Efficacy and safety of novel left ventricular pacing leads: 1-year analysis of the NAVIGATOR trial

OBJECTIVES

Assess safety and performance of novel quadripolar preshaped left ventricular (LV) leads: NAVIGO 4LV 2D ('S shaped') and NAVIGO 4LV ARC ('U shaped').

METHODS

Patients indicated for cardiac resynchronisation therapy were enrolled in a multicentre, prospective, controlled study (NAVIGATOR, NCT03279484). Patients were implanted with either a NAVIGO 4LV 2D or ARC lead, and assessed at 10 weeks, 6, 12 and 24 months post-implant. Co-primary safety and performance endpoints were assessed at 10 weeks. Safety endpoint was the patients' rate free from lead-related complications. Performance endpoint was the rate of patients with successful lead performance, defined as LV pacing threshold ≤2.5 V at 0.5 ms on at least one pacing vector, and the absence of phrenic nerve stimulation at the final programmed configuration. Lead-related complications and electrical parameters were monitored throughout study.

RESULTS

A NAVIGO 4LV lead was successfully implanted in 211 out of 217 patients (97.2%). The safety endpoint was met, with 100% and 96.1% of patients free from complications for NAVIGO 4LV 2D and ARC, respectively. The performance endpoint was met with 98.1% and 98.9% of patients with a successful lead performance for NAVIGO 4LV 2D and ARC, respectively. Over 12 months, the global complication-free rate for both leads was 97.1% (95% CI: 93.71% to 98.70%), with a mean pacing capture threshold of 1.23 V±0.73 V and a mean impedance of 951 Ω±300.1 Ω.

CONCLUSION

A high implantation success rate and low complication rate was reported for the novel NAVIGO 4LV 2D and ARC leads, along with successful performance up to 12 months.

Alternative atrial pacing site to improve cardiac function: focus on Bachmann's bundle pacing

Pacing from the right atrial appendage (RAA) prolongs the P wave duration and can induce interatrial and especially left-sided atrio-ventricular dyssynchrony. Pacing from Bachmann's bundle closely reproduces normal physiology and has the potential to avoid the electromechanical dysfunction associated with conventional RAA pacing. Interatrial conduction delay is associated with an increased risk of stroke, heart failure, and death. In addition to a reduction in atrial fibrillation, Bachmann's bundle pacing has emerging applications as a hemodynamic pacing modality. This review outlines the pathophysiology of atrial conduction disturbances and their potential remedies and provides the reader with a practical guide to implementing Bachmann's bundle pacing with an emphasis on the recapitulation of normal electrical and mechanical function.

Declining Risk of Sudden Cardiac Death in Heart Failure: Fact or Myth?

The notion that the risk of sudden cardiac death (SCD) in patients with heart failure (HF) is declining seems to be gaining traction. Numerous editorials and commentaries have suggested that SCD, specifically arrhythmic SCD, is no longer a significant risk for patients with HF on guideline-directed medical therapy. In this review, we question whether the risk of SCD has indeed declined in HF trials and in the real world. We also explore whether, despite relative risk reductions, the residual SCD risk after guideline-directed medical therapy still suggests a need for implantable cardioverter defibrillator therapy. Among our arguments is that SCD has not decreased in HF trials, nor in the real world. Moreover, we argue that data from HF trials, which have not adhered to guideline-directed device therapy, do not obviate or justify delays to implantable cardioverter defibrillator therapy. In this context, we underline the challenges of translating the findings of HF randomized, controlled trials of guideline-directed medical therapy to the real world. We also make the case for HF trials that adhere to current guideline-directed device therapy so that we can better understand the role of implantable cardioverter defibrillators in chronic HF.

[Approach to patients with Assurity® and Endurity® pacemakers : Recommendations from the nucleus of the Working Group Electrophysiology and Rhythmology of the German Cardiac Society]

In a subset of patients with pacemaker models Assurity® and Endurity® (Abbott, Sylmar, California, USA; worldwide outside the USA approximately 83,000 devices), a mistake during production may have occurred resulting in insufficient adhesion between the pulse generator header and device housing which in turn may allow moisture to enter the header. This may cause loss of telemetry, switch to back-up mode, reduced battery longevity, or in worst case loss of pacing. Until June 2022, these malfunctions were reported for 128 devices worldwide (0.15%); no permanent harm to patients due to this issue has been reported. The nucleus of the AGEP suggests the following recommendations: (1) Patients with a device under safety advisory should be informed. (2) The risks for the patient in case of loss of stimulation should be assessed. Patients should be categorized into "likely pacemaker-dependent" (e.g., indication permanent atrioventricular [AV] block, no intrinsic rhythm at the last follow-up, percentage of ventricular pacing in the device memory > 90%), "unknown", or "likely not pacemaker-dependent" (e.g., indication sick sinus syndrome, intrinsic rhythm > 50 bpm at the last follow-up, percentage of ventricular pacing in the device memory < 1%). (3) In likely pacemaker-non-dependent patients, information about this issue should be provided together with an unchanged follow-up or a follow-up with shortened intervals (e.g., every 3 months) and/or remote monitoring. (4) In patients with unknown risk if stimulation failure occurs, at least follow-up intervals should be shortened to, for example, 3 months and/or remote monitoring should be initialized. In addition, risks and benefits of a device exchange should be weighed against each other. (5) In patients who are likely pacemaker-dependent, device exchange is recommended.

Änderung der Indikation zur primärprophylaktischen ICD-Implantation

Die Versorgung mit einem implantierbaren Kardioverter-Defibrillator (ICD) bietet einen effektiven Schutz vor lebensgefährlichen Herzrhythmusstörungen. Da es sich beim plötzlichen Herztod um ein unvorhersehbares Ereignis handelt, stellt die Selektion des Patientenguts, das von einer ICD-Implantation profitiert, jedoch nach wie vor eine große Herausforderung dar. Die Evidenz, auf der die aktuellen Leitlinienempfehlungen zur ICD-Implantation aufbauen, begründet sich zu einem relevanten Teil auf Studien, die bereits vor 20–30 Jahren durchgeführt wurden. Seitdem hat sich die medikamentöse und interventionelle Herzinsuffizienztherapie deutlich weiterentwickelt. Zudem stellen neuere Studien den prognostischen Nutzen einer primärprophylaktischen ICD-Implantation bei Patienten mit nicht ischämischer Kardiomyopathie infrage. Im Folgenden soll anhand der zugrunde liegenden Daten erörtert werden, welche Implikationen sich hieraus für den Alltag ergeben und welche Entwicklungen zukünftig zu erwarten sind.

Neue Aspekte der Schrittmacherindikation bei atrioventrikulären Überleitungsstörungen

Die neuen europäischen Leitlinien zur Herzschrittmachertherapie bilden den aktuellen Stand des Wissens ab. Im Vergleich zu den vorhergehenden Leitlinien ist die Klarstellung, dass die Empfehlungen auch für Vorhofflimmern/-flattern mit AV-Block und für intermittierende und permanente bzw. symptomatische und asymptomatische infranodale AV-Blockierungen gleichermaßen gelten, neu. Bei Synkopen im Kontext mit Schenkelblockierungen wird die Bedeutung der elektrophysiologischen Untersuchung und des prolongierten kontinuierlichen EKG-Monitorings unterstrichen, was auch für Leitungsstörungen nach Transkatheter-Aortenklappen-Implantation gilt. Bei AV-Block nach Myokardinfarkt und Herzoperation sollte 5 Tage auf ein Sistieren gewartet werden, wenn die Klinik des Patienten es erlaubt. Neuromuskuläre Erkrankungen erfordern aufgrund des erhöhten Risikos für eine rasche Progression eine Schrittmacherimplantation oft bereits bei leichteren Überleitungsstörungen.

Estimated incidence of previously undetected atrial fibrillation on a 14-day continuous electrocardiographic monitor and associated risk of stroke

Aims

There is uncertainty about whether and how to perform screening for atrial fibrillation (AF). To estimate the incidence of previously undetected AF that would be captured using a continuous 14-day ECG monitor and the associated risk of stroke.

Methods and results

We analysed data from a cohort of patients &gt;65 years old with hypertension and a pacemaker, but without known AF. For each participant, we simulated 1000 ECG monitors by randomly selecting 14-day windows in the 6 months following enrolment and calculated the average AF burden (total time in AF). We used Cox proportional hazards models adjusted for CHA2DS2-VASc score to estimate the risk of subsequent ischaemic stroke or systemic embolism (SSE) associated with burdens of AF &gt; and &lt;6 min. Among 2470 participants, the median CHA2DS2-VASc score was 4.0, and 44 patients experienced SSE after 6 months following enrolment. The proportion of participants with an AF burden &gt;6 min was 3.10% (95% CI 2.53–3.72). This was consistent across strata of age and CHA2DS2-VASc scores. Over a mean follow-up of 2.4 years, the rate of SSE among patients with &lt;6 min of AF was 0.70%/year, compared to 2.18%/year (adjusted HR 3.02; 95% CI 1.39–6.56) in those with &gt;6 min of AF.

Conclusions

Approximately 3% of individuals aged &gt;65 years with hypertension may have more than 6 min of AF detected by a 14-day ECG monitor. This is associated with a stroke risk of over 2% per year. Whether oral anticoagulation will reduce stroke in these patients is unknown.

[How-to case report]

Case reports are often the first step of innovations and new techniques in science and thus are fundamental for some later established procedures. In addition, they have a great educational effect and offer young scientists the opportunity to gain their first experiences in writing manuscripts. In addition to an interesting detail (e.g. figure), a clear message is essential for a good case report.

Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care

Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.

Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: A joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology

Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.

[Bradycardia in pregnancy : Case report and review of the literature]

We report the case of a pregnant woman with complete heart block during her first trimester who presented with dyspnea at the East African Heart Rhythm Project in Nairobi. There was no evidence of an acute cause (e.g., myocarditis, cardiomyopathy, autoimmune or neuromuscular disease). No ECG had been previously documented; therefore, congenital complete heart block was likely. We implanted a dual-chamber pacemaker using conventional fluoroscopy. Several measures at implantation allowed us to limit fluoroscopy to 30 s and radiation to < 100 µGym². The implantation was uneventful, dyspnea improved instantaneously and further pregnancy, labor and birth were uncomplicated. Bradycardia requiring pacemaker implantation is rare during pregnancy and usually consists of symptomatic complete heart block. Beyond undiagnosed or untreated pre-existing atrioventricular block, drug therapy for fetal tachycardia, myocarditis (including Lyme borreliosis and Chagas disease), inflammatory infiltrative diseases (e.g., sarcoidosis), cardiomyopathies and neuromuscular disease may have caused bradycardia. In the absence of treatable causes, pacemaker implantation becomes necessary if bradycardia brings about risks for the mother or the fetus. Using transesophageal or intracardiac echocardiography, radiation can be avoided completely or, by taking some simple measures, may be kept to a minimum so that there is no risk for the fetus.

[Perioprocedural mortality after ICD implantation]

Hintergrund

Implantierbare Kardioverter-Defibrillatoren (ICD) sind zum Schutz vor plötzlichem Herztod bei Patienten mit primär- oder sekundärprophylaktischer Indikation etabliert. Wie bei allen komplexen operativen Verfahren verbleibt auch bei der ICD-Implantation ein Risiko für Komplikationen bis hin zum Tod. Gegenstand der vorliegenden Arbeit ist es, anhand der Datensätze zur obligaten Qualitätssicherung in Nordrhein-Westfalen die prozedurbezogene Mortalität nach ICD-Implantation zu analysieren.

Methoden

Aus den Datensätzen erfolgte eine Analyse der stationären Todesfälle bei allen 18.625 ICD-Implantationen der Jahre 2010 bis 2012.

Ergebnisse

Während des stationären Aufenthalts verstarben 118 Patienten (0,6 %) nach ICD-Implantation. Patienten im Alter über 80 Jahre (7 %) zeigten eine höhere Mortalität (1,9 % vs. 0,5 % bei < 80-jährigen Patienten, p > 0,001), ebenso Frauen (0,95 % vs. 0,54 % bei Männern; p = 0,004) und Patienten mit hoher NYHA(New York Heart Association)-Klasse (0,3 % bei NYHA II, 0,7 % bei NYHA III, 3,4 % bei NYHA IV; p < 0,001 für alle Vergleiche). Das Vorliegen von Diabetes mellitus (23 % des Kollektivs) beeinflusste die perioperative Letalität nicht, während eine dialysepflichtige Niereninsuffizienz eine signifikant erhöhte Mortalität aufwies (p < 0,001 gegenüber Patienten mit Kreatinin ≤ 1,5 mg/dl; p = 0,002 gegenüber nicht dialysepflichtigen Patienten mit Kreatinin > 1,5 mg/dl). Patienten mit sekundärprophylaktischer ICD-Indikation wiesen eine signifikant höhere Mortalität auf (1,2 % vs. 0,4 %; p < 0,001), die sich beim Auftreten von Komplikationen von 0,6 % auf 3,7 % erhöhte (p < 0,001).

Schlussfolgerung

Die operationsbezogene Mortalität bei ICD-Implantation ist bei Patienten über 80 Jahre, hoher NYHA-Klasse, Dialysepflicht, sekundärprophylaktischer Indikation und nach Auftreten von Komplikationen erhöht.

Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

Withdrawn as duplicate: Optimized Implementation of cardiac resynchronization therapy - a call for action for referral and optimization of care

Ahead of Print article withdrawn by publisher. This article has been withdrawn due to a publisher error that caused the article to be duplicated. The definitive version of this article is published under https://doi.org/10.1093/europace/euaa411.

Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

Safety and efficacy of dronedarone from clinical trials to real-world evidence: implications for its use in atrial fibrillation

Efficacy and safety of dronedarone was shown in the ATHENA trial for paroxysmal or persistent atrial fibrillation (AF) patients. Further trials revealed safety concerns in patients with heart failure and permanent AF. This review summarizes insights from recent real-world studies and meta-analyses, including reports on efficacy, with focus on liver safety, mortality risk in patients with paroxysmal/persistent AF, and interactions of dronedarone with direct oral anticoagulants. Reports of rapidly progressing liver failure in dronedarone-prescribed patients in 2011 led to regulatory cautions about potential liver toxicity. Recent real-world evidence suggests dronedarone liver safety profile is similar to other antiarrhythmics and liver toxicity could be equally common with many Class III antiarrhythmics. Dronedarone safety concerns (increased mortality in patients with permanent AF) were raised based on randomized controlled trials (RCT) (ANDROMEDA and PALLAS), but comedication with digoxin may have increased the mortality rates in PALLAS, considering the dronedarone-digoxin pharmacokinetic (PK) interaction. Real-world data on apixaban-dronedarone interactions and edoxaban RCT observations suggest no significant safety risks for these drug combinations. Median trough plasma concentrations of dabigatran 110 mg during concomitant use with dronedarone are at acceptable levels, while PK data on the rivaroxaban-dronedarone interaction are unavailable. In RCTs and real-world studies, dronedarone significantly reduces AF burden and cardiovascular hospitalizations, and demonstrates a low risk for proarrhythmia in patients with paroxysmal or persistent AF. The concerns on liver safety must be balanced against the significant reduction in hospitalizations in patients with non-permanent AF and low risk for proarrhythmias following dronedarone treatment.

[Pifalls in the interpretation of pacemaker ECGs]

The analysis of the pacemaker ECG is usually regarded as difficult and may generate rather mediocre interpretations. It is a common opinion that a pacemaker ECG can only be analyzed if the type of pacemaker (single-, dual-, triple-chamber, manufacturer, model) and its programming are known. The following pitfalls illustrate how to achieve a clinically meaningful ECG interpretation in daily practice, even if these details are not known. A systematic approach to ECG interpretation is particularly crucial in this context: Basic rhythm (P waves, intrinsic or paced rhythm), paced QRS complex (axis, width, bundle branch block morphology), signs of pacemaker malfunction (under‑/oversensing, loss of capture), arrhythmia to which the pacemaker reacts, or activity of any pacemaker algorithm. Many small details should not be overlooked and many questions can be answered if a few principles are applied. Understanding of the pacemaker ECG can improve the life of a device patient at the touch of a button.

Device-Detected Atrial Fibrillation Before and After Hospitalisation for Noncardiac Surgery or Medical Illness: Insights From ASSERT

BACKGROUND

Atrial fibrillation (AF) is often detected during hospitalisation for surgery or medical illness and is often assumed to be due to the acute condition.

METHODS

The Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial (ASSERT) study enrolled patients ≥ 65 years old without AF. Pacemakers or implantable cardioverter-defibrillators recorded device-detected AF. We identified participants who were hospitalised and compared the prevalence of AF before and after hospitalisation.

RESULTS

Among 2580 participants, 436 (16.9%) had a surgical or medical hospitalisation. In the 30 days following a first hospitalisation, 43 participants (9.9%, 95% confidence interval [CI] 7.2%-13.1%) had > 6 minutes of device-detected AF; 20 (4.6%, 95% CI 2.8%-7.0%) had > 6 hours. More participants had AF > 6 minutes in the 30 days following hospitalisation compared with the period 30-60 days before hospitalisation (9.9% vs 4.4%; P < 0.001). Similar results were observed for episodes > 6 hours (4.6% vs 2.3%, P = 0.03). Roughly half of participants with device-detected AF in the 30 days following hospitalisation had at least 1 episode of the same duration in the 6 months before (50% [95% CI 31.3%-68.7%] for > 6 min; 68.8% [95% CI 41.3%-89.0%] for > 6 h). Those with AF in the 30 days following hospitalisation were more likely to have had AF in the past (adjusted odds ratio [OR] 7.2, 95% CI 3.2-15.8 for > 6 min; adjusted OR 32.6, 95% CI 10.3-103.4 for > 6 h).

CONCLUSIONS

The prevalence of device-detected AF increases around the time of hospitalisation for noncardiac surgery or medical illness. About half of patients with AF around the time of hospitalisation previously had similar episodes.

["That's torn it": my daftest complication in transvenous device implantation : And its fast solution]

The loss of a guidewire in the subclavian vein represents an unpleasant complication during pacemaker implantation with venous access by puncture in Seldinger's technique. Using another venous puncture and a gooseneck snare, this problem can be solved quickly and without any trace.

[Dislodgement of a left atrial appendage occluder : Step-by-step management by retrograde extraction with a "home-made snare" and two sheaths]

Dislodgement of a left atrial appendage occluder after liberation represents a nightmare in cardiac interventions. We present a case with this complication and an easy step-by-step protocol that can help to retrieve and venously extract this foreign body with less stress. Particularly the do-it-yourself construction of a "home-made snare" facilitates trapping of large implants which are too large for conventional snares.

Therapie mit kardialen implantierbaren elektrischen Devices im Alter

Die Therapie mit Herzschrittmacher, implantierbarem Kardioverter-Defibrillator (ICD) oder kardialer Resynchronisation (CRT) ist bei Patienten im Alter besonders oft indiziert und hilfreich, stellt jedoch besondere Anforderungen an Indikationsstellung, Systemwahl, Implantation und Nachsorge. In der Schrittmachertherapie muss Einfühlungsvermögen angewandt werden, um eine oft unspezifische Symptomatik mit einer Bradykardie zu assoziieren. In der ICD-Therapie muss berücksichtigt werden, ob bei hohem Alter und Komorbidität eine Lebensverlängerung durch den ICD möglich und vom Patienten gewünscht ist. Bevor die Akutsituation nicht arrhythmischen Sterbens eintritt, sollte eine Deaktivierung der Schocktherapie erfolgen. Bei hohem Alter muss eine Implantation sicher und zügig durchgeführt, aber immer das optimale System (z. B. CRT) und eine optimale Elektrodenposition verwendet werden, da gerade alte Patienten sehr empfindlich auf eine suboptimale Hämodynamik reagieren.

[Cardiac electrical device therapy in heart failure]

Heart failure is one of the most common reasons for inpatient treatment and one of the most common causes of death in Germany. In addition to coronary heart disease (ischemic cardiomyopathy, ICM), there are also numerous other diseases as non-ischemic cardiomyopathy, NICM. Chronic heart failure is the final stage of diseases with cardiac involvement and limits the prognosis and quality of life of patients. The course can be favorably influenced by cardiac implantable electrical devices (CIEDs). There are different uses of CIEDs which are shown in this article.

[Indications for His bundle and left bundle branch pacing]

His bundle pacing (HBP) allows ventricular excitation through the entire cardiac conduction system, resulting in a better synchronicity and efficacy of contraction compared to myocardial pacing. Due to better, dedicated implantation tools and exact practical implantation recommendations, HBP has developed into a form of stimulation that can be successfully applied with reasonable time and effort in >90% of patients. The rate of lead dislodgement and threshold increase is similar to conventional pacemaker systems. Despite a rather weak data base and a paucity of randomized trials, HBS represents an alternative to conventional right or biventricular pacing in the following conditions: (1) high-degree atrioventricular (AV) block with expected ventricular pacing >20% of the time, (2) AV block 1st degree with long PQ (alone or in combination with intermittent 2nd to 3rd degree AV block or sick sinus syndrome), (3) AV node ablation due to refractory atrial fibrillation, and (4) upgrade in pacing-induced cardiomyopathy. Moreover, HBP may be useful in context with cardiac resynchronization therapy (CRT). Left bundle branch block below the level of His represents a limitation of HBP. Therefore, more recently left bundle branch pacing (LBBP) has been introduced to correct left bundle branch block. LBBP seems to be possible in a wider anatomic area and may be easier to implant. However, LBBP requires active screw-in of the lead deep into the ventricular septum. Experience with this new technique is limited, particularly regarding long-term performance.

[Echocardiographic assessment of myocardial function during His bundle and right ventricular pacing]

INTRODUCTION

In patients with pacemaker (PM) therapy, His bundle stimulation (HBS) may lead to a more synchronous activation of the left ventricle (LV) than conventional right ventricular stimulation (RVS). In this study, we investigated to which extent this effect can be objectified by means of contemporary echocardiographic functional imaging.

METHODS

In all, 15 RVS patients (6 women, mean age 76.6 ± 4.1 years) and 15 HBS patients (6 women, mean age 74.6 ± 3.7 years) underwent echocardiography with and without cardiac pacing. Besides LV end-diastolic volume (EDV), ejection fraction (EF), and global strain (GLS), we measured global and regional myocardial work and LV efficiency based on noninvasive pressure-strain loops.

RESULTS

In all HBS patients, optimization of PM settings resulted in immediate changes in myocardial function parameters. With pacing, RVS patients showed a higher decrease in EF and GLS than HBS patients. Global LV work and LV work efficiency decreased significantly only in RVS patients.

CONCLUSION

Changes in regional and global myocardial function can by proven and quantified by functional echocardiography. In patients under PM therapy, HBS shows functional advantages in comparison to conventional RVS.

His bundle pacing: troubleshooting during follow-up

Follow-up of pacemaker systems for His bundle pacing (HBP) requires electrocardiogram (ECG) knowledge and creative thinking. This relates to ventricular threshold measurement in which it can be difficult to distinguish between selective HBP and loss of capture with pseudofusion since, by definition, intrinsic QRS complexes and those selectively paced via the His bundle look identical. Threshold testing in HBP is best performed in unipolar pacing mode, recording of a 12-lead ECG and pacing in VVI mode significantly above the intrinsic rate. Peculiarities of HBP relate to oversensing by the His bundle lead of atrial activity or the His bundle potential itself, leading to ventricular asystole or incorrect measurements during sensing testing. Ventricular undersensing and the use of His bundle plus additional right ventricular leads may lead to complex ECGs. However, other daily pacemaker problems (such as tachycardia above the upper rate limit or premature beats) and specific phenomena (such as paradoxical cardiac memory) may also be demanding in ECG troubleshooting of HBP.

Value of surface electrocardiography in His bundle pacing

His bundle pacing (HBP) provides physiological ventricular activation and is frequently used to treat patients with bradyarrhythmias. HBP reduces the risk of developing heart failure and atrial fibrillation by preventing ventricular electromechanical dyssynchrony associated with conventional right ventricular pacing. There are two types of HBP, including selective (S-HBP) and non-selective HBP (NS-HBP). It is important to determine the type of HBP during implantation and follow-up. This review discusses the role of standard surface electrocardiography in differentiating S‑HBP and NS-HBP and diagnosing loss of His bundle capture.

Comparison of current German and European practice in cardiac resynchronization therapy: lessons from the ESC/EHRA/HFA CRT Survey II

INTRODUCTION

The European CRT Survey II was introduced to offer insights into CRT implantation practice in Europe. We compared the national data from the participating German centres with that of the other European countries with regard to differences in patient selection, implant results, and initial properties.

METHODS AND RESULTS

11,088 patients were enrolled in 288 centres from 42 countries between 2015 and 2017. Of these, 675 (6.1%) were included in 17 centres in Germany. Patients from Germany were older, had more comorbidities and more symptoms of heart failure (HF) than patients from other European countries. There were no differences with regard to HF aetiology and guideline-directed medical treatment was overall well implemented. There was a high use of CRT in patients with atrial fibrillation, even higher in German patients. CRT was most often applied due to HF with wide QRS complex (class I recommendation) but with relatively higher frequency in Germany due to HF with primary indication for an implantable cardioverter-defibrillator (class IIb) or a pacemaker with expected pacing dependency (class I). The overall implant success rate was high with some differences in the implant procedure. The use of remote monitoring was lower in Germany.

CONCLUSION

This analysis from the European CRT Survey II overall shows good guideline adherence, high implantation success and a low rate of complications in daily practice. There are some regional differences in baseline characteristics, CRT indication, and procedural aspects. The use of remote monitoring in Germany lags behind other European countries.

[Device therapy in cardiological palliative care situations]

There is considerable uncertainty about the management of patients with cardiac implantable electronic devices (CIEDs) threatened by immediate or medium-term death due to heart failure or other disease, for patients and their relatives as well as for physicians and medical staff. Patients can be afraid that they cannot die as long as pacing persists; medical staff may forget to deactivate shock therapies in an agonal phase or may not know how to do this without a programmer. For optimal handling of CIEDs in a palliative care situation, patients have to be informed that pacemakers or cardiac resynchronization therapy have no life-prolonging effect in this situation but only limit suffering, particularly due to dyspnea. Palliative care physicians must be informed that ICDs can be temporarily deactivated by magnet application, requiring neither a device specialist nor a programmer. Medical staff has to be trained in empathic discussions about CIED deactivation. An optimal setting for this talk may occur if the patient asks about the course and prognosis of his disease or an advance directive, which includes statements about resuscitation. Palliative care physicians have to understand the different functions of a CIED (antibradycardia pacing, resynchronization, antitachycardia pacing, shock therapy) and the deactivation of each of these components to ensure an appropriate decision; otherwise, CIED management at the end of a patient's life may cause suffering and a sense of guilt in relatives and medical staff.