We present a rare case of a 79-year-old man who developed contralateral pneumothorax, pneumomediastinum, and pneumopericardium following dual-chamber pacemaker implantation for symptomatic second-degree atrioventricular block. The procedure itself was uneventful, with appropriate lead placement and good electrical parameters. However, 30 minutes post-procedure, the patient developed right-sided pleuritic chest pain and dyspnea. Imaging revealed a right-sided pneumothorax, pleural effusion, pneumomediastinum, and pneumopericardium. A chest drain was inserted due to the significant pneumothorax volume, leading to symptom resolution. Electrocardiographic changes and inflammatory marker elevation suggested pericarditis, which was successfully treated with ibuprofen and colchicine. The patient was discharged after 13 days and remained stable at a 1-year follow-up. The suspected mechanism of injury was atrial lead perforation, although other causes, such as pleural puncture or superior vena cava injury, were considered. Management of such cases varies, with lead revision being unnecessary in this patient due to stable pacing parameters. This case highlights an unusual complication of pacemaker implantation and underscores the importance of prompt diagnosis and individualized management.

Pre-existing pulmonary hypertension (PH) is associated with unfavorable in-hospital outcomes in cardiac as well as noncardiac surgeries and procedures. However, its impact on cardiac implantable electronic device (CIED) implantations is not established.

The purpose of the study was to investigate the extent of pre-existing PH among patients undergoing CIED implantations and to evaluate its effect on in-hospital outcomes.

Using the National Inpatient Sample database, we identified patients who were hospitalized in the United States between 2016 and 2019 and underwent CIED implantation with a pre-existing diagnosis of PH. Patients with any CIED in situ were excluded. Sociodemographic and clinical data, in-hospital procedures and outcomes, and in-hospital mortality were collected. Multivariable logistic regression models were used to identify predictors of in-hospital complications.

An estimated total of 718,980 patients underwent CIED implantation during the study period. Of them, 74,150 patients (10.3%) had a pre-existing PH diagnosis. Compared with non-PH patients, PH patients were older, had higher Charlson Comorbidity Index, and were more often implanted with implantable cardioverter defibrillators and cardiac resynchronization therapy devices. A higher rate of total complications was observed in PH patients (14.5% vs 9.9%; P < 0.001), driven mainly by respiratory complications as well as in-hospital mortality (2.3% vs 1.2%; P < 0.001). Multivariable analyses confirmed PH as an independent predictor for respiratory complications, total complications, and in-hospital mortality.

Pre-existing PH in patients undergoing CIED implantation was associated with increased risk for respiratory complications as well as in-hospital mortality in a nationwide, all-comer registry.

Cardiac implantable electronic devices (CIED) are frequently used in the treatment of arrhythmias. Maintenance of lead position is a key element for proper functioning of the CIEDs. There are two suturing techniques that are commonly used to anchor the leads to pectoral muscle (simple knot and anchor knot techniques). While there is one in vitro study comparing lead stabilizing efficacy of these two techniques, there is no in vivo study in the literature. In this in vivo study, the efficacy of lead stabilization between these two techniques was compared.

Twenty rabbits were included in this study, and they were divided into two equal groups. The anchor knot technique was used in one group, whereas the simple knot technique was used in the other group. The rabbits were followed up for 2 weeks and 4 weeks (acute term and chronic term, respectively). At the end of the acute term, the leads were evaluated for spontaneous dislocation and resistance to at least 10 N of traction force. Whether the leads maintained their position in the sleeve was evaluated by measurement. At the end of 4 weeks, in addition to aforementioned criteria, whether necrosis had occurred was evaluated on pectoral muscle biopsy specimens that included the area where suture was taken. Additionally, the two suturing techniques were also compared for procedural time on the last two rabbits of each group.

Seven and nine rabbits were evaluated for outcomes throughout acute and chronic terms, respectively. Four rabbits died during follow-up, two of which due to anesthetic complications. No lead- or suture-related complications were observed at postmortem examinations of these rabbits. All leads stabilized by using the anchor knot technique maintained their position in the sleeve and were resistant to at least 10 N of traction force in acute and chronic terms. The leads stabilized by the simple knot technique (three rabbits) maintained their position in the acute term, two of them were dislocated under traction and only one of them was found to be partially resistant to at least 10 N of traction force. 0.5 cm of dislocation was observed between that lead and its sleeve after applying traction. Only two leads (50%) stabilized by using the simple knot technique in chronic term remained their position. Lead and sleeve dislocated together in one subject, while the other lead was found separately dislocated from its sleeve. One of the two other leads was resistant to at least 10 N of traction force and that lead remained in stable in sleeve. Muscle biopsy specimens of eight rabbits were evaluated for necrosis. Two of the three samples were found to have necrosis in the simple knot technique group; however, none of the five rabbits in the anchor knot group had necrosis. The time required for the complete stabilization process in the last two rabbits of each suturing technique group was 215 s and 313.5 s on average for simple knot and anchor knot techniques, respectively.

The anchor knot technique provided more effective mechanical stabilization compared to the simple knot technique in acute and chronic terms. The simple knot technique was found to be associated with an increased risk of necrosis in chronic term. Applying the simple knot technique was faster than the anchor knot technique by only 98.5 s on average. Nevertheless, this advantage of the simple knot technique was not considered to be adequately significant when compared to lead stabilization efficiency of the anchor knot technique.

ICI-associated myocarditis is an uncommon yet potentially fatal condition, particularly when concomitant with atrioventricular block (AVB) necessitating pacing. The role of pacing therapy for ICI-associated AVB remains unknown.

The aim of this study is to investigate the efficacy and safety of pacing therapy for ICI-associated AVB.

Patients with ICI-associated myocarditis admitted to Peking Union Medical College Hospital from May 1st 2019 to April 30th 2024 were consecutively screened and the patients with AVB requiring pacing therapy were retrospectively included. Baseline clinical characteristics and initial temporary pacing therapy were evaluated. Follow-up assessments were conducted to evaluate the survival rate and the recovery of atrioventricular conduction.

A total of 43 patients with ICI-associated myocarditis were screened. Among them, a total of 11 (11/43, 25.6%) patients (mean age 64.5 ± 8.6 years, female 18.2%) were diagnosed with advanced or complete AVB and subsequently underwent pacing therapy. Short-term (within 90-days after procedure) survival rate was 72.7% (8/11). Atrioventricular conduction recovered in 4 (4/11, 36.4%) patients, without AVB recurrence after temporary pacemaker removal. For safety endpoints, right ventricular (RV) pacing parameters including pacing threshold, sensing amplitude and impedance were acceptable and no procedure-related complications occurred except RV temporary active fixation lead dislodgement in 1 patient (1/11, 9.1%). No pacing system related-infection occurred.

Pacing therapy for ICI-associated AVB demonstrates both safety and efficacy. ICI-associated AVB shows a high rate of recovery. Temporary pacemaker with active fixation lead may be a reasonable option for the initial pacing therapy.

Conduction system pacing (CSP), encompassing His bundle pacing and left bundle branch area pacing, has emerged as a physiological pacing technique designed to activate the heart's intrinsic conduction system. CSP is a promising alternative to traditional right ventricular pacing for bradycardia and to biventricular pacing for cardiac resynchronization therapy. This article outlines key considerations for achieving successful CSP implantation, including procedural techniques, available tools, and programming strategies.

The axillary vein approach has emerged as a promising alternative to subclavian venous access for pacemaker implantation, offering potential advantages including reduced infection risk and enhanced procedural success. However, standardized protocols for fluoroscopy-guided axillary vein puncture remain undefined.

This study aimed to (1) evaluate the feasibility of a simplified fluoroscopic technique for axillary vein puncture and (2) establish anatomical and clinical predictors of procedural success.

In this retrospective cohort study, 178 consecutive patients undergoing pacemaker implantation at Shanghai Tongji Hospital (January 2022-December 2023) were stratified by puncture technique: right anterior oblique (RAO) 30°, Caudal 35° (C-arm angled toward feet), and vein-guided fluoroscopy. Demographics (age, sex), comorbidities (chronic obstructive pulmonary disease (COPD), spinal disorders), smoking status, and radiographic parameters (subclavian fat thickness, clavicle-first rib angle) were analyzed.

Axillary vein puncture was successful in 169/178 patients (94.9%) without venography. First-attempt success rates were 75.8% (135/178) for RAO 30° and 79.1% (34/43) for Caudal 35°. Key predictors of success included: Sex-specific anatomy, BMI threshold and Clavicular angx les. There was a significant difference in smoking status, subclavian fat thickness 2 cm below the collarbone between males and females (P < 0.001).ROC analysis identified BMI ≥ 23.84 kg/m² as optimal for success (AUC = 0.64, 95% CI: 0.48-0.83).Frontal clavicle-first rib angle independently predicted RAO 30° success (P = 0.012, OR = 1.08, 95% CI: 1.02-1.15), while RAO clavicle-first rib angle correlated with Caudal 35° success (P = 0.031, OR = 1.05, 95% CI: 1.01-1.09). In this study, the cumulative incidence of procedure-related complications was 1.69%. Severe complications such as pneumothorax or lead dislodgement were not observed, highlighting the safety profile of the intervention.

Successful fluoroscopy-guided axillary vein puncture depends critically on patient-specific anatomical factors, including sex, BMI, clavicle-first rib spatial relationships, and smoking status. Our standardized protocol achieved high success rates (94.9%) without ultrasound assistance, highlighting its utility in resource-limited settings.

Ultrasound-guided axillary vein puncture (US-AVP) has recently emerged as a valid alternative to standard vein puncture (SVP) for cardiac implantable electronic device implantation. This meta-analysis aimed to compare the efficacy and safety of US-AVP versus SVP. A comprehensive search of PubMed, Embase, and Cochrane databases identified randomized clinical trials and nonrandomized clinical trials comparing these techniques. Pooled relative risks (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated using random- or fixed-effects models, and trial sequential analysis was conducted to assess the robustness of findings. Twelve studies met the inclusion criteria, including 3085 patients (1227 in the US-AVP group and 1858 in the SVP group). US-AVP significantly reduced total complication rates compared with SVP [RR, 0.65 (95% CI, 0.48-0.89); P = 0.006; I² = 0%], with no significant difference in success rates [RR, 1.05 (95% CI, 0.99-1.11); P = 0.137; I² = 60%]. Fluoroscopy duration was significantly shorter in the US-AVP group [MD, -1.58 min (95% CI, -2.16 to -0.99); P < 0.001; I² = 81%], and X-ray exposure was markedly lower [MD, -3.23 mGy·cm² (95% CI, -6.03 to -0.43); P = 0.024; I² = 93%]. The trial sequential analysis supported the robustness of the evidence for reduced complications. In conclusion, US-AVP demonstrated a safety advantage over SVP by reducing complications while achieving comparable efficacy.

Conduction system pacing (CSP) is being increasingly adopted as a more physiological alternative to right ventricular and biventricular pacing. Since the 2021 European Society of Cardiology pacing guidelines, there has been growing evidence that this therapy is safe and effective. Furthermore, left bundle branch area pacing was not covered in these guidelines due to limited evidence at that time. This Clinical Consensus Statement provides advice on indications for CSP, taking into account the significant evolution in this domain.

In the electrophysiologic (EP) lab, technical support for implantable cardioverter/defibrillators (ICD) and cardiac resynchronization therapy (CRT-D) procedures is often limited by the availability and costs of field clinical specialist (FCS) bioengineers.

This study explores the viability of using remote support through an internet-based platform for ICD and CRT-D implantation procedures, aiming to enhance efficiency and overcome geographical or pandemic-related barriers. After preclinical phases, thirty patients underwent ICD/CRT-D guided either remotely or with on-site FCS implantation at two primary cardiac care centers, with ten procedures guided remotely and twenty cases with on-site FCS.

All procedures in both study arms were successfully completed (100% of cases). Procedural time was shorter in the telemedicine group (P = 0.031). Although fluoroscopic time was slightly reduced in the remote guided group, the difference did not reach statistical significance (P = 0.5). No major adverse events occurred.

The study demonstrates the feasibility of remotely supported ICD and CRT-D implantation procedures.

Left bundle branch area pacing is currently the most common form of physiological pacing prior to His bundle pacing. It is intended to prevent or correct the development of pacemaker-induced cardiomyopathy and is being used more and more frequently. In order to be able to perform this successfully, knowledge regarding the specific anatomy and radiological anatomy as well as the ECG criteria for left bundle branch pacing is required in addition to knowledge of the tools. In this article, the technical requirements and steps for successful implantation are summarized and pitfalls are highlighted.

Whether it is reasonable to program ATP in patients with electrical heart disease (EHD) or hypertrophic cardiomyopathy (HCM) is not thoroughly clarified. Aim of the study was to define the types of ventricular arrhythmias and evaluate the safety and efficacy of ATP activation in these patients.

A total of 154 patients (53.9 % male, 64.9 % secondary prevention) with EHD or HCM, who had an implanted cardioverter defibrillator (ICD) with ATP activated, were included in this retrospective analysis; comprising a median of 65.0 months of follow-up. In 39/154 (25.3 %) patients appropriate ICD therapy was delivered during the follow-up. Patients with HCM had a significantly higher incidence rate of monomorphic VTs than patients with EHD (0.21 versus 0.01 per month, 0 < 0.001). ATP terminated monomorphic VT with an efficacy of 88,2 % in 94.9 % of the occurring episodes. The incidence rate per month of torsade de pointes (TdP) tachycardia and VF was significantly higher in patients with EHD versus HCM (0.04 vs. 0.001, p=<0.001; 0.06 vs. 0.007, p=<0.001). The termination of TdP tachycardia and VF was associated with ATP in 14.0 % and 0 % (ATP efficacy of 28.3 % and 0 % respectively). The implantation for secondary prevention was associated with the occurrence of appropriate ICD therapy during the follow-up period (OR 3.94 [95%CI 1.53-10.14], p = 0.005).

Ventricular tachycardias in patients with HCM are primarily monomorphic and can be effectively terminated with ATP. In patients with EHD, TdP tachycardias and VF occur more frequently and are preferentially terminated by ICD shock.

The effect of electrical delay at the left ventricular (LV) pacing site on acute hemodynamic response with cardiac resynchronization therapy (CRT) has been investigated only in small observational studies.

This study evaluates the impact of electrical delay, as assessed by interventricular (right ventricular-LV]) interval, on the acute hemodynamic response to CRT in a large, diverse multicenter cohort.

A total of 144 patients in 3 prospective studies, the PATH-CHF (Pacing Therapies in Congestive Heart Failure) I and II and the CRTAVO (CRT Optimization Algorithm Validation Study), were pooled and analyzed. At the time of CRT implantation, all pacing leads, pressure catheters placed in the right ventricle and left ventricle, and the surface electrocardiogram were connected to an external pacing computer. A standardized, randomized stimulation protocol was used to assess response.

The RV-LV interval was associated with an increase in the rate of LV pressure rise response. In the full cohort, LV effective contractility monotonically increased with a prolongation of the RV-LV time. Other significant predictors of the increase in rate of LV pressure rise were QRS duration and, to a lesser extent, female sex and ischemic etiology.

RV-LV and QRS durations are strong predictors of the acute hemodynamic response with CRT. These findings may help in patient selection, lead placement, and pacing benefit expectation.

Both the performance of electrophysiological examinations and the implantation of cardiac devices (pacemakers, implantable cardioverter-defibrillator [ICDs], and cardiac resynchronization therapy defibrillator [CRT-D] systems) are associated with vascular punctures. This article provides an overview of possible vascular complications and their management from the perspective of angiology. The most common access site for invasive electrophysiological procedures is usually via the femoral veins and/or arteries. Puncture of the brachial vessels is a possible but rarely used alternative. For implantation of transvenous cardiac devices, access via the cephalic vein or axillary vein is used. The electrodes located in the venous vascular system represent a foreign material and increase the risk of thrombus formation in the affected vein. Punctures of the femoral vessels can lead to bleeding, thrombosis and the formation of arteriovenous fistulas or pseudoaneurysms (aneurysma spurium). Venous thromboses can occur postprocedurally. The correct puncture technique is essential to avoid complications. Ultrasound-guided puncture also significantly reduces the rate of vascular complications.

Physicians are increasingly likely to encounter patients with both cardiac implantable electronic devices (CIED) and breast implants in situ. Our case indicates the importance of appropriate planning and multidisciplinary input for CIED procedures in patients with breast implants or vice versa. When planning the procedure, the aesthetic outcome needs to be considered.

Little data exists regarding the optimal antithrombotic strategy during S-ICD implantation to prevent pocket hematomas. This study explores the association between perioperative antithrombotic management and the occurrence of pocket hematoma following S-ICD implantation.

All patients who underwent de novo S-ICD implantation between February 2009 and January 2023 at Amsterdam UMC were included. Data was collected retrospectively from electronic patient records. Clinically significant pocket hematomas were defined as an accumulation of blood at the pocket site within 30 days after implantation.

A total of 347 patients were included of which 224 (64.6%) patients used antithrombotic therapy pre-implantation. The median age at implantation was 50 years (IQR 36-61 years), 33.4% of the patients were female, and the majority of implants were intermuscular (90.2%). A total of 18 patients (5.2%) developed a clinically significant pocket hematoma. There were significantly more pocket hematomas in patients with continued vitamin K antagonists (VKA) compared to patients with interrupted VKA (27.3% (6/22) vs. 4.3% (2/47), respectively, p = 0.01), and continuation of VKA was an independent predictor for pocket hematoma formation in the VKA group (p = 0.04). Moreover, continuation of dual antiplatelet therapy (DAPT) with ticagrelor was associated with significantly more pocket hematomas post-implantation compared to continuation of DAPT with clopidogrel (4/12 vs. 1/28, respectively, p = 0.02).

Continuation of VKA during S-ICD implantation was associated with an increased risk of pocket hematoma formation compared to interruption of VKA. This supports the need for specific perioperative antithrombotic therapy guidelines for S-ICD implantations to reduce the risk of pocket hematomas.

Left bundle branch area pacing (LBBAP) seems to be an alternative to coronary sinus pacing in patients with non-ischaemic dilated cardiomyopathy (NI-DCM) with left bundle branch block (LBBB) and in pacing-induced cardiomyopathy (PICM). The aim of the study was to compare the response of LBBAP in severe forms of both entities.

Prospective study of patients with severe forms of PICM and NI-DCM in NYHA II-IV who underwent LBBAP. Clinical, electrocardiographic, echocardiographic and electrical parameters were analysed and the medium-term prognostic impact was assessed.

Eighty patients were included, 25 with PICM and 55 with NI-DCM. PICM patients were older (PICM 75 [IQR 71-83.5] y.o vs NI-DCM 72 [IQR 60-78.5] y.o;p=0.01) and with longer baseline QRS duration (PICM 180 [IQR 167-194] ms vs NI-DCM 168 [IQR 153-178] ms;p<0.01), with no differences in left ventricular ejection fraction (LVEF) or medical treatment. QRS reduction occurred in both groups, being greater in PICM (PICM CI 95% 54±20 ms, p<0.01; NI-DCM CI 95% 40±15 ms;p<0.01). A NT-ProBNP levels reduction and LVEF improvement were observed without differences between groups. At follow-up, there were no differences in admissions for HF (PICM 4.2% vs NI-DCM 11%;p=0.413), cardiac mortality (PICM 14.9% vs NI-DCM 2.9%;p=0.13) and all-cause mortality (PICM 21.7% vs NI-DCM 10.9%;p=0.08).

LBBAP is an effective technique with a NT-ProBNP levels reduction and LVEF improvement in both groups without differences. At follow-up, both groups had a low rate of HF readmissions and there was a non-significant trend toward higher total mortality in PICM.

The number of cardiac implantable electronic devices (CIEDs) implanted has been growing and the population who receive the device is older and has more comorbidities. Long bed rest and immobilisation have always been common after the implant, but a consensus does not exist on the argument.

To map and synthesise available literature on the mobilisation approach after the implant of a CIED and which correlated outcomes exist.

A literature search was conducted in December 2023 on six databases. Screening of articles, data extraction and quality appraisal were performed by more than one author. Articles included were primary articles exploring bed rest or mobilisation after a CIED procedure. Descriptive analysis was conducted to present and synthesise the results.

Of the 113 records identified, eight matched the inclusion criteria. The majority of the articles were randomised controlled trials (n = 6). Other studies were quasi-experimental (n = 1), retrospective (n = 1) and cross-sectional (n = 1). Data descriptive analysis led to the development of three main topics: (1) mobilisation modalities, (2) potential complications and (3) type of device.

Early mobilisation after a CIED procedure appears to be safe and not associated with other complications. A predominant barrier to early mobilisation is the lack of a consensus on the time and type of mobilisation. Early mobilisation could be applied more safely with the use of an arm support. To strengthen the evidence there is a need for more rigorous research analysing the type of device and the leads utilised.

Pericardial effusion, a known complication to implantation of cardiac implantable electronic devices (CIED), may cause life-threatening cardiac tamponade. Limited knowledge is available about risk factors for clinically relevant procedural pericardial effusion. The aim is to identify the patient- and procedure-related risk factors associated with clinically relevant procedural pericardial effusion.

A nationwide observational cohort study based on data on 55 121 patients from the Danish Pacemaker Register between 2000 and 2018. We defined a clinically relevant procedural pericardial effusion related to the implantation if it occurred within 90 days after the primary CIED-procedure. Prespecified risk factors were analysed by multivariable logistic regression models to estimate the association with pericardial effusion.

There were 115 (0.21%) patients diagnosed with clinically relevant procedural pericardial effusion, with a median age of 75 years and 38.3% were females. Of these, 80.9% lead to a subsequent pericardiocentesis procedure. In adjusted logistic regression analysis, an increased risk of clinically relevant pericardial effusion was associated with female sex (OR:1.49 [95%CI: 1.03-2.16]), heart failure (OR:1.54 [95%CI: 1.06-2.23]), previous cardiac surgery (OR:1.63 [95%CI: 1.05-2.55]), CRT-device (OR:2.05 [95%CI: 1.23-3.41]), tertiary-centres (OR:1.8 [95%CI: 1.18-2.73]), increased procedural volume per year (>1000) (OR:1.85 [95%CI: 1.03-3.30]), indication of device-implantation (atrioventricular block) (OR:2.37 [95CI: 1.45-3.87]), and increasing number of leads implanted (two leads (OR:2.39 [95%CI: 1.43-4.00]), three leads (OR:4.77 [95%CI: 2.50-9.10])).

Clinically relevant procedural pericardial effusion is a rare complication after CIED-implantation in Denmark. This study reveals important patient- and procedure-related risk factors associated with clinically relevant procedural pericardial effusion.

The complications associated with cardiac device implants ranges between 5.3% and 14.3%. Cardiac perforation due to "leads" represent a very rare complication of cardiac device implantation, ranging between 0.3% and 0.7%. Clinically, they can manifest different, nonspecific symptoms; hence, the diagnosis may not be immediate.

Our clinical case describes the successful treatment of cardiac tamponade occurring in a Caucasian 79-year-old man following a pacemaker implantation. Two days after the procedure, the patient reported an episode of nonspecific chest pain associated with syncope. The echocardiogram performed revealed a pericardial effusion in the apical area, along the right chambers, with a thickness of 7 mm, not hemodynamically significant. A chest computed tomography scan with contrast showed hemopericardium (maximum thickness of 11 mm), caused by an atrial perforation. A few hours later, the patient experienced hemodynamic instability. For this reason, an urgent sternotomy was performed with drainage of a significant hemopericardial effusion, revealing a perforation of the upper free wall of the right atrium with pericardial injury caused by the retractable screw lead. The perforation site was sutured and the sternal wound was closed. The patient was discharged after 4 days without further complications. At the control visit, scheduled 30 days after the hospital discharge, the patient was in good conditions.

Although the atrial perforations from leads are very rare complications of pacemaker implantation procedures, they are potentially lethal. In conclusion, this clinical case highlights the need, before hospital discharge, of an accurate screening for evaluation the pericardial effusion in patients that undergo to the cardiac implantable electronic devices.

Data on implants of cardiac pacing systems in Spain in 2023 are presented.

The registry is based on the information provided by centers to the recording platform of the Heart Rhythm Association after device implantations, through Cardiodispositivos, the online platform of the National Registry. Other information sources include: a) data transfers from the manufacturing and marketing industry; b) the European pacemaker patient card; and c) local databases submitted by the implanting centers.

In 2023, 112 hospitals participated in the registry (30 more than in 2022). A total of 24 343 device implantations were reported (48.1% more than in 2022) compared with 45 120 reported by Eucomed (European Confederation of Medical Suppliers Associations). Of these, 1646 were cardiac resynchronization therapy pacemakers. The devices showing the largest increases were leadless pacemakers, with 963 devices implanted, representing an 18.1% increase over 2022. The most frequent indication was atrioventricular block followed, for the first time, by atrial tachyarrhythmia with slow ventricular response. The number of devices included in remote monitoring also increased (cardiac resynchronization therapy defibrillators, 71%; cardiac resynchronization therapy pacemakers, 63%; and conventional pacemakers, 28%), although more moderately.

In 2023, there was an increase in the number of institutions participating in the registry. The reporting of device implantations rose by 48.1%, and the implantation of leadless pacemakers grew by 18.1%. Remote monitoring also experienced modest growth compared with previous years.

This study reviews the published data comparing the efficacy and safety of apical and septal right ventricle defibrillator lead positioning at 1-year follow-up. Systemic research on Medline (PubMed), ClinicalTrials.gov , and Embase was performed using the keywords "septal defibrillation," "apical defibrillation," "site defibrillation," and "defibrillation lead placement," including implantable cardioverter-defibrillator and cardiac resynchronization therapy devices. Comparisons between apical and septal position were performed regarding R-wave amplitude, pacing threshold at a pulse width of 0.5 ms, pacing and shock lead impedance, suboptimal lead performance, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter, readmissions due to heart failure and mortality rates. A total of 5 studies comprising 1438 patients were included in the analysis. Mean age was 64.5 years, 76.9% were male, with a median LVEF of 27.8%, ischemic etiology in 51.1%, and a mean follow-up period of 26.5 months. The apical lead placement was performed in 743 patients and septal lead placement in 690 patients. Comparing the 2 placement sites, no significant differences were found regarding R-wave amplitude, lead impedance, suboptimal lead performance, LVEF, left ventricular end-diastolic diameter, and mortality rate at 1-year follow-up. Pacing threshold values favored septal defibrillator lead placement ( P = 0.003), as well as shock impedance ( P = 0.009) and readmissions due to heart failure ( P = 0.02). Among patients receiving a defibrillator lead, only pacing threshold, shock lead impedance, and readmission due to heart failure showed results favoring septal lead placement. Therefore, generally, the right ventricle lead placement does not appear to be of major importance.

The use of ultrasound (US)-guided venous puncture for cardiac pacing/defibrillation lead placement may minimize the risk of periprocedural complications and radiation exposure. However, none of the published studies have been sufficiently powered to recommend this approach as the standard of care. We compare the safety and efficacy of ultrasound-guided axillary venous puncture (US-AVP) vs. fluoroscopy-guided access for cardiac implantable electronic devices (CIEDs) by performing an individual patient data meta-analysis based on previously published studies.

We conducted a thorough literature search encompassing longitudinal investigations (five randomized and one prospective studies) reporting data on X-ray-guided and US-AVP for CIED procedures. The primary endpoint was to compare the safety of the two techniques. Secondary endpoints included the success rate of each technique, the necessity of switching to alternative methods, the time needed to obtain venous access, X-ray exposure, and the occurrence of periprocedural complications. Six longitudinal eligible studies were identified including 700 patients (mean age 74.9 ± 12.1 years, 68.4% males). The two approaches for venous cannulation showed a similar success rate. The use of an X-ray-guided approach significantly increased the risk of inadvertent arterial punctures (OR: 2.15, 95% CI: 2.10-2.21, P = 0.003), after adjustment for potential confounders. Conversely, a US-AVP approach reduces time to vascular access, radiation exposure, and the number of attempts to vascular access.

The US-AVP enhances safety by reducing radiation exposure and time to vascular access while maintaining a low rate of major complications compared to the X-ray-guided approach.

PROSPERO identifier: CRD42024539623.

Various surgical procedures have employed microporous polysaccharide hemosphere (MPH) hemostatic agents. However, data regarding their effectiveness in preventing pocket hematomas (PHs) during the implantation of cardiac implantable electronic devices (CIED) among the Asian population are limited. Therefore, this study aimed to investigate the potential benefits of using MPH hemostatic agents during CIED implantations as a preventive measure against post-procedural PHs.

We conducted a retrospective, single-center, observational study involving 255 consecutive Japanese patients who underwent CIED implantation between November 2017 and April 2021. We compared PH occurrences within 28 days after CIED implantation between patients who received MPH hemostatic agents (n = 145) and those who did not (n = 110).

PH development was observed in nine (6.2%) patients who received MPH hemostatic agents and in 13 (11.8%) patients without MPH hemostatic (p = .111). Kaplan-Meier analysis of PH development revealed no significant difference between the two groups (log-rank p = .102). However, utilizing MPH hemostatic agents among patients taking antithrombotic drugs, including antiplatelet medications, direct oral anticoagulants, and warfarin, significantly reduced PH incidence (log-rank p = .03). The multivariate Cox proportional hazards model demonstrated that MPH hemostatic agent utilization independently correlated with a decreased PH risk (hazard ratio 0.22, 95% confidence interval 0.08-0.63, p = .004).

The findings of this study suggest that the incorporation of MPH hemostatic agents into standard practice may benefit to mitigate PH risk during CIED implantations in patients on antithrombotic therapy. This simple and practical measure may be valuable, especially in high-risk patients, such as those taking antithrombotic medications.

The utility of atrioventricular (AV) optimization (AVO) algorithms remains in question. A substudy of the SMART-AV trial found that patients with prolonged interventricular delays ≥70 ms were more likely to benefit from cardiac resynchronization therapy (CRT) with AVO. The SMART-CRT trial evaluated AVO on the basis of these results, but the study was underpowered.

To increase statistical power, data from SMART-AV patients meeting the inclusion criterion of interventricular delay ≥70 ms were pooled with data from SMART-CRT to reassess AVO.

SMART-CRT and SMART-AV were prospective, randomized, multicenter clinical trials. Patients in both studies were randomized to be programmed with an AVO algorithm (SmartDelay) or fixed AV delay (120 ms). Paired echocardiograms obtained at baseline and 6 months were compared, with CRT response defined as ≥15% reduction in left ventricular end-systolic volume.

A total of 451 complete patient data sets were pooled and analyzed. The baseline demographics between studies did not differ statistically in terms of age, sex, left ventricular ejection fraction, or left ventricular end-systolic volume. The AVO group had a greater proportion of CRT responders (SmartDelay, 73.9%; fixed, 63.1%; P = .014) and greater changes in measures of reverse remodeling. SmartDelay patients with a recommended sensed AV delay outside the nominal range (100-120 ms) had 2.3 greater odds of CRT response than fixed AV delay patients.

Greater CRT response and measures of reverse remodeling were observed in patients with SmartDelay enabled vs a fixed AV delay. This study supports the use of SmartDelay in patients with a CRT indication and interventricular delay ≥70 ms.

Patients requiring extraction of infected or dysfunctional cardiac implantable electronic devices (CIED) have high morbidity and mortality. The Micra™ leadless cardiac pacemaker (LCP) may be beneficial for patients requiring permanent pacemaker therapy after CIED extraction.

This study aimed to assess the feasibility, timing and outcomes of LCP implantation in patients who underwent CIED extraction due to infection or dysfunction. The local Micra™ LCP registry was reviewed for LCP implantations and CIED extractions.

Micra™ LCP implantation was scheduled for 48 consecutive patients (21 women, 44%) undergoing CIED extraction for infection (n = 38, 79%) or dysfunction (n = 10, 21%), and feasible in 47 (98%). Complete CIED removal was feasible in 44 patients (92%) and in 37/38 patients with infected CIED (97%). Overall, 32 LCP (67%) were implanted in a single procedure: 3 (6%) before and 13 (27%) after CIED extraction. LCP were implanted in a single procedure in 24/38 patients (63%) with infected CIED and in 8/10 patients (80%) with dysfunctional CIED. The in-hospital mortality rate was 6% (n = 3), and the survival rates at 30 days, 90 days and 1 year were 94% (n = 45/48), 90% (n = 43/48), and 85% (n = 41/48), respectively. No recurrent LCP-related mortality or infections occurred during a median follow-up of 15 (interquartile range, 12-41) months.

Two-thirds of LCPs could be implanted in a single procedure with CIED extraction; no recurrent infections were detected. Overall, Micra™ LCP implantation in patients requiring CIED extraction was feasible.

There is an increase in the sale of legal drugs in our country. One of these substances is kratom. Kratom (Mitragyna speciosa) is a partial agonist of the opioid kappa, mu, and delta receptors. It acts as a stimulant at low concentrations, making users feel more energetic and euphoric. It has sedative and antinociceptive effects at higher doses.

An 18-year-old man collapsed during football training and required cardiopulmonary resuscitation; the initial rhythm was ventricular fibrillation managed by defibrillation. Laboratory parameters were unremarkable. Blood samples sent for toxicological evaluation were positive for kratom and caffeine. Echocardiographic examination, coronary computed tomography angiography, and cardiac magnetic resonance imaging did not prove the cause. Genetic testing did not find a pathogenic gene variant associated with familial ventricular fibrillation, but a variant of unknown significance was found in MYOM1. Given this situation, we implanted an implantable cardioverter-defibrillator (ICD) from the secondary prevention of sudden cardiac death (SCD) according to the guidelines of the European Society of Cardiology (ESC). No recurrence of ventricular arrhythmia has been reported by ambulatory ICD memory checks on our patient.

In some country, kratom is freely available and sold as a plant, not a drug. Only incident cases of ventricular fibrillation after kratom use are described in the literature. There is insufficient scientific evidence linking kratom to ventricular fibrillation. This is an absolutely crucial case report of this type, which has not yet been published in similar circumstances in the world. Therefore, the development of ventricular fibrillation was assumed to be due to a combination of kratom, caffeine, and exercise. The safety profile and effects of kratom should be the subject of future research. We would like to stress the importance of reporting further case series for more scientific evidence and thus increasing the pressure for stricter availability and regulation of kratom in some countries, especially where it is over-the-counter.

The establishment of venous access is one of the driving factors for complications during implantation of pacemakers and defibrillators (cardiac implantable electronic devices [CIED]). Recently, a novel approach of accessing the cephalic vein for CIED by cephalic vein puncture (CVP) using a modified Seldinger technique has been described, promising high success rates and simplified handling with steeper learning curves. In this single-center registry, we analyzed the safety and efficiency of CVP to SVP access after defining CVP as the primary access route in our center.

A total of 229 consecutive patients receiving a CIED were included in the registry. Sixty-one patients were implanted by primary or bail-out SVP; 168 patients received primary cephalic preparation and CVP was performed when possible, using a hydrophilic transradial sheath.

Implantation of at least one lead via CVP was successful in 151 of 168 patients (90%), and implantation of all leads was possible in 122 of 168 patients (72.6%). Total implantation times and fluoroscopy times and doses did not differ between CVP and SVP implantations. Pneumothorax occurred in 0/122 patients implanted via CVP alone, but 8/107 (7.5%) patients received at least one lead via SVP.

Our data confirms high success rates of the CVP for CIED implantation. Moreover, this method can be used without significantly prolonging the total procedure time or applying fluoroscopy dose compared to the highly efficient SVP while showing lower overall complication rates.

Venous spasm is an important reason for complicated or failed implantations of cardiac implantable electronic devices. Prevention or risk reduction of venous spasm during cardiac implantable electronic device implantation may be achieved by ultrasound or fluoroscopic imaging prior to puncture, cephalic vein cut-down, sufficient pre- and perioperative hydration, nitroglycerin injection and effective sedation, and analgesia.

This case report with literature review focuses on venous spasm as a potential cause for complicated implantations of cardiac implantable electronic devices. The case report is clinically relevant as it describes a progressive spasm affecting the axillary and the subclavian vein. A 66-year-old female complained of symptomatic atrial fibrillation (AF) and atypical atrial flutter despite interventional and medical treatment. As an ultimate treatment, she was scheduled for pacemaker implantation and atrioventricular node ablation. Several puncture attempts of the axillary vein failed. Despite venous blood aspiration, no guidewires could be advanced into the axillary vein. We performed a first venogram revealing significant spasm of the axillary vein. Another failed venous puncture occurred after change of access site to the subclavian vein. A second venogram displayed progression of the spasm, now affecting both the axillary and the subclavian veins. Normal saline perfusion was administered as well as intravenous isosorbide. Unfortunately, a repeated venogram after 15 min waiting time showed persistence of the spasm, still affecting both veins. The procedure was discontinued as the patient became uncomfortable. Venous spasm is an important reason for complicated or failed implantations of cardiac implantable electronic devices. Commonly used medical prevention and treatment are intravenous fluids and nitroglycerin. Prevention or risk reduction of venous spasm during cardiac implantable electronic device implantation may be achieved by ultrasound or fluoroscopic imaging prior to puncture, cephalic vein cut-down, sufficient pre- and perioperative hydration, nitroglycerin injection and effective sedation and analgesia.

Bleeding complications after pacemaker implantation pose risks, including infection and prolonged hospital stay. A case involving aortic intramural hematoma (IMH) arising from subclavian vein access during implantation and concomitant acute pulmonary embolism (PE) is presented. In the present case, IMH probably resulted from subclavian artery vasa vasorum trauma during vein puncture and guidewire advancement, leading to IMH and hemothorax. PE possibly stemmed from a prothrombotic state caused by the intervention and the IMH. Conservative management with serial CT scans was chosen due to hemodynamic stability and high surgical risk. IMH and PE resolution was confirmed at follow-up.

Cardiac tamponade due to perforation of a cardiac chamber is a rare complication occurring in only 0.3% of patients undergoing permanent pacemaker (PM) implantation. Notably, perforation of the right coronary artery (RCA) following permanent PM implantation has only been reported twice in the literature. We report a rare case of RCA perforation leading to life-threatening cardiac tamponade with symptom onset 4 days after PM implantation.

A 75-year-old woman underwent permanent PM implantation without any difficulties in placing pacemaker leads and with good thresholds. Four days later, the patient was readmitted in a state of shock due to cardiac tamponade. A blood gas analysis on the bloody pericardial effusion raised suspicion of ongoing arterial bleeding. A CT scan ruled out aortic dissection; instead, the source of bleeding was identified as a perforation in the RCA, which was managed surgically.

This case highlights the necessity of coronary artery perforation being among the differential diagnoses of cardiac tamponade after PM implantation, and it stresses the usefulness of performing a blood gas analysis on the bloody pericardial effusion.

While supported by robust evidence and decades of clinical experience, right ventricular apical pacing for bradycardia is associated with a risk of progressive left ventricular dysfunction. Cardiac resynchronization therapy for heart failure with reduced ejection fraction can result in limited electrical resynchronization due to anatomical constraints and epicardial stimulation. In both settings, directly stimulating the conduction system below the atrio-ventricular node (either the bundle of His or the left bundle branch area) has potential to overcome these limitations. Conduction system pacing has met with considerable enthusiasm in view of the more physiological electrical conduction pattern, is rapidly becoming the preferred option of pacing for bradycardia, and is gaining momentum as an alternative to conventional biventricular pacing.

This article provides a review of the current efficacy and safety data for both people requiring treatment for bradycardia and the management of heart failure with conduction delay and discusses the possible future roles for conduction system pacing in routine clinical practice.

Conduction system pacing might be the holy grail of pacemaker therapy without the disadvantages of current approaches. However, hypothesis and enthusiasm are no match for robust data, demonstrating at least equivalent efficacy and safety to standard approaches.

This updated guidance is designed to help with implantation and follow-up with agreed standards of practice. The update includes new guidance on subcutaneous defibrillators, leadless pacemakers and conduction system pacing. It includes new guidance on considerations at the time of a potential box change and techniques to be considered to minimise the risk of infection.

Atrioventricular block (AVB) is a frequent complication in patients undergoing transcatheter aortic valve implantation (TAVI). Right apex ventricular pacing (RVP) represents the standard treatment but may induce cardiomyopathy over the long term. Left bundle branch area pacing (LBBAP) is a promising alternative, minimizing the risk of desynchrony. However, available evidence with LBBAP after TAVI is still low.

To assess the feasibility and safety of LBBAP for AVB post-TAVI compared with RVP.

Consecutive patients developing AVB early after TAVI were enrolled between 1 January 2022 and 31 December 2022 at three high-volume hospitals and received LBBAP or RVP. Data on procedure and at short-term follow-up (at least 3 months) were collected.

A total of 38 patients (61% men, mean age 83 ± 6 years) were included; 20 patients (53%) received LBBAP. Procedural success was obtained in all patients according to chosen pacing strategy. Electrical pacing performance at implant and after a mean follow-up of 4.2 ± 2.8 months was clinically equivalent for both pacing modalities. In the LBBAP group, procedural time was longer (70 ± 17 versus 58 ± 15 min in the RVP group, P  = 0.02) and paced QRS was shorter (120 ± 19 versus 155 ± 12 ms at implant, P  < 0.001; 119 ± 18 versus 157 ± 9 ms at follow-up, P  < 0.001). Complication rates did not differ between the two groups.

In patients with AVB after TAVI, LBBAP is feasible and safe, resulting in a narrow QRS duration, either acutely and during the follow-up, compared with RVP. Further studies are needed to evaluate if LBBAP reduces pacing-induced cardiomyopathy in this clinical setting.

Cardiac device therapy provides not only treatment options for bradyarrhythmia but also advanced treatment for heart failure and preventive measures against sudden cardiac death. In heart failure treatment it enables synergistic reverse remodelling and reduces pharmacological side effects. Cardiac resynchronization therapy (CRT) has revolutionized the treatment of reduced left ventricular ejection fraction (LVEF) and left bundle branch block by decreasing the mortality and morbidity with improvement of the quality of life and resilience. Conduction system pacing (CSP) as an alternative method of physiological stimulation can improve heart function and reduce the risk of pacemaker-induced cardiomyopathy. Leadless pacers and subcutaneous/extravascular defibrillators offer less invasive options with lower complication rates. The prevention of infections through preoperative and postoperative strategies enhances the safety of these therapies.

In Tunisia, the number of cardiac implantable electronic devices (CIEDs) is increasing, owing to the increase in patient life expectancy and expanding indications. Despite their life-saving potential and a significant reduction in population morbidity and mortality, their increased numbers have been associated with the development of multiple early and late complications related to vascular access, pockets, leads, or patient characteristics.

The study aims to identify the rate, type, and predictors of complications occurring within the first year after CIED implantation. It also aims to describe the demographic and epidemiological characteristics of a nationwide sample of patients with CIED in Tunisia. Additionally, the study will evaluate the extent to which Tunisian electrophysiologists follow international guidelines for cardiac pacing and sudden cardiac death prevention.

The Tunisian National Study of Cardiac Implantable Electronic Devices (NATURE-CIED) is a national, multicenter, prospectively monitored study that includes consecutive patients who underwent primary CIED implantation, generator replacement, and upgrade procedure. Patients were enrolled between January 18, 2021, and February 18, 2022, at all Tunisian public and private CIED implantation centers that agreed to participate in the study. All enrolled patients entered a 1-year follow-up period, with 4 consecutive visits at 1, 3, 6, and 12 months after CIED implantation. The collected data are recorded electronically on the clinical suite platform (DACIMA Clinical Suite).

The study started on January 18, 2021, and concluded on February 18, 2023. In total, 27 cardiologists actively participated in data collection. Over this period, 1500 patients were enrolled in the study consecutively. The mean age of the patients was 70.1 (SD 15.2) years, with a sex ratio of 1:15. Nine hundred (60%) patients were from the public sector, while 600 (40%) patients were from the private sector. A total of 1298 (86.3%) patients received a conventional pacemaker and 75 (5%) patients received a biventricular pacemaker (CRT-P). Implantable cardioverter defibrillators were implanted in 127 (8.5%) patients. Of these patients, 45 (3%) underwent CRT-D implantation.

This study will establish the most extensive contemporary longitudinal cohort of patients undergoing CIED implantation in Tunisia, presenting a significant opportunity for real-world clinical epidemiology. It will address a crucial gap in the management of patients during the perioperative phase and follow-up, enabling the identification of individuals at particularly high risk of complications for optimal care.

ClinicalTrials.gov NCT05361759; https://classic.clinicaltrials.gov/ct2/show/NCT05361759.

RR1-10.2196/47525.