A Review of Temporary Permanent Pacemakers and a Comparison with Conventional Temporary Pacemakers

Permanent pacemaker reduction using temporary-permanent pacemaker as a 1-month bridge after transcatheter aortic valve replacement: a prospective, multicentre, single-arm, observational study

Background

The permanent pacemaker (PPM) implantation and pacemaker dependency rates after transcatheter aortic valve replacement (TAVR) are highly variable as some of the conduction disturbances are reversible. It remains poorly investigated how to optimise temporary pacing in these patients. This study aimed to explore the potential reduction in the PPM implantation rate using temporary-permanent pacemaker (TPPM) as a 1-month bridge.

Methods

This is a prospective, multicentre, single-arm, observational study. Consecutive patients undergoing TAVR from March 1, 2022 to March 1, 2023 in 13 tertiary hospitals in China were screened. Patients who developed high-degree atrioventricular block, complete heart block, or first-degree atrioventricular block plus new onset left bundle branch block during the TAVR procedure or within 1 month after TAVR were included to receive TPPM. Patients with pre-existing PPM implantation or indications for PPM implantation before the TAVR procedure were excluded. Patients with TPPM were monitored to determine whether the conduction disturbances persisted or recovered. The primary endpoint was the rate of freedom from indications for PPM implantation 1 month after TAVR. This study is registered with ChiCTR, ChiCTR2200057931.

Findings

Of 688 patients who have undergone TAVR, 71 developed conduction disturbance and met the inclusion criteria, 1 patient withdrew due to noncompliance, 70 patients received TPPM and completed follow-up. There were 41 (58.6%) men and 29 (41.4%) women in the study, with a mean age of 74.3 ± 7.3 years. At 1 month follow-up, 75.7% (53/70) of the patients with TPPM did not require PPM implantation. For 688 patients who have undergone TAVR, the rate of PPM implantation at 1 month was 2.47% (17/688, 95% CI 1.55%-3.92%), representing a significant reduction in self-comparison with the rate at 48 h after TPPM (2.47% vs. 8.28% [95% CI 6.45%-10.58%], P < 0.0001). Similar results were obtained in the subgroup analysis of patients with HAVB/CHB. Multivariate analysis revealed the baseline PR interval, difference between the membranous septum length and implantation depth, and timing of postprocedural conduction disturbance occurrence were independent predictors of freedom from indications for PPM implantation at 1 month after TAVR.

Interpretation

Using TPPM as a 1-month bridge allows for a buffer period to distinguish whether conduction disturbances are reversible or persistent, resulting in a significant reduction in the PPM implantation rate after TAVR when compared with the current strategy. However, this is an observational study, the results need to be confirmed in a randomized trial.

Funding

Beijing Science and Technology Plan 2022 from Beijing Municipal Science & Technology Commission.

Single-center experience of temporary-permanent pacemaker use in COVID-19 patients supported with veno-venous ECMO: A case series

INTRODUCTION

In the first year of the COVID-19 pandemic, nine out of 129 patients (7%) developed life-threatening bradycardia episodes ultimately requiring a TPPM, whilst being supported with VV-ECMO for severe COVID-19 ARDS in our tertiary cardio-pulmonary failure center.

ANALYSIS

All subjects had asystole due to sinus node dysfunction and experienced at least one episode involving cardiopulmonary resuscitation. Most bradycardic events were seen in the context of vagal hypersensitivity. Mean time from general ICU admission to TPPM insertion was 20.6 ± 8.9 days. One patient developed a large chest wall hematoma weeks after TPPM implantation, no other TPPM-related issues were observed. No patient required a long-term pacing system. Six-months survival rate was high (89%).

CONCLUSION

These findings suggested that transient life-threatening sinus node disease is not uncommon in ECMO-dependent COVID-19 ARDS patients. TPPM with an active fixation lead is sometimes needed to facilitate ongoing ICU care, however, long-term permanent pacing was not required.

Bedside zero-fluoroscopy temporary permanent pacemaker implantation in the electrical storm treatment under the guidance of EnSite 3D system: a case report

BACKGROUND

Electrical storm (ES) is a clinical emergency characterized by multiple malignant ventricular arrhythmias or ICD discharges within 24 h, requiring early rational management.

CASE PRESENTATION

We report a 55-year-old man who underwent aortic valve replacement experienced recurrent ventricular tachycardia/ventricular fibrillation. A temporary permanent pacemaker with the EnSite system was implanted, and significant inhibition of the electrical storm, attributed to the atrial overdrive pacing, ensued.

CONCLUSIONS

In emergency regarding an electrical storm, the bedside temporary permanent pacemaker implantation with the EnSite system is concluded to be feasible and safe.

Temporary-permanent pacemakers are associated with better clinical and safety outcomes compared to balloon-tipped temporary pacemakers

BACKGROUND

Balloon Tipped Temporary Pacemakers (BTTP) are the most used temporary pacemakers; however, they are associated with a risk of dislodgement and thromboembolism. Recently, Temporary Permanent Pacemakers (TPPM) have been increasingly used. Evidence of outcomes with TPPM compared to BTTP remains scarce.

METHODS

Retrospective, chart review study evaluating all patients who underwent temporary pacemaker placement between 2014 and 2022 (N = 126) in the cardiac catheterization laboratory (CCL) at a level 1 trauma center. Primary outcome of this study is to evaluate the safety profile of TPPM versus BTTP. Secondary objectives include patient ambulation and healthcare utilization in patients with temporary pacemakers.

RESULTS

Both groups had similar baseline characteristics distribution including gender, race, and age at temporary pacemaker insertion (p > .05). Subclavian vein was the most common site of access for the TPPM cohort (89.0%) versus the femoral vein in the BTTP group (65.1%). Ambulation was only possible in the TPPM group (55.6%, p < .001). Lead dislodgement, venous thromboembolism, local hematoma, and access site infections were less frequently encountered in the TPPM group (OR = 0.23 [95% CI (0.10-0.67), p < .001]). Within the subgroup of patients with TPPM, 36.6% of the patients were monitored outside the ICU setting. There was no significant difference in the pacemaker-related adverse events among patients with TPPM based on their in-hospital setting.

CONCLUSION

TPPM is associated with a more favorable safety profile compared to BTTP. They are also associated with earlier patient ambulation and reduced healthcare utilization.

Atrioventricular Synchrony Restoration Aided by a Temporary Permanent Pacemaker in Right Ventricular Infarction and Complete Heart Block

Pacemakers are effective treatments for a variety of bradyarrhythmias. Cardiac pacemakers generally consist of a pulse generator and one or more leads. The conventional temporary transvenous ventricular cardiac pacemaker utilizing a passive fixation lead is commonly associated with multiple complications such as increased infection rate, lead dislodgement, venous thrombosis, longer duration of hospital stay, and atrioventricular (AV) dyssynchrony. On the other hand, temporary permanent pacemakers (TPPM) utilize active fixation leads; hence, they provide lower capture thresholds, reliable pacing, lower rates of displacement, and fewer pacemaker-related infections. Here, we present a case of TPPM aiding AV synchrony restoration in complete heart block accompanying right ventricular (RV) infarction with refractory cardiogenic shock. Pacemakers are effective treatments for a variety of bradyarrhythmias. Cardiac pacemakers generally consist of a pulse generator and one or more leads. We present a case of TPPM aiding AV synchrony restoration in complete heart block accompanying RV infarction with refractory cardiogenic shock. TPPM pacing is a safe and effective technique for temporary bridge pacing to prevent AV dyssynchrony in hemodynamically unstable patients with cardiogenic shock from RV infarction and complete heart block. It also hastens recovery compared to a traditional single-chamber temporary pacemaker.

Temporary pacemaker implantation via median cubital vein: A simple safe and effective technique

BACKGROUND

Temporary cardiac pacemaker implantation (PM) via the femoral and subclavian veins is widely used in clinics to treat patients with severe bradycardia or tachycardia, but it is technically challenging and potentially associated with various complications.

HYPOTHESIS

This study investigated the feasibility and safety of a novel method of PM implantation via the median cubital vein.

METHODS

A total of 279 patients of the First Affiliated Hospital of Xiamen University between March 2020 and December 2021 who required no-emergency PM implantation were enrolled. The patients were divided into three groups based on the temporary PM implantation routes: F-control (n = 107), via the femoral vein; S-control (n = 67), via the subclavian vein, and N-group (n = 105), via the median cubital vein. The sheath placement time (SPT), electrode placement time (EPT), electrode arrival rate (EAR), rate of sensing and pacing (RSP), radiation quantity (RD), electrode dislocation rate (EDR) and average electrode retention time (AERT) were recorded and evaluated. In addition, the Hamilton Anxiety Scale (HAMA) and Self-Rating Depression Scale (SDS) were used to evaluate the comfort levels of patients in the three groups.

RESULTS

There were no significant differences between the groups with regard to age, EAR, RSP, EPT, RD, and AERT (p > 0.05). However, the N-group had significantly lower SPT than the F-control and S-control groups (67.0 ± 22.0 s vs. 321.7 ± 122.2 s and 307.3 ± 128.5 s, p = 0.000). Additionally, the F-control had significantly higher EDR than the S-control group and the N-group (11 (10.3%) vs. 2 (3.0%) and 3 (2.9%), p = 0.036). Besides, comparison of the HAMA and SDS scores before and after PM implantation showed significant differences in the S-control group (p = 0.010) and the N-group (p = 0.000).

CONCLUSIONS

Temporary PM implantation via the median cubital vein is safe, effective, and less time-consuming.

Soft Bioelectronics for Therapeutics

Soft bioelectronics play an increasingly crucial role in high-precision therapeutics due to their softness, biocompatibility, clinical accuracy, long-term stability, and patient-friendliness. In this review, we provide a comprehensive overview of the latest representative therapeutic applications of advanced soft bioelectronics, ranging from wearable therapeutics for skin wounds, diabetes, ophthalmic diseases, muscle disorders, and other diseases to implantable therapeutics against complex diseases, such as cardiac arrhythmias, cancer, neurological diseases, and others. We also highlight key challenges and opportunities for future clinical translation and commercialization of soft therapeutic bioelectronics toward personalized medicine.

A Systematic Review of Short-Term Outcomes of Leadless Pacemaker Implantation After Transvenous Lead Removal of Infected Cardiac Implantable Electronic Device

The outcomes of leadless pacemaker (LP) implantation after transvenous lead removal (TLR) of infected cardiac implantable electronic devices (CIEDs) are not well-established. This study sought to describe the outcomes of LP implantation after TLR of infected CIED. We conducted a literature search using PubMed and Embase for a combination of terms including LP implantation, transvenous lead extraction, TLR, transvenous lead explant, infected CIED, infected pacemaker, and infected implantable cardioverter defibrillator. The inclusion criterion was LP implantation after TLR of infected CIED. The exclusion criterion was TLR for noninfectious reasons. Study end points included procedural complications and LP infection during follow-up. Of 132 publications reviewed, 13 studies with a total of 253 patients (74 ± 14 years of age, 174 [69%] males) were included. The most common indication of the initial device implantations was a high-degree atrioventricular block (n = 100 of 253, 39.5%). Of the 253 patients included, 105 patients (41.5%) underwent concomitant LP implantation during the TLR procedure, and 36 patients (14.2%) had temporary transvenous pacing as a bridge from TLR to LP implantation. Of the 148 patients with data on the type of CIED infection, 56.8% had systemic CIED infection and 43.2% had isolated pocket infection. Staphylococcus aureus was the most common causative organism in 33% of the reported patients. The LP was implanted an average of 5.4 ± 10.7 days after TLR of infected CIED. During the LP implantation, 1 patient (0.4%) had unsuccessful implantation because of an intraprocedural complication requiring sternotomy. After LP implantation, 2 patients (0.8%) developed groin hematoma, 2 patients (0.8%) developed femoral arteriovenous fistula, and 1 patient (0.4%) developed pericardial effusion requiring pericardiocentesis. During a mean follow-up of 11.3 ± 10.6 months, 3 patients (1.2%) developed pacemaker syndrome, 1 patient (0.4%) developed acute on chronic heart failure exacerbation, and only 1 patient (0.4%) developed LP-related infection requiring LP retrieval. This study suggests that LP implant is feasible and safe after removal of infected CIED with cumulative adverse events at 4% and a reinfection rate of 0.4%. Large prospective studies are needed to better evaluate the best timing of LP implantation after TLR of an infected CIED.

Rate of various access sites for temporary transvenous pacing and different outcomes at Lady Reading Hospital, Peshawar Pakistan

Objective

To evaluate the various temporary transvenous pacemaker (TPM) access sites, its indications, procedural complications, and outcomes of patients.

Methods

This prospective study conducted in a tertiary care hospital of Peshawar, included 100 patients, who underwent TPM for any reasons, via the trans jugular, subclavian, or trans-femoral route. The duration of the study was from October 1st, 2021 to March 31st, 2022. The demographic, procedure -related complications, causes of complete heart block and in hospital outcomes were recorded.

Results

Of the 100 patients who underwent temporary transvenous pacing, 56%were males and 44% were females, with an age range of 46-80 years. In majority of the patients, (N =54) internal jugular vein was used as the venous access site followed by the subclavian vein. (N=24). Coronary artery disease was prevalent in 42% of the patients. 50% had complete AV block, 19% had symptomatic second-degree block, and 10% had sinus nodal diseases. Seventy three percent of the patients needed TPM implantation on an emergency basis, which is statistically significant (p=0.009). Almost 40% of the patient ultimately underwent a permanent pacemaker. Out of 100 patients, 16 patients expired. The major procedure related complications were bleeding 16% overall at the puncture site and 14.8% in the internal jugular group. Other complications were local infection 13% at the insertion site followed by hemopericardium 3%, in the internal jugular group.

Conclusion

Atrioventricular block is the commonest indication for temporary pacing in our study. The average time the TPM remained in place was significantly higher in the trans jugular approach group along with a higher complication rate in this group.

Comparison of the safety and efficiency of temporary cardiac pacing methods during left bundle branch pacemaker implantation: Femoral vein pacing versus atrial spiral pacing with electrodes placed at the ventricle

BACKGROUND

Left bundle branch pacemakers (LBBPs) can better maintain ventricular electrical synchronization than traditional right ventricular pacing (RVP). Temporary cardiac pacing (TCP) is needed to ensure the safety of the operation in patients undergoing LBBP. Currently, there are two methods of installing TCP in conventional permanent pacemaker implantation.

HYPOTHESIS

To evaluate the safety and efficiency of replacing femoral vein pacing with atrial spiral pacing in the right ventricle for temporary cardiac pacing (TCP) during left bundle branch pacemaker (LBBP) implantation.

METHOD

A total of 179 patients who underwent TCP during LBBP were selected for retrospective analysis from April 2019 to 2021 and divided into two groups: the atrial spiral electrode group (n = 76) and the femoral vein electrode group (n = 103). The following were observed: operation time; radiation dose; radiation time; operation expenses; hospitalization time; pacemaker parameters immediately after the operation and at 1 week, 1 month, 3 months, and 6 months after the operation; operation complications and femoral vein puncture point complications were observed in the two groups.

RESULTS

Compared to the femoral vein electrode group, the atrial electrode group had significantly lower operation times ([116.86 ± 24.63] versus [128.94 ± 25.27] min, p < 0.05), radiation doses ([805.07 ± 132.94] versus [846.42 ± 87.37] mgy, p < 0.05), and decreased risk of a displaced or dislodged temporary pacing electrode during the operation ([0.00%] versus [4.85%], p < 0.05). The atrial electrode group did not have significant operation costs or material costs associated with femoral vein temporary pacing electrode implantation. In addition, the atrial electrode group did not have an increased risk of pacemaker-related infections, and the parameters of the pacemaker were unaffected. However, some puncture point complications appeared in the femoral vein electrode group (8 cases of local subcutaneous hematoma, 3 cases of pseudoaneurysms, 3 cases of arteriovenous fistula).

CONCLUSION

The replacement of the femoral vein pacing electrode with an atrial spiral pacing electrode in the right ventricle for TCP during LBBP implantation was safe and effective.

Concomitant leadless pacing in pacemaker-dependent patients undergoing transvenous lead extraction for active infection: Mid-term follow-up

BACKGROUND

The rate of transvenous lead extraction (TLE) due to cardiac implantable electronic device (CIED) infection continues to rise. CIED infections are associated with significant morbidity and mortality. Temporary pacing in patients with active CIED infections after TLE can be challenging. Leadless pacing has emerged as an alternative approach in this patient population.

OBJECTIVE

The purpose of this study was to describe the outcomes of a strategy using concomitant leadless pacemaker implantation and TLE in patients with active infections and ongoing pacing requirements.

METHODS

This study involved all leadless pacemaker implantation procedures performed during TLE between June 2018 and September 2022 in the setting of active infection. Demographic characteristics, procedural details, and clinical outcomes were analyzed.

RESULTS

The study included 86 patients with indications for ongoing pacing, 60 (70%) men with mean age 77.4 ± 10.5 years, who underwent TLE and concomitant leadless pacemaker implantation in the setting of active infection. There were no procedure-related complications. Sixty-five patients (76%) had evidence of bacteremia, 80% of whom were discharged to complete their antimicrobial treatment. During a median follow-up of 163 days (interquartile range 57-403 days), there were no recurrent infections. Of the 25 deaths (29%) during the study period, 22 (88%) were unrelated to the initial infection. Nine deceased patients (36%) had methicillin-resistant Staphylococcus aureus or Candida infections, 3 of whom had persistent infection despite TLE.

CONCLUSION

Leadless pacing is a safe and efficacious approach for the management of patients with pacing requirements that undergo CIED extraction in the setting of active infection.

New Practices in Transcatheter Aortic Valve Implantation: How I Do It in 2023

Transcatheter aortic valve implantation (TAVI) went through a huge evolution in the last decades. Previously performed under general anesthesia, with transoperative transesophageal echocardiography guidance and using cutdown femoral artery access, the procedure has now evolved into a minimalist approach, with local anesthesia, conscious sedation, and the avoidance of invasive lines becoming the new standards. Here, we discuss the minimalist TAVI approach and how we incorporate it into our current clinical practice.

Feasibility study of temporary permanent pacemaker in patients with conduction block after TAVR

Background

Limited data exist on the use of temporary permanent pacemaker (TPPM) to reduce unnecessary PPM in patients with high-degree atrioventricular block (HAVB) after transcatheter aortic valve replacement (TAVR).

Objectives

This study aims to determine the feasibility of TPPM in patients with HAVB after TAVR to provide prolonged pacing as a bridge.

Materials and methods

One hundred and eleven consecutive patients undergoing TAVR were screened from August 2021 to June 2022. Patients with HAVB eligible for PPM were included. TPPM were used in these patients instead of conventional temporary pacing or early PPM. Patients were followed up for 1 month. Holter and pacemaker interrogation were used to determine whether to implant PPM.

Results

Twenty one patients met the inclusion criteria for TPPM, of which 14 patients were third-degree AVB, 1 patient was second-degree AVB, 6 patients were first degree AVB with PR interval > 240 ms and LBBB with QRS duration > 150 ms. TPPM were placed on the 21 patients for 35 ± 7 days. Among 15 patients with HAVB, 26.7% of them (n = 4) recovered to sinus rhythm; 46.7% (n = 7) recovered to sinus rhythm with bundle branch block. The remains of 26.7% patients (n = 4) still had third-degree AVB and received PPM. For patients with first-degree AVB and LBBB, PR interval shortened to < 200 ms in all 6 patients and LBBB recovered in 2 patients. TPPM were successfully removed from all patients and no procedure-related adverse events occurred.

Conclusion

TPPM is reliable and safe in the small sample of patients with conduction block after TAVR to provide certain buffer time to distinguish whether a PPM is necessary. Future studies with larger sample are needed for further validation of the current results.

Untying the Knot: A Rare Case of Formation of a Life-Threatening Intracardiac Knot Following the Placement of a Temporary Transvenous Pacemaker

The implantation of a temporary pacemaker lead is a very common procedure performed in most hospitals and is known to be relatively safe, but there can be serious complications in rare circumstances. Reported complications including arrhythmias, infection, thromboembolic phenomena, and perforation of the vessel or the heart are all extensively described. However, an unusual and life-threatening complication that is not frequently discussed is the formation of intracardiac knots. We present a case of a rare complication of a temporary pacemaker placement with the formation of a knot in the distal lead requiring expert technique for removal.

Clinical profile and outcomes of semi-permanent pacing in a tertiary care institute in southern India

BACKGROUND

Semi-permanent pacing (SPP) includes the placement of a permanent lead through the internal jugular vein and connection to a pulse generator on the skin outside the venous access site.

AIM

To evaluate the clinical profile and outcomes of semi-permanent pacing in a tertiary care institute in Southern India.

METHODS

This is a retrospective observational study. All patients admitted and requiring management with semi-permanent pacing from January 2017 to June 2020 were included.

RESULTS

From January 2017 to June 2020, 20 patients underwent semi-permanent pacing (SPP) with a median age of 54 (21-74) years. Males comprised a majority of the patients (55%). Hypertension was noted in 50% of patients and 30% were diabetic. The right internal jugular vein was the most common access in 95% of patients. The most common indication for semi-permanent pacing was pocket site infection in 30% of patients. There were no procedural complications. The median duration on SPP was 7 (5-14) days and the median duration of hospital stay was 13 (8-21) days. Permanent pacemaker implantation was done in 55% of patients. Mortality in our study group was 15% with 10% dying due to cardiogenic shock (post resuscitated cardiac arrest) and 5% dying due to non-cardiac cause (Epidural hematoma).

CONCLUSION

In our study, semi-permanent pacing was noted to be a safe procedure and was more commonly indicated in emergent conditions with complete heart block secondary to underlying reversible causes and in the management of pocket site infection.

Validation of the Emory Risk Score in the Transcatheter Aortic Valve Implantation Population: A Canadian Perspective

Background

Permanent pacemaker (PPM) implantation may be indicated post-transcatheter aortic valve implantation (TAVI). The Emory Risk Score (ERS) is a validated predictive risk score of the need for a PPM post-TAVI using a balloon-expandable valve. Our objectives were to determine the validity of the ERS in our local TAVI population with both balloon-expandable and self-expanding valves and to identify additional electrocardiographic (ECG) parameters predictive of the need for a PPM post-TAVI.

Methods

Retrospective chart and electronic database reviews were performed to collect demographic and procedural information. Two expert readers reviewed all ECGs. Independent factors associated with PPM implantation were examined with multivariable logistic regression via a stepwise selection process with calculation of the area under the receiver operating characteristic curve to assess model discrimination.

Results

The overall PPM implantation rate was 11.7%; rates were 9% for the Sapien 3 valves, 10% for the Evolut Pro valves, and 17% for the Evolut R valves. The ERS was found to not be predictive of need for PPM post-TAVI for the entire cohort. Right bundle branch block was the only ERS parameter independently associated with new PPM implant (8.5% vs 25%, odds ratio = 3.59, P = 0.01). No additional ECG parameters met the criteria for statistical significance.

Conclusions

The poor predictive value of the ERS in determining the need for a PPM post-TAVI in our patient population suggests that further refinement of a formula (or risk-calculator) is warranted. Identification of a precise risk-calculator is likely to facilitate patient mobilization and reduce inpatient healthcare resource utilization.

Multi-lead atrioventricular sequential pacing: A promising alternative to conventional temporary pacing techniques

Temporary right ventricular pacing in unstable bradycardia and cardiovascular interventions is associated with atrioventricular dyssynchrony and reduced cardiac output. Currently, sequential atrioventricular pacing options are limited andnot routinely used. Herein, we discuss a novel, first in-human technique of temporary atrioventricular sequential pacing and how it compares to existing modalities of atrioventricular pacing.

Cardiac Magnetic Resonance Imaging-Based Screening for Cardiac Sarcoidosis in Patients With Atrioventricular Block Requiring Temporary Pacing

Background Some myocardial diseases, such as cardiac sarcoidosis, predispose to complete atrioventricular block. The European Society of Cardiology Guidelines on cardiac pacing in 2021 recommend myocardial disease screening in patients with conduction disorder requiring pacemaker with multimodality imaging, including cardiac magnetic resonance (CMR) imaging. The ability of CMR imaging to detect myocardial disease in patients with a temporary pacing wire is not well documented. Methods and Results Our myocardial disease screening protocol is based on using an active fixation pacing lead connected to a reusable extracorporeal pacing generator (temporary permanent pacemaker) as a bridge to a permanent pacemaker. From 2011 to 2019, we identified 17 patients from our CMR database who underwent CMR imaging with a temporary permanent pacemaker for atrioventricular block. We analyzed their clinical presentations, CMR data, and pacemaker therapy. All CMRs were performed without adverse events. Pacing leads induced minor artifacts to the septal myocardial segments. The extent of late gadolinium enhancement in CMR imaging was used to screen patients for the presence of myocardial disease. Patients with evidence of late gadolinium enhancement underwent endomyocardial biopsy. If considered clinically indicated, also 18-F-fluorodeoxyglucose positron emission tomography and extracardiac tissue biopsy were performed if sarcoidosis was suspected. Eventually, 8 of 17 patients (47.1%) were diagnosed with histologically confirmed granulomatous inflammatory cardiac disease. Importantly, only 1 had a previously diagnosed extracardiac sarcoidosis at the time of presentation with high-degree atrioventricular block. Conclusions CMR imaging with temporary permanent pacemaker protocol is an effective and safe early screening tool for myocardial disease in patients presenting with atrioventricular block requiring immediate, continuous pacing for bradycardia.

Simplified TAVR Procedure: How Far Is It Possible to Go?

Increasing operators’ experience and improvement of the technique have resulted in a drastic reduction in complications following transcatheter aortic valve replacement (TAVR) in patients with lower surgical risk. In parallel, the procedure was considerably simplified, with a routine default approach including local anesthesia in the catheterization laboratory, percutaneous femoral approach, radial artery as the secondary access, prosthesis implantation without predilatation, left ventricle wire pacing and early discharge. Thus, the “simplified” TAVR adopted in most centers nowadays is a real revolution of the technique. However, simplified TAVR must be accompanied upstream by a rigorous selection of patients who can benefit from a minimalist procedure in order to guarantee its safety. The minimalist strategy must not become dogmatic and careful pre-, per- and post-procedural evaluation of patients with well-defined protocols guarantee optimal care following TAVR. This review aims to evaluate the benefits and limits of the simplified TAVR procedure in a current and future vision.

Working on the dirty side—the ipsilateral subclavian access for temporary pacing after lead extraction

Background

Temporary pacing is necessary in pacemaker‐dependent patients after transvenous lead extraction (TLE) for cardiac implantable electronic device infection. In case of unavailability of other accesses, we propose to use the ipsilateral subclavian access (ISA) combined with a standard permanent active fixation lead for the temporary pacemaker and present preliminary data.

Methods

We consecutively enrolled patients undergoing TLE who received a temporary pacemaker using the ISA between August 2016 and April 2020 at our centre.

Results

During the observation period, 36 patients undergoing TLE for pocket infection (72.2%), endocarditis (25.0%) or other causes received a temporary pacemaker over the ISA. Their mean age was 77.0 ± 10.7 years, and 13.9% were female. Complete TLE was achieved in 94.4%. There were no major periprocedural complications. Intra‐hospital mortality was 11.1%. Pocket revision was performed in 19.4%. During long‐term follow‐up (23 ± 13 months), 8.3% had a relapse of local pocket infection and 2.8% needed rehospitalization for reintervention.

Conclusions

Temporary pacing using a standard permanent active fixation lead using the ISA is a convenient alternative to conventional venous accesses. However, risks of implanting a lead into a previously infected area have to be taken into account.

Incidence of carditis and predictors of pacemaker implantation in patients hospitalized with Lyme disease

BACKGROUND

Lyme carditis, defined as direct infection of cardiac tissue by Borrelia bacteria, affects up to 10% of patients with Lyme disease. The most frequently reported clinical manifestation of Lyme carditis is cardiac conduction system disease. The goal of this study was to identify the incidence and predictors of permanent pacemaker implantation in patients hospitalized with Lyme disease.

METHODS

A retrospective cohort analysis of the Nationwide Inpatient sample was performed to identify patients hospitalized with Lyme disease in the US between 2003 and 2014. Patients with Lyme carditis were defined as those hospitalized with Lyme disease who also had cardiac conduction disease, acute myocarditis, or acute pericarditis. Patients who already had pacemaker implants at the time of hospitalization (N = 310) were excluded from the Lyme carditis subgroup. The primary study outcome was permanent pacemaker implantation. Secondary outcomes included temporary cardiac pacing, permanent pacemaker implant, and in-hospital mortality.

RESULTS

Of the 96,140 patients hospitalized with Lyme disease during the study period, 10,465 (11%) presented with Lyme carditis. Cardiac conduction system disease was present in 9,729 (93%) of patients with Lyme carditis. Permanent pacemaker implantation was performed in 1,033 patients (1% of all Lyme hospitalizations and 11% of patients with Lyme carditis-associated conduction system disease). Predictors of permanent pacemaker implantation included older age (OR: 1.06 per 1 year; 95% CI:1.05-1.07; P<0.001), complete heart block (OR: 21.5; 95% CI: 12.9-35.7; P<0.001), and sinoatrial node dysfunction (OR: 16.8; 95% CI: 8.7-32.6; P<0.001). In-hospital mortality rate was higher in patients with Lyme carditis (1.5%) than in patients without Lyme carditis (0.5%).

CONCLUSIONS

Approximately 11% of patients hospitalized with Lyme disease present with carditis, primarily in the form of cardiac conduction system disease. In this 12-year study, 1% of all hospitalized patients and 11% of those with Lyme-associated cardiac conduction system disease underwent permanent pacemaker implantation.

Application of the improved simple bedside method for emergency temporary pacemaker implantation suitable for primary hospitals

The purpose of the research was to evaluate the safety and effectiveness of the X-ray-free improved simple bedside method for emergency temporary pacemaker implantation as well as the practicability of the method in primary hospitals. Patients [including those suffering from sick sinus syndrome and third-degree and advanced atrioventricular blockage (AVB)] who needed emergency temporary pacemaker implantation from July 2017 to August 2020 in Hunan Provincial People’s Hospital were selected. They were stochastically divided into a research group (95 cases) treated with the improved simple bedside method and a control group (95 cases) with X-ray guidance. The ordinary bipolar electrodes were used in both groups. On this condition, the operation duration, the first-attempt success rate of electrodes, pacing threshold, success rate of the operation, the rate of electrode displacement, and complications in the two groups were separately calculated. The comparison results of the research group with the control group are shown as follows: operation time [(18 ± 5.91) min vs. (43 ± 2.99) min, P < 0.05], the first-attempt success rate of the electrode (97% vs. 98%, P > 0.05), pacing threshold [(0.97 ± 0.35) vs. (0.97 ± 0.32) V, P > 0.05], success rate of the operation (98.9% vs. 100%, P > 0.05), the rate of electrode displacement (8.4% vs. 7.3%, P > 0.05) and complications (3.2% vs. 2.1%, P > 0.05). The emergency temporary pacemaker implantation based on the improved simple bedside method is as safe and effective as the surgical method under X-ray guidance, and the operation is simpler and easier to learn and requires a shorter operating time, therefore, it is more suitable for use in emergency and primary hospitals.

Safety and efficacy of His-bundle pacing/left bundle branch area pacing versus right ventricular pacing: a systematic review and meta-analysis

BACKGROUND

Recent studies have demonstrated that right ventricular pacing (RVP) has deleterious effects on non-synchronized ventricular contraction, while His-bundle pacing (HBP) or left bundle branch area pacing (LBBaP) contribute to improvements in patients' mid- and long-term outcomes. This meta-analysis aimed to compare the safety and efficacy of physiologic pacing (HBP/LBBaP) versus those of RVP.

METHODS

A systematic search of PubMed, Cochrane Library, and Embase was conducted for studies that compared the effects of physiologic pacing and RVP. All eligible studies were published before January 1, 2021 and were conducted in humans. STATA software version 15.0 was used for all the data analyses.

RESULTS

Twenty articles (n = 2787 patients) were included in this meta-analysis. Compared to RVP, physiologic pacing was associated with a significantly shorter QRS duration and better cardiac function. Physiologic pacing was also correlated with lower rates of mitral regurgitation, pacing-induced cardiomyopathy, death, heart failure hospitalization, and atrial fibrillation, although the above results were not statistically significant. In addition, RVP led to the achievement of higher success rates than physiologic pacing, a shorter fluoroscopic time and mean procedure duration, a lower pacing threshold: the results were statistically significant. Compared with HBP, LBBaP appeared to have some advantages in R wave amplitudes, pacing threshold, fluoroscopic time, procedure time, and success rate, with statistically significant differences. Whereas HBP was associated with fewer surgical complications and shorter QRS duration, the results were not statistically significant.

CONCLUSION

Physiologic pacing (HBP/LBBaP) might be a better strategy than RVP and improve long-term clinical outcomes like cardiac function. Although LBBaP appears to have some advantages over HBP, the long-term benefits are still controversial. More large-scale randomized clinical trials are needed for further verification.

The Alpha-bent and Tunneling: A Novel Technique for Fixing the Transvenous Pacer Lead during Temporary Transvenous Pacing in the Emergency Department

The last step in the management of symptomatic bradycardia according to the advanced cardiac life support algorithm is temporary transvenous pacemaker insertion (TPI). TPI done by an emergency physician in the emergency department (ED) is on the rise particularly in South India owing to the increased incidence of yellow oleander poisoning. As in ED, we use passive fixation leads, fixation of a transvenous pacer lead is very important. In the following case series, we describe two novel techniques namely, “the alpha-bent” and “tunneling” for fixing the transvenous pacer lead. This technique of fixing the lead reduces lead displacement thus minimizing the potential complications.