Pacing devices to treat bradycardia: current status and future perspectives

High Initial Heart Rate Score is an Independent Predictor of New Atrial High-Rate Episodes in Pacemaker Patients with Sinus Node Dysfunction

BACKGROUND

Heart Rate Score (HRSc), the percent of atrial depolarizations in the largest paced/sensed 10-bpm histogram bin recorded in cardiac devices, is associated with several adverse outcomes but it remains uncertain if HRSc independently predicts atrial high-rate episodes (AHREs) in patients with sinus node dysfunction (SND) undergoing pacemaker (PM) implantation.

OBJECTIVE

To determine if initial HRSc post-PM implant predicts new-onset AHREs in patients with SND.

METHODS

Patients had Boston Scientific PMs implanted for SND from 2012-2021 at Cleveland Clinic, University of Occupational and Environmental Health, Japan, Kyushu Rosai Hospital, and JCHO Kyushu Hospital. Patients were excluded if they had atrial fibrillation before PM implant or AHREs within 3-months post-implant. Subsequent AHREs post-implant were evaluated and correlated with HRSc.

RESULTS

Over 48.9 (IQR 25.7-50.4) months, 130 consecutive PM patients (76±10 years, 40% male) had a median initial HRSc of 74(57-86)%. AHREs defined by >1%, >6h/day burden, and ATR events>24h developed in 27/130(21%), 15/130(12%), and 9/130(7%), respectively. For each definition, patients with HRSc≥80% had higher occurrence of AHREs than those with HRSc<80% (both p=0.008, log-rank test). After adjusting for age, race, comorbidities, left ventricular ejection fraction, left atrial diameter, and cumulative %RA/RV pacing, initial HRSc ≥80% (HR:3.33, 95% CI:1.35-8.18; P=0.009) and male sex (HR:2.59, 95% CI:1.06-6.33; P=0.04) independently predicted AHREs.

CONCLUSION

HRSc≥80% is associated with new-onset, device-determined AHREs for patients undergoing PM implant for SND. HRSc may have prognostic and therapeutic implications.

Cardiac pacing and lead devices management: 25 years of research at EP Europace journal

AIMS

Cardiac pacing represents a key element in the field of electrophysiology and the treatment of conduction diseases. Since the first issue published in 1999, EP Europace has significantly contributed to the development and dissemination of the research in this area.

METHODS

In the last 25 years, there has been a continuous improvement of technologies and a great expansion of clinical indications making the field of cardiac pacing a fertile ground for research still today. Pacemaker technology has rapidly evolved, from the first external devices with limited longevity, passing through conventional transvenous pacemakers to leadless devices. Constant innovations in pacemaker size, longevity, pacing mode, algorithms, and remote monitoring highlight that the fascinating and exciting journey of cardiac pacing is not over yet.

CONCLUSION

The aim of the present review is to provide the current 'state of the art' on cardiac pacing highlighting the most important contributions from the Journal in the field.

Impact of Right Ventricular Pacing in Patients With TAVR Undergoing Permanent Pacemaker Implantation

BACKGROUND

Long-term right ventricular pacing (VP) has been related to negative left ventricular remodeling and heart failure (HF), but there is a lack of evidence regarding the prognostic impact on transcatheter aortic valve replacement (TAVR) patients.

OBJECTIVES

The aim of the PACE-TAVI registry is to evaluate the association of high percentage of VP with adverse outcomes in patients with pacemaker implantation after TAVR.

METHODS

PACE-TAVI is an international multicenter registry of all consecutive TAVR patients who underwent permanent pacemaker implantation for conduction disturbances in the first 30 days after the procedure. Patients were divided into 2 subgroups according to the percentage of VP (<40% vs ≥40%) at pacemaker interrogation. The primary endpoint was the composite of cardiovascular mortality or hospitalization for HF.

RESULTS

A total of 377 patients were enrolled, 158 with VP <40% and 219 with VP ≥40%. After multivariable adjustment, VP ≥40% was associated with a higher incidence of the primary endpoint (HR: 2.76; 95% CI: 1.39-5.51; P = 0.004), first HF hospitalization (HR: 3.37; 95% CI: 1.50-7.54; P = 0.003), and cardiovascular death (HR: 3.77; 95% CI: 1.02-13.88; P = 0.04), while the incidence of all-cause death was not significantly different (HR: 2.17; 95% CI: 0.80-5.90; P = 0.13). Patients with VP ≥ 40% showed a higher New York Heart Association functional class both at 1 year (P = 0.009) and at last available follow-up (P = 0.04) and a nonsignificant reduction of left ventricular ejection fraction (P = 0.18) on 1-year echocardiography, while patients with VP <40% showed significant improvement (P = 0.009).

CONCLUSIONS

In TAVR patients undergoing permanent pacemaker implantation, a high percentage of right VP at follow-up is associated with an increased risk for cardiovascular death and HF hospitalization. These findings suggest the opportunity to minimize right VP through dedicated algorithms in post-TAVR patients without complete atrioventricular block and to evaluate a more physiological VP modality in patients with persistent complete atrioventricular block.

Relationship between CIED extent of displacement toward the shoulder while in the supine position and shoulder impairment

BACKGROUND

Device-related shoulder impairment is a common complication in cardiac implantable electronic device (CIED) recipients. This study examined the relationship between the extent of device displacement toward the shoulder while in the supine position and ipsilateral shoulder impairment.

METHODS

This cross-sectional study included 142 consecutive patients with CIEDs. The effects of the extent of device displacement on functional limitations, muscle strength, pain-disability, and quality of life were evaluated. Range of motion (ROM), grip strength (GS), the Shoulder Pain and Disability Index (SPADI), and the 36-item Short-Form (SF-36) Health Survey were used.

RESULTS

The mean device displacement was greater in patients with than without device-related shoulder impairment (51 ± 19 vs. 38 ± 15 mm; p < .001). Female gender (p = .046), high body mass index (p = .008), and defibrillator implantation (p = .004) were significantly more frequent in patients with than without impairment. Patients with excessive device displacement had significantly higher ROM limitation rates (p = .003) and SPADI scores (p = .02) and significantly lower GS (p = .04) and SF-36 scores (p = .032). Defibrillator implantation (OR: 2.569, 95% CI: 1.216-4.681; p = .03) and the extent of device displacement (OR: 1.502, 95% CI: 1.186-1.852; p = .01) were independent predictors of shoulder impairment.

CONCLUSIONS

Excessive displacement of the device toward the shoulder while in the supine position causes shoulder impairment by contacting more muscle fibers. Obese female patients with defibrillators have the highest risk.

Is Less Always More? A Prospective Two-Centre Study Addressing Clinical Outcomes in Leadless versus Transvenous Single-Chamber Pacemaker Recipients

(1) Background: Leadless (LL) stimulation is perceived to lower surgical, vascular, and lead-related complications compared to transvenous (TV) pacemakers, yet controlled studies are lacking and real-life experience is non-conclusive. (2) Aim: To prospectively analyse survival and complication rates in leadless versus transvenous VVIR pacemakers. (3) Methods: Prospective analysis of mortality and complications in 344 consecutive VVIR TV and LL pacemaker recipients between June 2015 and May 2021. Indications for VVIR pacing were “slow” AF, atrio-ventricular block in AF or in sinus rhythm in bedridden cognitively impaired patients. LL indication was based on individualised clinical judgement. (4) Results: 72 patients received LL and 272 TV VVIR pacemakers. LL pacemaker indications included ongoing/expected chronic haemodialysis, superior venous access issues, active lifestyle with low pacing percentage expected, frailty causing high bleeding/infectious risk, previous valvular endocarditis, or device infection requiring extraction. No significant difference in the overall acute and long-term complication rate was observed between LL and TV cohorts, with greater mortality occurring in TV due to selection of older patients. (5) Conclusions: Given the low complication rate and life expectancy in this contemporary VVIR cohort, extending LL indications to all VVIR candidates is unlikely to provide clear-cut benefits. Considering the higher costs of LL technology, careful patient selection is mandatory for LL PMs to become advantageous, i.e., in the presence of vascular access issues, high bleeding/infectious risk, and long life expectancy, rendering lead-related issues and repeated surgery relevant in the long-term perspective.

His Bundle pacing for congenital complete AV block: An attempt to fix a broken heart?

Congenital complete atrioventricular block (CCAVB) is usually due to failure of atrioventricular nodal conduction with preservation of the His‐Purkinje system. Most patients with CCAVB ultimately require pacemaker therapy to restore physiologic heart rates, dealing with the detrimental effects of chronic right ventricular (RV) pacing on cardiac structure and function. The ideal stimulation pattern aims to mimic the normal conduction to restore electromechanical coupling, preventing the harmful effects of lack of atrioventricular and inter‐intraventricular synchrony. This can be done through conduction system pacing. Using His bundle pacing (HBP) for cardiac resynchronization therapy in two complete congenital atrioventricular block patients, we have reported better exercise tolerance and echocardiographic improvements related to reversible left ventricular dysfunction that can be corrected by restoration of the normal activation pathway via the His‐Purkinje network.

Efficacy and safety of different exercises in preventing cardiac implantable electronic device-related shoulder impairment

BACKGROUND

Shoulder impairment on the implant-side is common after cardiac implantable electronic device (CIED) implantation. The aim of this study was to compare the efficacy and safety of the pendulum exercise (PE) and stretching & strengthening exercises (SSE) in preventing postimplantation shoulder impairment.

METHODS

This prospective, randomized study collected data from 89 patients, including 30 in a control group, 31 in a PE group, and 28 in a SSE group. Shoulder functions on the implant-side were evaluated by grip strength (GS), range of motion (ROM), Visual Analog Scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and 36-Item Short-Form Survey (SF-36).

RESULTS

Shoulder median flexion and abduction ROM were significantly improved two-month postimplantation compared to two-week postimplantation in PE (156±11 vs. 146±10, p = .002; 147±9 vs. 136±9, p = .001, respectively) and SSE (158±13 vs. 147±11, p = .003; 149±13 vs. 138±9, p = .002, respectively) groups, but not in the control group. Two months after implantation, the two exercise groups showed no significant differences in any assessment. Compared with the PE and SSE groups, the control group had significantly lower GS (p = .012 and p = .002, respectively) and SF-36 physical component summary (p = .007 and p = .003, respectively) and significantly higher VAS (p = .003 and p = .001, respectively) and QuickDASH (p = .002 and p = .005, respectively) scores two-month postimplantation.

CONCLUSIONS

PE and SSE for the ipsilateral upper arm starting two-week after CIED implantation provided similar benefits in preserving shoulder girdle muscle strength, maintaining shoulder motion, relieving shoulder pain, preventing shoulder injury, and improving quality of life, without the risk of lead dislodgement. This article is protected by copyright. All rights reserved.

Pacemaker and Atrioventricular Junction Ablation in Patients With Atrial Fibrillation—A Systematic Review of Systematic Review and Meta-Analysis

Background

Cardiac resynchronization therapy (CRT) could be considered for heart failure (HF) patients with atrial fibrillation (AF) unless a potent ventricular capture strategy is conducted. However, the benefit of a pacemaker (PM; as part of CRT) in patients with AF and whether atrioventricular junction (or nodal) ablation (AVAB) can improve the prognosis of these patients compared with those treated medically to support ventricular capture are unclear.

Methods and Results

Systematic reviews and meta-analyses investigating the roles of PMs and AVAB in patients with AF were obtained in a search of the PubMed, Embase, and Medline databases and then analyzed with respect to the following outcomes: mortality, left ventricular ejection fraction, and clinical findings including the New York Heart Association class, 6-min walk distance (6MWD), quality of life as assessed in a specific questionnaire, and response to CRT. The quality of the included reviews was assessed using the Assessing the Methodological Quality of Systematic Reviews 2 tool, which includes 16 items. This study was finally based on 13 systematic reviews or meta-analyses. The results showed that patients with AF have higher all-cause mortality rates compared with patients with sinus rhythm and that AVAB can reduce all-cause mortality in patients with AF. Although the functional improvement was better in sinus rhythm than in patients with AF, in the latter, AVAB increased the 6MWD and reduced the CRT nonresponse rate in patients with AF.

Conclusion

Atrial fibrillation is associated with a higher all-cause mortality rate in patients with CRT implantation. AVAB, by increasing the 6MWD and survival, can improve the prognosis of these patients.