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Shah S, Zalavadia D, Shah N, Ponnusamy SS, Vijayaraman P, Schaller RD. Outcomes of Left Bundle Branch Area Pacing Upgrade in Patients with Right Ventricular Pacing-Induced Cardiomyopathy. Heart Rhythm 2025:S1547-5271(25)02458-0. [PMID: 40409383 DOI: 10.1016/j.hrthm.2025.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2025] [Revised: 05/12/2025] [Accepted: 05/17/2025] [Indexed: 05/25/2025]
Abstract
BACKGROUND Pacemaker-induced cardiomyopathy (PICM) is an increasingly recognized consequence of right ventricular pacing (RVP), which can lead to significant decline in left ventricular ejection fraction (LVEF) and development of heart failure symptoms. Left bundle branch area pacing (LBBAP) is an effective strategy for cardiac resynchronization therapy (CRT), but its role in PICM is not well defined. OBJECTIVE This study sought to determine what the clinical and echocardiographic responses were in patients with PICM who underwent LBBAP. METHODS This was an observational, retrospective, multicenter study. Patient and lead-related characteristics along with clinical and echocardiographic data were tracked. RESULTS Sixty-four patients were included, with a mean LVEF of 36.5 ± 8.8 and New York Heart Association (NYHA) status of 2.72 ± 0.68 before LBBAP. Successful LBBAP was achieved with a significant reduction in QRS duration (172.5 ± 21.9 to 133.4 ± 19.2 ms, p<0.001) which was associated with an increase in LVEF by an average of 1.0 ± 17.7% (p<0.001), and an improvement in NYHA status (2.72 ± 0.68 to 1.75 ± 0.6, p<0.001). Lead extraction was performed in 18/64 patients (28%). Outcomes did not significantly differ between patients with ≥90% and <90% RV pacing burdens. CONCLUSIONS This study - the largest series investigating LBBAP for PICM to date - supports LBBAP as a viable, effective alternative to conventional CRT in PICM, offering improvements in cardiac function and patient symptoms. However, larger randomized trials are needed to validate these findings in a broader, more heterogeneous population.
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Affiliation(s)
- Samir Shah
- Department of Medicine, Division of Cardiology, Einstein Medical Center, Philadelphia, PA, USA
| | - Dipen Zalavadia
- Division of Cardiovascular Disease, The Wright Center, Scranton, PA
| | - Nischay Shah
- Division of Cardiovascular Disease, The Wright Center, Scranton, PA
| | - Shunmuga S Ponnusamy
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | - Pugazhendi Vijayaraman
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania
| | - Robert D Schaller
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA.
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Abdin A, Burri H, Imnadze G, Turkmani K, Al Ghorani H, Almasri A, Werner C, Kulenthiran S. Outcomes of stylet-driven leads compared to lumenless leads for left bundle branch are pacing: systematic review and meta-analysis. Clin Res Cardiol 2025:10.1007/s00392-025-02673-w. [PMID: 40372481 DOI: 10.1007/s00392-025-02673-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2024] [Accepted: 05/02/2025] [Indexed: 05/16/2025]
Abstract
BACKGROUND Most initial experience with Left bundle branch are pacing (LBBAP) has involved lumenless leads (LLLs). Recently, stylet-driven leads (SDLs) have also been introduced for LBBAP. This study examined the clinical success rates, outcomes, and complication rates between SDLs and LLLs. METHODS AND RESULTS A systematic review of randomized clinical trials and observational studies comparing LLL and SDL up to November 30, 2024, was conducted. Random- and fixed-effects meta-analyses assessed the impact of implant technology on outcomes, including pacing metrics, lead complications, and procedural parameters. In total, 11 studies with 12,916 patients (SDLs: 3920; LLLs: 8996) were included. Implant success rates were comparable between SDL and LLL (RR 1.00, 95% CI 0.96-1.04, P = 0.96). SDL was associated with shorter procedure time (MD - 11.94 min, 95% CI - 19.48 to - 4.40, P = 0.002) and shorter fluoroscopy times, though this differences was not statistically significant (MD - 1.27 min, 95% CI - 2.92 to 0.39, P = 0.13). Pacing metrics, including impedance, pacing threshold, and R-wave amplitude, also showed no significant differences during follow-up (up to 28 months). However, SDLs were associated with a significantly higher risk of lead-related complications compared to LLLs (RR 1.89, 95% CI 1.47-2.41, P < 0001). CONCLUSION LBBAP using SDL is feasible and demonstrates comparable success rates with a shorter procedure duration. A higher incidence of lead-related complications was observed in the SDL group; however, due to potential confounding factors and the absence of randomized head-to-head comparisons, no definitive conclusions can be drawn regarding causality. Further prospective studies are warranted to clarify this association.
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Affiliation(s)
- Amr Abdin
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic III, Saarland University Hospital, Kirrberger Street 100, 66421, Homburg, Germany.
| | - Haran Burri
- Cardiology Department, Geneva University Hospital, Geneva, Switzerland
| | - Guram Imnadze
- Clinic for Electrophysiology, Herz- Und Diabeteszentrum NRW, Ruhr-Universität Bochum, Med. Fakultät OWL (Universität Bielefeld), Bad Oeynhausen, Germany
| | - Khaled Turkmani
- Department of General Surgery, Saarland University Hospital, Homburg, Germany
| | - Hussam Al Ghorani
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic III, Saarland University Hospital, Kirrberger Street 100, 66421, Homburg, Germany
| | - Alhasan Almasri
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic III, Saarland University Hospital, Kirrberger Street 100, 66421, Homburg, Germany
| | - Christian Werner
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic III, Saarland University Hospital, Kirrberger Street 100, 66421, Homburg, Germany
| | - Saarraaken Kulenthiran
- Cardiology, Angiology and Intensive Care Medicine, Internal Medicine Clinic III, Saarland University Hospital, Kirrberger Street 100, 66421, Homburg, Germany
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Karakasis P, Theofilis P, Vlachakis PK, Ktenopoulos N, Patoulias D, Antoniadis AP, Fragakis N. Atrial Cardiomyopathy in Atrial Fibrillation: Mechanistic Pathways and Emerging Treatment Concepts. J Clin Med 2025; 14:3250. [PMID: 40364280 PMCID: PMC12072501 DOI: 10.3390/jcm14093250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2025] [Revised: 05/01/2025] [Accepted: 05/07/2025] [Indexed: 05/15/2025] Open
Abstract
Atrial fibrillation (AF) is increasingly recognized not merely as an arrhythmia, but as a clinical manifestation of atrial cardiomyopathy (AtCM)-a progressive, multifaceted disease of the atrial myocardium involving structural, electrical, mechanical, and molecular remodeling. AtCM often precedes AF onset, sustains its perpetuation, and contributes to thromboembolic risk independently of rhythm status. Emerging evidence implicates diverse pathophysiological drivers of AtCM, including inflammation, epicardial adipose tissue, metabolic dysfunction, oxidative stress, ageing, and sex-specific remodeling. The NLRP3 inflammasome has emerged as a central effector in atrial inflammation and remodeling. Gut microbial dysbiosis, lipid dicarbonyl stress, and fibro-fatty infiltration are also increasingly recognized as contributors to arrhythmogenesis. AtCM is further linked to atrial functional valve regurgitation and adverse outcomes in AF. Therapeutically, substrate-directed strategies-ranging from metabolic modulation and immunomodulation to early rhythm control-offer promise for altering the disease trajectory. This review synthesizes mechanistic insights into AtCM and discusses emerging therapeutic paradigms that aim not merely to suppress arrhythmia but to modify the underlying substrate. Recognizing AF as a syndrome of atrial disease reframes management strategies and highlights the urgent need for precision medicine approaches targeting the atrial substrate.
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Affiliation(s)
- Paschalis Karakasis
- Second Department of Cardiology, Hippokration General Hospital, Medical School, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (A.P.A.); (N.F.)
| | - Panagiotis Theofilis
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (P.T.); (P.K.V.); (N.K.)
| | - Panayotis K. Vlachakis
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (P.T.); (P.K.V.); (N.K.)
| | - Nikolaos Ktenopoulos
- First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (P.T.); (P.K.V.); (N.K.)
| | - Dimitrios Patoulias
- Second Propedeutic Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Antonios P. Antoniadis
- Second Department of Cardiology, Hippokration General Hospital, Medical School, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (A.P.A.); (N.F.)
| | - Nikolaos Fragakis
- Second Department of Cardiology, Hippokration General Hospital, Medical School, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (A.P.A.); (N.F.)
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Sales-Belles C, Mincholé A, Melero-Polo J, Cabrera-Ramos M, Vadillo-Martín P, Montilla-Padilla I, Sorinas-Villanueva L, Julián-García I, Mayo-Carlos GV, Ruiz-Arroyo JR, Pueyo E, Ramos-Maqueda J. ECG-based evaluation of ventricular synchrony in left bundle branch area pacing through characterization of the activation sequence. Sci Rep 2025; 15:15584. [PMID: 40320473 PMCID: PMC12050288 DOI: 10.1038/s41598-025-98608-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2025] [Accepted: 04/14/2025] [Indexed: 05/08/2025] Open
Abstract
Left bundle branch area pacing (LBBAP) overcomes ventricular dyssynchrony induced by conventional right ventricular pacing (RVP). Despite QRS duration (QRSd) being the standard ECG marker for biventricular synchrony, it lacks insights into the ventricular activation sequence. Our aim is to assess biventricular synchrony by characterizing the ventricular activation sequence and introducing robust markers using the 12-lead ECG. A prospective single-center study was conducted, involving patients with pacemaker indication due to bradycardia. Patients were divided into LBBAP and RVP, and classified by baseline-QRS morphology. To assess biventricular synchrony, low frequency-based QRS analysis was performed to compute the ventricular activation sequence and precordial activation delay (pAD). Additional QRS markers including QRSd, QRS60, and QRS area (QRSa) were calculated. A total of 176 patients (107 LBBAP, 69 RVP) were included. The paced ventricular activation sequence indicated a more physiological pattern after LBBAP than RVP, with lower pAD values in narrow QRS, RBBB, and LBBB subgroups [ - 10( - 20,14) vs. 26(5, 39) ms; - 18( - 30, - 8) vs. 34(26, 55) ms; 10( - 14, 25) vs. 32(12, 48) ms] (p < 0.01). In all subgroups, QRS60 showed lower values after LBBAP than RVP [52(41, 62) vs.73(65, 80) ms; 60(55, 66) vs. 77(67, 83) ms; 59(53, 64) vs. 77(74, 82) ms] (p < 0.01) and QRSa were also lower [53(38, 66) vs. 121(92, 143) μVs; 60(50, 89) vs. 124(97, 159) μVs; 62(52, 80) vs. 133(99, 148) μVs] (p < 0.01). pAD provides valuable insights into ventricular activation beyond paced-QRSd. Together with QRS60 and QRSa, pAD could be a promising tool to assess biventricular synchrony.
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Affiliation(s)
- Clara Sales-Belles
- BSICoS Group, Aragon Institute of Engineering Research, IIS Aragón, University of Zaragoza, Zaragoza, Spain
| | - Ana Mincholé
- BSICoS Group, Aragon Institute of Engineering Research, IIS Aragón, University of Zaragoza, Zaragoza, Spain
- CIBER de Bioingeniería, Biomateriales y Nanomedicina, Instituto de Salud Carlos III, Madrid, Spain
| | - Jorge Melero-Polo
- Arrhythmias Unit, Cardiology Department, Lozano Blesa Clinical University Hospital, Calle San Juan Bosco 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute, Zaragoza, Spain
| | - Mercedes Cabrera-Ramos
- Arrhythmias Unit, Cardiology Department, Lozano Blesa Clinical University Hospital, Calle San Juan Bosco 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute, Zaragoza, Spain
| | - Pablo Vadillo-Martín
- Arrhythmias Unit, Cardiology Department, Lozano Blesa Clinical University Hospital, Calle San Juan Bosco 15, 50009, Zaragoza, Spain
| | - Isabel Montilla-Padilla
- Arrhythmias Unit, Cardiology Department, Lozano Blesa Clinical University Hospital, Calle San Juan Bosco 15, 50009, Zaragoza, Spain
- Aragon Health Research Institute, Zaragoza, Spain
| | - Laura Sorinas-Villanueva
- Arrhythmias Unit, Cardiology Department, Lozano Blesa Clinical University Hospital, Calle San Juan Bosco 15, 50009, Zaragoza, Spain
| | - Inés Julián-García
- Arrhythmias Unit, Cardiology Department, Lozano Blesa Clinical University Hospital, Calle San Juan Bosco 15, 50009, Zaragoza, Spain
| | - Gualber Vitto Mayo-Carlos
- Arrhythmias Unit, Cardiology Department, Lozano Blesa Clinical University Hospital, Calle San Juan Bosco 15, 50009, Zaragoza, Spain
| | - José Ramón Ruiz-Arroyo
- Arrhythmias Unit, Cardiology Department, Lozano Blesa Clinical University Hospital, Calle San Juan Bosco 15, 50009, Zaragoza, Spain
| | - Esther Pueyo
- BSICoS Group, Aragon Institute of Engineering Research, IIS Aragón, University of Zaragoza, Zaragoza, Spain
- CIBER de Bioingeniería, Biomateriales y Nanomedicina, Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Ramos-Maqueda
- Arrhythmias Unit, Cardiology Department, Lozano Blesa Clinical University Hospital, Calle San Juan Bosco 15, 50009, Zaragoza, Spain.
- Aragon Health Research Institute, Zaragoza, Spain.
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Schaller RD, Johnson EA, Schaerf RH, Ponnusamy SS, Sprowls M, Nagawekar L, Alleman W, Sabet L, Charan V, Vijayaraman P. Chronic extraction of stylet-driven leads implanted at the left bundle branch area in a pre-clinical model. Heart Rhythm 2025:S1547-5271(25)02382-3. [PMID: 40286974 DOI: 10.1016/j.hrthm.2025.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2025] [Revised: 04/17/2025] [Accepted: 04/18/2025] [Indexed: 04/29/2025]
Abstract
BACKGROUND Implantation of cardiac pacemaker leads in the left bundle branch area (LBBA) has been increasingly adopted into clinical practice, driven by the goal of leveraging the natural conduction system to achieve physiologic cardiac pacing. Long-term management of pacemaker leads may require lead extraction to address infection or device malfunction, yet limited clinical data exists on the extraction of LBBA leads chronically implanted deep within the interventricular septum. OBJECTIVE The objective of the study is to assess the chronic extractability of a new stylet-driven lead implanted in the LBBA in a pre-clinical model. METHODS A pacing lead recently approved for LBBA pacing (UltiPace) was implanted in the LBBA of 6 canines and extracted after a dwell time of 19 months. Retraction of the extended helix was attempted, followed by measurement of extraction force using a force gauge. RESULTS Leads were successfully extracted in 5 out of 6 canines without the use of additional extraction tools other than a locking stylet. In successfully extracted leads (5/6), attempted helix retraction resulted in partial retraction in 3 leads and unsuccessful retraction in 2. Overall average linear tensile extraction force was 0.95 ± 0.54 lbf. The partially retracted group included the lead that required the least force (0.20 lbf) and the unretracted group included the lead that required the most force (1.70 lbf). CONCLUSION Overall extraction success of UltiPace LPA1231 stylet-driven leads implanted in the LBBA was high, with extraction forces comparable to prior canine model extraction studies of leads implanted in the apex of the right ventricle.
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Affiliation(s)
- Robert D Schaller
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | | | - Raymond H Schaerf
- Smidt Heart Institute Cedars Sinai Medical Center, Los Angeles, California
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Yang W, Jiang Z, Wang S, Chen C, Zhou X, Shan Q. The Outcomes of Physiological Ventricular Rhythm Resetting With AV Node Ablation and Left Bundle Branch Pacing in Patients With AF-Induced Cardiomyopathy: A Prospective Cohort Study. Am J Cardiol 2025; 248:42-49. [PMID: 40188903 DOI: 10.1016/j.amjcard.2025.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2025] [Revised: 03/18/2025] [Accepted: 03/31/2025] [Indexed: 04/24/2025]
Abstract
The mechanism of AF-induced cardiomyopathy (AF-CM) is still unclear. Expect for heart rate, atrial contraction lost and ventricular rhythm irregularity are believed as possible contributors to AF-CM. This study aimed to investigate ventricular rhythm irregularity effects on AF-CM. The AF-CM patients underwent the physiological ventricular rhythm resetting (PVRR) with atrioventricular node ablation combined with left bundle branch pacing or pharmacological therapy. To avoid heart rate effects, the heart rate (HR) setting according to preoperative Holter averages heart rate for each patient in the PVRR group. The primary endpoint was the echocardiographic response rate, defined as an absolute increase of left ventricular ejection fraction (LVEF) > 5%. Secondary endpoints included heart failure (HF) rehospitalization and worsening HF. Finally, 71 patients (mean age 65 ± 11 years, 36 PVRR and 35 no-PVRR group) were enrolled this study. Compared with no-PVRR group, the PVRR without changed pre-and postprocedure HR significantly enhance echocardiographic response rate (86.1% vs 31.4%, p <0.001), improve LVEF (12.0% ± 6.6% vs 4.0% ± 8.1%, p <0.001), and shorten left ventricular end-diastolic diameter, and left ventricular end-systolic diameter (-4.6 ± 4.1 mm vs -1.7 ± 5.5 mm, p <0.05; -6.8 ± 3.8 mm vs -2.4 ± 6.3 mm, p <0.01, respectively) in 13.1 ± 6.6 months follow-up. Furthermore, HF rehospitalization and worsening HF rates were significantly lower in the PVRR group (5.6% vs 31.4%, p <0.01). In conclusion, the ventricular rhythm irregularity is an important reversible contributor for AF-CM. The PVRR significantly enhances cardiac function, lowers HF rehospitalization and worsening HF rates. The PVRR could become a promising therapeutic strategy for AF-CM patients.
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Affiliation(s)
- Wen Yang
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province People's Hospital), Nanjing, China
| | - Zhixin Jiang
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province People's Hospital), Nanjing, China
| | - Shengchan Wang
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province People's Hospital), Nanjing, China
| | - Chun Chen
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province People's Hospital), Nanjing, China
| | - Xiujuan Zhou
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province People's Hospital), Nanjing, China
| | - Qijun Shan
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province People's Hospital), Nanjing, China.
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Russo AM, Desai MY, Do MM, Butler J, Chung MK, Epstein AE, Guglin ME, Levy WC, Piccini JP, Bhave NM, Russo AM, Desai MY, Do MM, Ambardekar AV, Berg NC, Bilchick KC, Dec GW, Gopinathannair R, Han JK, Klein L, Lampert RJ, Panjrath GS, Reeves RR, Yoerger Sanborn DM, Stevenson LW, Truong QA, Varosy PD, Villines TC, Volgman AS, Zareba KM. ACC/AHA/ASE/HFSA/HRS/SCAI/SCCT/SCMR 2025 Appropriate Use Criteria for Implantable Cardioverter-Defibrillators, Cardiac Resynchronization Therapy, and Pacing. J Am Coll Cardiol 2025; 85:1213-1285. [PMID: 39808105 PMCID: PMC11998028 DOI: 10.1016/j.jacc.2024.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2025]
Abstract
This appropriate use criteria (AUC) document is developed by the American College of Cardiology along with key specialty and subspecialty societies. It provides a comprehensive review of common clinical scenarios where implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), cardiac contractility modulation, leadless pacing, and conduction system pacing therapies are frequently considered. The 335 clinical scenarios covered in this document address ICD indications including those related to secondary prevention, primary prevention, comorbidities, generator replacement at elective replacement indicator, dual-chamber, and totally subcutaneous ICDs, as well as device indications related to CRT, conduction system pacing, leadless pacing, cardiac contractility modulation, and ICD therapy in the setting of left ventricular assist devices (LVADs). The indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining device implantation. The indications in this document were developed by a multidisciplinary writing group and scored by a separate independent rating panel on a scale of 1 to 9 to designate care that is considered “Appropriate” (median 7 to 9), “May Be Appropriate” (median 4 to 6), and “Rarely Appropriate” (median 1 to 3). The final ratings reflect the median score of the 17 rating panel members. In general, Appropriate designations were assigned to scenarios for which clinical trial evidence and/or clinical experience was available that supported device implantation. In contrast, scenarios for which clinical trial evidence was limited or device implantation seemed reasonable for extenuating or practical reasons were categorized as May Be Appropriate. Scenarios for which there were data showing harm, or no data were available, and medical judgment deemed device therapy was illadvised were categorized as Rarely Appropriate. For example, comorbidities including reduced life expectancy related to noncardiac conditions or severe cognitive dysfunction would negatively impact appropriateness ratings. The appropriate use criteria for ICD, CRT, and pacing have the potential to enhance clinician decision making, healthcare delivery, and payment policy. Furthermore, recognition of clinical scenarios rated as May Be Appropriate facilitates the identification of areas where there may be gaps in evidence that would benefit from future research. The American College of Cardiology (ACC) has a long history of developing documents (eg, expert consensus decision pathways, health policy statements, AUC documents) to provide members with guidance on both clinical and nonclinical topics relevant to cardiovascular care. In most circumstances, these documents have been created to complement clinical practice guidelines and to inform clinicians about areas where evidence is new and evolving or where sufficient data are more limited. Despite this, numerous gaps persist, highlighting the need for more streamlined and efficient processes to implement best practices in patient care. Central to the ACC’s strategic plan is the generation of actionable knowledge —a concept that places emphasis on making clinical information easier to consume, share, integrate, and update. To this end, the ACC has shifted from developing isolated documents to creating integrated “solution sets.” These are groups of closely related activities, policy, mobile applications, decision-support tools, and other resources necessary to transform care and/or improve heart health. Solution sets address key questions facing care teams and attempt to provide practical guidance to be applied at the point of care. They use both established and emerging methods to disseminate information for cardiovascular conditions and their related management. The success of solution sets rests firmly on their ability to have a measurable impact on the delivery of care. Because solution sets reflect current evidence and ongoing gaps in care, the associated tools will be refined across time to match changing evidence and member needs. AUC represent a key component of solution sets. They consist of common clinical scenarios associated with given disease states and ratings that define when it is reasonable to perform testing or provide therapies and, importantly, when it is not. AUC methodology relies on content development work groups, which create patient scenarios, and independent rating panels that employ a modified Delphi process to rate the relevant options for testing and intervention as Appropriate, May Be Appropriate, or Rarely Appropriate. AUC should not replace clinician judgment and practice experience but should function as tools to improve patient care and health outcomes in a cost-effective manner. I extend sincere gratitude to the writing group for their invaluable contributions to the development of this document’s structure and clinical scenarios; to the rating panelists—a distinguished group of professionals with diverse expertise—for their thoughtful deliberation of the merits of device implantation across various clinical contexts; and to the reviewers for their thoughtful evaluation of the clinical scenarios and evidence mapping. Additionally, I am grateful to the members of the Solution Set Oversight Committee, which provided insight and guidance, and to ACC staff members María Velásquez and Lara Gold, for their support in bringing this document to fruition.
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Yu D, Lin Y, Chen Q, Liu X, Wang J. [Research of tricuspid regurgitation associated with cardiac implantable electronic devices]. Zhejiang Da Xue Xue Bao Yi Xue Ban 2025; 54:219-229. [PMID: 40194915 PMCID: PMC12062947 DOI: 10.3724/zdxbyxb-2024-0396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2024] [Revised: 01/03/2025] [Accepted: 02/25/2025] [Indexed: 04/09/2025]
Abstract
Tricuspid regurgitation associated with cardiac implantable electronic devices (CIED) constitutes a significant subset of secondary tricuspid regurgitation, characterized by a multifactorial etiology involving pacing lead-mediated mechanical interference and CIED-related systemic factors. The pathogenesis of CIED-related tricuspid regurgitation encompasses direct mechanical trauma or functional disruption of the tricuspid valve apparatus by pacing leads, pacing mode-induced hemodynamic alterations, and clinical risk factors such as permanent atrial fibrillation, apical pacing, and high right ventricular pacing burden. The natural progression and clinical outcomes of CIED-related tricuspid regurgitation parallel those of tricuspid regurgitation stemming from other etiologies. Advanced imaging modalities, including echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, enable precise diagnosis and longitudinal assessment of CIED-related tricuspid regurgitation. Management strategies emphasize multidisciplinary collaboration as well as integration of preventive approaches-such as refined lead implantation techniques and tailored pacing modalities-with therapeutic interventions ranging from pharmacotherapy to surgical valve repair or replacement. This article reviews the current understanding of CIED-related tricuspid regurgitation to provide a reference for clinical practice and research.
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Affiliation(s)
- Danqing Yu
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, State Key Laboratory of Transvascular Implantation Devices, Zhejiang Provincial Key Laboratory of Cardiovascular Disease Diagnosis and Treatment, Hangzhou 310009, China.
| | - Yan Lin
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, State Key Laboratory of Transvascular Implantation Devices, Zhejiang Provincial Key Laboratory of Cardiovascular Disease Diagnosis and Treatment, Hangzhou 310009, China
| | - Qi Chen
- Department of Cardiovascular Intervention, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Xianbao Liu
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, State Key Laboratory of Transvascular Implantation Devices, Zhejiang Provincial Key Laboratory of Cardiovascular Disease Diagnosis and Treatment, Hangzhou 310009, China.
| | - Jian'an Wang
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, State Key Laboratory of Transvascular Implantation Devices, Zhejiang Provincial Key Laboratory of Cardiovascular Disease Diagnosis and Treatment, Hangzhou 310009, China
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Kronborg MB, Varma N, Nielsen JC. How harmful is right ventricular pacing? The question revived by the BioPace trial. Europace 2025; 27:euaf005. [PMID: 40105784 PMCID: PMC11921416 DOI: 10.1093/europace/euaf005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2025] Open
Affiliation(s)
- Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard, Aarhus 8200, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus 8200, Denmark
| | - Niraj Varma
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44118, USA
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard, Aarhus 8200, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus 8200, Denmark
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10
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Spadotto A, Paamand R, Clua I Sánchez E, Valiton V, Leonard O, Firth K, Burri H. Automated Beat-to-Beat Measurement of R-Wave Peak Time for Left Bundle Branch Area Pacing. JACC Clin Electrophysiol 2025; 11:596-598. [PMID: 39846924 DOI: 10.1016/j.jacep.2024.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Revised: 10/29/2024] [Accepted: 10/30/2024] [Indexed: 01/24/2025]
Affiliation(s)
- Alberto Spadotto
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland
| | | | | | - Valérian Valiton
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland
| | | | | | - Haran Burri
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland.
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11
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Redzepi B, Bengueddache S, Schwitter J, Antiochos P, Pruvot E. Late gadolinium enhancement in mid infero-septal area after left bundle branch area pacing in the setting of bifascicular block and syncope: a case report. Eur Heart J Case Rep 2025; 9:ytaf035. [PMID: 39963310 PMCID: PMC11830951 DOI: 10.1093/ehjcr/ytaf035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Revised: 10/25/2024] [Accepted: 01/17/2025] [Indexed: 02/20/2025]
Abstract
Background Conduction system pacing, which includes His bundle pacing and left bundle branch area pacing (LBBAP), is becoming increasingly common in clinical practice. His bundle pacing, introduced over two decades ago, continues to see growing use, while LBBAP is gaining traction due to its broader target area and shorter procedure times. However, complications such as septal perforation and lead-related issues may still arise. This case report explores the evaluation and management of recurrent syncope in the context of bifascicular block (BFB), highlighting the importance of thorough assessment, continuous ECG monitoring, and the potential need for permanent pacemaker implantation. Case summary A 60-year-old woman with a history of myocardial infarction, Type II diabetes, and dyslipidaemia presented with recurrent syncope and BFB, for which a LBBAP device was implanted in August 2023. In February 2024, she was admitted again due to recurrent syncope and frequent premature ventricular contractions. Cardiac magnetic resonance imaging revealed two localized myocardial scars: one at the basal anterior wall from the 2018 ischaemic event and another in the mid infero-septal wall at the site of the LBBAP lead. During her hospital stay, she experienced multiple episodes of near fainting due to orthostatic hypotension, indicative of underlying autonomic neuropathy. Discussion This narrative explores the evolving landscape of cardiac pacing techniques, with a focus on LBBAP, highlighting its advantages over traditional methods while also acknowledging potential complications. Additionally, it emphasizes the importance of a comprehensive workup for syncope and the need for tailored interventions that extend beyond pacemaker implantation.
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Affiliation(s)
- Betim Redzepi
- Department of Cardiology, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1005 Lausanne, Switzerland
| | - Samir Bengueddache
- Department of Cardiology, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1005 Lausanne, Switzerland
| | - Juerg Schwitter
- Department of Cardiology, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1005 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Quartier Centre, 1015 Lausanne, Switzerland
| | - Panagiotis Antiochos
- Department of Cardiology, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1005 Lausanne, Switzerland
| | - Etienne Pruvot
- Department of Cardiology, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1005 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Quartier Centre, 1015 Lausanne, Switzerland
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12
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Karwiky G, Kamarullah W, Pranata R, Iqbal M, Achmad C, Martha JW, Setiawan I. Stylet-driven leads versus lumenless pacing leads in patients with left bundle branch area pacing: A systematic review and meta-analysis. Heart Rhythm O2 2025; 6:166-175. [PMID: 40231099 PMCID: PMC11993787 DOI: 10.1016/j.hroo.2024.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2024] Open
Abstract
BACKGROUND Despite advancements in lead designs for optimum left bundle branch area pacing (LBBAP), limited data exist on the performance of stylet-driven leads (SDLs). OBJECTIVE This meta-analysis sought to compare the performance and safety of SDLs in comparison with lumenless leads (LLLs) following LBBAP. METHODS Systematic literature search was conducted using PubMed, Europe PMC, and ScienceDirect for studies that compared the outcomes of SDLs during LBBAP compared with LLLs. Study outcomes included periprocedural parameters, pacing metrics, and complications. RESULTS A total of 6 studies involving 3991 participants were included. LBBAP procedural success was comparable between SDLs and LLLs (90.2% and 90.5%, respectively). Compared with LLLs, SDLs appeared to result in shortened procedural (-11.50 minutes) and fluoroscopy (-2.56 minutes) times, along with increased capture threshold and reduced lead impedance at implantation. However, paced QRS, R-wave amplitude, capture threshold, and lead impedance remained comparable between both groups during follow-up. The number of lead-implantation attempts was similar between SDLs and LLLs (2.6 ± 1.0 vs 2.2 ± 0.6). Lead dislodgement and lead-related complications (except septal perforation) occurred mostly in the SDL group. No statistical differences were found in life-threatening complications. CONCLUSION SDLs demonstrated comparable effectiveness in achieving LBBAP, exhibiting similar success rates, mean attempts for lead placement, and pacing parameters, although they were associated with a higher overall incidence of lead-related complications. The reduced overall procedural and fluoroscopy time may be attributed to the ability of SDLs' different delivery sheath selections in identifying the optimal anatomical site, rather than being lead specific.
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Affiliation(s)
- Giky Karwiky
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - William Kamarullah
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Raymond Pranata
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Mohammad Iqbal
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Chaerul Achmad
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Januar Wibawa Martha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Iwan Setiawan
- Department of Biomedical Science, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
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13
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Vijayaraman P, Trivedi R, Ellenbogen KA. Output-dependent transition during LBBP: Variable myocardial capture masquerading as loss of conduction system capture. Heart Rhythm 2025:S1547-5271(25)00102-X. [PMID: 39894138 DOI: 10.1016/j.hrthm.2025.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Revised: 01/17/2025] [Accepted: 01/23/2025] [Indexed: 02/04/2025]
Affiliation(s)
| | - Rohan Trivedi
- Geisinger Heart Institute, Wilkes-Barre, Pennsylvania
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14
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Niazi I. Conduction System Pacing: Where Are We in 2025? J Innov Card Rhythm Manag 2025; 16:6151-6153. [PMID: 39897726 PMCID: PMC11784394 DOI: 10.19102/icrm.2025.16015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Accepted: 11/17/2024] [Indexed: 02/04/2025] Open
Affiliation(s)
- Imran Niazi
- Aurora St. Lukes Medical Center, Advocate Health, Milwaukee, WI, USA
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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15
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Doğan M, Canpolat U, Çöteli C, Yorgun H, Aytemir K. Immediate changes in depolarization and repolarization after left bundle branch area pacing and atrioventricular nodal ablation. J Electrocardiol 2025; 88:153847. [PMID: 39632298 DOI: 10.1016/j.jelectrocard.2024.153847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2024] [Revised: 10/28/2024] [Accepted: 11/18/2024] [Indexed: 12/07/2024]
Abstract
BACKGROUND Malignant arrhythmia due to ventricular depolarization and repolarization alterations after atrioventricular node (AVN) ablation is a known clinical entity. Here, we aimed to demonstrate the ventricular depolarization and repolarization changes in patients who underwent left bundle branch area pacing (LBBaP) and AVN ablation. METHODS This is a single-center, retrospective preliminary study (n = 10). All patients underwent single-chamber pacemaker implantation with LBBaP before the AVN ablation procedure. Electrocardiographic (ECG) parameters [QRS duration (QRSd), QTc (Fridericia formula), Tp-e, and JT interval] were measured and analyzed before and after the procedure. RESULTS The mean age of the study population was 67.1 ± 8.88 years, and 70 % of the patients were female. 60 % of the patients had AF, and 40 % of them had atrial tachycardia during the procedures. Eight patients had undergone more than two catheter ablations before the procedure. The QT interval (263.47 ± 26.79 vs. 416.14 ± 36.31 msec) and QRSd (93.3 ± 7.3 vs. 122.32 ± 21.16 msec) were prolonged when the patient's ECG parameters were analyzed. Still, the Tp-Te interval (75.57 ± 18.62 vs. 80.93 ± 17.35 msec) did not change, and the QTc (Fridericia formula) interval (425 ± 29.82 vs. 461.70 ± 35.33 msec) did not show a significant difference. CONCLUSION Malignant arrhythmia may occur due to ventricular depolarization and repolarization changes after the AVN ablation procedure. This study showed no significant change in Tp-e and QTc durations previously defined for malignant arrhythmia development. At the same time, JT time, which indicates ventricular repolarization duration, did not show a significant difference. LBBaP is more physiological and safer for patients planning to undergo AVN ablation.
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Affiliation(s)
- Mert Doğan
- Hacettepe University, Faculty of Medicine, Department of Cardiology, Ankara, Turkey
| | - Uğur Canpolat
- Hacettepe University, Faculty of Medicine, Department of Cardiology, Ankara, Turkey.
| | - Cem Çöteli
- Hacettepe University, Faculty of Medicine, Department of Cardiology, Ankara, Turkey
| | - Hikmet Yorgun
- Hacettepe University, Faculty of Medicine, Department of Cardiology, Ankara, Turkey
| | - Kudret Aytemir
- Hacettepe University, Faculty of Medicine, Department of Cardiology, Ankara, Turkey
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16
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De Pooter J, Breitenstein A, Özpak E, Haeberlin A, Hofer D, Le Polain de Waroux JB, Wauters A, Kim TH, Lee SR, Park YJ, Gobitz M, Kiełbasa G, Zalavadia D, Tolppanen H, Žižek D, Zanon F, Marcantoni L, Sundaram Ponnusamy S, Karvonen J, Cano O, Jastrzebski M, Vijayaraman P, Burri H. Lead Integrity and Failure Evaluation in Left Bundle Branch Area Pacing: The LIFE-LBBAP Study. JACC Clin Electrophysiol 2025; 11:158-170. [PMID: 39570266 DOI: 10.1016/j.jacep.2024.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 09/11/2024] [Accepted: 09/13/2024] [Indexed: 11/22/2024]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) has gained increased adoption globally with the use of both lumenless leads (LLLs) and stylet-driven leads (SDLs). As these leads have been developed for conventional endocardial pacing sites, concerns remain regarding the lead integrity with LBBAP. OBJECTIVES This study evaluates lead integrity of pacing leads used for LBBAP in a large, real-world cohort of patients with LBBAP. METHODS Patients with successful LBBAP from 17 international centers were enrolled in this observational study. Data on overall lead integrity, fracture rates, and locations of fractures were collected. RESULT The study enrolled 8,255 patients with LBBAP (age 73 ± 13 years, 42% female, 68% LLLs, and 32% SDLs). Overall lead survival rate was 99.7% with median follow-up of 16.4 (Q1-Q3: 6.4-28.8) months. Lead fracture occurred in 12 of 8,255 (0.15%) patients. Lead fracture rates of LLLs occurred in 2 of 5,609 (0.04%) vs 10 of 2,646 (0.4%) patients for SDLs, during a follow-up of 19.5 (Q1-Q3: 9.7-33) and 10.3 (Q1-Q3: 2.9-19.7) months, respectively (P < 0.001). SDL fractures occurred at 13.9 (Q1-Q3: 6.1-17.7) months after implant, whereas 2 LLL fractures occurred at 21 and 31.4 months. SDL and LLL conductor fractures were observed in 7 of 17 and 2 of 17 centers, respectively. Confirmed fractures of the SDL lead originated within the interelectrode lead segment, whereas LLL fractures occurred proximal to the ring. CONCLUSIONS LBBAP lead performance of LLLs and SDLs is high at midterm follow-up. SDLs exhibit higher rates of fracture compared to LLLs. Hot spots for conductor fracture are the distal interelectrode segment in SDLs and the segment proximal to the ring electrode in LLLs.
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Affiliation(s)
- Jan De Pooter
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium.
| | | | - Emine Özpak
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | | | - Aurélien Wauters
- Service de Cardiologie, Clinique Saint Pierre, Ottignies, Belgique
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Jun Park
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Michael Gobitz
- Universitäres Herzzentrum Zürich, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Grzegorz Kiełbasa
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | | | - Heli Tolppanen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - David Žižek
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Francesco Zanon
- Arrhythmia and Electrophysiology Unit, Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Lina Marcantoni
- Arrhythmia and Electrophysiology Unit, Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | | | - Jarkko Karvonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Oscar Cano
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Marek Jastrzebski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | | | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
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17
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Palmisano P, Mandurino C, Parlavecchio A, Luzzi G, Guido A, Accogli M, Coluccia G. Ablate and pace strategy for atrial fibrillation: pacing modalities, ablation approaches and impact on patient outcomes. Expert Rev Med Devices 2025; 22:127-140. [PMID: 39784491 DOI: 10.1080/17434440.2025.2452286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2024] [Revised: 12/26/2024] [Accepted: 12/29/2024] [Indexed: 01/12/2025]
Abstract
INTRODUCTION In patients with symptomatic, refractory atrial fibrillation the ablate and pace (A&P) strategy (pacemaker implantation followed by atrio-ventricular junction ablation (AVJA)) is superior to medical therapy in improving quality of life and prognosis. Despite its well-proven benefits, this invasive therapeutic option is still underutilized in clinical practice. The choice of pacing modality (right ventricular pacing, biventricular pacing, BVP, or conduction system pacing, CSP) is crucial and can have significant clinical implications. In particular, in recent years CSP is emerging as an alternative to BVP, showing a good effectiveness and safety profile. Other important aspects are the timing of ablation, the approach used for AVJA, and the correct device programming after AVJA. AREAS COVERED This article reviews the currently available evidence on this therapeutic strategy with a particular focus on its impact on patient outcome, recognized indications, technical considerations, and future perspectives. EXPERT OPINION With the availability of more robust evidence confirming the better effectiveness and safety profile of CSP compared to conventional pacing modalities, in the next few years CSP will become the standard pacing modality in candidates for A&P. The routine adoption of this pacing modality could lead to a wider use of A&P in clinical practice.
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Affiliation(s)
- Pietro Palmisano
- Cardiology Unit, "Card. G. Panico" Hospital, Tricase (Le), Italy
| | - Cosimo Mandurino
- Division of Cardiology, Ospedale Santissima Annunziata, Taranto, Italy
| | | | - Giovanni Luzzi
- Division of Cardiology, Ospedale Santissima Annunziata, Taranto, Italy
| | - Alessandro Guido
- Cardiology Unit, "Card. G. Panico" Hospital, Tricase (Le), Italy
| | - Michele Accogli
- Cardiology Unit, "Card. G. Panico" Hospital, Tricase (Le), Italy
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18
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Joza J, Burri H, Andrade JG, Linz D, Ellenbogen KA, Vernooy K. Atrioventricular node ablation for atrial fibrillation in the era of conduction system pacing. Eur Heart J 2024; 45:4887-4901. [PMID: 39397777 PMCID: PMC11631063 DOI: 10.1093/eurheartj/ehae656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/30/2024] [Accepted: 09/15/2024] [Indexed: 10/15/2024] Open
Abstract
Despite key advances in catheter-based treatments, the management of persistent atrial fibrillation (AF) remains a therapeutic challenge in a significant subset of patients. While success rates have improved with repeat AF ablation procedures and the concurrent use of antiarrhythmic drugs, the likelihood of maintaining sinus rhythm during long-term follow-up is still limited. Atrioventricular node ablation (AVNA) has returned as a valuable treatment option given the recent developments in cardiac pacing. With the advent of conduction system pacing, AVNA has seen a revival where pacing-induced cardiomyopathy after AVNA is felt to be overcome. This review will discuss the role of permanent pacemaker implantation and AVNA for AF management in this new era of conduction system pacing. Specifically, this review will discuss the haemodynamic consequences of AF and the mechanisms through which 'pace-and-ablate therapy' enhances outcomes, analyse historical and more recent literature across various pacing methods, and work to identify patient groups that may benefit from earlier implementation of this approach.
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Affiliation(s)
- Jacqueline Joza
- Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Haran Burri
- Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
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19
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Onishi Y, Barengo A, Fioravanti F, Rampa L, Paglino G, Maisano F, Bella PD. Successful left bundle branch area pacing in a patient with three TriClip devices. J Interv Card Electrophysiol 2024; 67:1965-1967. [PMID: 38995605 DOI: 10.1007/s10840-024-01875-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 07/09/2024] [Indexed: 07/13/2024]
Affiliation(s)
- Yoshimi Onishi
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Alberto Barengo
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Fioravanti
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Rampa
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Paglino
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Maisano
- Cardiac Surgery, Valve Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
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20
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Rijks JHJ, Heckman L, Westra S, Cornelussen R, Ghosh S, Curila K, Smisek R, Grieco D, Bressi E, Nguyên UC, Lumens J, van Stipdonk AMW, Linz D, Prinzen FW, Luermans JGLM, Vernooy K. Assessment of ventricular electrical heterogeneity in left bundle branch pacing and left ventricular septal pacing by using various electrophysiological methods. J Cardiovasc Electrophysiol 2024; 35:2282-2292. [PMID: 39313856 DOI: 10.1111/jce.16435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 08/13/2024] [Accepted: 09/08/2024] [Indexed: 09/25/2024]
Abstract
INTRODUCTION Left bundle branch area pacing (LBBAP) comprises pacing at the left ventricular septum (LVSP) or left bundle branch (LBBP). The aim of the present study was to investigate the differences in ventricular electrical heterogeneity between LVSP, LBBP, right ventricular pacing (RVP) and intrinsic conduction with different dyssynchrony measures using the ECG, vectorcardiograpy, ECG belt, and Ultrahigh frequency (UHF-)ECG. METHODS Thirty-seven patients with a pacemaker indication for bradycardia or cardiac resynchronization therapy underwent LBBAP implantation. ECG, vectorcardiogram, ECG belt and UHF-ECG signals were recorded during RVP, LVSP and LBBP, and intrinsic activation. QRS duration (QRSd) was measured from the ECG, QRS area was calculated from the vectorcardiogram, LV activation time (LVAT) and standard deviation of activation time (SDAT) from ECG belt and electrical dyssynchrony (e-DYS16) from UHF-ECG. RESULTS Both LVSP and LBBP significantly reduced ventricular electrical heterogeneity as compared to underlying LBBB and RV pacing in terms of QRS area (p < .001), SDAT (p < .001), LVAT (p < .001) and e-DYS16 (p < .001). QRSd was only reduced as compared to RV pacing(p < .001). QRS area was similar during LBBP and normal intrinsic conduction, e-DYS16 was similar during LVSP and normal intrinsic conduction, whereas SDAT was similar for LVSP, LBBP and normal intrinsic conduction. For all these variables there was no significant difference between LVSP and LBBP. CONCLUSION Both LVSP and LBBP resulted in a more synchronous LV activation than LBBB and RVP. Especially LBBP resulted in levels of LV synchrony comparable to normal intrinsic conduction.
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Affiliation(s)
- Jesse H J Rijks
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Luuk Heckman
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Sjoerd Westra
- Department of Cardiology, Radboud University Medical Center (RadboudUMC), Nijmegen, The Netherlands
| | | | - Subham Ghosh
- Medtronic, Fridley, Minnesota, United States of America
| | - Karol Curila
- Department of Cardiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Pregue, Czechia
| | - Radovan Smisek
- The Czech Academy of Sciences, Institute of Scientific Instruments, Brno, Czechia
| | - Domenico Grieco
- Department of Cardiology, Policlinico Casilino of Rome, Rome, Italy
| | - Edoardo Bressi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
- Department of Cardiology, Policlinico Casilino of Rome, Rome, Italy
| | - Uyên Châu Nguyên
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Antonius M W van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Justin G L M Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
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21
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Shroff JP, Nair A, Raja DC, Abhilash SP, Fiorese S, Ariyaratnam JP, Abhayaratna WP, Sanders P, Vijayaraman P, Pathak RK. Comparison of Procedural Outcomes of Lumenless Fixed-Helix Versus Stylet-Driven Extendable-Helix Lead Systems in Left Bundle Branch Pacing: COMPARE LBBP. Circ Arrhythm Electrophysiol 2024; 17:e013385. [PMID: 39611251 DOI: 10.1161/circep.124.013385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Accepted: 10/23/2024] [Indexed: 11/30/2024]
Abstract
BACKGROUND Left bundle branch pacing (LBBP) has emerged as a safe and effective alternative to right ventricular pacing. Traditionally, LBBP is performed with lumenless lead (LLL); however, the use of stylet-driven lead (SDL) is on rise. We aimed to assess acute success and procedural outcomes of SDL versus LLL for LBBP. METHODS One hundred consecutive patients with bradyarrhythmia, indication of cardiac resynchronization therapy, or ablate and pace strategy were randomized in a 1:1 fashion to the SDL and LLL arms. Tendril STS lead with a CPS Locator 3D catheter and SelectSecure 3830 lead with a C315HIS catheter were used in the SDL and LLL arms, respectively. LBBP was confirmed by standard criteria with measurements done on Labsystem Pro. RESULTS Patients in the LLL arm were significantly younger (71.9±11 versus 76.4±8.9 years; P=0.02); all other baseline characteristics were not significantly different. Acute success in LBBP was similar with SDL versus LLL (90% versus 92%; P=0.7). In patients with successful LBBP, screw attempts were not significantly different between the groups (2.3±1.7 in SDL versus 1.9±1.3 in LLL; P=0.2). Implant duration (11±9.6 versus 9.9±7.1 minutes; P=0.4), mean fluoroscopy dose (65.3±82.7 versus 53.5±50.5 mGy; P=0.5), and fluoroscopy time (7.8±4.8 versus 7.4±4 minutes; P=0.7) were also not different in the SDL versus the LLL arm, respectively. Incidence of lead failure (P=0.6), microdislodgement (P=1), and macrodislodgement (P=0.6) were not significantly different. Pacing threshold was comparable at implant and on follow-up at 1, 3, and 6 months. CONCLUSIONS LBBP was feasible with both lead systems with similar success rate and low capture threshold. No significant difference was observed in procedure duration or fluoroscopy use. No major complications were recorded with either lead. REGISTRATION URL: https://www.anzctr.org.au; Unique identifier: ACTRN12624000304538.
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Affiliation(s)
- Jenish P Shroff
- The School of Medicine and Psychology, Australian National University, Australian Capital Territory (J.P.S., A.N., D.C.R., W.P.A., R.K.P.)
- Canberra Heart Rhythm Centre, Australian Capital Territory (J.P.S., A.N., S.P.A., S.F., R.K.P.)
| | - Anugrah Nair
- The School of Medicine and Psychology, Australian National University, Australian Capital Territory (J.P.S., A.N., D.C.R., W.P.A., R.K.P.)
- Canberra Heart Rhythm Centre, Australian Capital Territory (J.P.S., A.N., S.P.A., S.F., R.K.P.)
| | - Deep Chandh Raja
- The School of Medicine and Psychology, Australian National University, Australian Capital Territory (J.P.S., A.N., D.C.R., W.P.A., R.K.P.)
| | - Sreevilasam P Abhilash
- Canberra Heart Rhythm Centre, Australian Capital Territory (J.P.S., A.N., S.P.A., S.F., R.K.P.)
| | - Simon Fiorese
- Canberra Heart Rhythm Centre, Australian Capital Territory (J.P.S., A.N., S.P.A., S.F., R.K.P.)
| | - Jonathan P Ariyaratnam
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Australia (J.P.A., P.S.)
| | - Walter P Abhayaratna
- The School of Medicine and Psychology, Australian National University, Australian Capital Territory (J.P.S., A.N., D.C.R., W.P.A., R.K.P.)
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Australia (J.P.A., P.S.)
| | - Pugazhendhi Vijayaraman
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, PA (P.V.)
| | - Rajeev K Pathak
- The School of Medicine and Psychology, Australian National University, Australian Capital Territory (J.P.S., A.N., D.C.R., W.P.A., R.K.P.)
- Canberra Heart Rhythm Centre, Australian Capital Territory (J.P.S., A.N., S.P.A., S.F., R.K.P.)
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van Koll J, Rijks JH, Vernooy K, Joza J. Different levels of recruitment during conduction system pacing. HeartRhythm Case Rep 2024; 10:861-866. [PMID: 39897693 PMCID: PMC11781892 DOI: 10.1016/j.hrcr.2024.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2025] Open
Affiliation(s)
- Johan van Koll
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jesse H.J. Rijks
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
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23
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Ludwik B, Labus M, Roleder T, Moskal P, Kiełbasa G, Śpikowski J, Jastrzębski M. Novel approach to left bundle branch area pacing lead implantation using a 3-dimensional stylet. Heart Rhythm 2024:S1547-5271(24)03569-0. [PMID: 39551119 DOI: 10.1016/j.hrthm.2024.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Revised: 11/03/2024] [Accepted: 11/11/2024] [Indexed: 11/19/2024]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) requires implantation of the lead deep in the interventricular septum. We developed a novel implantation method that does not require dedicated delivery catheters but only a manually shaped 3-dimensional (3D) stiff stylet. OBJECTIVE The aim of the study was to characterize procedural outcomes of this technique when used as a routine approach for LBBAP. METHODS A case-control study compared procedural outcomes of consecutive patients who underwent pacemaker implantation at 2 centers: one using only the 3D stylet-based LBBAP technique and the other using the conventional catheter-based LBBAP lead implantation. RESULTS A total of 400 patients (age, 75.3 ± 9.8 years; 48.3% female) were analyzed and 230 were matched and included in a 1:1 ratio in each arm of the implantation techniques. No differences were observed in the success rate (95.0% vs 94.8%), fluoroscopy time (9.9 minutes vs 9.6 minutes), paced QRS duration (151 ms vs 148 ms), and sensitivity values (8.2 mV vs 8.5 mV) between the 3D stylet-based and catheter-based techniques, respectively. Small differences were observed in V6 R-wave peak time (73.2 ms vs 76.5 ms) and capture threshold (0.63 V vs 0.83 V), with a higher percentage of confirmed left bundle branch captures (98.3% vs 77.4%) and a numerically higher occurrence of delayed perforations (2/115 vs 0/115) in the 3D stylet group. CONCLUSION LBBAP lead implantation with the use of a manually shaped stiff 3D stylet is feasible and results in comparable outcomes to those achieved with leads implanted by dedicated preshaped delivery catheters.
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Affiliation(s)
- Bartosz Ludwik
- Department of Cardiology, Regional Specialist Hospital, Wroclaw, Poland
| | - Michał Labus
- Department of Cardiology, Regional Specialist Hospital, Wroclaw, Poland
| | - Tomasz Roleder
- Department of Cardiology, Regional Specialist Hospital, Wroclaw, Poland; Department of Non-Surgical Clinical Sciences, Faculty of Medicine, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Paweł Moskal
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Grzegorz Kiełbasa
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Jerzy Śpikowski
- Department of Cardiology, Regional Specialist Hospital, Wroclaw, Poland
| | - Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland.
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24
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Onishi Y, Barengo A, Fioravanti F, Rampa L, Paglino G, Della Bella P. His-bundle pacing from the right atrium: Solving pacemaker implantation challenges post-TriClip. J Cardiovasc Electrophysiol 2024; 35:2258-2261. [PMID: 39256904 DOI: 10.1111/jce.16431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 08/22/2024] [Accepted: 09/01/2024] [Indexed: 09/12/2024]
Abstract
INTRODUCTION This case report highlights the novel role of His-bundle pacing (HBP) from right atrium, not just for preserving cardiac function, but also for avoiding interference with TriClip devices. METHODS AND RESULTS A 78-year-old female with severe tricuspid regurgitation received two TriClip devices. Postprocedure, frequent significant sinus pauses required a pacemaker. HBP was chosen to avoid lead complications. Under local anesthesia, a His pacing lead was inserted via the axillary vein using specialized catheter. Follow-ups over 2.5 years showed stable parameters with no complications. CONCLUSION HBP is effective for patients with TriClip devices, ensuring optimal cardiac function and lead stability.
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Affiliation(s)
- Yoshimi Onishi
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Medicine, Division of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Alberto Barengo
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Fioravanti
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Rampa
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Paglino
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Cardiac Electrophysiology and Clinical Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
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25
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Kiełbasa G, Jastrzębski M, Bednarek A, Kusiak A, Sondej T, Bednarski A, Ostrowska A, Żydzik Ł, Rajzer M, Vijayaraman P, Moskal P. Strength-duration curves for left bundle branch area pacing. Heart Rhythm 2024; 21:2262-2269. [PMID: 38759916 DOI: 10.1016/j.hrthm.2024.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Despite growing clinical use of left bundle branch pacing (LBBP), data regarding the fundamentals of this pacing modality, including chronaxie and rheobase, are scarce. OBJECTIVE The purpose of this study was to calculate strength-duration curves with chronaxie and rheobase values for LBBP and left ventricular septal pacing (LVSP), and to analyze battery current drain and presence of selective LBBP at very short pulse duration (PD). METHODS A group of 141 patients with permanent LBBP were studied. LBBP and LVSP capture thresholds were assessed at 6 different PDs to calculate the strength-duration curves. Battery current drain at these PDs and presence of selective LBBP were determined. For comparison of strength-duration curves between His-bundle pacing (HBP) and LBBP, source data from our previous work based on 127 patients with HBP were obtained. RESULTS The chronaxies for LBBP and LVSP were very similar (0.38 vs 0.39 ms), and the rheobases were identical (0.27 V). The chronaxie for LBBP was lower than for HBP (0.38 vs 0.53 ms; P <.001), whereas rheobases were similar (0.27 vs 0.26 V). A narrow zone of selective capture was present in 19% and 41% of patients at PD of 0.06 and 0.03 ms, respectively. When pacing with the safety margin of +1 V, the lowest battery current drain was achieved with PD of 0.2 ms. CONCLUSION The obtained strength-duration curves for LBBP and LVSP provide insights to optimal programming of left bundle branch area pacing devices with regard to PD, voltage amplitude, battery longevity, and selective capture.
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Affiliation(s)
- Grzegorz Kiełbasa
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; First Department of Cardiology, Interventional Electrocardiology and Hypertension University Hospital in Krakow, Krakow, Poland.
| | - Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; Electrophysiology Laboratory, University Hospital in Krakow, Krakow, Poland
| | - Agnieszka Bednarek
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; First Department of Cardiology, Interventional Electrocardiology and Hypertension University Hospital in Krakow, Krakow, Poland
| | - Aleksander Kusiak
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Tomasz Sondej
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Adam Bednarski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Aleksandra Ostrowska
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Łukasz Żydzik
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Marek Rajzer
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; First Department of Cardiology, Interventional Electrocardiology and Hypertension University Hospital in Krakow, Krakow, Poland
| | - Pugazhendhi Vijayaraman
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; Geisinger Heart Institute, Wilkes-Barre, Pennsylvania
| | - Paweł Moskal
- Electrophysiology Laboratory, University Hospital in Krakow, Krakow, Poland
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26
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Jastrzębski M, Foley P, Chandrasekaran B, Whinnett Z, Vijayaraman P, Upadhyay GA, Schaller RD, Gardas R, Richardson T, Kudlik D, Stadler RW, Zimmerman P, Burrell J, Waxman R, Cornelussen RN, Lyne J, Herweg B. Multicenter Hemodynamic Assessment of the LOT-CRT Strategy: When Does Combining Left Bundle Branch Pacing and Coronary Venous Pacing Enhance Resynchronization?: Primary Results of the CSPOT Study. Circ Arrhythm Electrophysiol 2024; 17:e013059. [PMID: 39440428 PMCID: PMC11575906 DOI: 10.1161/circep.124.013059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 08/15/2024] [Indexed: 10/25/2024]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) may be an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT). We sought to compare the acute hemodynamic and ECG effects of LBBAP, BVP, and left bundle-optimized therapy CRT (LOT-CRT) in CRT candidates with advanced conduction disease. METHODS In this multicenter study, 48 patients with either nonspecific interventricular conduction delay (n=29) or left bundle branch block (n=19) underwent acute hemodynamic testing to determine the change in left ventricular pressure maximal first derivative (LV dP/dtmax) from baseline atrial pacing to BVP, LBBAP, or LOT-CRT. RESULTS Atrioventricular-optimized increases in LV dP/dtmax for LOT-CRT (mean, 25.8% [95% CI, 20.9%-30.7%]) and BVP (26.4% [95% CI, 20.2%-32.6%]) were greater than unipolar LBBAP (19.3% [95% CI, 15.0%-23.7%]) or bipolar LBBAP (16.4% [95% CI, 12.7%-20.0%]; P≤0.005). QRS shortening was greater in LOT-CRT (29.5 [95% CI, 23.4-35.6] ms) than unipolar LBBAP (11.9 [95% CI, 6.1-17.7] ms), bipolar LBBAP (11.7 ms [95% CI, 6.4-17.0]), or BVP (18.5 [95% CI, 11.0-25.9] ms), all P≤0.005. Compared with patients with left bundle branch block, patients with interventricular conduction delay experienced less QRS reduction (P=0.026) but similar improvements in LV dP/dtmax (P=0.29). Bipolar LBBAP caused anodal capture in 54% of patients and resulted in less LV dP/dtmax improvement than unipolar LBBAP (18.6% versus 23.7%; P<0.001). Subclassification of LBBAP capture (European Heart Rhythm Association criteria) indicated LBBAP or LV septal pacing in 27 patients (56%) and deep septal pacing in 21 patients (44%). The hemodynamic benefit of adding left ventricular coronary vein pacing to LBBAP depended on baseline QRS duration (P=0.031) and success of LBBAP (P<0.004): LOT-CRT provided 14.5% (5.0%-24.1%) greater LV dP/dtmax improvement and 20.8 (12.8-28.8) ms greater QRS shortening than LBBAP in subjects with QRS ≥171 ms and deep septal pacing capture type. CONCLUSIONS In a CRT cohort with advanced conduction disease, LOT-CRT and BVP provided greater acute hemodynamic benefit than LBBAP. Subjects with wider QRS or deep septal pacing are more likely to benefit from the addition of a left ventricular coronary vein lead to implement LOT-CRT. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04905290.
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Affiliation(s)
- Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland (M.J.)
| | - Paul Foley
- Wiltshire Cardiac Center, Great Western Hospital, Swindon, United Kingdom (P.F., B.C.)
| | | | - Zachary Whinnett
- Division of Cardiology, National Heart and Lung Institute, Imperial College, London, United Kingdom (Z.W.)
| | - Pugazhendhi Vijayaraman
- Division of Cardiology, Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, PA (P.V.)
| | - Gaurav A. Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago, Pritzker School of Medicine, IL (G.A.U.)
| | - Robert D. Schaller
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (R.D.S.)
| | - Rafał Gardas
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland (R.G.)
| | - Travis Richardson
- Division of Cardiovascular Medicine, Vanderbilt Heart, Nashville, TN (T.R.)
| | - D’Anne Kudlik
- Medtronic, Minneapolis, MN (D.K., R.W.S., P.Z., J.B., R.W.)
| | | | | | - James Burrell
- Medtronic, Minneapolis, MN (D.K., R.W.S., P.Z., J.B., R.W.)
| | - Robert Waxman
- Medtronic, Minneapolis, MN (D.K., R.W.S., P.Z., J.B., R.W.)
| | | | - Jonathan Lyne
- Division of Cardiac Electrophysiology, Beacon Hospital (UCD), Dublin, Ireland (J.L.)
| | - Bengt Herweg
- Division of Cardiology, University of South Florida Morsani College of Medicine and Tampa General Hospital, Tampa, FL (B.H.)
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27
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Bednarek A, Kiełbasa G, Moskal P, Ostrowska A, Bednarski A, Sondej T, Kusiak A, Rajzer M, Burri H, Jastrzębski M. Left bundle branch area pacing improves right ventricular function and synchrony. Heart Rhythm 2024; 21:2234-2241. [PMID: 38750909 DOI: 10.1016/j.hrthm.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/04/2024] [Accepted: 05/08/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND The impact of left bundle branch area pacing (LBBAP) on right ventricular (RV) function and tricuspid regurgitation (TR) remains unclear. OBJECTIVE We aimed to assess the long-term effects of LBBAP on RV performance and on TR. METHODS RV function was evaluated using RV free wall strain, tricuspid annular plane systolic excursion, fractional area changing, and systolic velocity of the lateral tricuspid annulus. The presence of reverse septal flash (RSF) and basal bulge (BB) was used to assess RV motion pattern. The distance between the lead entry site on the interventricular septum and the septal leaflet of the tricuspid annulus (lead-TV distance) was measured. RESULTS The analysis included 122 subjects [62 men (50.8%); mean age 76.5 ± 11.4 years] with a median follow-up of 21 months (18-24.5 months). During follow-up, RV free wall strain improved significantly (15.2 ± 5.8 vs 16.4 ± 5.5; P < .001) while tricuspid annular plane systolic excursion, systolic, and fractional area changing remained unchanged. Left ventricular ejection fraction was an independent predictor of improved RV function (B = 3.51; 95% confidence interval 1.39-8.9; P = .01). With LBBAP, RSF disappeared in 22 of 23 patients (96%) and BB in 15 of 22 patients (68%) in whom RSF and BB were present at baseline, respectively. RV function improvement was significantly higher when RSF was present at baseline (14 patients vs 11 patients; P = .02). At follow-up, no significant deterioration in TR occurred for the overall group. However, a lead-TV distance of <24.5 mm was associated with TR progression. CONCLUSION LBBAP has a favorable impact on RV function. A basal LBBAP position is associated with worsening TR.
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Affiliation(s)
- Agnieszka Bednarek
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; Cardiology, Interventional Cardiac Electrophysiology and Arterial Hypertension Clinical Department, University Hospital, Krakow, Poland.
| | - Grzegorz Kiełbasa
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; Cardiology, Interventional Cardiac Electrophysiology and Arterial Hypertension Clinical Department, University Hospital, Krakow, Poland
| | - Paweł Moskal
- Electrophysiology Laboratory, University Hospital, Krakow, Poland
| | - Aleksandra Ostrowska
- Cardiology, Interventional Cardiac Electrophysiology and Arterial Hypertension Clinical Department, University Hospital, Krakow, Poland
| | - Adam Bednarski
- Cardiology, Interventional Cardiac Electrophysiology and Arterial Hypertension Clinical Department, University Hospital, Krakow, Poland
| | - Tomasz Sondej
- Cardiology, Interventional Cardiac Electrophysiology and Arterial Hypertension Clinical Department, University Hospital, Krakow, Poland
| | - Aleksander Kusiak
- Cardiology, Interventional Cardiac Electrophysiology and Arterial Hypertension Clinical Department, University Hospital, Krakow, Poland
| | - Marek Rajzer
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; Cardiology, Interventional Cardiac Electrophysiology and Arterial Hypertension Clinical Department, University Hospital, Krakow, Poland
| | - Haran Burri
- Cardiac Pacing Unit, University Hospital of Geneva, Geneva, Switzerland
| | - Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; Electrophysiology Laboratory, University Hospital, Krakow, Poland
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28
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Ezzeddine FM, Killu AM, Mulpuru SK, Friedman P, Cha YM. Left bundle branch area pacing guided by intracardiac echocardiography imaging. Heart Rhythm O2 2024; 5:842-843. [PMID: 39651439 PMCID: PMC11624322 DOI: 10.1016/j.hroo.2024.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2024] Open
Affiliation(s)
| | - Ammar M. Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Siva K. Mulpuru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Paul Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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29
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Karwiky G, Kamarullah W, Pranata R, Achmad C, Iqbal M. A meta-analysis of the distance between lead-implanted site and tricuspid valve annulus with postoperative tricuspid regurgitation deterioration in patients with left bundle branch area pacing. J Cardiovasc Electrophysiol 2024; 35:2220-2229. [PMID: 39327904 DOI: 10.1111/jce.16444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 09/07/2024] [Accepted: 09/13/2024] [Indexed: 09/28/2024]
Abstract
Tricuspid regurgitation (TR) is a known complication of cardiac implantable electrical devices (CIEDs), with prevalences ranging from 10% to as high as 30%. Despite left bundle branch area pacing (LBBAP) has emerged as an alternative to the limits of His-bundle pacing (HBP), the long-term safety of this procedure, notably the worsening of TR after implantation, has yet to be thoroughly investigated. This meta-analysis sought to determine the frequency of post-LBBAP TR deterioration and identify the predictors, particularly the distance between lead-implanted site and the tricuspid valve annulus (lead-TA-distance). A systematic literature search was conducted using PubMed, Europe PMC, and ScienceDirect for studies that reported the incidence of deterioration and measurement of TR grade at baseline and follow-up following LBBAP, in addition to the differences in exposure between short and long lead-TA-distances. A total of three studies involving 480 participants were included in this meta-analysis. The incidence of TR deterioration was 22%. Patients with TR deterioration also demonstrated a significantly shorter lead-TA-distance in comparison to the opposing group (MD: -5.74 mm (-0.70, -10.78); p < .001; I2 = 92.6%). The pooled results of three comparative studies suggest that participants in the longer lead-TA-distance group had a significant decrement in the likelihood of TR worsening (adjusted OR = 0.59 (0.36-0.96); p = .034; I2 = 79%). Multivariate analysis conducted in each of the included investigations supported the independence of the connection between lead-TA-distance and TR deterioration. A shorter lead-TA-distance was an independent risk factor for TR deterioration in individuals with post-LBBAP implantation.
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Affiliation(s)
- Giky Karwiky
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - William Kamarullah
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Raymond Pranata
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Chaerul Achmad
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Mohammad Iqbal
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
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Chen X, Dong J. Stylet-driven leads compared with lumenless leads for left bundle branch area pacing: a systematic review and meta-analysis. BMC Cardiovasc Disord 2024; 24:598. [PMID: 39462327 PMCID: PMC11514867 DOI: 10.1186/s12872-024-04273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 10/17/2024] [Indexed: 10/29/2024] Open
Abstract
OBJECTIVE Left bundle branch area pacing (LBBAP) is a novel physiological pacing method for treating left ventricular dyssynchrony. LBBAP is often delivered using lumenless leads (LLL). However, recent studies have also reported the use of style-driven leads (SDL). This study is the first systematic review comparing the outcomes of LBBAP with SDL vs. LLL. METHODS The review and meta-analysis included all available comparative studies published on Embase, PubMed, Web of Science, CENTRAL, and Scopus up to 6th March 2024. RESULTS Eight observational studies were included in the review. Meta-analysis showed that success rates of LBBAP performed with LLL and SDL were comparable (OR: 1.72 95% CI: 0.94, 3.17 I2 = 38%). Duration of implantation and total procedural duration were significantly lower in LBBAP performed with SDL. The pacing threshold was significantly higher, while pacing impedance was significantly lower in the SDL compared to the LLL group. Pacing QRS interval, R-wave amplitude, and stimulus to peak left ventricular activation time were similar in the two groups. Intra-operative and post-operative dislodgement were significantly higher in the SDL group, but no difference was noted in intra-operative perforation and pneumothorax risk. CONCLUSION Limited evidence from observational studies with inherent selection bias shows that success rates for LBBAP may not differ between SDL and LLL. While implantation of SDL may be significantly faster, it carries a higher risk of lead dislodgement. Both SDL and LLL are associated with comparable pacing characteristics except for reduced pacing impedance with SDL.
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Affiliation(s)
- Xuezhi Chen
- Department of Cardiology, Capital Medical University Affiliated Anzhen Hospital, No.2 of Anzhen Road, Chaoyang District, 100029, Beijing, People's Republic of China
- Department of Cardiology, Peking University International Hospital, Beijing, China
| | - Jianzeng Dong
- Department of Cardiology, Capital Medical University Affiliated Anzhen Hospital, No.2 of Anzhen Road, Chaoyang District, 100029, Beijing, People's Republic of China.
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31
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Friedman DJ, Chelu MG. Left Bundle Branch Area Pacing for LBBB: Will Left Ventricular Septal Pacing Do? JACC Clin Electrophysiol 2024; 10:2247-2249. [PMID: 39177552 DOI: 10.1016/j.jacep.2024.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 06/18/2024] [Indexed: 08/24/2024]
Affiliation(s)
- Daniel J Friedman
- Department of Medicine, Section of Cardiology, Duke University, Durham, North Carolina, USA
| | - Mihail G Chelu
- Department of Medicine, Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA; Cardiovascular Research Institute, Houston, Texas, USA; Texas Heart Institute at Baylor St. Luke's Medical Center, Houston, Texas, USA.
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32
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Cano Ó, Pooter JD, Zanon F. Stylet-driven Leads or Lumenless Leads for Conduction System Pacing. Arrhythm Electrophysiol Rev 2024; 13:e14. [PMID: 39385772 PMCID: PMC11462514 DOI: 10.15420/aer.2024.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 05/30/2024] [Indexed: 10/12/2024] Open
Abstract
Stylet-driven leads have been recently introduced for conduction system pacing, while most of the previous experience has been obtained with lumenless leads. Design and structural characteristics of both lead types are significantly different, resulting in different implant techniques and independent learning curves. Lead performance appears to be comparable, whereas data on direct comparison of clinical outcomes are scarce. Currently, there are no specific clinical scenarios favouring the use of one lead type over another and the decision should rely on the individual experience of the implanter.
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Affiliation(s)
- Óscar Cano
- Unidad de Arritmias, Hospital Universitario y Politécnico La FeValencia, Spain
- Centro de Investigaciones Biomédicas en Red en Enfermedades Cardiovasculares (CIBERCV)Madrid, Spain
| | - Jan De Pooter
- Heart Centre, University Hospital GhentGhent, Belgium
| | - Francesco Zanon
- Department of Cardiology, Santa Maria della Misericordia General HospitalRovigo Italy
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Farouq M, Rorsman C, Marinko S, Mörtsell D, Chaudhry U, Wang L, Platonov P, Borgquist R. Risk factors and incidence of new-onset heart failure with conventional pacemaker implant: A nationwide study. Heart Rhythm O2 2024; 5:623-630. [PMID: 39493904 PMCID: PMC11524952 DOI: 10.1016/j.hroo.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2024] Open
Abstract
Background Studies have shown that the risk of new-onset heart failure (HF) is higher postimplantation for patients receiving right ventricular pacing. Objective This study aimed to investigate incidence, risk factors, and implications for long-term prognosis of new-onset HF in patients after pacemaker implantation. Methods Patients without pre-existing HF who received a pacemaker in Sweden during the period of 2005 to 2020 were identified via the nationwide Pacemaker Registry. Data were crossmatched with the population registry and national disease registries. The primary outcome was new-onset HF within 5 years, and a risk score for this was developed and validated. Results In all, 65,579 patients met the inclusion criteria (10,351 single-chamber ventricular and 55,228 dual-chamber pacemakers). A total of 13,792 (21.0%) patients were diagnosed with HF within 5 years postimplantation. Of these, 6244 (45.3%) were hospitalized for HF. Patients with new-onset HF were more likely to die within 5 years (41.2% vs 19.7%, P < .0001). Risk factors for new-onset HF included increasing age, male sex, hypertension, diabetes, atrial fibrillation, chronic lung and kidney disease, ischemic heart disease, and atrioventricular block. In a combined score using these variables, patients in the highest risk-score quartile had a hazard ratio of 5.36 (95% CI 4.91-5.86, P < .001) and an absolute risk of 32% for developing HF. Conclusion Pacemaker therapy is associated with >20% risk of new-onset HF within 5 years, and we identified 9 risk factors associated with the diagnosis of new-onset HF. The proposed score based on these variables can be used to identify patients at high risk for new-onset HF.
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Affiliation(s)
- Maiwand Farouq
- Cardiology Section, Department of Clinical sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Cecilia Rorsman
- Cardiology Section, Department of Clinical sciences, Lund University, Lund, Sweden
- Internal Medicine Department, Varberg Hospital, Varberg, Sweden
| | - Sofia Marinko
- Cardiology Section, Department of Clinical sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - David Mörtsell
- Cardiology Section, Department of Clinical sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Uzma Chaudhry
- Cardiology Section, Department of Clinical sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Lingwei Wang
- Cardiology Section, Department of Clinical sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Pyotr Platonov
- Cardiology Section, Department of Clinical sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Rasmus Borgquist
- Cardiology Section, Department of Clinical sciences, Lund University, Lund, Sweden
- Arrhythmia Section, Skane University Hospital, Lund, Sweden
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Nomura T, Isawa T, Onodera K, Toyoda S, Yamashita K, Honda T. Transvenous extraction of a left bundle branch area pacing lead and an attempt to reimplant it: A case report. HeartRhythm Case Rep 2024; 10:671-675. [PMID: 39355823 PMCID: PMC11440134 DOI: 10.1016/j.hrcr.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2024] Open
Affiliation(s)
- Takehiro Nomura
- Department of Cardiovascular Medicine, Heart Rhythm Center, Sendai Kosei Hospital, Sendai, Miyagi, Japan
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, Shimotsuga-gun, Tochigi, Japan
| | - Tsuyoshi Isawa
- Department of Cardiovascular Medicine, Sendai Kousei Hospital, Sendai, Miyagi, Japan
| | - Kosuke Onodera
- Department of Cardiovascular Medicine, Heart Rhythm Center, Sendai Kosei Hospital, Sendai, Miyagi, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, Shimotsuga-gun, Tochigi, Japan
| | - Kennosuke Yamashita
- Department of Cardiovascular Medicine, Heart Rhythm Center, Sendai Kosei Hospital, Sendai, Miyagi, Japan
| | - Taku Honda
- Department of Cardiovascular Medicine, Sendai Kousei Hospital, Sendai, Miyagi, Japan
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Gardas R, Loboda D, Biernat J, Soral T, Kulesza P, Gladysz-Wanha S, Joniec M, Sajdok M, Zub K, Golba KS. Extraction of lumenless pacing leads from the His bundle and left bundle branch area: outcomes of the high-volume centre. Europace 2024; 26:euae213. [PMID: 39137240 PMCID: PMC11363868 DOI: 10.1093/europace/euae213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 08/08/2024] [Indexed: 08/15/2024] Open
Abstract
AIMS The application of conduction system pacing (CSP) in clinical practice is growing, and the need for lead extraction will also increase. The data on outcomes and safety of CSP lead extraction are limited. The aim of this study was to assess procedural outcomes and safety of CSP lead removal. METHODS AND RESULTS Forty-seven patients from the EXTRACT Registry with the indication for CSP lead removal were enrolled in the study conducted at the Department of Electrocardiology in Katowice, Poland. Extraction technique, outcomes, safety, and complication were evaluated. Forty-three (91.5%) leads were successfully removed, and 41 (87.2%) were removed with traction only. The dwelling time of 28 extracted leads was longer than 1 year, and the oldest extracted lead was implanted for 89 months. Seven (14.9%) leads were removed from the left bundle branch (LBB) area and 36 from the His bundle (HB). Transient complete atrioventricular block occurred during the procedure in two patients. In 27 out of 31 attempts (87.1%), new CSP leads were implanted: nine (33.3%) HB pacing leads and 18 (66.7%) LBB area pacing leads. CONCLUSION The CSP lead extraction is safe and feasible with a low complication rate and high rate of CSP lead reimplantation.
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Affiliation(s)
- Rafal Gardas
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
- Department of Electrocardiology, Leszek Giec Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, Ziolowa 45/47, Katowice 40–635, Poland
| | - Danuta Loboda
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
- Department of Electrocardiology, Leszek Giec Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, Ziolowa 45/47, Katowice 40–635, Poland
| | - Jolanta Biernat
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Tomasz Soral
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Piotr Kulesza
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Sylwia Gladysz-Wanha
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Michal Joniec
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Mateusz Sajdok
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Kamil Zub
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Krzysztof S Golba
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
- Department of Electrocardiology, Leszek Giec Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, Ziolowa 45/47, Katowice 40–635, Poland
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Goette A, Corradi D, Dobrev D, Aguinaga L, Cabrera JA, Chugh SS, de Groot JR, Soulat-Dufour L, Fenelon G, Hatem SN, Jalife J, Lin YJ, Lip GYH, Marcus GM, Murray KT, Pak HN, Schotten U, Takahashi N, Yamaguchi T, Zoghbi WA, Nattel S. Atrial cardiomyopathy revisited-evolution of a concept: a clinical consensus statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asian Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS). Europace 2024; 26:euae204. [PMID: 39077825 PMCID: PMC11431804 DOI: 10.1093/europace/euae204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 07/31/2024] Open
Abstract
AIMS The concept of "atrial cardiomyopathy" (AtCM) had been percolating through the literature since its first mention in 1972. Since then, publications using the term were sporadic until the decision was made to convene an expert working group with representation from four multinational arrhythmia organizations to prepare a consensus document on atrial cardiomyopathy in 2016 (EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication). Subsequently, publications on AtCM have increased progressively. METHODS AND RESULTS The present consensus document elaborates the 2016 AtCM document further to implement a simple AtCM staging system (AtCM stages 1-3) by integrating biomarkers, atrial geometry, and electrophysiological changes. However, the proposed AtCM staging needs clinical validation. Importantly, it is clearly stated that the presence of AtCM might serve as a substrate for the development of atrial fibrillation (AF) and AF may accelerates AtCM substantially, but AtCM per se needs to be viewed as a separate entity. CONCLUSION Thus, the present document serves as a clinical consensus statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asian Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS) to contribute to the evolution of the AtCM concept.
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Affiliation(s)
- Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St. Vincenz-Hospital Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
- MAESTRIA Consortium at AFNET, Münster, Germany
- Otto-von-Guericke University, Medical Faculty, Magdeburg, Germany
| | - Domenico Corradi
- Department of Medicine and Surgery, Unit of Pathology; Center of Excellence for Toxicological Research (CERT), University of Parma, Parma, Italy
| | - Dobromir Dobrev
- Institute of Pharmacology, University Duisburg-Essen, Essen, Germany
- Montréal Heart Institute, Université de Montréal, 5000 Belanger St. E., Montréal, Québec H1T1C8, Canada
- Department of Integrative Physiology, Baylor College of Medicine, Houston, TX, USA
| | - Luis Aguinaga
- Director Centro Integral de Arritmias Tucumán, Presidente Sociedad de Cardiología de Tucumàn, Ex-PRESIDENTE DE SOLAECE (LAHRS), Sociedad Latinoamericana de EstimulaciónCardíaca y Electrofisiología, Argentina
| | - Jose-Angel Cabrera
- Hospital Universitario QuirónSalud, Madrid, Spain
- European University of Madrid, Madrid, Spain
| | - Sumeet S Chugh
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA, USA
| | - Joris R de Groot
- Department of Cardiology; Cardiovascular Sciences, Heart Failure and Arrhythmias, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurie Soulat-Dufour
- Department of Cardiology, Saint Antoine and Tenon Hospital, AP-HP, Unité INSERM UMRS 1166 Unité de recherche sur les maladies cardiovasculaires et métaboliques, Institut Hospitalo-Universitaire, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, Paris, France
| | | | - Stephane N Hatem
- Department of Cardiology, Assistance Publique—Hôpitaux de Paris, Pitié-Salpêtrière Hospital; Sorbonne University; INSERM UMR_S1166; Institute of Cardiometabolism and Nutrition-ICAN, Paris, France
| | - Jose Jalife
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, 28029 Madrid, Spain
| | - Yenn-Jiang Lin
- Cardiovascular Center, Taipei Veterans General Hospital, and Faculty of Medicine National Yang-Ming University Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory M Marcus
- Electrophysiology Section, Division of Cardiology, University of California, San Francisco, USA
| | - Katherine T Murray
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pharmacology, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Ulrich Schotten
- MAESTRIA Consortium at AFNET, Münster, Germany
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University and Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University and Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Japan
| | - Takanori Yamaguchi
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - William A Zoghbi
- Department of Cardiology, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Stanley Nattel
- McGill University, 3655 Promenade Sir-William-Osler, Montréal, Québec H3G1Y6, Canada
- West German Heart and Vascular Center, Institute of Pharmacology, University Duisburg, Essen, Germany
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Bulava A, Sitek D, Tesařík J. Left bundle branch area pacing via persistent superior vena cava: A case report. HeartRhythm Case Rep 2024; 10:586-590. [PMID: 39155893 PMCID: PMC11328577 DOI: 10.1016/j.hrcr.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024] Open
Affiliation(s)
- Alan Bulava
- Department of Cardiology, České Budějovice Hospital, České Budějovice, Czech Republic
- Faculty of Health and Social Sciences, University of South Bohemia in České Budějovice, České Budějovice, Czech Republic
| | - David Sitek
- Department of Cardiology, České Budějovice Hospital, České Budějovice, Czech Republic
| | - Jan Tesařík
- Department of Cardiology, České Budějovice Hospital, České Budějovice, Czech Republic
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38
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Seow SC. A novel method to disengage trapped helix during left bundle branch pacing. Heart Rhythm 2024; 21:1412-1414. [PMID: 38508298 DOI: 10.1016/j.hrthm.2024.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Swee-Chong Seow
- Department of Cardiology, National University Hospital, Singapore.
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Beer D, Vijayaraman P. Current Role of Conduction System Pacing in Patients Requiring Permanent Pacing. Korean Circ J 2024; 54:427-453. [PMID: 38859643 PMCID: PMC11306426 DOI: 10.4070/kcj.2024.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 04/11/2024] [Indexed: 06/12/2024] Open
Abstract
His bundle pacing (HBP) and left bundle branch pacing (LBBP) are novel methods of pacing directly pacing the cardiac conduction system. HBP while developed more than two decades ago, only recently moved into the clinical mainstream. In contrast to conventional cardiac pacing, conduction system pacing including HBP and LBBP utilizes the native electrical system of the heart to rapidly disseminate the electrical impulse and generate a more synchronous ventricular contraction. Widespread adoption of conduction system pacing has resulted in a wealth of observational data, registries, and some early randomized controlled clinical trials. While much remains to be learned about conduction system pacing and its role in electrophysiology, data available thus far is very promising. In this review of conduction system pacing, the authors review the emergence of conduction system pacing and its contemporary role in patients requiring permanent cardiac pacing.
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Foley P, Thomas H, Dayer M, Robinson S, Ezzatt V, Swift M, Johal N, Roberts E. British Heart Rhythm Society Standards for Implantation and Follow-up of Cardiac Rhythm Management Devices in Adults: January 2024 Update. Arrhythm Electrophysiol Rev 2024; 13:e10. [PMID: 39082056 PMCID: PMC11287656 DOI: 10.15420/aer.2024.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/20/2024] [Indexed: 08/02/2024] Open
Abstract
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.
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Affiliation(s)
- Paul Foley
- Wiltshire Cardiac Centre, Great Western HospitalSwindon, UK
| | - Honey Thomas
- British Heart Rhythm SocietyCheshire, UK
- Department of Cardiology, Northumbria Healthcare NHS Foundation TrustNorth Shields, UK
| | - Mark Dayer
- Somerset NHS Foundation TrustTaunton, Somerset, UK
| | - Sophie Robinson
- British Heart Rhythm SocietyCheshire, UK
- Sandwell District General HospitalWest Bromwich, UK
| | - Vivienne Ezzatt
- British Heart Rhythm SocietyCheshire, UK
- Department of Cardiac Electrophysiology, Barts Heart Center, St Bartholomew’s HospitalLondon, UK
| | - Matthew Swift
- Wiltshire Cardiac Centre, Great Western HospitalSwindon, UK
| | - Nadiya Johal
- Wiltshire Cardiac Centre, Great Western HospitalSwindon, UK
| | - Eleri Roberts
- Department of Cardiology, Wythenshawe HospitalManchester, UK
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Ghosh A, Sekar A, Sriram CS, Sivakumar K, Upadhyay GA, Pandurangi UM. Septal venous channel perforation during left bundle branch area pacing: a prospective study. Europace 2024; 26:euae124. [PMID: 38703372 PMCID: PMC11160494 DOI: 10.1093/europace/euae124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/09/2024] [Accepted: 04/26/2024] [Indexed: 05/06/2024] Open
Abstract
AIMS To characterize the diagnosis, frequency, and procedural implications of septal venous channel perforation during left bundle branch area pacing (LBBAP). METHODS AND RESULTS All consecutive patients undergoing LBBAP over an 8-month period were prospectively studied. During lead placement, obligatory septal contrast injection was performed twice, at initiation (implant entry zone) and at completion (fixation zone). An intuitive fluoroscopic schema using orthogonal views (left anterior oblique/right anterior oblique) and familiar landmarks is described. Using this, we resolved zonal distribution (I-VI) of lead position on the ventricular septum and its angulation (post-fixation angle θ). Subjects with and without septal venous channel perforation were compared. Sixty-one patients {male 57.3%, median age [interquartile range (IQR)] 69.5 [62.5-74.5] years} were enrolled. Septal venous channel perforation was observed in eight (13.1%) patients [male 28.5%, median age (IQR) 64 (50-75) years]. They had higher frequency of (i) right-sided implant (25% vs. 1.9%, P = 0.04), (ii) fixation in zone III at the mid-superior septum (75% vs. 28.3%, P = 0.04), (iii) steeper angle of fixation-median θ (IQR) [19 (10-30)° vs. 5 (4-19)°, P = 0.01], and (iv) longer median penetrated-lead length (IQR) [13 (10-14.8) vs. 10 (8.5-12.5) mm, P = 0.03]. Coronary sinus drainage of contrast was noted in five (62.5%) patients. Abnormal impedance drops during implantation (12.5% vs. 5.7%, P = NS) were not significantly different. CONCLUSION When evaluated systematically, septal venous channel perforation may be encountered commonly after LBBAP. The fiducial reference framework described using fluoroscopic imaging identified salient associated findings. This may be addressed with lead repositioning to a more inferior location and is not associated with adverse consequence acutely or in early follow-up.
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Affiliation(s)
- Anindya Ghosh
- Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure Academy, The Madras Medical Mission, 4-A, Dr. JJ Nagar, Mogappair, Chennai, Tamil Nadu 600037, India
| | - Anbarasan Sekar
- Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure Academy, The Madras Medical Mission, 4-A, Dr. JJ Nagar, Mogappair, Chennai, Tamil Nadu 600037, India
| | - Chenni S Sriram
- Division of Cardiology, Sub-section of Electrophysiology, Children’s Hospital of Michigan and Detroit Medical Center, Detroit, MI, USA
| | - Kothandam Sivakumar
- Department of Pediatric Cardiology, Institute of Cardiovascular Diseases, The Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Ulhas M Pandurangi
- Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure Academy, The Madras Medical Mission, 4-A, Dr. JJ Nagar, Mogappair, Chennai, Tamil Nadu 600037, India
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Kuschyk J, Sattler K, Fastenrath F, Rudic B, Akin I. [Treatment with cardiac electronic implantable devices]. Herz 2024; 49:233-246. [PMID: 38709278 DOI: 10.1007/s00059-024-05246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 05/07/2024]
Abstract
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.
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Affiliation(s)
- Jürgen Kuschyk
- I. Medizinische Klinik, Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Katherine Sattler
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Fabian Fastenrath
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Boris Rudic
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Ibrahim Akin
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
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Burri H, Valiton V, Spadotto A, Herbert J, Masson N. Current of injury amplitude during left bundle branch area pacing implantation: impact of filter settings, ventricular pacing, and lead type. Europace 2024; 26:euae130. [PMID: 38753644 PMCID: PMC11139776 DOI: 10.1093/europace/euae130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 04/25/2024] [Indexed: 05/18/2024] Open
Abstract
AIMS Monitoring current of injury (COI) during left bundle branch area pacing (LBBAP) implantation is useful to evaluate lead depth. Technical aspects for recording COI amplitude have not been well studied. Our aims were to evaluate the impact of high-pass filter settings on electrogram recordings during LBBAP implantation. METHODS AND RESULTS Consecutive patients with successful LBBAP implantation had unipolar recordings of COI at final lead position at different high-pass filter settings (0.01-1 Hz) from the tip electrode during sensing and pacing, and from the ring electrode during sensing. Duration of saturation-induced signal loss was also measured at each filter setting. COI amplitudes were compared between lumenless and stylet-driven leads. A total of 156 patients (96 males, aged 81.4 ± 9.6 years) were included. Higher filter settings led to significantly lower COI amplitudes. In 50 patients with COI amplitude < 10 mV, the magnitude of the drop was on average 1-1.5 mV (and up to 4 mV) between 0.05 and 0.5 Hz, meaning that cut-offs may not be used interchangeably. Saturation-induced signal loss was on average 10 s at 0.05 Hz and only 2 s with 0.5 Hz. When pacing was interrupted, the sensed COI amplitude varied (either higher or lower) by up to 4 mV, implying that it is advisable to periodically interrupt pacing to evaluate the sensed COI when reaching levels of ∼10 mV. Lead type did not impact COI amplitude. CONCLUSION High-pass filters have a significant impact on electrogram characteristics at LBBAP implantation, with the 0.5 Hz settings having the most favourable profile.
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Affiliation(s)
- Haran Burri
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, rue Gabrielle Perret Gentil 4, 1211 Geneva, Switzerland
| | - Valérian Valiton
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, rue Gabrielle Perret Gentil 4, 1211 Geneva, Switzerland
| | - Alberto Spadotto
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, rue Gabrielle Perret Gentil 4, 1211 Geneva, Switzerland
| | - Julia Herbert
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, rue Gabrielle Perret Gentil 4, 1211 Geneva, Switzerland
| | - Nicolas Masson
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, rue Gabrielle Perret Gentil 4, 1211 Geneva, Switzerland
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Taddeucci S, Marallo C, Merello G, Santoro A. Cardiac resynchronization therapy with conduction system pacing in a long-term heart transplant recipient: A case report. Indian Pacing Electrophysiol J 2024; 24:147-149. [PMID: 38199455 PMCID: PMC11143729 DOI: 10.1016/j.ipej.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/01/2023] [Accepted: 01/08/2024] [Indexed: 01/12/2024] Open
Abstract
We performed cardiac resynchronization therapy by means of conduction system pacing in a heart transplant patient suffering from heart failure with reduced ejection fraction and atrial fibrillation with conduction disturbance (bifascicular block and QRS >160 ms). ECG monitoring showed paroxysmal atrioventricular block. Biventricular pacing was not feasible due to the absence of a suitable coronary sinus branch for pacing. His bundle pacing was performed, and an implantable cardioverter-defibrillator was implanted due to severe left ventricular dysfunction. Cardiac allograft vasculopathy was excluded. During follow-up, the patient's left ventricular function improved, and symptoms alleviated with a high percentage of ventricular stimulation.
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Affiliation(s)
| | | | | | - Amato Santoro
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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Batta A, Hatwal J. Left bundle branch pacing set to outshine biventricular pacing for cardiac resynchronization therapy? World J Cardiol 2024; 16:186-190. [PMID: 38690215 PMCID: PMC11056871 DOI: 10.4330/wjc.v16.i4.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/09/2024] [Accepted: 03/18/2024] [Indexed: 04/23/2024] Open
Abstract
The deleterious effects of long-term right ventricular pacing necessitated the search for alternative pacing sites which could prevent or alleviate pacing-induced cardiomyopathy. Until recently, biventricular pacing (BiVP) was the only modality which could mitigate or prevent pacing induced dysfunction. Further, BiVP could resynchronize the baseline electromechanical dssynchrony in heart failure and improve outcomes. However, the high non-response rate of around 20%-30% remains a major limitation. This non-response has been largely attributable to the direct non-physiological stimulation of the left ventricular myocardium bypassing the conduction system. To overcome this limitation, the concept of conduction system pacing (CSP) came up. Despite initial success of the first CSP via His bundle pacing (HBP), certain drawbacks including lead instability and dislodgements, steep learning curve and rapid battery depletion on many occasions prevented its widespread use for cardiac resynchronization therapy (CRT). Subsequently, CSP via left bundle branch-area pacing (LBBP) was developed in 2018, which over the last few years has shown efficacy comparable to BiVP-CRT in small observational studies. Further, its safety has also been well established and is largely free of the pitfalls of the HBP-CRT. In the recent metanalysis by Yasmin et al, comprising of 6 studies with 389 participants, LBBP-CRT was superior to BiVP-CRT in terms of QRS duration, left ventricular ejection fraction, cardiac chamber dimensions, lead thresholds, and functional status amongst heart failure patients with left bundle branch block. However, there are important limitations of the study including the small overall numbers, inclusion of only a single small randomized controlled trial (RCT) and a small follow-up duration. Further, the entire study population analyzed was from China which makes generalizability a concern. Despite the concerns, the meta-analysis adds to the growing body of evidence demonstrating the efficacy of LBBP-CRT. At this stage, one must acknowledge that the fact that still our opinions on this technique are largely based on observational data and there is a dire need for larger RCTs to ascertain the position of LBBP-CRT in management of heart failure patients with left bundle branch block.
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Affiliation(s)
- Akash Batta
- Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana 141001, India.
| | - Juniali Hatwal
- Department of Internal Medicine, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
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Alfieri M, Bruscoli F, Di Vito L, Di Giusto F, Scalone G, Marchese P, Delfino D, Silenzi S, Martoni M, Guerra F, Grossi P. Novel Medical Treatments and Devices for the Management of Heart Failure with Reduced Ejection Fraction. J Cardiovasc Dev Dis 2024; 11:125. [PMID: 38667743 PMCID: PMC11050600 DOI: 10.3390/jcdd11040125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/13/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Heart failure (HF) is a growing issue in developed countries; it is often the result of underlying processes such as ischemia, hypertension, infiltrative diseases or even genetic abnormalities. The great majority of the affected patients present a reduced ejection fraction (≤40%), thereby falling under the name of "heart failure with reduced ejection fraction" (HFrEF). This condition represents a major threat for patients: it significantly affects life quality and carries an enormous burden on the whole healthcare system due to its high management costs. In the last decade, new medical treatments and devices have been developed in order to reduce HF hospitalizations and improve prognosis while reducing the overall mortality rate. Pharmacological therapy has significantly changed our perspective of this disease thanks to its ability of restoring ventricular function and reducing symptom severity, even in some dramatic contexts with an extensively diseased myocardium. Notably, medical therapy can sometimes be ineffective, and a tailored integration with device technologies is of pivotal importance. Not by chance, in recent years, cardiac implantable devices witnessed a significant improvement, thereby providing an irreplaceable resource for the management of HF. Some devices have the ability of assessing (CardioMEMS) or treating (ultrafiltration) fluid retention, while others recognize and treat life-threatening arrhythmias, even for a limited time frame (wearable cardioverter defibrillator). The present review article gives a comprehensive overview of the most recent and important findings that need to be considered in patients affected by HFrEF. Both novel medical treatments and devices are presented and discussed.
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Affiliation(s)
- Michele Alfieri
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I-Lancisi-Salesi”, 60121 Ancona, Italy; (M.A.); (F.G.)
| | - Filippo Bruscoli
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Luca Di Vito
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Federico Di Giusto
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Giancarla Scalone
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Procolo Marchese
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Domenico Delfino
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Simona Silenzi
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Milena Martoni
- Medical School, Università degli Studi “G. d’Annunzio”, 66100 Chieti, Italy;
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I-Lancisi-Salesi”, 60121 Ancona, Italy; (M.A.); (F.G.)
| | - Pierfrancesco Grossi
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
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Tan ESJ, Soh R, Lee JY, Boey E, Chan SP, Lim TW, Yeo WT, Leong KMW, Seow SC, Kojodjojo P. Prognostic benefits of His-Purkinje capture in physiological pacemakers for bradycardia. J Cardiovasc Electrophysiol 2024; 35:727-736. [PMID: 38351331 DOI: 10.1111/jce.16211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/11/2023] [Accepted: 01/29/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Clinical outcomes of long-term ventricular septal pacing (VSP) without His-Purkinje capture remain unknown. This study evaluated the differences in clinical outcomes between conduction system pacing (CSP), VSP, and right ventricular pacing (RVP). METHODS Consecutive patients with bradycardia indicated for pacing from 2016 to 2022 were prospectively followed for the clinical endpoints of heart failure (HF)-hospitalizations and all-cause mortality at 2 years. VSP was defined as septal pacing due to unsuccessful CSP implant or successful CSP followed by loss of His-Purkinje capture within 90 days. RESULTS Among 1016 patients (age 73.9 ± 11.2 years, 47% female, 48% atrioventricular block), 612 received RVP, 335 received CSP and 69 received VSP. Paced QRS duration was similar between VSP and RVP, but both significantly longer than CSP (p < .05). HF-hospitalizations occurred in 130 (13%) patients (CSP 7% vs. RVP 16% vs. VSP 13%, p = .001), and all-cause mortality in 143 (14%) patients (CSP 7% vs. RVP 19% vs. VSP 9%, p < .001). The association of pacing modality with clinical events was limited to those with ventricular pacing (Vp) > 20% (pinteraction < .05). Adjusting for clinical risk factors among patients with Vp > 20%, VSP (adjusted hazard ratio [AHR]: 4.74, 95% confidence interval [CI]: 1.57-14.36) and RVP (AHR: 3.08, 95% CI: 1.44-6.60) were associated with increased hazard of HF-hospitalizations, and RVP (2.52, 95% CI: 1.19-5.35) with increased mortality, compared to CSP. Clinical endpoints did not differ between VSP and RVP with Vp > 20%, or amongst groups with Vp < 20%. CONCLUSION Conduction system capture is associated with improved clinical outcomes. CSP should be preferred over VSP or RVP during pacing for bradycardia.
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Affiliation(s)
- Eugene S J Tan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Rodney Soh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Jie-Ying Lee
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Elaine Boey
- Department of Cardiology, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Siew-Pang Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Toon Wei Lim
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Wee Tiong Yeo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Kevin M W Leong
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Swee-Chong Seow
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
- Department of Cardiology, Ng Teng Fong General Hospital, Singapore, Singapore
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Kono H, Kuramitsu S, Fukunaga M, Korai K, Nagashima M, Hiroshima K, Ando K. Outcomes of left bundle branch area pacing compared to His bundle pacing and right ventricular apical pacing in Japanese patients with bradycardia. J Arrhythm 2024; 40:333-341. [PMID: 38586856 PMCID: PMC10995588 DOI: 10.1002/joa3.12997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 04/09/2024] Open
Abstract
Background His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) emerge as better alternatives to right ventricular apical pacing (RVAP) in patients with bradycardia requiring permanent cardiac pacing. We aimed to compare the clinical outcomes of LBBAP, HBP, and RVAP in Japanese patients with bradycardia. Methods A total of 424 patients who underwent successful pacemaker implantation (HBP, n = 53; LBBAP, n = 75; and RVAP, n = 296) were retrospectively enrolled in this study. The primary study endpoint was the cumulative incidence of heart failure hospitalization (HFH) during the follow-up. Results The success rate for implantation was higher in the LBBAP group than in the HBP group (94.9% and 81.5%, respectively). Capture threshold increase >1V during the follow-up occurred in the HBP and RVAP groups (9.4% and 5.1%, respectively), while it did not in the LBBAP group. The cumulative incidence of HFH was significantly lower in the LBBAP group than the RVAP (adjusted hazard ratio, 0.12 [95% confidence interval: 0.02-0.86]; p = .034); it did not differ between the HBP and RVAP groups (adjusted hazard ratio, 0.48 [95% confidence interval: 0.17-1.34]; p = .16). Advanced age, mean percent right ventricular pacing (per 10% increase), left ventricular ejection fraction <50%, and RVAP were associated with HFH. Conclusions Compared to RVAP and HBP, LBBAP appeared more feasible and effective in patients with bradycardia requiring permanent cardiac pacing.
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Affiliation(s)
- Hiroyuki Kono
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | - Shoichi Kuramitsu
- Department of Cardiovascular MedicineSapporo Cardiovascular Clinic, Sapporo Heart CenterSapporoJapan
| | - Masato Fukunaga
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | - Kengo Korai
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | | | | | - Kenji Ando
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
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Sánchez-Quintana D, Cabrera JA, Anderson RH. The clinical anatomy of the atrioventricular conduction axis. Europace 2024; 26:euae048. [PMID: 38364795 PMCID: PMC10911402 DOI: 10.1093/europace/euae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/12/2024] [Indexed: 02/18/2024] Open
Abstract
It is axiomatic that the chances of achieving accurate capture of the conduction axis and its fascicles will be optimized by equally accurate knowledge of the relationship of the components to the recognizable cardiac landmarks, and we find it surprising that acknowledged experts should continue to use drawings that fall short in terms of anatomical accuracy. The accuracy achieved by Sunao Tawara (1906) in showing the location of the atrioventricular conduction axis is little short of astounding. Our purpose in bringing this to current attention is to question the need of the experts to have produced such inaccurate representations, since the findings of Tawara have been extensively endorsed in very recent years. The recent studies do no more than point to the amazing accuracy of the initial account of Tawara. At the same time, we draw attention to the findings described in the middle of the 20th century by Ivan Mahaim (1947). These observations have tended to be ignored in recent accounts. They are, perhaps, of equal significance to those seeking specifically to pace the left fascicles of the branching atrioventricular bundle.
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Affiliation(s)
- Damián Sánchez-Quintana
- Departamento de Anatomía Humana y Biología Celular, Facultad de Medicina, Universidad de Extremadura, Elvas Avenue, Badajoz 06006, Spain
| | - Jose-Angel Cabrera
- Departamento de Cardiología, Unidad de Arritmias, Hospital Universitario Quirón-Salud Madrid and complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
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50
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Burri H. Maintaining mechanical synchrony with left bundle branch area pacing. Eur Heart J Cardiovasc Imaging 2024; 25:337-338. [PMID: 37966280 DOI: 10.1093/ehjci/jead310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/16/2023] Open
Affiliation(s)
- Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Rue Gabrielle Perret Gentil 4, Geneva 1211, Switzerland
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