EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS)

Intra-pocket ultrasound-guided axillary vein puncture vs. cephalic vein cutdown for cardiac electronic device implantation: the ACCESS trial

BACKGROUND AND AIMS

Intra-pocket ultrasound-guided axillary vein puncture (IPUS-AVP) for venous access in implantation of transvenous cardiac implantable electronic devices (CIED) is uncommon due to the lack of clinical evidence supporting this technique. This study investigated the efficacy and early complications of IPUS-AVP compared to the standard method using cephalic vein cutdown (CVC) for CIED implantation.

METHODS

ACCESS was an investigator-led, interventional, randomized (1:1 ratio), monocentric, controlled superiority trial. A total of 200 patients undergoing CIED implantation were randomized to IPUS-AVP (n = 101) or CVC (n = 99) as a first assigned route. The primary endpoint was the success rate of insertion of all leads using the first assigned venous access technique. The secondary endpoints were time to venous access, total procedure duration, fluoroscopy time, X-ray exposure, and complications. Complications were monitored during a follow-up period of three months after procedure.

RESULTS

IPUS-AVP was significantly superior to CVC for the primary endpoint with 100 (99.0%) vs. 86 (86.9%) procedural successes (P = .001). Cephalic vein cutdown followed by subclavian vein puncture was successful in a total of 95 (96.0%) patients, P = .21 vs. IPUS-AVP. All secondary endpoints were also significantly improved in the IPUS-AVP group with reduction in time to venous access [3.4 vs. 10.6 min, geometric mean ratio (GMR) 0.32 (95% confidence interval, CI, 0.28-0.36), P < .001], total procedure duration [33.8 vs. 46.9 min, GMR 0.72 (95% CI 0.67-0.78), P < .001], fluoroscopy time [2.4 vs. 3.3 min, GMR 0.74 (95% CI 0.63-0.86), P < .001], and X-ray exposure [1083 vs. 1423 mGy.cm², GMR 0.76 (95% CI 0.62-0.93), P = .009]. There was no significant difference in complication rates between groups (P = .68).

CONCLUSIONS

IPUS-AVP is superior to CVC in terms of success rate, time to venous access, procedure duration, and radiation exposure. Complication rates were similar between the two groups. Intra-pocket ultrasound-guided axillary vein puncture should be a recommended venous access technique for CIED implantation.

Real-world evidence for the use of subcutaneous implantable cardioverter-defibrillators in China: A single-center experience

BACKGROUND

Subcutaneous implantable cardioverter-defibrillators (S-ICDs) have been shown to be non-inferior to transvenous ICDs in the prevention of sudden cardiac death (SCD), but there is still a lack of evidence from clinical trials in China. We investigated whether S‑ICD implantation in the Chinese population is safe and feasible and should be promoted in the future.

METHODS

Consecutive patients undergoing S‑ICD implantation at our center were enrolled in this retrospective study. Data were collected within the median follow-up period of 554 days. Data concerning patient selection, implantation procedures, complications, and episodes of shock were analyzed.

RESULTS

In total, 70.2% of all 47 patients (median age = 39 years) were included for secondary prevention of SCD with different etiologies. Vector screening showed that 98% of patients were with > 1 appropriate vector in all postures. An intraoperative defibrillation test was not performed on six patients because of the high risk of disease deterioration, while all episodes of ventricular fibrillation induced post implantation were terminated by one shock. As expected, no severe complications (e.g., infection and device-related complications) were observed, except for one case of delayed healing of the incision. Overall, 15 patients (31.9%) experienced appropriate shocks (AS) with all episodes terminated by one shock. Two patients (4.3%) experienced inappropriate shocks (IAS) due to noise oversensing, resulting in a high Kaplan-Meier IAS-free rate of 95.7%.

CONCLUSION

Based on appropriate patient selection and standardized implantation procedures, this real-world study confirmed the safety and efficacy of S‑ICD in Chinese patients, indicating that it may help to promote the prevention of SCD in China.

A Personalized Approach to the Management of Congestion in Acute Heart Failure

Heart failure (HF) is the common final pathway of several conditions and is characterized by hyperactivation of numerous neurohumoral pathways. Cardiorenal interaction plays an essential role in the progression of the disease, and the use of diuretics is a cornerstone in the treatment of hypervolemic patients, especially in acute decompensated HF (ADHF). The management of congestion is complex and, to avoid misinterpretations and errors, one must understand the interface between the heart and the kidneys in ADHF. Congestion itself may impair renal function and must be treated aggressively. Transitory elevations in serum creatinine during decongestion is not associated with worse outcomes and diuretics should be maintained in patients with clear hypervolemia. Monitoring urinary sodium after diuretic administration seems to improve the response to diuretics as it allows for adjustments in doses and a personalized approach. Adequate assessment of volemia and the introduction and titration of guideline-directed medical therapy are mandatory before discharge. An early visit after discharge is highly recommended, to assess for residual congestion and thus avoid readmissions.

Video-assisted thoracoscopic epicardial pacing: A contemporary overview

Video-assisted thoracoscopic surgery (VATS) has revolutionized the approach and management of pulmonary and cardiac diseases, and its applications have significantly expanded in the last two decades. Beyond its established role in thoracic procedures, VATS has also emerged as a valuable technique for various electrophysiological procedures, including pacemaker implantations, ablation procedures, and left atrial appendage exclusion. This paper presents a thorough review of the existing literature on pacing procedures performed using a VATS approach. By analyzing and synthesizing the available studies, we aim to provide an in-depth understanding of the current knowledge and advancements in VATS-based pacing procedures. A key focus of this review is the detailed description of implantation techniques via a VATS approach.

[Venous access routes for cardiac implantable electronic devices]

Various venous access routes in the region of the clavicle are available for cardiac device treatment. After many years of choosing access via the subclavian vein, current data explicitly show that lateral approaches such as preparation of the cephalic vein or puncture of the axillary vein are clearly superior in terms of probe durability and risk of complications. This article describes the preparation and performance of the various access techniques and is intended to provide a practical guide for the work in cardiac pacemaker operations. This work continues a series of articles designed for advanced training in specialized rhythmology.

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

AIMS

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

METHODS

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

CONCLUSION

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

Single- Versus Dual-Chamber Implantable Cardioverter-Defibrillator for Primary Prevention of Sudden Cardiac Death in the United States

Background Routine addition of an atrial lead during an implantable cardioverter-defibrillator (ICD) implantation for primary prevention of sudden cardiac death, in patients without pacing indications, was not shown beneficial in contemporary studies. We aimed to investigate the use and safety of single- versus dual-chamber ICD implantations in these patients. Methods and Results Using the National Inpatient Sample database, we identified patients with no pacing indications who underwent primary-prevention ICD implantation in the United States between 2015 and 2019. Sociodemographic and clinical characteristics, as well as in-hospital complications, were analyzed. Multivariable logistic regression was used to identify predictors of in-hospital complications. An estimated total of 15 940 patients, underwent ICD implantation for primary prevention of sudden cardiac death during the study period, 8860 (55.6%) received a dual-chamber ICD. The mean age was 64 years, and 66% were men. In-hospital complication rates in the dual-chamber ICD and single-chamber ICD group were 12.8% and 10.7%, respectively (P<0.001), driven by increased rates of pneumothorax/hemothorax (4.6% versus 3.4%; P<0.001) and lead dislodgement (3.6% versus 2.3%; P<0.001) in the dual-chamber ICD group. Multivariable analyses confirmed atrial lead addition as an independent predictor for "any complications" (odds ratio [OR], 1.1 [95% CI, 1.0-1.2]), for pneumo/hemothorax (odds ratio, 1.1 [95% CI, 1.0-1.4]), and for lead dislodgement (odds ratio, 1.3 [95% CI, 1.1-1.6]). Conclusions Despite lack of evidence for clinical benefit, dual-chamber ICDs are implanted for primary prevention of sudden cardiac death in a majority of patients who do not have pacing indication. This practice is associated with increased risk of periprocedural complications. Avoidance of routine implantation of atrial leads will likely improve safety outcomes.

Combined effects of high atrial septal pacing and reactive atrial antitachycardia pacing for reducing atrial fibrillation in sick sinus syndrome

Background

It is unknown whether atrial fibrillation (AF) burden varies by pacing site in patients with reactive atrial antitachycardia pacing (rATP). We aimed to compare AF burden in patients with high atrial septal pacing (HASp) via delivery catheter and right atrial appendage pacing (RAAp) in patients with sick sinus syndrome (SSS).

Methods

We retrospectively identified 109 patients with a history of paroxysmal AF and SSS who had received dual-chamber pacemaker implantation between January 2017 and December 2019, of whom 39 and 70 patients had HASp and RAAp, respectively. rATP was initiated after a 1-month post-implantation run-in period.

Results

Patients with HASp had a significantly shorter P-wave duration during atrial pacing than those with RAAp (99.3 ± 10.4 vs. 116.0 ± 14.3 ms, p < .001). During the 3-year follow-up period, the incidence of an AF lasting longer than 1 or 7 days was significantly lower (hazard ratio [HR], 0.45; p = .016; HR, 0.24; p = .004) than in those with RAAp. The median time of AF/AT per day in the follow-up periods was significantly shorter in the HASp group than in the RAAp group (10 vs. 18 min/day, p = .018). Atrial lead division did not occur in the HASp group during the follow-up period.

Conclusions

HASp via delivery catheter is as safe as RAAp, and HASp combined with rATP is effective for reducing AF burden in patients with SSS and paroxysmal AF.

Axillary vein puncture versus cephalic vein cutdown for cardiac implantable electronic device implantation: A meta-analysis

INTRODUCTION

Cephalic vein cutdown (CVC) and axillary vein puncture (AVP) are both recommended for transvenous implantation of leads for cardiac implantable electronic devices (CIEDs). Nonetheless, it is still debated which of the two techniques has a better safety and efficacy profile.

METHODS

We systematically searched Medline, Embase, and Cochrane electronic databases up to September 5, 2022, for studies that evaluated the efficacy and safety of AVP and CVC reporting at least one clinical outcome of interest. The primary endpoints were acute procedural success and overall complications. The effect size was estimated using a random-effect model as risk ratio (RR) and relative 95% confidence interval (CI).

RESULTS

Overall, seven studies were included, which enrolled 1771 and 3067 transvenous leads (65.6% [n = 1162] males, average age 73.4 ± 14.3 years). Compared to CVC, AVP showed a significant increase in the primary endpoint (95.7 % vs. 76.1 %; RR: 1.24; 95% CI: 1.09-1.40; p = .001) (Figure 1). Total procedural time (mean difference [MD]: -8.25 min; 95% CI: -10.23 to -6.27; p < .0001; I2  = 0%) and venous access time (MD: -6.24 min; 95% CI: -7.01 to -5.47; p < .0001; I2  = 0%) were significantly shorter with AVP compared to CVC. No differences were found between AVP and CVC for incidence overall complications (RR: 0.56; 95% CI: 0.28-1.10; p = .09), pneumothorax (RR: 0.72; 95% CI: 0.13-4.0; p = .71), lead failure (RR: 0.58; 95% CI: 0.23-1.48; p = .26), pocket hematoma/bleeding (RR: 0.58; 95% CI: 0.15-2.23; p = .43), device infection (RR: 0.95; 95% CI: 0.14-6.60; p = .96) and fluoroscopy time (MD: -0.24 min; 95% CI: -0.75 to 0.28; p = .36).

CONCLUSION

Our meta-analysis suggests that AVP may improve procedural success and reduce total procedural time and venous access time compared to CVC.

Ultrasound-guided access to the axillary vein for implantation of cardiac implantable electronic devices: A systematic review and meta-analysis

The aims of our systematic review were to quantify the expected rate of procedural success, early and late complications during CIED implantation using US-guided puncture of the axillary vein and to perform a meta-analysis of those studies that compared the US technique (intervention) versus conventional techniques (control) in terms of complication rates. MEDLINE, ISI Web of Science, and EMBASE were searched for eligible studies. Pooled Odds Ratio (OR) and Pooled Mean Difference (PMD) for each predictor were calculated. The quality of evidence (QOE) was evaluated according to the GRADE guidelines. Thirteen studies were included a total of 2073 patients. The overall success of US-guided venipuncture for CIED implantation was 96.8%. As regards early complications, pneumothorax occurred in 0.19%, arterial puncture in 0.63%, and severe hematoma/bleeding requiring intervention in 1.1%. No cases of hemothorax, brachial plexus, or phrenic nerve injury were reported. As regards late complications, the incidence of pocket infection, venous thromboembolism, and leads dislodgement was respectively 0.4%, 0.8%, and 1.2%. In the meta-analysis (five studies), the intervention group (US-guided venipuncture) had a trend versus a lower likelihood of having a pneumothorax (0.19% vs 0.75%, p = 0.21), pocket hematoma (0.8% vs 1.7%, p = 0.32), infection (0.28% vs 1.05%, p = 0.29) than the control group, but this did not reach statistical significance. The overall QOE was low or very low. In conclusions we found that the US-guided axillary venipuncture for CIEDs implantation was associated with a low incidence of early and late complications and a steep learning curve.

Frame-rate reduction to reduce radiation dose for cardiac device implantation is safe

Background

Radiation exposure to patient and surgeon during cardiac implantable electrical device (CIED) procedures remains a substantial health hazard to date. Advanced technical options for radiation dose reduction often pose considerable financial hurdles. We propose a near-zero cost, low-effort modification to a clinical x-ray system significantly reducing radiation dose during CIED implantation.

Objective

We aim to evaluate a reduced frame rate protocol in CIED implantation for complication rates and reduction in radiation exposure.

Methods

Starting May 2019, the frame rate during CIED implantations at our hospital was halved from 7.5 frames/s to 3.8 frames/s, and no further technical changes were made. During the following year, 264 patients were operated using this protocol and retrospectively compared with 231 cases implanted in the year before the protocol change, totaling 495 cases. Of these, 17%, 63%, and 19% were single-chamber, dual-chamber, or resynchronization devices, respectively. Incidence of complication prior to hospital discharge was considered the primary endpoint of the analysis. Radiation dose and procedural parameters were secondary endpoints.

Results

There was no increase in complications with the reduced frame rate protocol. Regression analysis further supported that the reduced frame rate radiation protocol was not associated with complication rates. Radiation exposure measured as dose area product was significantly reduced by ∼62% (median 369 [interquartile range 154-1207] cGy·cm² via the reduced frame rate protocol vs median 970 [interquartile range 400-1906] cGy·cm² with the standard frame rate; P < 0.01).

Conclusion

A reduction of frame rate during CIED implantation is safe in terms of complication incidence and effective in terms of reducing radiation exposure.

Direct anchoring technique for pacing and defibrillation leads inserted through cephalic vein: insight for a single high-volume center

BACKGROUND

Direct anchoring of PM and ICD leads over cephalic vein body is officially discouraged by manufactures due to a supposed risk of conductor fracture or insulation failure, however careful tightening of anchoring knots can probably prevent lead damage. Direct anchoring (DA) technique is routinely used in our center for all leads inserted by cephalic vein while standard anchoring sleeves are used to secure subclavian leads only. Aim of the study is to assess short- and long-term safety of cephalic direct anchoring technique.

METHODS

All patients undergoing PM and ICD implantation in our center from November 2014 to March 2016 were consecutively enrolled. Primary endpoints were acute lead fracture, lead dislodgement and chronic lead failure. Secondary endpoint was a composite of short-term surgical complications (pocket hematoma, pneumothorax, and pericardial effusion) plus device infections. Subclavian leads secured with sleeve anchoring (SA) were used as control.

RESULTS

A total of 550 leads were implanted in 310 consecutive patients. DA involved 323 leads (59%) while SA was used for 227 (41%). Median follow-up was 50 months (IQR 24-62 months). 17 lead malfunctions (3.1%) were observed during follow-up. No difference was observed between groups (10 DA vs. 7 SP, P=ns). Survival analysis found no difference between groups. Secondary endpoints were not statistically different between groups (5 vs. 1, P=0.08).

CONCLUSIONS

Direct anchoring technique of PM and ICD leads is a safe technique and does not increase lead malfunction risk.

Right ventricular function is a predictor for sustained ventricular tachycardia requiring anti-tachycardic pacing in arrhythmogenic ventricular cardiomyopathy: insight into transvenous vs. subcutaneous implantable cardioverter defibrillator insertion

AIMS

Arrhythmogenic right ventricular cardiomyopathy (ARVC) patients develop ventricular arrhythmias (VAs) responsive to anti-tachycardia pacing (ATP). However, VA episodes have not been characterized in accordance with the device therapy, and with the emergence of the subcutaneous implantable cardioverter defibrillator (S-ICD), the appropriate device prescription in ARVC remains unclear. Study aim was to characterize VA events in ARVC patients during follow-up in accordance with device therapy and elicit if certain parameters are predictive of specific VA events.

METHODS AND RESULTS

This was a retrospective single-centre study utilizing prospectively collated registry data of ARVC patients with ICDs. Forty-six patients were included [54.0 ± 12.1 years old and 20 (43.5%) secondary prevention devices]. During a follow-up of 12.1 ± 6.9 years, 31 (67.4%) patients had VA events [n = 2, 6.5% ventricular fibrillation (VF), n = 14], 45.2% VT falling in VF zone resulting in ICD shock(s), n = 10, 32.3% VT resulting in ATP, and n = 5, 16.1% patients had both VT resulting in ATP and ICD shock(s). Lead failure rates were high (11/46, 23.9%). ATP was successful in 34.5% of patients. Severely impaired right ventricular (RV) function was an independent predictor of VT resulting in ATP (hazard ratio 16.80, 95% confidence interval 3.74-75.2; P < 0.001) with a high predictive accuracy (area under the curve 0.88, 95%CI 0.76-1.00; P < 0.001).

CONCLUSION

VA event rates are high in ARVC patients with a majority having VT falling in the VF zone resulting in ICD shock(s). S-ICDs could be of benefit in most patients with ARVC with the absence of severely impaired RV function which has the potential to avoid consequences of the high burden of lead failure.

Impact of peri-procedural management of direct oral anticoagulants on pocket haematoma after cardiac electronic device implantation: the StimAOD multicentre prospective study

AIMS

The study aims to investigate the impact of direct oral anticoagulant (DOAC) management on the incidence of pocket haematoma in patients undergoing pacemaker or implantable cardioverter-defibrillator implantation.

METHODS AND RESULTS

All consecutive patients receiving DOAC and undergoing cardiac electronic device implantation were included in a large multicentre prospective observational study (NCT03879473). The primary endpoint was clinically relevant haematoma within 30 days after implantation. Overall, 789 patients were enrolled [median age 80 (IQR 72-85) years old, 36.4% women, median CHA2DS2-VASc score 4 (IQR 0-8)], of which 632 (80.1%) received a pacemaker implantation. Antiplatelet therapy was combined with DOAC in 146 patients (18.5%). Direct oral anticoagulants (DOACs) were interrupted 52 (IQR 37-62) h before the procedure and resumed 31 (IQR 21-47) h later. Ninety-six percent of the patients had at least 12 h DOAC interruption before the procedure, and 78% had at least 12 h DOAC interruption after the procedure. Overall, anticoagulation was interrupted for 72 (IQR 48-96) h. Pre- or post-procedural heparin bridging was used in 8.2% and 3.9%, respectively. Timing of DOAC interruption of resumption was not associated with clinically relevant haematoma. Clinically relevant haematoma occurred in 26 patients (3.3%), and thromboembolic events occurred in 5 patients (0.6%).

CONCLUSION

In this large real-life registry where most patients had DOAC interruption, clinically relevant haematoma was rare. Despite DOAC interruption and high CHA2DS2-VASc score, thromboembolic events occurred seldomly, highlighting that bleeding exceeds thromboembolic risk in this peri-procedural period. Future research is needed to identify risk factors for clinically relevant haematoma and meaningfully guide clinicians in optimizing DOAC management.

Perioperative coagulation activation after permanent pacemaker placement

BACKGROUND

Bradyarrhythmias are typically treated with permanent pacemakers (PM). The elimination of bradyarrhythmia by PM implantation improves the patient's quality of life and prognosis, but it can also result in a number of sequalae. It is still unclear how PM implantation affects the hemostasis system's parameters and how such parameters relate to different consequences after PM placement.

AIM

To assess the blood coagulation factor activity in PM patients throughout the perioperative period.

METHODS

Patients treated in the Department of Surgical Therapy of Cardiac Arrhythmias and Pacing at the Ryazan State "Regional Clinical Cardiology Dispensary" from April 2020 to December 2021 were included in the study. Before surgery, 7 and 30 d after PM placement, peripheral venous blood samples were withdrawn to measure the level of blood coagulation factor I (FI) and the activity of blood coagulation factors II (FII), V (FV), VII (FVII), VIII (FVIII), IX (FIX), X (FX), XI (FXI), XII (FXII). We used an automatic coagulometer Sysmex CA 660 (Sysmex Europe, Germany) and reagents from Siemens (Siemens Healthcare Diagnostics Products GmbH, Germany).

RESULTS

The study included 146 patients. The activity of factors FV [147.7 (102.1-247.55)% vs 103.85 (60-161.6)% vs 81.8 (67.15-130.65)%, P = 0.002], FVIII [80.4 (60.15-106.25)% vs 70.3 (48.5-89.1)% vs 63.7 (41.6-88.25)%, P = 0.039], FIX [86.2 (70.75-102.95)% vs 75.4 (59.2-88.3)% vs 73.9 (56.45-93.05)%, P = 0.014], FX [188.9 (99.3-308.18)% vs 158.9 (83.3-230)% vs 127.2 (95.25-209.35)%, P = 0.022], FXI [82.6 (63.9-103.6)% vs 69.75 (53.8-97.6)% vs 67.3 (54.25-98.05)%, P = 0.002], FXII [87.6 (67.15-102.3)% vs 78.9 (63.4-97.05)% vs 81.2 (62.15-97.4)%, P < 0.001] decreased at 7 and 30 d after surgery; FII activity [157.9 (109.7-245.25)% vs 130 (86.8-192.5)% vs 144.8 (103.31-185.6)%, P = 0.021] decreased at 7 d and increased at 30 d postoperatively. There were no statistically significant changes in the FVII activity within 30 d after PM placement [182.2 (85.1-344.8)% vs 157.2 (99.1-259)% vs 108.9 (74.9-219.8)%, P = 0.128]. Subgroup analysis revealed similar changes only in patients on anticoagulant therapy. FXII activity decreased in patients on antiplatelet therapy [82 (65.8-101.9)% vs 79.9 (63.3-97.1)% vs 89.7 (75.7-102.5)%, P = 0.01] 7 d after surgery, returning to baseline values at 30 d postoperatively.

CONCLUSION

PM placement and anticoagulant therapy were associated with decreased activity of clotting factors FV, FVIII, FIX, FX, FXI, FXII in the postoperative period. FVII activity did not decrease within 30 d after PM placement, which may indicate endothelial injury caused by lead placement.

Risk Factors of Upper Extremity Deep Vein Thrombosis After Pacemaker Implantation

Objective. To evaluate the prevalence, risk factors and treatment outcomes of upper extremity deep vein thrombosis after pacemaker implantation. Material and methods. A prospective single-center study included patients with indications for pacemaker implantation. The follow-up period was 12 months. Physical examination, ultrasound of upper and lower extremity veins and monitoring of pacemaker function were carried out before implantation, 1 and 12 months later. Additional ultrasound was necessary for treatment control in case of upper extremity deep vein thrombosis. Results. There were 148 patients. Venous thromboembolism occurred in 10 (6.8%) cases throughout the follow-up period: 8 (5.4%) cases of subclavian vein thrombosis and 2 (1.4%) cases of superficial thrombophlebitis of lower extremities. According to multivariate analysis, the odds ratio of upper extremity deep vein thrombosis was 6.4 times (p=0.033) higher in patients receiving antiplatelet agents (acetylsalicylic acid) compared to anticoagulants. Treatment of venous thrombosis implied rivaroxaban. In 5 out of 6 patients, vein recanalization was achieved within 3 months, in 1 case — within 12 months. One patient had subconjunctival hemorrhage that required short-term discontinuation of anticoagulation without effect on baseline result. Conclusion. Annual incidence of venous thromboembolism after pacemaker implantation was 6.8%. Risk factor of upper extremity deep vein thrombosis was the type of antithrombotic therapy.

Paradigm Shifts in Cardiac Pacing: Where Have We Been and What Lies Ahead?

The history of cardiac pacing dates back to the 1930s with externalized pacing and has evolved to incorporate transvenous, multi-lead, or even leadless devices. Annual implantation rates of cardiac implantable electronic devices have increased since the introduction of the implantable system, likely related to expanding indications, and increasing global life expectancy and aging demographics. Here, we summarize the relevant literature on cardiac pacing to demonstrate the enormous impact it has had within the field of cardiology. Further, we look forward to the future of cardiac pacing, including conduction system pacing and leadless pacing strategies.

5G Service and Pacemakers/Implantable Defibrillators: What Is the Actual Risk?

Rapidly growing worldwide, 5G service is expected to deeply change the way we communicate, connect and share data. It encompasses the whole spectrum of new technology, infrastructure and mobile connectivity, and will touch not only every sector in the industry, but also many aspects of our everyday life. Although the compliance with international regulations provides reasonable protection to public health and safety, there might be specific issues not fully covered by the current technical standards. Among the aspects that shall be carefully considered, there is the potential interference that can be induced on medical devices, and in particular on implantable medical devices that are critical for the patient's life, such as pacemakers and implantable defibrillators. This study aims to assess the actual risk that 5G communication systems pose to pacemakers and implantable defibrillators. The setup proposed by the ISO 14117 standard was adapted to include 5G characteristic frequencies of 700 MHz and 3.6 GHz. A total number of 384 tests were conducted. Among them, 43 EMI events were observed. Collected results reveal that RF hand-held transmitters operating in these two frequency bands do not pose additional risk compared to pre-5G bands and that the safety distance of 15 cm typically indicted by the PM/ICD manufacturer is still able to guarantee the patient's safety.

Adverse clinical events during the first 24 h of bedrest following cardiac electronic device implantation: a prospective observational study

AIMS

To describe the incidence and impact of adverse clinical events (ACEs) during first 24 h of bedrest of patients after cardiac implantable electronic device (CIED) implantation.

METHODS AND RESULTS

We conducted a prospective observational study of patients aged over 18 years undergoing elective placement of permanent bicameral pacemaker (PM), cardiac resynchronization therapy (CRT) PM, CRT defibrillator, or implantable cardioverter-defibrillator. Patients were maintained on bedrest post-operatively for 24 h and delirium, post-operative urinary retention, severe post-operative pain, pressure ulcer, and sleep disturbance were recorded using standardized assessments. Of 90 patients, 66 (73.3%) were male and average age was 76 ± 10 years. The median time to first mobilization was 23 (21-24) h. The adverse clinical events occurred in 48/90, with severe pain (38/90), sleep disturbance (12/90), delirium (9/90), and urinary retention requiring urinary catheterization (8/90) most frequent. Patients receiving implantable cardioverter-defibrillator or CRT defibrillator experienced ACEs significantly more frequently than those receiving PM. Adverse clinical event was associated with prolonged hospital stay [odds ratio (OR) 2.5; 95% confidence interval (CI) 1.16-6.17]. Patients with delirium were more dependent for daily living activities on admission (OR 8.0; 95% CI 1.55-41.3).

CONCLUSION

Adverse clinical events frequently occur post-insertion of a CIED and impact patient clinical course and experience. The progressive increase in ageing and frailty of CIED implant candidates requires special nursing attention to improve patients' satisfaction and to prevent increased healthcare resource use.

European Society of Cardiology quality indicators for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

To develop a suite of quality indicators (QIs) for the management of patients with ventricular arrhythmias (VA) and the prevention of sudden cardiac death (SCD). The Working Group comprised experts in heart rhythm management including Task Force members of the 2022 European Society of Cardiology (ESC) Clinical Practice Guidelines for the management of patients with VA and the prevention of SCD, members of the European Heart Rhythm Association, international experts, and a patient representative. We followed the ESC methodology for QI development, which involves (i) the identification of the key domains of care for the management of patients with VA and the prevention of SCD by constructing a conceptual framework of care, (ii) the development of candidate QIs by conducting a systematic review of the literature, (iii) the selection of the final set of QIs using a modified-Delphi method, and (iv) the evaluation of the feasibility of the developed QIs. We identified eight domains of care for the management of patients with VA and the prevention of SCD: (i) structural framework, (ii) screening and diagnosis, (iii) risk stratification, (iv) patient education and lifestyle modification, (v) pharmacological treatment, (vi) device therapy, (vii) catheter ablation, and (viii) outcomes, which included 17 main and 4 secondary QIs across these domains. Following a standardized methodology, we developed 21 QIs for the management of patients with VA and the prevention of SCD. The implementation of these QIs will improve the care and outcomes of patients with VA and contribute to the prevention of SCD.

Late Incidental Discovery of Compression of the Left Anterior Descending Coronary Artery by an Endocardial Defibrillator Lead

Coronary artery compression/damage by cardiac pacing/defibrillation leads is very rare and often an unknown complication of pacemaker implantation. Here, we present the case of a 71-year-old woman with late discovery of an asymptomatic compression of the left anterior descending (LAD) coronary artery by a defibrillation lead implanted ten years before. This dissuaded us in removing this now malfunctioning lead with high threshold, and an additional right ventricular (RV) lead was implanted along with atrial and left ventricular (LV) leads for allowing resynchronization therapy. Based on the published data, a majority of RV leads are currently implanted in the "anteroseptal area," which is neighboring the course of the LAD.

Efficacy of the antibacterial envelope to prevent cardiac implantable electronic device infection in a high-risk population

AIMS

Infection is a serious complication of cardiac implantable electronic device (CIED) therapy. An antibiotic-eluting absorbable envelope has been developed to reduce the infection rate, but studies investigating the efficacy and a reasonable number needed to treat in high-risk populations for infections are limited.

METHODS AND RESULTS

One hundred and forty-four patients undergoing CIED implantation who received the antibacterial envelope were compared with a matched cohort of 382 CIED patients from our institution. The primary outcome was the occurrence of local infection, and secondary outcomes were any CIED-related local or systemic infections, including endocarditis, and all-cause mortality. The results were stratified by a risk score for CIED infection, PADIT. The envelope group had a higher PADIT score, 5.9 ± 3.1 vs. 3.9 ± 3.0 (P < 0.0001). For the primary endpoint, no local infections occurred in the envelope group, compared with 2.6% in the control group (P = 0.04), with a more pronounced difference in the stratum with a high (>7 points) PADIT score, 0 vs. 9.9% (P = 0.01). The total CIED-related infections were similar between groups, 6.3% compared with 5.0% (P = 0.567). Mortality after 1600 days of follow-up did not differ between groups, 22.9 vs. 26.4%, P = 0.475.

CONCLUSION

Our study confirms the clinical efficacy of an antibacterial envelope in the prevention of local CIED infection in patients with a higher risk according to the PADIT score. In an effort to improve cost-benefit ratios, ration of use guided by the PADIT score is advocated. Further prospective randomized studies in high-risk populations are called for.

Externalized Reusable Permanent Pacemaker for Prolonged Temporary Cardiac Pacing in Critical Cardiac Care Units: An Observational Monocentric Retrospective Study

INTRODUCTION

The use of temporary cardiac pacing is frequent in critical care units for severe bradycardia or electrical storm, but may be associated with frequent and potentially severe complications, especially when indwelling for several days. In some cases, transient indication or ongoing contraindication for a permanent pacemaker justifies prolonged temporary pacing. In that case, the implantation of an active-fixation lead connected to an externalized pacemaker represents a valuable option to increase safety and patient comfort. Yet, evidence remains scarce. We aimed to describe the population receiving prolonged temporary cardiac pacing (PTCP) and their outcomes.

METHODS

We retrospectively included all consecutive patients, admitted to our hospital from 2016 to 2021, who underwent PTCP. We collected in-hospital and six-month outcomes.

RESULTS

Forty-six patients (median age of 73, 63% male) were included, and twenty-nine (63%) had prior heart disease. Indications for PTCP were found: seventeen (37%) potentially reversible high-grade conduction disorders, fourteen (30%) indications for permanent pacemaker but ongoing infection, seven (15%) cardiac implantable electronic device infections requiring extraction in pacing-dependent patients, seven (15%) severe vagal hyperreactivity in prolonged critical care hospitalizations, and one (2%) recurrent sustained ventricular tachycardia requiring overdrive pacing. The median PTCP duration was nine (5-13) days. Ten (22%) patients exhibited at least one complication during hospitalization. Twenty-six (56.5%) patients required definite device implantation (twenty-five pacemakers and one cardioverter-defibrillator) and twenty (43.5%) did not (fifteen PTCP device removal for recovery and five deaths under PTCP). At six months, two (5%) deaths and two (5%) new infections of a definite implanted device occurred, all in patients with initial active infection.

CONCLUSION

The use of prolonged temporary cardiac pacing, with an active -fixation lead connected to an externalized pacemaker, is possible and reasonable; this would allow for the possible recovery or resolution of contraindication for definite device implantation.

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

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

Predictors of pocket hematoma after cardiac implantable electronic device surgery: A nationwide cohort study

Purpose

Clinically significant pocket hematoma (CSH) is a common complication to cardiac implantable electronic device (CIED) surgery. We aimed to evaluate predictors of CSH after CIED surgery.

Methods

We performed a nationwide population-based prospective cohort study with systematic patient chart review of all Danish patients undergoing CIED surgery during a 12-month period. Multiple logistic regression analysis was used to estimate adjusted odds ratios (aOR) with 95% confidence intervals for association between predictors and CSH.

Results

We included 5918 consecutive patients, 63% males, mean age 72.6 years. A total of 148 (2.5%) patients experienced CSH, including 10 patients (0.2%) requiring re-operation with hematoma evacuation. The risk of CSH was significantly increased in patients treated with aspirin (aOR 1.8; 1.2-2.7), aspirin and clopidogrel (aOR 3.9; 2.3-6.5), or heparin (aOR 2.1; 1.1-4.1), and in patients with INR≥2.0 (aOR 2.0; 1.2-3.2). Patients operated by low-volume operators (aOR 2.7; 1.6-4.6) or undergoing more complex CIED surgery such as cardiac resynchronization therapy (aOR 2.0; 1.1-3.5) or dual-chamber defibrillator (aOR 2.1; 1.2-3.8) also had significantly increased CSH risk.

Conclusion

In a large nationwide cohort of consecutive patients undergoing CIED surgery, the risk of CSH was 2.5%, with 0.2% necessitating evacuation. CSH risk was increased both in patients receiving aspirin, dual antiplatelet therapy or continued vitamin K-antagonist therapy. Dual antiplatelet therapy had the highest risk (aOR) of CSH. Both low operator volume and more complex CIED surgery were independently associated with higher CSH risk. These data should be considered when planning CIED surgery.

Anatomy for right ventricular lead implantation

To understand the position of a pacing lead in the right ventricle and to correctly interpret fluoroscopy and intracardiac signals, good anatomical knowledge is required. The right ventricle can be separated into an inlet, an outlet, and an apical compartment. The inlet and outlet are separated by the septomarginal trabeculae, while the apex is situated below the moderator band. A lead position in the right ventricular apex is less desirable, last but not least due to the thin myocardial wall. Many leads supposed to be implanted in the apex are in fact fixed rather within the trabeculae in the inlet, which are sometimes difficult to pass. In the right ventricular outflow tract (RVOT), the free wall is easier to reach than the septal due to the fact that the RVOT wraps around the septum. A mid-septal position close to the moderator band is relatively simple to achieve and due to the vicinity of the right bundle branch may produce a narrower paced QRS complex. Special and detailed knowledge is necessary for His bundle and left bundle branch pacing.

Sex-Related Differences in Patient Selection for and Outcomes after Pace and Ablate for Refractory Atrial Fibrillation: Insights from a Large Multicenter Cohort

Background: A pace and ablate strategy may be performed in refractory atrial fibrillation with rapid ventricular response. Objective: We aimed to assess sex-related differences in patient selection and clinical outcomes after pace and ablate. Methods: In a retrospective multicentre study, patients undergoing AV junction ablation were studied. Sex-related differences in baseline characteristics, all-cause mortality, heart failure (HF) hospitalizations, and device-related complications were assessed. Results: Overall, 513 patients underwent AV junction ablation (median age 75 years, 50% men). At baseline, men were younger (72 vs. 78 years, p < 0.001), more frequently had non-paroxysmal AF (82% vs. 72%, p = 0.006), had a lower LVEF (35% vs. 55%, p < 0.001) and more frequently had cardiac resynchronization therapy (75% vs. 25%, p < 0.001). Interventional complications were rare in both groups (1.2% vs. 1.6%, p = 0.72). Patients were followed for a median of 42 months in survivors (IQR 22−62). After 4 years of follow-up, the combined endpoint of all-cause death or HF hospitalization occurred more often in men (38% vs. 27%, p = 0.008). The same was observed for HF hospitalizations (22% vs. 11%, p = 0.021) and all-cause death (28% vs. 21%, p = 0.017). Sex category remained an independent predictor of death or HF hospitalization after adjustment for age, LVEF and type of stimulation. Lead-related complications, infections, and upgrade to ICD or CRT occurred in 2.1%, 0.2% and 3.5% of patients, respectively. Conclusions: Pace and ablate is safe with a need for subsequent device-related re-interventions in 5.8% over 4 years. We found significant sex-related differences in patient selection, and women had a more favourable clinical course after AV junction ablation.

Complications in Device Therapy: Spectrum, Prevalence, and Management

PURPOSE OF REVIEW

Cardiac implantable electronic device implant numbers are continually increasing due to the expanding indications and ageing population. This review explores the complications associated with device therapy and discusses ways to minimise and manage such complications.

RECENT FINDINGS

Complications related to device therapy contribute to mortality and morbidity. Recent publications have detailed clear guidelines for appropriate cardiac device selection, as well as consensus documents discussing care quality and optimal implantation techniques. There have also been advances in device technologies that may offer alternative options to patients at high risk of/or already having encountered a complication. Adherence to guidelines, appropriate training, and selection of device, in addition to good surgical technique are key in reducing the burden of complications and improving acceptability of device therapy.

Physiology of Left Ventricular Septal Pacing and Left Bundle Branch Pacing

Following the recognition of the adverse effects of right ventricular pacing, alternative permanent pacing strategies aiming to maintain a synchronous ventricular contraction have been sought. The quest for the optimal pacing site has recently led to several promising and rapidly emerging new pacing strategies, such as left ventricular septal pacing and left bundle branch pacing. In both animal and human studies, these pacing strategies seem to maintain electrical and mechanical activation of the left ventricle to a (near)physiologic level. However, more studies on the long-term effects of both strategies are needed.

Neue ESC-Leitlinien zur Herzschrittmacher- und Resynchronisationstherapie – Patientenevaluation und Implantation

Die Herzschrittmachertherapie ist ein wesentlicher Teil der klinischen Elektrophysiologie sowie der allgemeinen Kardiologie. Auch wenn sich im Bereich manch klarer Indikationen über die Jahre wenig verändert hat, sind seit der Publikation der ESC-Leitlinien zur Schrittmachertherapie im Jahr 2013 neue Erkenntnisse z. B. im Bereich der Schrittmachertherapie bei Synkope, nach TAVI, der kardialen Resynchronisationstherapie und dem Conduction-System-Pacing hinzugekommen. Eine wesentliche Bedeutung kommt daneben sowohl der präoperativen Evaluation eines Patienten mit vermuteter oder dokumentierter Bradykardie als auch der eigentlichen Implantation und dem perioperativen Management zu. Im Fokus stehen dabei eine standardisierte Diagnostik zur Abklärung der Indikation sowie die Vermeidung von Komplikationen während der Implantation.

How to: Basics der Schrittmacherprogrammierung

Die Programmierung von Schrittmachersystemen, insbesondere von Zweikammerschrittmachersystemen kann die untersuchenden Ärzte vor große Herausforderungen stellen. Eine genaue Kenntnis der zu programmierenden Parameter sowie der herstellerspezifischen Algorithmen ist essentiell. Bei der Programmierung sollte darauf geachtet werden, die Programmierung den individuellen Bedürfnissen der Patient:innen anzupassen und „Out-of-the-box“-Programmierungen zu vermeiden. Ein weiteres wichtiges Ziel der Programmierung ist es, unnötige Stimulation im rechten Ventrikel zu vermeiden und dem Patienten eine gute Belastbarkeit zu ermöglichen sowie zu vermeiden, dass er eine Stimulation wahrnimmt. Algorithmen der Hersteller können hierbei helfen, müssen jedoch verstanden und bei inadäquatem Verhalten ggf. deaktiviert werden.

An unusual cause of a haemothorax following pacemaker implantation: A case report

Background

Haemothoraces are a reported but extremely rare complication of pacemaker implantation. Haemothoraces can be a consequence of lead perforation through the right ventricle (RV) and pericardium into the pleural space, direct lung or vascular injury during access.

Case summary

A 72-year-old woman presented 24 h after a pacemaker implantation with chest pain and shortness of breath. Computed tomography of the chest confirmed perforation of the RV lead into the left pleural cavity with a large left sided haemothorax. Following percutaneous drainage of the left sided haemothorax, the patient became haemodynamically unstable necessitating emergent sternotomy. During surgery, the extra-cardiac portion of the pacing lead was cut, the RV repaired and a large haematoma evacuated from the left pleural space. Despite this, the patient remained hypotensive, and further exploration showed a bleeding intercostal artery that had been lacerated by the pacing lead. This was treated by electrocautery, and the patient's haemodynamic status improved. The RV lead remnant was removed transvenously via the subclavian vein, and the patient was left with a single chamber atrial pacemaker.

Discussion

Prompt recognition of RV lead perforation and its associated sequalae, often utilising multi-modality imaging, is vital to enable transfer to a centre with cardiac surgical expertise. In this case, the perforating RV lead lacerated an intercostal artery, and this was only identified at the time of surgery. In order to minimize the risk of perforation, multiple fluoroscopic views should be used, and care should be taken during helix deployment.

Transvenous Lead Extraction in Patients with Cardiac Implantable Device: The Impact of Systemic and Local Infection on Clinical Outcomes-An ESC-EHRA ELECTRa (European Lead Extraction Controlled) Registry Substudy

Background: Infections of cardiac implantable devices (CIEDI) have poor outcomes despite improvement in lead extraction (TLE) procedures. Methods: To explore the influence of CIEDI on the outcomes of TLE and the differences between patients with systemic (Sy) vs. local (Lo) CIEDI, we performed a sub-analysis of the EORP ELECTRa (European Lead Extraction ConTRolled) Registry. Results: Among 3555 patients enrolled by 73 centers in 19 Countries, the indication for TLE was CIEDI in 1850: 1170 with Lo-CIEDI and 680 with Sy-CIEDI. Patients with CIEDI had a worse in-hospital prognosis in terms of major complications (3.57% vs. 1.71%; p = 0.0007) and mortality (2.27% vs. 0.49%; p < 0.0001). Sy-CIEDI was an independent predictor of in-hospital death (H.R. 2.14; 95%CI 1.06−4.33. p = 0.0345). Patients with Sy-CIEDI more frequently had an initial CIED implant and a higher prevalence of comorbidities, while subjects with Lo-CIEDI had a higher prevalence of previous CIED procedures. Time from signs of CIEDI and TLE was longer for Lo-CIEDI despite a shorter pre-TLE antibiotic treatment. Conclusions: Patients with CIEDI have a worse in-hospital prognosis after TLE, especially for patients with Sy-CIEDI. These results raise the suspicion that in a relevant group of patients CIEDI can be systemic from the beginning without progression from Lo-CIEDI. Future research is needed to characterize this subgroup of patients.

Pocket hematoma after pacemaker or defibrillator surgery: Direct oral anticoagulants versus vitamin K antagonists

Background

Direct oral anticoagulants (DOACs) are the preferred choice of oral anticoagulation in patients with atrial fibrillation (AF). Randomized trials have demonstrated the efficacy and safety of DOAC in patients undergoing a cardiac implantable electronic device procedure (CIED); however, there is limited real-world data.

Objective

To evaluate the outcome of patients undergoing an elective CIED procedure in a tertiary referral center with an interrupted DOAC or continued vitamin K antagonist (VKA) regimen.

Methods

This was a retrospective single-center study of consecutive patients with AF undergoing an elective CIED procedure between January 2016 and June 2019. The primary endpoint was a clinically significant pocket hematoma < 30 days after surgery. The secondary endpoint was any systemic thromboembolic complication < 30 days after surgery.

Results

Of a total of 1,033 elective CIED procedures, 283 procedures were performed in patients with AF using oral anticoagulation. One-third of the procedures were performed under DOAC (N = 81, 29%) and the remainder under VKA (N = 202, 71%). The DOAC group was younger, had less chronic renal disease, more paroxysmal AF and a lower HAS-BLED score. The VKA group more often underwent a generator change only in comparison to the DOAC group. Clinically significant pocket hematoma occurred in 5 patients (2.5%) in the VKA group and did not occur in the DOAC group (P = 0.33). There were no thromboembolic events reported.

Conclusion

In patients with AF undergoing an elective CIED procedure, the risk of a pocket hematoma and a systemic thromboembolic event is comparably low when using either continued VKA or interrupted DOAC.

Risk Mitigation of Pacemaker Pocket Erosion in the Thin – A Case Report

The aging population, particularly the thin and frail, has an increased risk of long-term cardiac implantable electronic device complications. This case is that of an elderly, thin-skinned patient who presented with a pacemaker pocket erosion 4 years after elective generator change, potentiated by a small pocket size with a superficial suture fixating the generator in the subcutaneous pocket. The risk for device erosion may have been mitigated during the generator change by increasing the size of the pocket, using a submuscular pocket, and potentially an absorbable antibacterial envelope. Fixation of the generator is considered optional.

Subcutaneous ICD for more and transvenous ICD for few?!

Implantable cardioverter defibrillators (ICDs) have been shown to reduce the risk of sudden cardiac death in primary or secondary prevention with thousands of ICDs implanted every year worldwide. Whilst ICD are more commonly implanted transvenously (TV), this approach carries high risk of peri- and post-procedural complications. Subcutaneous ICD (S-ICD) have been introduced to overcome the intravascular complications of TV system by placing all metalware outside the chest cavity for those with an indication for a defibrillator and no pacing requirements. In conclusion, a review of the current guidelines recommendations regarding S-ICD may be needed considering the emerging evidence which shows high efficacy and safety with contemporary devices and programming algorithms. A stronger recommendation may be developed for selective patients who have an indication for single-chamber ICD in the absence of negative screening, recurrent monomorphic ventricular tachycardia, cardiac resynchronization therapy, or pacemaker indication. These criteria encapsulate a large proportion (around 70%!) of all ICD eligible patients.

Access Site Bleeding Complications with NOACs versus VKAs in Patients with Atrial Fibrillation Undergoing Cardiac Implantable Device Intervention

There are no data on procedure-related bleeding outcome with non-vitamin K antagonist anticoagulants (NOACs) versus vitamin K antagonist anticoagulants (VKAs) in patients with atrial fibrillation (AF) undergoing cardiac implantable electronic device (CIED) intervention. Our aim was to evaluate whether NOACs have a safety benefit even in terms of fewer hemorrhagic complications at the site of CIED implant. Consecutive AF patients receiving NOACs or VKAs at the time of CIED procedure were included in this observational, retrospective, and monocentric investigation. Primary endpoint was the incidence of post-intervention pocket hematoma. A total of 311 patients were enrolled, 146 on NOACs, and 165 on VKAs. The incidence of pocket hematoma was 3.4% in the NOAC versus 13.3% in the VKA group (p = 0.002). Primary outcome-free survival at 30-days was 96.6% in patients on NOACs and 86.0% in those on VKAs (p = 0.019). Multivariate analysis, adjusted by propensity-score calculation of inverse-probability-weighting, showed a significantly lower occurrence of pocket hematoma in patients receiving NOACs versus VKAs (HR 0.35, 95% CI 0.13–0.96, p = 0.042). Such NOACs benefit was confirmed versus patients on VKAs without peri-procedural bridging with low-molecular-weight heparin (HR 0.34, 95% CI 0.11–0.99, p = 0.048). The incidence of pocket infection, surgical pocket evacuation, ischemic events, and major bleeding complications at 30 days (secondary endpoints) was similar in the two groups. In conclusion, our data suggest that, among patients with AF undergoing implantable cardiac defibrillator or pacemaker intervention, the use of NOACs versus VKAs may be associated with significant reduction of post-procedural pocket hematoma, regardless of bridging with low-molecular-weight heparin in the VKA group. These results are hypothesis generating and need to be confirmed in a specific randomized study.

[A practical approach to device interrogation]

For many cardiologists in training, interrogation of implantable cardiac devices is the first step into the fascinating world of electrophysiology. A growing number of patients implanted with pacemakers, implantable cardioverter-defibrillators (ICDs) or cardiac resynchronization therapy devices (CRTs) fuels the need for a basic understanding of those devices by every cardiologist. This article is meant to address the most important theoretical points to facilitate an easy, quick but still comprehensive device interrogation in nine steps.