthm.2022.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/01/2022] [Accepted: 02/14/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Leadless left ventricular (LV) endocardial pacing to achieve cardiac resynchronization therapy (CRT) is a novel procedure for treatment of patients with dyssynchronous heart failure. Current evidence is limited to observational studies with small patient numbers. OBJECTIVE The purpose of this systematic review and meta-analysis was to assess the safety and efficacy of leadless LV endocardial pacing. METHODS A literature search was conducted through PubMed, EMBASE, and Cochrane databases. Mean differences (MDs) in New York Heart Association (NYHA) functional class and LV ejection fraction (LVEF) from baseline to 6 months postprocedure were combined using a random effects model. Heterogeneity was evaluated using the Cochrane Q test, I2, meta-regression, and sensitivity analysis. Funnel plots were constructed to detect publication bias. RESULTS Five studies with 181 patients were included in the final analysis. Procedural success rate was 90.6%. Clinical response rate was 63%, with mean improvement in NYHA functional class of 0.43 (MD -0.43; 95% confidence interval [CI] -0.76 to -0.1; P = .01), with high heterogeneity (P <.001; I2 = 81.1%). There was a mean increase in LVEF of 6.3% (MD 6.3; 95% CI 4.35-8.19; P <.001, with low heterogeneity (P = 0.84; I2 <0.001%). The echocardiographic response rate was 54%. Procedure-related complication and mortality rates were 23.8% and 2.8%, respectively. CONCLUSION The efficacy of leadless LV endocardial pacing for CRT supports its use as a second-line therapy in patients in whom standard CRT is not possible or has been ineffective. Improvements in safety profile will facilitate widespread uptake in the treatment of these patients.
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Affiliation(s)
- Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Baldeep S Sidhu
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jonathan M Behar
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Wijesuriya N, Elliott MK, Mehta V, Sidhu BS, Strocchi M, Behar JM, Niederer S, Rinaldi CA. Leadless Left Bundle Branch Area Pacing in Cardiac Resynchronisation Therapy: Advances, Challenges and Future Directions. Front Physiol 2022; 13:898866. [PMID: 35733988 PMCID: PMC9208327 DOI: 10.3389/fphys.2022.898866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/20/2022] [Indexed: 11/20/2022] Open
Abstract
Leadless left bundle branch area pacing (LBBAP) represents the merger of two rapidly progressing areas in the field of cardiac resynchronisation therapy (CRT). It combines the attractive concepts of pacing the native conduction system to allow more physiological activation of the myocardium than conventional biventricular pacing, with the potential added benefits of avoiding long-term complications associated with transvenous leads via leadless left ventricular endocardial pacing. This perspective article will first review the evidence for the efficacy of leadless pacing in CRT. We then summarise the procedural steps and pilot data for leadless LBBAP, followed by a discussion of the safety and efficacy of this novel technique. Finally, we will examine how further mechanistic evidence may shed light to which patients may benefit most from leadless LBBAP, and how improvements in current experience and technology could promote widespread uptake and expand current clinical indications.
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Affiliation(s)
- Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Mark K. Elliott
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Baldeep S. Sidhu
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Jonathan M. Behar
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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Mondésert B, Moore JP, Khairy P. Cardiac Implantable Electronic Devices in the Fontan Patient. Can J Cardiol 2022; 38:1048-1058. [PMID: 35588949 DOI: 10.1016/j.cjca.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 12/22/2022] Open
Abstract
As a result of remarkable progress in operative techniques and cardiology care during childhood, Fontan patients continue to age and require team-based multidisciplinary expertise to manage complications encountered in adulthood. They face particular challenges in terms of altered hemodynamic stressors, cardiac and hepatic failure, and arrhythmias. Arrhythmias in Fontan patients are highly prevalent and associated with underlying anatomy, surgical technique, and postoperative sequelae. Diagnostic tools, treatments, and device strategies for arrhythmias in Fontan patients should be adapted to the specific anatomy, type of surgical repair, and clinical status. Great strides in our understanding of arrhythmia mechanisms, options and techniques to obtain access to relevant cardiac structures, and application of both old and new technologies have contributed to improving cardiac implantable electronic device (CIED) therapies for this unique population. In this state-of-the-art review, we discuss the various arrhythmias encountered in Fontan patients, their diagnosis, and options for treatment and prevention, with a focus on CIEDs. Throughout, access challenges particular to the Fontan circulation are considered. Recently developed technologies, such as the sub-cutaneous implantable cardioverter defibrillator carry the potential to be transformative but require awareness of Fontan-specific issues. Moreover, new leadless pacing technology represents a promising strategy that may soon become applicable to Fontan patients with sinus node dysfunction. CIEDs are essential tools in managing Fontan patients but the complex clinical scenarios that arise in this patient population are among the most challenging for the congenital electrophysiologist.
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Affiliation(s)
- Blandine Mondésert
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada.
| | - Jeremy P Moore
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, CA; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, CA; Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, CA
| | - Paul Khairy
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada
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Allam C. Acoustic energy and cardiac electrophysiology: Ultrasonic cardiac pacing and novel shockwave ablation catheters. Pacing Clin Electrophysiol 2022; 45:800-806. [DOI: 10.1111/pace.14513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/11/2022] [Accepted: 04/22/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Chadi Allam
- Faculty of Medicine Saint‐Joseph University Beirut Lebanon
- Department of Cardiology Hôtel‐Dieu de France Hospital Beirut Lebanon
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Haydock P, Camm AJ. History and evolution of pacing and devices. BRITISH HEART JOURNAL 2022; 108:794-799. [PMID: 35459730 DOI: 10.1136/heartjnl-2021-320149] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 02/23/2022] [Indexed: 12/11/2022]
Abstract
Cardiac implanted electronic devices are commonplace in the modern practice of cardiology. This article reviews the history of the development of these technologies, with particular reference to the role played by UK physicians and members of the British Cardiovascular Society. Key breakthroughs in the treatment of heart block, ventricular arrhythmia and heart failure are presented in their historical and contemporary context so that the reader might look back on the incredible progress and achievements of the last 100 years and also look forward to what may be achieved in the coming decades.
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Affiliation(s)
- Paul Haydock
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - A John Camm
- Cardiology, St George's University of London, London, UK
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First-in-Human Wireless Left Ventricular Endocardial Pacing in a Patient with Obliterated Venous System & Complete Heart Block. HeartRhythm Case Rep 2022; 8:497-500. [PMID: 35860785 PMCID: PMC9289050 DOI: 10.1016/j.hrcr.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Cang J, Liu Y, Zhu D, Liu S, Shen J, Miao H, Zhou Q, Chen L. WiSE CRT Is Beneficial for Heart Failure Patients as a Rescue Therapy: Evidence From a Meta-Analysis. Front Cardiovasc Med 2022; 9:823797. [PMID: 35369306 PMCID: PMC8964787 DOI: 10.3389/fcvm.2022.823797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundLeadless endocardial left ventricular (LV) pacing resynchronization therapy is a novel solution for patients with heart failure (HF) in whom conventional cardiac resynchronization therapy (CRT) failed.MethodsPubMed and the Cochrane Library were searched for relevant cohort studies. Clinical outcomes of interest such as ejection fraction (EF), QRS duration (QRSd), and left ventricular end-systolic volume (LVESV) were extracted and analyzed.ResultsFive studies involving 175 HF patients for WiSE CRT were included, and patients were followed-up for 6 months. The implanted success rate ranged from 76.5 to 100%. WiSE CRT resulted in significantly narrower QRSd [mean difference (MD): −38.21 ms, 95% confidence interval (CI): −44.36 to −32.07, p < 0.001], improved left ventricular ejection fraction (MD: 6.07%, 95% CI: 4.43 to 7.71, I2 = 0%, p < 0.001), reduced left ventricular end-systolic volume (MD: −23.47 ml, 95% CI: −37.18 to −9.13, p < 0.001), and reduced left ventricular end-diastolic volume (MD: −24.02 ml, 95% CI: −37.01 to −11.03, p = 0.02).ConclusionEvidence from current studies suggests that leadless endocardial LV pacing resynchronization is effective for HF patients who failed conventional CRT or needed a device upgrade, and it may be an interesting rescue therapy.
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Vanneman M, Kothari P, Bodmer NJ, Convissar D, Desai GA, Kumar N, Iyer MH, Neuburger PJ, Essandoh MK, Cronin B, Dalia AA. The Year in Electrophysiology: Selected Highlights from 2021. J Cardiothorac Vasc Anesth 2022; 36:1526-1539. [DOI: 10.1053/j.jvca.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 11/11/2022]
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Doldi F, Biller B, Reinke F, Eckardt L. [New developments in leadless pacing systems]. Herz 2021; 46:513-519. [PMID: 34686910 DOI: 10.1007/s00059-021-05075-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/29/2022]
Abstract
Leadless pacing systems, especially the Micra™ TPS system, deliver an effective and safe alternative to the previous conventional transvenous systems in patients with impossible transvenous access and seem to be compatible with other implantable devices (S-ICD, deep brain stimulators) with no limitations in efficacy or safety. Also, new outlooks on leadless resynchronization therapy seem promising and could prevent future patients from lead- or operation-associated complications. Current limits to the implementation in everyday clinical practice are mostly the unavailability of the devices or cost issues through lack of health insurance reimbursement. However, more promising data through further studies and rising implantation rates are expected based on the positive current clinical data.
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Affiliation(s)
- Florian Doldi
- Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1 Gebäude A1, 48149, Münster, Deutschland.
| | - Benedikt Biller
- Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1 Gebäude A1, 48149, Münster, Deutschland
| | - Florian Reinke
- Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1 Gebäude A1, 48149, Münster, Deutschland
| | - Lars Eckardt
- Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1 Gebäude A1, 48149, Münster, Deutschland
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