Grupo de trabajo sobre estimulación cardiaca y terapia de resincronización cardiaca de la Sociedad Europea de Cardiología (ESC)

Improved all-cause mortality with left bundle branch area pacing compared to biventricular pacing in cardiac resynchronization therapy: a meta-analysis

BACKGROUND

Left bundle branch area pacing (LBBAP) has emerged as a physiological alternative pacing strategy to biventricular pacing (BIVP) in cardiac resynchronization therapy (CRT). We aimed to assess the impact of LBBAP vs. BIVP on all-cause mortality and heart failure (HF)-related hospitalization in patients undergoing CRT.

METHODS

Studies comparing LBBAP and BIVP for CRT in patients with HF with reduced left ventricular ejection fraction (LVEF) were included. The coprimary outcomes were all-cause mortality and HF-related hospitalization. Secondary outcomes included procedural and fluoroscopy time, change in QRS duration, and change in LVEF.

RESULTS

Thirteen studies (12 observational and 1 RCT, n = 3239; LBBAP = 1338 and BIVP = 1901) with a mean follow-up duration of 25.8 months were included. Compared to BIVP, LBBAP was associated with a significant absolute risk reduction of 3.2% in all-cause mortality (9.3% vs 12.5%, RR 0.7, 95% CI 0.57-0.86, p < 0.001) and an 8.2% reduction in HF-related hospitalization (11.3% vs 19.5%, RR 0.6, 95% CI 0.5-0.71, p < 0.00001). LBBAP also resulted in reductions in procedural time (mean weighted difference- 23.2 min, 95% CI - 42.9 to - 3.6, p = 0.02) and fluoroscopy time (- 8.6 min, 95% CI - 12.5 to - 4.7, p < 0.001) as well as a significant reduction in QRS duration (mean weighted difference:- 25.3 ms, 95% CI - 30.9 to - 19.8, p < 0.00001) and a greater improvement in LVEF of 5.1% (95% CI 4.4-5.8, p < 0.001) compared to BIVP in the studies that reported these outcomes.

CONCLUSION

In this meta-analysis, LBBAP was associated with a significant reduction in all-cause mortality as well as HF-related hospitalization when compared to BIVP. Additional data from large RCTs is warranted to corroborate these promising findings.

QRS axis and polarity in the inferior leads during left bundle branch pacing: Novel criteria in the search for better results

BACKGROUND

Left bundle branch pacing (LBBP) may be achieved in various anatomical sites within the interventricular septum (IVS), thus influencing paced QRS duration (QRSd).The purpose of this study was to determine whether paced QRS axis (QRSâ) and predominant polarity in inferior leads could be associated with a shorter paced QRSd.

METHODS

We analyzed paced QRSd, QRSâ, polarity in inferior leads, and IVS thickness in patients referred for LBBP. Three paced morphology patterns in the inferior leads were considered: All positive (P), all negative (N) and intermediate (combination of isoelectric, positive, and negative complexes, (I). Patients were divided into two groups according to a paced QRSd < 120 or ≥ 120 ms.

RESULTS

A total of 125 patients were included (age 76 ± 10 years, 46% female). Mean baseline QRSâ was 8 ± 37°. Paced QRSd was significantly shorter as compared to baseline (120 ± 10 vs. 127 ± 33 ms; p = .017) and significantly different according to paced QRS morphology pattern in the inferior leads (P 49%, 119 ± 9; N 30%, 126 ± 12; I 21%; 113 ± 10 ms; p < .001) or paced QRSâ (Normal 59%, 116 ± 1; Right 6%, 129 ± 1; Left 35%, 124 ± 11 ms; p < .001). On multivariate analysis, a QRSâ > -30°(OR 5.79 [2.40-13.93; 95% CI] p = .001), an Intermediate pattern in inferior leads (OR 3.00 [1.67-8.43; 95% CI] p = .037), and an IVS thickness ≤ 10 mm (OR 2.59 [1.10-6.10; 95% CI]; p = .029) were significantly associated with a paced QRSd < 120 ms.

CONCLUSIONS

During LBBP, a QRSâ > -30° and intermediate final polarity in inferior leads are associated with a shorter paced QRSd.

[Follow-up of the patient with pacemakers: Interrogation and basic programming]

Permanent pacemakers are a frequently used therapeutic modality. Its use has had a great impact on the morbidity and mortality and quality of life of patients with heart rhythm disturbances, with an exponential increase observed in recent decades. The use of this strategy presents different phases, in which follow-up throughout the useful life of the device is a fundamental and determinant pillar of the efficacy and safety of this therapeutic modality. This review seeks to provide a clear and structured update of the fundamental aspects to consider in the follow-up of all patients with pacemakers. The follow-up of the patient with a pacemaker must follow a complete, systematic and periodic protocol, evaluating aspects and parameters related to the patient and the pacemaker, in order to ensure the proper and safe operation of the device adapted to the person.

Impact of Remote Cardiac Monitoring on Greenhouse Gas Emissions: Global Cardiovascular Carbon Footprint Project

Background

Remote monitoring (RM) of patients with cardiac implantable electronic devices (CIEDs) is efficient and requires fewer resources than conventional monitoring. However, the impact of RM on the carbon footprint (CF) is not known.

Objectives

The authors sought to evaluate the reduction in cost and greenhouse gas (GHG) emissions with RM as compared to conventional monitoring of CIEDs and its relevance to CF.

Methods

Data were obtained from a third-party RM provider on 32,811 patients from 67 device clinics across the United States. Distance from home address to the device clinic for patients on RM was calculated. Savings in total distance traveled over 2 years was calculated using frequency of follow-up required for the device type. National fuel efficiency data and carbon emission data were obtained from the Bureau of Transportation Statistics and U.S. Environmental Protective Agency, respectively. The average gas price during the study period was obtained from U.S. Energy Information Administration.

Results

In the study population, RM resulted in a total saving of 31.7 million travel miles at $3.45 million and reduction of 12,518 metric ton of GHG from gasoline. There was a reduction of 14.2-million-page printouts, $3 million in cost, and 78 tons of GHG. Improvement in workforce efficiency with RM resulted in savings of $3.7 million. There was a net saving of $10.15 million and 12,596 tons of GHG emissions.

Conclusions

RM of patients with a CIED resulted in significant reductions in GHG emissions. Efforts to actively promoting RM can result in significant reduction in CF.

Impact of socioeconomic aspects on cardiac implantable electronic device treatment and application of the EHRA guidelines : A European comparison

BACKGROUND

Cardiac implantable electronic devices (CIED) have become an indispensable part in everyday clinical practice in cardiology. The indications for CIED implantation are based on the guidelines of the European Heart Rhythm Association (EHRA). Nevertheless, numbers of CIED implantations in Europe are subject to considerable differences. We hypothesized that reimbursements linked to the respective health systems may influence implantation behavior.

METHODS

Based on the EHRA White Book 2017, CIED implantation data as well as socioeconomic key figures were collected, in particular gross domestic product (GDP) and share of gross domestic product spent on healthcare. Implantation numbers for pacemakers, implantable cardioverter defibrillators and cardiac resynchronization treatment as well as all in total were assessed, compared with the health care expenditures and visualized using heat maps.

RESULTS

Total implantation numbers per 100,000 inhabitants varied from 196.53 (Germany) to 2.81 (Kosovo). Higher implantation numbers correlated moderately with a higher GDP (r = 0.456, p 0.002) and higher health expenditure (r = 0.586, p < 0.001). The annual financial resources per inhabitant were also subject to fluctuations ranging from 9476 $ (Switzerland) to 140 $ (Ukraine); however, there were countries with high financial means, such as Switzerland or Scandinavian countries, which showed significantly lower implantation rates.

CONCLUSION

There were considerable differences in CIED implantations in Europe. These seem to be explained in part by socioeconomic disparities within Europe. Also, a potential influence by the respective remuneration system is likely.