2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay

Cardiac implantable electronic devices in female patients: Esthetic, breast implant, and anatomic considerations

INTRODUCTION

The implantation of a cardiac implantable electronic device (CIED) can have esthetic and psychological consequences on patients. We explore a heart team model for care coordination and discuss esthetic approaches for improved cosmetic outcomes in patients undergoing (CIED)-related procedures or de novo implantation.

METHODS

Patients undergoing CIED surgery for approved indications between June 2015 and June 2022 were identified. Patients were included when surgical care was provided by a collaborative relationship between the primary electrophysiologist and the plastic surgeon. Patient demographics, details of the surgical procedure, information on breast implants, complications, and outcomes related to cosmesis were recorded.

RESULTS

Twenty-two female patients were included in this study. The mean age was 50.2 ± 18.2 years. The mean follow-up duration was 2.2 ± 5.5 months. The top two indications for the procedure included CIED generator change (n = 9, 41%) and implantable cardioverter-defibrillator (ICD) implantation (n = 7, 32%). The most common reasons for involving plastic surgery in the procedure included surgery near breast implants (n = 10, 45%) and device displacement or discomfort (n = 8, 36%). CIED pocket position was prepectoral in 10 cases (45%), subpectoral in 11 patients (50%), and intramuscular in one patient (4.5%). The majority of the patients (20, 91%) had cosmetically acceptable results postprocedure. One patient (4.5%) had breast asymmetry on the CIED side, and another continued to have skin erosion over the CIED and leads.

CONCLUSION

A heart team approach incorporating the expertize of cardiac electrophysiology and plastic surgery is essential for providing optimal care for patients with breast implants and patients requesting esthetic appeal.

Electrocardiographic abnormalities in patients with cardiomyopathies

Abnormalities in impulse generation and transmission are among the first signs of cardiac remodeling in cardiomyopathies. Accordingly, 12-lead electrocardiogram (ECG) of patients with cardiomyopathies may show multiple abnormalities. Some findings are suggestive of specific disorders, such as the discrepancy between QRS voltages and left ventricular (LV) mass for cardiac amyloidosis or the inverted T waves in the right precordial leads for arrhythmogenic cardiomyopathy. Other findings are less sensitive and/or specific, but may orient toward a specific diagnosis in a patient with a specific phenotype, such as an increased LV wall thickness or a dilated LV. A "cardiomyopathy-oriented" mindset to ECG reading is important to detect the possible signs of an underlying cardiomyopathy and to interpret correctly the meaning of these alterations, which differs in patients with cardiomyopathies or other conditions.

The impact of chronotropic incompetence on atrioventricular conduction times in heart failure patients

BACKGROUND

Intrinsic atrioventricular (AV) conduction is used to optimize AV intervals with cardiac resynchronization therapy (CRT) in most device algorithms. Atrial pacing and heart rate affect conduction times, but little is known regarding differeces among chronotropic incompetent(CI) and competent(CC) patients to guide programming.

METHODS

RAVE was a multicenter prospective trial of CRT patients. Heart rate was increased with incremental atrial pacing and with submaximal exercise. According to the maximal heart rate achieved during exercise, patients were classified as either CI or CC. For CI patients, an additional symptom-limited exercise with rate-adaptive pacing activated was performed. Intracardiac intervals were measured from the implantable lead electrograms in multiple postures.

RESULTS

There were 12 subjects with CI and 24 with CC. With atrial pacing, AV interval immediately increased and gradually increased with incremental atrial pacing in all patients. However, the changes in the atrial to right ventricular (ARV) and atrial to left ventricular (ALV) intervals with increasing atrial pacing rates were about threefold greater in CI patients compared to CC patients (24.3 ± 28.9 vs. 7.2 ± 5.5 ms/10 bpm for ARV and 22.7 ± 25.6 vs. 7.1 ± 5.7 ms/10 bpm for ALV in the standing position, p < 0.05). In CI pacing with rate-adaptive pacing during exercise, AV interval changes with paced heart rate were variable.

CONCLUSIONS

The AV response to overdrive atrial pacing at rest may provide a simple means of identifying chronotropic competence in CRT patients. For patients with CI, who often require rate-adaptive atrial pacing, rate-adaptive AV algorithms should be adjusted individually.

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.

Lamin A/C cardiomyopathy presenting as high-grade atrioventricular (AV) block, atrial fibrillation, heart failure and ventricular tachycardia in a single-family cluster

Mutations in the lamin A/C (LMNA) gene have been associated with both cardiac and skeletal muscle abnormalities. Cardiac manifestations in LMNA cardiomyopathy have a variable age of onset and range from mild to life-threatening. We describe a case series illustrating manifestations of LMNA mutation in a single family with an extensive history of cardiac disease, including sudden cardiac death, and the implications for diagnosis and management. This discussion highlights potential presentations of LMNA mutations and the importance of genetic testing in patients with a family history of conduction abnormalities.

Cardiovascular implantable electronic device lead safety: Harnessing real-world remote monitoring data for medical device evaluation

BACKGROUND

Current methods to identify cardiovascular implantable electronic device lead failure include postapproval studies, which may be limited in scope, participant numbers, and attrition; studies relying on administrative codes, which lack specificity; and voluntary adverse event reporting, which cannot determine incidence or attribution to the lead.

OBJECTIVE

The purpose of this study was to determine whether adjudicated remote monitoring (RM) data can address these limitations and augment lead safety evaluation.

METHODS

Among 48,191 actively monitored patients with a cardiovascular implantable electronic device, we identified RM transmissions signifying incident lead abnormalities and, separately, identified all leads abandoned or extracted between April 1, 2019, and April 1, 2021. We queried electronic health record and Medicare fee-for-service claims data to determine whether patients had administrative codes for lead failure. We verified lead failure through manual electronic health record review.

RESULTS

Of the 48,191 patients, 1170 (2.4%) had incident lead abnormalities detected by RM. Of these, 409 patients had administrative codes for lead failure, and 233 of these 409 patients (57.0%) had structural lead failure verified through chart review. Of the 761 patients without administrative codes, 167 (21.9%) had structural lead failure verified through chart review. Thus, 400 patients with RM transmissions suggestive of lead abnormalities (34.2%) had structural lead failure. In addition, 200 patients without preceding abnormal RM transmissions had leads abandoned or extracted for structural failure, making the total lead failure cohort 600 patients (66.7% with RM abnormalities, 33.3% without). Patients with isolated right atrial or left ventricular lead failure were less likely to have lead replacement and administrative codes reflective of lead failure.

CONCLUSION

RM may strengthen real-world assessment of lead failure, particularly for leads where patients do not undergo replacement.

Minimally invasive epicardial left-ventricular lead implantation and simultaneous left atrial appendage closure

Background

Atrial fibrillation (AF) is common in patients with heart failure resulting in a high prevalence of AF in patients receiving Cardiac Resynchronization Therapy (CRT) implantation. In patients, unsuitable for transvenous left ventricular (LV)-lead implantation, epicardial LV-lead implantation represents a valuable alternative. Epicardial LV-lead placement can be achieved totally thoracoscopical or via minimally invasive left lateral thoracotomy. In patients with atrial fibrillation, concomitant left atrial appendage (LAA) clipping is feasible via the same access. Therefore, the aim of our study was the analysis of safety and efficacy of epicardial LV lead implantation and concomitant LAA clipping via minimally invasive left-lateral thoracotomy.

Methods

Between December 2019 and March 2022, 8 patients received minimally invasive left atrial LV-lead implantation with concomitant LAA closure using the AtriClip. Transesophageal echocardiography (TEE) was performed to intraoperatively guide and control LAA closure.

Results

Mean patients age was 64 ± 11.2 years, 67% were male patients. Minimally invasive left-lateral thoracotomy was used in 6 patients while a totally thoracoscopic approach was performed in 2 cases. Epicardial lead implantation was successfully performed in all patients with good pacing threshold (mean 0.8 ± 0.2 V) and sensing values (10.1 ± 2.3 mV). Posterolateral position of the LV lead was achieved in all patients. Furthermore, successful LAA closure was confirmed during TEE in all patients. No procedure-related complications occurred in any of the patients. Two patients additionally received simultaneous laser lead extraction during the same procedure. Complete lead extraction was achieved in both patients. All patients were extubated in the OR and had an uneventful postoperative course.

Conclusion

Our study highlights a novel treatment approach for patients with atrial fibrillation and the necessity of epicardial LV leads. Placement of a posterolateral LV lead position with concomitant occlusion of the left atrial appendage via a minimally-invasive left-lateral thoracotomy or even a totally thoracoscopic approach is safe and feasible with superior cosmetic result and complete occlusion of the left atrial appendage.

A Case of Sick Sinus Syndrome With Prolonged Asystole Masquerading as a Transient Ischemic Attack

Sick sinus syndrome (SSS) is a term used to describe dysfunction of the sinoatrial (SA) node that can lead to various cardiac arrhythmias that predominately manifest in the elderly. Commonly implicated arrhythmias vary from inappropriate bradycardia, tachycardia, sinus pauses, and rarely sinus arrest. Despite being a common reason for permanent pacemaker implantation, little is known regarding the incidence of SSS and there is even less reporting on SSS complicated by prolonged asystole. We present a case highlighting an infrequently observed manifestation of SSS with recurrent, prolonged ventricular asystolic episodes that were causing previously unexplained episodes of confusion and agonal breathing. Our patient was a 75-year-old male with a past medical history of hypertension, dyslipidemia, and prior transient ischemic attacks (TIAs) that presented after an acute mental status change. The initial leading differential diagnosis was believed to be a TIA and he was admitted to neurology service for further evaluation. The patient had recurring episodes of confusion associated with agonal breathing that upon closer review of the cardiac telemetry revealed sinus bradycardia to the 40s interrupted by several prolonged episodes of asystole, the longest lasting 20 seconds. Due to his symptoms and to avoid potential deterioration resulting in hemodynamic instability, the electrophysiology service urgently placed a temporary transvenous pacemaker and then later implanted a leadless pacemaker. On outpatient follow-up, he no longer had episodes of confusion, and no further asystolic episodes were noted on his device check.

Network pharmacology and LC-MS approachs to explore the active compounds and mechanisms of Yuanjiang decoction for treating bradyarrhythmia

BACKGROUND

Yuanjiang decoction (YJD), a traditional Chinese medicinal prescription, has been found to have a significant heart rate-increasing effect and is effective in the treatment of symptomatic bradyarrhythmia in previous studies. However, its specific components and potential mechanisms remain unclear.

METHODS

In this study, we detected and identified the main compounds of YJD using liquid chromatography-mass spectrometry (LC-MS). Through the approach of network pharmacology, we predicted the core targets of the active components, bradyarrhythmia targets, and obtained potential anti-bradyarrhythmia targets of YJD. We further performed protein to protein interaction (PPI), gene ontology (GO) enrichment analyses and kyoto encyclopedia of genes and genomes (KEGG) signaling pathway analyses for core targets, and constructed network of key active ingredients-core targets of YJD. Finally, molecular docking and molecular dynamics simulation were performed for key active ingredients and core targets.

RESULTS

The YJD contains a total of 35 main chemical components. The key active ingredients-core targets network contains 36 nodes and 90 edges, including 20 key active ingredients and 16 core targets. The core targets in the PPI network were TP53, TNF, HRAS, PPARG, IL1B, KCNH2, SCN5A, IDH1, LMNA, ACHE, F2, DRD2, CALM1, KCNQ1, TNNI3, IDH2 and TNNT2. KEGG pathway analysis showed that YJD treatment of bradyarrhythmia mainly involves neuroactive ligand-receptor interaction, adrenergic signaling in cardiomyocytes, cAMP signaling pathway, calcium signaling pathway, cholinergic synaptic and serotonergic synapse signaling pathway. The biological processes mainly include regulation of hormone levels, regulation of cardiac contraction, chemical synaptic transmission, circadian rhythm, positive regulation of heart rate, smooth muscle contraction, response to metal ion, oxidation-reduction process, neurotransmitter transport and import across plasma membrane. Molecular docking and molecular dynamics simulation results showed that hesperidin and tetrahydropalmatine had higher affinity with DRD2 and KCNQ1, respectively.

CONCLUSION

This study reveals the pharmacodynamic material basis of YJD and its potential multicomponent-multitarget-multipathway pharmacological effects, predicted its potential anti-bradyarrhythmia mechanism may be related to the regulation of myocardial autonomic nervous function and related ion channels. Our work demonstrates that YJD has great potential for treating bradyarrhythmias as a complementary medicine, and the results can provide a theoretical basis for the development and clinical application of YJD.

His-Purkinje system pacing reduced tricuspid regurgitation in patients with persistent atrial fibrillation after left-sided valve surgery

Background & objective

Tricuspid regurgitation after left-sided valve surgery was a common and difficult problem. Atrial fibrillation was considered to be an important etiology of tricuspid regurgitation. His-Purkinje system pacing (HPSP) was a physiological pacing method, which could prevent and treat heart failure and might reduce tricuspid regurgitation. Our study aimed to investigate the effect of HPSP on tricuspid regurgitation in patients with persistent atrial fibrillation after left-sided valve surgery.

Methods

This study was a retrospective study. The 3-year patient review focused on those who underwent permanent cardiac pacemaker implantation of HPSP after mitral valve and/or aortic valve replacement from Jan 1st, 2019 to Jan 1st, 2022. HPSP included His bundle pacing (HBP) or left bundle branch pacing (LBBP). Clinical data collected included electrocardiogram, pacing parameters, ultrasonic cardiogram parameters and chest x-ray at implantation and 3-month follow up. Univariate and multivariate linear regression analysis of tricuspid regurgitation velocity were performed.

Results

A total of 44 patients was retrospectively reviewed. Eight patients who had undergone implantation of HPSP after left-sided heart valve replacement were enrolled in the study. All patients had persistent atrial fibrillation. Three of them received HBP and five underwent LBBP. At 3-month follow-up, the tricuspid regurgitation grade was significantly lower than that before implantation (P = 0.007). The tricuspid regurgitation velocity significantly decreased (317 ± 74 cm/s vs. 261 ± 52 cm/s, P = 0.022) and tricuspid valve pressure gradient (PG) reduced (42 ± 21 mmHg vs. 28 ± 10 mmHg, P = 0.040). The cardiothoracic ratio of patients was significantly lower than that before implantation (0.61 ± 0.08 vs. 0.64 ± 0.09, P = 0.017). The NYHA classification of patients also improved (P = 0.013). In multivariate liner regression analysis, the pacing ratio (β = 0.736, P = 0.037) was an independent determinant of tricuspid regurgitation velocity variation.

Conclusion

HPSP might reduce tricuspid regurgitation and improve cardiac function in patients with persistent atrial fibrillation after left-sided valve surgery.

Electrophysiological characteristics and possible mechanism of bipolar pacing in left bundle branch pacing

BACKGROUND

Left bundle branch pacing is a physiological pacing modality with a low and stable threshold. The electrophysiological characteristics and mechanisms of bipolar pacing remain unclear.

OBJECTIVES

This study aimed to assess the electrophysiological characteristics of bipolar pacing of left bundle branch pacing and to infer the mechanisms underlying each electrocardiogram and electrogram waveform morphology.

METHODS

A total of 65 patients who strictly met the criteria for left bundle branch capture were enrolled. The changes in the morphology of the electrocardiogram and electrogram during the threshold testing with different outputs on unipolar and bipolar pacing were recorded. The electrophysiological characteristics were then analyzed.

RESULTS

Four distinct morphologies and 3 different types of transitions during bipolar pacing threshold testing were identified; we labeled the 4 types of morphologies as nonselective (NS)-bipolar-left bundle (LB), NS-cathodal-LB, selective (S)-cathodal-LB, and left ventricular septal-cathodal. Except left ventricular septal-cathodal, the other 3 types (NS-bipolar-LB, NS-cathodal-LB, and S-cathodal-L) had a short and constant V₆ R-wave peak time (RWPT) (64.8 ± 7.7 ms vs 65.7 ± 7.8 ms vs 65.7 ± 7.3 ms). The paced QRS (P-QRS) complex was the narrowest in NS-bipolar-LB rather than in NS-cathodal-LB (118.2 ± 14.2 ms vs 133.8 ± 15.8 ms; P < .001). NS-bipolar-LB had a higher threshold than did NS-cathodal-LB (2.5 ± 1.2 V vs 0.8 ± 0.4 V; P < .001).

CONCLUSION

With a higher output on bipolar pacing, NS-bipolar-LB capture had the shortest V₆ RWPT, V₁ RWPT, and P-QRS. S-cathodal-LB capture had the longest V₁ RWPT and P-QRS complex.

Left bundle branch area pacing: A promising modality for cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is recognized as the first-line management for patients with heart failure (HF) and conduction disorders. As a conventional mode for delivering CRT, biventricular pacing (BVP) improves cardiac function and reduces HF hospitalizations and mortality, but there are still limitations given the high incidence of a lack of response rates. Alternative pacing methods are needed either for primary or rescue therapy. In recent years, conduction system pacing (CSP) has emerged as a more physiological pacing modality for simultaneous stimulation of the ventricles, including His bundle pacing (HBP) and left bundle branch pacing (LBBP). CSP activates the His-Purkinje system, allowing normal ventricular stimulation. However, HBP is technically challenging with a relatively low success rate, high pacing threshold, and failure to correct distal conduction abnormalities. Therefore, LBBP stands out as a novel ideal physiological pacing modality for CRT. Several non-randomized studies compared the feasibility and safety of LBBP with BVP and concluded that LBBP is superior to BVP for delivering CRT with a narrower QRS and greater improvements in left ventricular ejection fraction (LVEF) and New York Heart Association (NYHA) functional class. Concurrently, some studies showed lower and stable pacing thresholds and greater improvement of B-type natriuretic peptide (BNP) levels, as well as better mechanical synchronization and efficiency. LBBP ensures better ventricular electromechanical resynchronization than BVP. In this review, we discuss current knowledge of LBBP, compare LBBP with BVP, and explore the potential of LBBP to serve as an alternative primary therapy to realize cardiac resynchronization.

2022 HRS expert consensus statement on evaluation and management of arrhythmic risk in neuromuscular disorders

This international multidisciplinary document is intended to guide electrophysiologists, cardiologists, other clinicians, and health care professionals in caring for patients with arrhythmic complications of neuromuscular disorders (NMDs). The document presents an overview of arrhythmias in NMDs followed by detailed sections on specific disorders: Duchenne muscular dystrophy, Becker muscular dystrophy, and limb-girdle muscular dystrophy type 2; myotonic dystrophy type 1 and type 2; Emery-Dreifuss muscular dystrophy and limb-girdle muscular dystrophy type 1B; facioscapulohumeral muscular dystrophy; and mitochondrial myopathies, including Friedreich ataxia and Kearns-Sayre syndrome, with an emphasis on managing arrhythmic cardiac manifestations. End-of-life management of arrhythmias in patients with NMDs is also covered. The document sections were drafted by the writing committee members according to their area of expertise. The recommendations represent the consensus opinion of the expert writing group, graded by class of recommendation and level of evidence utilizing defined criteria. The recommendations were made available for public comment; the document underwent review by the Heart Rhythm Society Scientific and Clinical Documents Committee and external review and endorsement by the partner and collaborating societies. Changes were incorporated based on these reviews. By using a breadth of accumulated available evidence, the document is designed to provide practical and actionable clinical information and recommendations for the diagnosis and management of arrhythmias and thus improve the care of patients with NMDs.

Factors associated with remote monitoring adherence for cardiovascular implantable electronic devices

BACKGROUND

Professional societies strongly recommend remote monitoring (RM) of all cardiac implantable electronic devices, and higher RM adherence is associated with improved patient outcomes. However, adherence with RM is suboptimal.

OBJECTIVE

The purpose of this study was to better understand factors associated with RM adherence.

METHODS

We linked RM data from the Veterans Affairs National Cardiac Device Surveillance Program to clinical data for patients monitored between October 25, 2018, and October 24, 2020. RM adherence was defined as the percentage of days covered by an RM transmission during the study period. Patients were classified into 3 categories: complete (100% of days covered by an RM transmission), intermediate (above median in patients with <100% adherence), and low (below median in patients with <100% adherence) adherence. We used multivariable logistic regression to examine patient, device, and facility characteristics associated with adherence.

RESULTS

In 52,574 patients, average RM adherence was 71.9%. Only 30.9% (16,224) of patients had complete RM adherence. Black or African American patients had a lower odds of complete RM adherence than white patients (odds ratio 0.88; 95% confidence interval 0.82-0.94), and Hispanic or Latino patients had a lower odds of complete RM adherence (odds ratio 0.79; 95% confidence interval 0.70-0.89) than non-Hispanic or Latino patients. Dementia, depression, and posttraumatic stress disorder were associated with a lower odds of RM adherence.

CONCLUSION

There are significant disparities in RM adherence by race, ethnicity, and neuropsychiatric comorbidities. These findings can inform strategies to improve health equity and ensure that all patients with cardiac implantable electronic devices receive the evidence-based clinical benefits of RM.

Case report: An unusual case of desmin myopathy associated with heart failure and arrhythmia

Introduction

Desmin myopathy is a novel desmin (DES) indel mutation that causes severe atypical cardiomyopathy as well as atrioventricular block and skeletal myopathy. The mutation of the gene of the nodal tail causes myocardial injury. Rarely does desmin myopathy cause bilateral ventricular changes.

Case presentation

We present a case of a 48-year-old man admitted with dyspnea and edema of both lower extremities. Due to bilateral lower limb weakness and calf muscle atrophy, gene sequencing was performed. The results showed that there was a pure missense mutation in the 8th exon region of the DES gene (c.1366G&gt;A), encoding amino acid p.G456R (glycine&gt;arginine). Supplementary examination suggests a high possibility of heart failure, atrial flutter, and desmin myopathy. Atrial flutter was treated by radiofrequency ablation. The clinical symptoms were stable after oral administration of rivaroxaban, coenzyme Q10, and ARNI.

Conclusion

In our case, mutation results are the gold standard for the diagnosis of nodular myopathy. Cardiac magnetic resonance can define the extent and degree of cardiomyopathy and quantitatively evaluate cardiac function. At present, there is a lack of specific treatment for proteolytic myopathy. Therefore, the treatment for heart failure proves effective. Due to the multiple systems involved, early diagnosis and multidisciplinary management are critical to improving patient outcomes.

Paroxysmal Atrioventricular Block: A Rare Cause of Cardiac Arrest

Paroxysmal atrioventricular block (PAVB) is characterized by a sudden and unanticipated repetitive block of atrial impulses to the ventricles. It is often triggered by supraventricular and ventricular ectopic beats in patients with diseased His-Purkinje system. We present the case of a 69-year-old woman with a history of fascicular block who was admitted with gastrointestinal bleeding. Her hospital course was complicated by cardiac arrest. At the time of the loss of consciousness, telemetry tracings showed sudden onset high-grade second-degree atrioventricular (AV) block with a delayed escape rhythm resulting in a prolonged pause. Adult cardiac life support was necessary along with transvenous pacing until she ultimately underwent the placement of a permanent pacemaker. Thorough evaluation of electrocardiograms (EKGs) and telemetry allowed for accurate diagnoses and appropriate treatment of cardiac arrest secondary to paroxysmal AV block.

Unusual course of congenital complete heart block in an adult: A case report

BACKGROUND

Congenital complete heart block (CCHB) with normal cardiac structure and negativity for anti-Ro/La antibody is rare. Additionally, CCHB is much less frequently diagnosed in adults, and its natural history in adults is less well known.

CASE SUMMARY

A 23-year-old woman was admitted to our hospital for frequent syncopal episodes. She had bradycardia at the age of 1 year but had never had impaired exercise capacity or a syncopal episode before admission. The possible diagnosis of acquired complete atrioventricular block was carefully ruled out, and then the diagnosis of CCHB was made. According to existing guidelines, permanent pacemaker implantation was recommended, but the patient declined. With regular follow-up for 28 years, the patient had an unusually good outcome without any invasive intervention or medicine. She had an uneventful pregnancy and led a normally active life without any symptoms of low cardiac output or syncopal recurrence.

CONCLUSION

This case implies that CCHB in adulthood may have good clinical outcomes and does not always require permanent pacemaker implantation.

His bundle pacing guided by automated intrinsic morphology matching is feasible in patients with narrow QRS complexes

Pace mapping and visual comparison of the local pacing response with the intrinsic QRS morphology form the mainstay of His bundle pacing (HBP). We evaluated the performance of a surface lead morphology match algorithm for automated classification of the pacing response in patients with narrow intrinsic QRS undergoing electroanatomic mapping (EAM)-guided HBP. HBP was attempted in 43 patients. In 28 cases with narrow QRS, the EnSite AutoMap Module was used for automated assessment of the QRS morphology resulting from pace mapping in the His cloud area with either a diagnostic catheter or the His lead. An intrinsic morphology match score (IMS) was calculated for 1.546 QRS complexes and assessed regarding its accuracy and performance in classifying the individual pacing response as either selective HBP (S-HBP), nonselective HBP (NS-HBP) or right ventricular stimulation. Automated morphology comparison of 354 intrinsic beats with the individual reference determined a test accuracy of 99% (95% CI 98.96–99.04) and a precision of 97.99–99.5%. For His-lead stimulation, an IMS ≥ 89% identified S-HBP with a sensitivity, specificity and positive predictive value of 1.00 (0.99, 1.00) and a negative predictive value of 0.99 (0.98, 1.00). An IMS between 78 and < 89% indicated NS-HBP with a sensitivity and specificity of 1.00 (0.99, 1.00) and 0.99 (0.98, 1.00), respectively. IMS represents a new automated measure for standardized individual morphology classification in patients with normal QRS undergoing EAM-guided HBP.

Clinical trial registration: NCT04416958.

Beta-Blocker-Related Atrioventricular Conduction Disorders—A Single Tertiary Referral Center Experience

Background and Objectives: Drug-related bradyarrhythmia is a well-documented major adverse event among beta-blocker users and a potential cause for hospitalization or additional interventions. Whether beta-blocker use is associated with specific bradyarrhythmia presentations, and how this relates to other predisposing factors, is not well known. We aim to evaluate the association between beta-blocker use and the type of atrioventricular (AV) conduction disorder in patients with symptomatic bradycardia. Materials and Methods: We conducted a retrospective cohort study on 596 patients with a primary diagnosis of symptomatic bradyarrhythmia admitted to a single tertiary referral center. Of the cases analyzed, 253 patients were on beta-blocker treatment at presentation and 343 had no bradycardic treatment. We analyzed demographics, clinical and paraclinical parameters in relation to the identified AV conduction disorder. A multivariate regression analysis was performed to explore factors associated with beta-blocker use. Results: Of the 596 patients (mean age 73.9 ± 8.8 years, 49.2% male), 261 (43.8%) had a third-degree AV block, 92 (15.4%) had a second-degree AV block, 128 (21.5%) had slow atrial fibrillation, 93 (15.6%) had sick sinus syndrome and 21 (3.5%) had sinus bradycardia/sinus pauses. Beta-blocker use was associated with the female gender (p < 0.001), emergency admission (p < 0.001), dilated cardiomyopathy (p = 0.003), the lower left ventricular ejection fraction (p = 0.02), mitral stenosis (p = 0.009), chronic kidney disease (p = 0.02), higher potassium levels (p = 0.04) and QRS duration > 120 ms (p = 0.02). Slow atrial fibrillation (OR = 4.2, p < 0.001), sick sinus syndrome (OR = 2.8, p = 0.001) and sinus bradycardia/pauses (OR = 32.9, p < 0.001) were more likely to be associated with beta-blocker use compared to the most common presentation (third-degree AV block), after adjusting for other patient characteristics. Conclusions: Beta-blocker use is more likely to be associated with slow atrial fibrillation, sick sinus syndrome and sinus bradycardia/pauses, compared to a second- or third-degree AV block, after adjusting for other patient factors such as gender, admission type, ECG, comorbidities, cardiac function and lab testing.

Efficacy and safety of different exercises in preventing cardiac implantable electronic device-related shoulder impairment

BACKGROUND

Shoulder impairment on the implant-side is common after cardiac implantable electronic device (CIED) implantation. The aim of this study was to compare the efficacy and safety of the pendulum exercise (PE) and stretching & strengthening exercises (SSE) in preventing postimplantation shoulder impairment.

METHODS

This prospective, randomized study collected data from 89 patients, including 30 in a control group, 31 in a PE group, and 28 in a SSE group. Shoulder functions on the implant-side were evaluated by grip strength (GS), range of motion (ROM), Visual Analog Scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and 36-Item Short-Form Survey (SF-36).

RESULTS

Shoulder median flexion and abduction ROM were significantly improved two-month postimplantation compared to two-week postimplantation in PE (156±11 vs. 146±10, p = .002; 147±9 vs. 136±9, p = .001, respectively) and SSE (158±13 vs. 147±11, p = .003; 149±13 vs. 138±9, p = .002, respectively) groups, but not in the control group. Two months after implantation, the two exercise groups showed no significant differences in any assessment. Compared with the PE and SSE groups, the control group had significantly lower GS (p = .012 and p = .002, respectively) and SF-36 physical component summary (p = .007 and p = .003, respectively) and significantly higher VAS (p = .003 and p = .001, respectively) and QuickDASH (p = .002 and p = .005, respectively) scores two-month postimplantation.

CONCLUSIONS

PE and SSE for the ipsilateral upper arm starting two-week after CIED implantation provided similar benefits in preserving shoulder girdle muscle strength, maintaining shoulder motion, relieving shoulder pain, preventing shoulder injury, and improving quality of life, without the risk of lead dislodgement. This article is protected by copyright. All rights reserved.

Is the pacing site closer to the left ventricular septal endocardium in left bundle branch pacing or in left ventricular septal pacing?

PURPOSE

Distinguishing between left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP) is challenging. This study aimed to compare the echocardiographic distance from the pacing lead tip to the left ventricular (LV) septal endocardium between patients who underwent LBBP and those who underwent LVSP successfully.

METHODS

Fifty-nine consecutive patients (age 71.9 ± 12.0 years, 35.6% male) with traditional indications for permanent cardiac pacing were included (LBBP group, n = 46; LVSP group, n = 13). Unipolar pacing from the final pacing sites generated narrow QRS complexes with a right bundle branch block pattern in all patients. After the procedure, a physician blinded to the group allocation performed echocardiographic measurements of the distance between the lead tip and the LV septal endocardium.

RESULTS

The mean paced QRS duration was comparable between the LBBP group and the LVSP group (105.3 ± 15.6 ms vs. 109.2 ± 9.6 ms, P = 0.287). In the LBBP group, the interval from the left bundle branch potential to QRS onset was 28.7 ± 9.0 ms. During diastole, the mean distance between the lead tip and the LV septal endocardium was 0.6 ± 0.9 mm in the LBBP group and 3.0 ± 1.6 mm in the LVSP group (P < 0.001). During systole, the distance was 1.5 ± 1.4 mm in the LBBP group and 4.3 ± 2.6 mm in the LVSP group (P < 0.001).

CONCLUSIONS

The landing zone of the lead tip was closer to the LV septal endocardium in the patients who underwent LBBP. There is a need for real-time intraprocedural monitoring of the distance between the lead tip and the LV septal endocardium when performing LBBP.

Fascicular heart blocks and risk of adverse cardiovascular outcomes: Results from a large primary care population

BACKGROUND

Fascicular heart blocks can progress to complete heart blocks, but this risk has not been evaluated in a large general population.

OBJECTIVE

The purpose of this study was to investigate the association between various types of fascicular blocks diagnosed by electrocardiographic (ECG) readings and the risk of incident higher degree atrioventricular block (AVB), syncope, pacemaker implantation, and death.

METHODS

We studied primary care patients referred for ECG recording between 2001 and 2015. Cox regression models were used to estimate hazard ratios (HRs) as well as absolute risks of cardiovascular outcomes.

RESULTS

Of 358,958 primary care patients (median age 54 years; 55% women), 13,636 (3.8%) had any type of fascicular block. Patients were followed up to 15.9 years. We found increasing HRs of incident syncope, pacemaker implantation, and third-degree AVB with increasing complexity of fascicular block. Compared with no block, isolated left anterior fascicular block (LAFB) was associated with 0%-2% increased 10-year risk of developing third-degree AVB (HR 1.6; 95% confidence interval [CI] 1.25-2.05), whereas right bundle branch block combined with LAFB and first-degree AVB was associated with up to 23% increased 10-year risk (HR 11.0; 95% CI 7.7-15.7), depending on age and sex group. Except for left posterior fascicular block (HR 2.09; 95% CI 1.87-2.32), we did not find any relevant associations between fascicular block and death.

CONCLUSION

We found that higher degrees of fascicular blocks were associated with increasing risk of syncope, pacemaker implantation, and complete heart block, but the association with death was negligible.

Current Guidelines and Clinical Practice

Guidelines exist for monitoring to diagnose and manage patients with several different conditions. Although there have been recent updates to the guidelines, the constantly evolving and advancing nature of the technologies creates a gap at times between the newest monitors, the indications for their use, and the reimbursement by the payers. The key element to the choice of the modality of monitoring remains matching the correct technology to the type, severity, frequency, and duration of the patient's symptoms.

Outcomes associated with pacemaker implantation following transcatheter aortic valve replacement: A nationwide cohort study

BACKGROUND

Conduction abnormalities following transcatheter aortic valve replacement (TAVR) often may require permanent pacemaker implantation (PPM).

OBJECTIVE

The purpose of this study was to evaluate outcomes associated with PPM after a TAVR procedure in a large, nationwide-level population.

METHODS

Based on the administrative hospital discharge database, the incidence of all-cause death, cardiovascular death, and hospitalization for heart failure (HF) were retrospectively collected, based on the presence or absence of PPM, in the first 30 days following all TAVRs in France from 2010 to 2019.

RESULTS

Among 520,662 patients hospitalized for aortic stenosis, 49,201 were treated with TAVR. A total of 29,422 patients had follow-up ≥6 months (median 1.7 years), 22% already had PPM at baseline, and 22% underwent PPM within the first 30 days post-TAVR. Adjusted hazard ratios for the combined risk of all-cause death and hospitalization for HF, during the whole follow-up, were higher in both patients with a previous PPM and in those implanted within 30 days (hazard ratio [95% confidence interval] 1.12 [1.07-1.17] and 1.11 [1.06-1.16], respectively).

CONCLUSION

PPM at baseline and within 30 days post-TAVR are independently associated with higher mortality and HF hospitalization during follow-up.

Heart Failure Association of the ESC, Heart Failure Society of America and Japanese Heart Failure Society Position statement on endomyocardial biopsy

Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant (HTx) rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumours. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples have significantly improved diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, the Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (i) an overview of the practical approach to EMB, (ii) an update on indications for EMB, (iii) a revised plan for HTx rejection surveillance, (iv) the impact of multimodality imaging on EMB, and (v) the current clinical practice in the worldwide use of EMB.

Heart Failure Association, Heart Failure Society of America, and Japanese Heart Failure Society Position Statement on Endomyocardial Biopsy

Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumors. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples has significantly improved the diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (1) an overview of the practical approach to EMB, (2) an update on indications for EMB, (3) a revised plan for heart transplant rejection surveillance, (4) the impact of multimodality imaging on EMB, and (5) the current clinical practice in the worldwide use of EMB.

Causes of syncopal recurrences in patients treated with permanent pacing for bradyarrhythmic syncope: Findings from the SYNCOPACED registry

BACKGROUND

Few studies have examined the causes of syncope/collapse recurrences in patients with a previously implanted pacemaker for bradyarrhythmic syncope.

OBJECTIVE

The purpose of this study was to assess the causes of syncope/collapse recurrences after pacemaker implantation for bradyarrhythmic syncope in a large patient population.

METHODS

The SYNCOpal recurrences in patients treated with permanent PACing for bradyarrhythmic syncope (SYNCOPACED) registry was a prospective multicenter observational registry enrolling 1364 consecutive patients undergoing pacemaker implantation for bradyarrhythmic syncope. During follow-up, the time to the first syncope/collapse recurrence was recorded. Patients with syncope/collapse recurrences underwent a predefined diagnostic workup aimed at establishing the mechanism of syncope/collapse.

RESULTS

During a median follow-up of 50 months, 213 patients (15.6%) reported at least 1 syncope/collapse recurrence. The risk of syncope/collapse recurrence was highest in patients who underwent implantation for cardioinhibitory vasovagal syncope (26.4%), followed by unexplained syncope and chronic bifascicular block (21.5%), cardioinhibitory carotid sinus syndrome (17.2%), atrial fibrillation needing pacing (15.5%), atrioventricular block (13.6%), and sinus node disease (12.5%) (P = .017). The most frequent cause of syncope/collapse recurrence was reflex syncope (27.7%), followed by orthostatic hypotension (26.3%), pacemaker or lead malfunction (5.6%), structural cardiac disease (5.2%), and atrial and ventricular tachyarrhythmias (4.7% and 3.8%, respectively). In 26.8% of cases, the mechanism of syncope/collapse remained unexplained.

CONCLUSION

In patients receiving a pacemaker for bradyarrhythmic syncope, reflex syncope and orthostatic hypotension are the most frequent mechanisms of syncope/collapse recurrence after implantation. Pacing system malfunction, structural cardiac diseases, and tachyarrhythmias are rare mechanisms. The mechanism remains unexplained in >25% of patients.

[Indications for His bundle and left bundle branch pacing]

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

Permanent conduction system pacing for congenitally corrected transposition of the great arteries: A Pediatric and Congenital Electrophysiology Society (PACES)/International Society for Adult Congenital Heart Disease (ISACHD) Collaborative Study

BACKGROUND

Congenitally corrected transposition of the great arteries (CCTGA) is associated with spontaneous atrioventricular block and pacing-induced cardiomyopathy. Conduction system pacing is a potential alternative to conventional cardiac resynchronization therapy (CRT).

OBJECTIVE

The purpose of this study was to determine the outcomes of conduction system pacing for CCTGA.

METHODS

Retrospective data were collected from 10 international centers.

RESULTS

His bundle (HBP) or left bundle branch pacing (LBBP) was attempted in 15 CCTGA patients (median age 23 years; 87% male). Previous surgery had been performed in 8 and chronic ventricular pacing in 7. Conduction system pacing (11 HBP, 2 LBBP 2; nonselective in 10, selective in 3) was acutely successful in 13 (86%) without complication. In 9 cases, electroanatomic mapping was available and identified the distal His bundle and proximal left bundle branches within the morphologic left ventricle below the pulmonary valve separate from the mitral annulus. Median implant HV interval was 42 ms (interquartile range [IQR] 35-48), R wave 6 mV (IQR 5-18), and threshold 0.5 V (IQR 0.5-1.2) at median 0.5 ms. QRSd was unchanged compared to junctional escape rhythm (124 vs 110 ms; P = .17) and decreased significantly compared to baseline ventricular pacing (112 vs 164 ms; P <.01). At a median of 8 months, all patients were alive without significant change in pacing threshold or lead dysfunction. New York Heart Association functional class improved in 5 patients.

CONCLUSION

Permanent conduction system pacing is feasible in CCTGA by either HBP or proximal LBBP. Narrow paced QRS and stable lead thresholds were observed at intermediate follow-up. Unique anatomic characteristics may favor this approach over conventional CRT.

Clinical evidence-guided network pharmacology analysis reveals a critical contribution of β1-adrenoreceptor upregulation to bradycardia alleviation by Shenxian-Shengmai

Background

Shenxian-Shengmai (SXSM) Oral Liquid is a CFDA-approved patent Chinese Herbal medicine, which has been clinically used for the treatment of bradycardia. However, its active components and action mechanism remain to be established. The present study aimed to evaluate the efficacy of SXSM on bradycardia and to identify the possible active components and their pharmacological targets for this action.

Methods

A literature-based meta-analysis was performed to evaluate the clinical efficacy of SXSM on bradycardia, which was confirmed by a rat ex vivo cardiac model. Network pharmacology analysis was then conducted to reveal the potential targets of SXSM active components and their anti-arrhythmia mechanisms. Finally, the identified drug-target interaction was confirmed by immunofluorescence assay in cardiomyocyte.

Results

Meta-analysis of the available clinical study data shows that Shenxian-Shengmai Oral Liquid has a favorable effect for bradycardia. In an ex vivo bradycardia model of rat heart, SXSM restored heart rate by affecting Heart rate variability (HRV) which is associated with autonomic nervous system activity. A drug-target-pathway network analysis connecting SXSM components with arrhythmia suggested that a prominent anti-arrhythmia mechanisms of SXSM was via β1-adrenergic signaling pathway, which was subsequently validated by immunofluorescence assay showing that SXSM indeed increased the expression of ADRB1 in cultured cardiomyocytes.

Conclusion

By combining approaches of clinical evidence mining, experimental model confirmation, network pharmacology analyses and molecular mechanistic validation, we show that SXSM is an effective treatment for bradycardia and it involves multiple component interacting via multiple pathways, among which is the critical β1-adrenergic receptor upregulation. Our integrative approach could be applied to other multi-component traditional Chinese medicine investigation where ample clinical data are accumulated but advanced mechanistic studies are lacking.

Compound danshen dripping pills combined with trimetazidine in treating unstable angina pectoris: Protocol for a systematic review of randomized controlled trials

BACKGROUND

Compound danshen dripping pills (CDDP) and trimetazidine (TMZ) are commonly used in the treatment of unstable angina pectoris (UAP). Currently, the combination of CDDP and TMZ has been widely used for UAP. However, the clinical evidence CDDP combined with TMZ for treating UAP is not sufficient.

METHODS

We searched for randomized controlled trials testing CDDP combined with TMZ for the treatment of UAP in Chinese National Knowledge Infrastructure database, VIP database, Chinese Biological and Medicine database, Wangfang database, MEDLINE, EMBASE, Cochrane Library, and Web of Science. Extracted data are analyzed using Review Manager 5.3 software. The quality evaluation, forest plots and funnel plots will be conducted by RevMan5.3 software. Moreover, subgroup analysis and sensitivity analysis will also be completed by RevMan5.3.

RESULTS

This systematic review will provide powerful clinical evidence of combination CDDP and TMZ for treating UAP.

CONCLUSIONS

This systematic review will be provided up-to-date clinical evidence to evaluate the effectiveness and safety of CDDP combined with TMZ for the treatment of parents with UAP.Registration Number: PROSPERO CRD42019143100.

Pure Autonomic Failure

Pure autonomic failure (PAF) is a neurodegenerative disorder of the autonomic nervous system clinically characterized by orthostatic hypotension. The disorder has also been known as Bradbury-Eggleston syndrome, named for the authors of the 1925 seminal description. Patients typically present in midlife or later with orthostatic hypotension or syncope. Autonomic failure may also manifest as genitourinary, bowel, and thermoregulatory dysfunction. With widespread involvement, patients may present to a variety of different specialties and require multidisciplinary treatment approaches. Pathologically, PAF is characterized by predominantly peripheral deposition of α-synuclein. However, patients with PAF may progress into other synucleinopathies with central nervous system involvement.

The Added Value of Cardiac Magnetic Resonance in Muscular Dystrophies

Muscular dystrophies (MD) represent a heterogeneous group of rare genetic diseases that often lead to significant weakness due to progressive muscle degeneration. In many forms of MD, cardiac manifestations including heart failure, atrial and ventricular arrhythmias and conduction abnormalities can occur and may be a predominant feature of the disease. Cardiac magnetic resonance (CMR) can assess cardiac anatomy, global and regional ventricular function, volumes and mass as well as presence of myocardial inflammation, infiltration or fibrosis. The role for cardiac MRI has been well-established in a wide range of muscular dystrophies related cardiomyopathies. CMR is a more sensitive technique than echocardiography for early diagnosis of cardiac involvement. It has also great potential to improve the prediction of long-term outcome, particularly the development of heart failure and arrhythmic events; however it still has to be validated by longitudinal studies including large populations. This review will outline the utility of CMR in patients with muscular dystrophies for assessment of myocardial involvement, risk stratification, and in guiding therapeutic management.

Multivariable Analysis of Patients With Severe Persistent Postprocedural Hypotension After Carotid Artery Stenting

Purpose: To assess the incidence and predictors of severe, persistent postprocedural hypotension (PPH) after carotid artery stenting (CAS). Materials and Methods: A total of 146 patients (mean age 72.8 years; 104 men) who underwent 160 CAS procedures using a standardized protocol at 3 vascular centers were retrospectively analyzed. The primary endpoint was postprocedural hypotension, defined as a reduction in systolic blood pressure (SBP) >40 mm Hg from baseline or an SBP of <90 mm Hg sustained for >1 hour after CAS. Potential prognostic factors for postprocedural hypotension were identified and subjected to logistic regression analyses; outcomes are presented as the odds ratios (ORs) with 95% confidence intervals (CIs). Results: PPH developed in 36 (24.7%) patients after 37 (23.1%) CAS procedures. These patients had significantly longer intensive care unit and hospital stays than those who did not develop hypotension (p<0.001). PPH was associated with severe lesion calcification (OR 6.28, 95% CI 1.81 to 21.98, p=0.004) and contrast volume (OR 1.02, 95% CI 1.01 to 1.02, p<0.001). A 4-fold increase in the risk of PPH (OR 4.22, 95% CI 1.38 to 13.33, p=0.012) was found between the embolic protection device most associated with PPH (Angioguard) and the device least associated with PPH (Emboshield NAV6). A similar trend was also observed for the Precise vs Xact stents (OR 6, 95% CI 2.08 to 17.6, p=0.001). Bootstrapped multivariable modeling identified the Precise stent and contrast volume as significant predictors of persistent postprocedural hypotension. Further investigation of the contrast volume revealed associations with sex, severe calcification, arch type, previous coronary artery bypass surgery, and primary stenting, suggesting that the contrast volume reflects the complexity of the procedure. Conclusion: The complexity of the procedure and type of stent may play a role in the development of postprocedural hypotension after CAS.