Clinically oriented device programming in bradycardia patients

Comparison of 30-day complications between a tine-based and a screw-in helix fixation single-chamber ventricular leadless pacemaker: Results of a propensity score-matched analysis from a multicenter, nationwide registry

BACKGROUND

Medtronic Micra VR and Abbott Aveir VR are 2 single-chamber ventricular leadless pacemakers (L-PMs) currently available in clinical practice. They differ in their design, fixation mechanism (tine-based fixation for Micra VR, screw-in helix fixation for Aveir VR), and implantation technique. Few comparative safety data are available for these L-PMs.

OBJECTIVE

We aimed to compare the rate of acute procedure-related complications of patients undergoing Aveir VR vs Micra VR implantation.

METHODS

A prospective, multicenter, observational registry enrolled consecutive patients who underwent Aveir VR or Micra VR implantation. The rate and nature of device-related complications at 30-day follow-up were analyzed and compared between the groups. Individual 1:1 propensity score matching of baseline characteristics was performed.

RESULTS

A total of 1141 patients (75.9 ± 14.8 years; 60.2% male) were enrolled: 211 Aveir VR and 930 Micra VR. Propensity score matching yielded 189 matched pairs. In the matched cohort, the risk of device-related complications at 30 days of follow-up of the 2 L-PMs was similar (2.1% vs 2.1%; P = 1). Device migration (1.6% vs 0.5%; P = .315) and vascular complications (0.5% vs 1.1%; P = .562) were the most frequent complications, with no significant differences between the groups. Cardiac perforation was rare (1 case in the Micra VR group, no cases in the Aveir VR group).

CONCLUSION

The risk of acute device-related complications associated with Aveir VR and Micra VR L-PM implantation was similar. These findings suggest that despite differences in design, fixation mechanism, and implantation technique, these 2 devices appear to have a similar short-term safety profile.

Ablate and pace strategy for atrial fibrillation: pacing modalities, ablation approaches and impact on patient outcomes

INTRODUCTION

In patients with symptomatic, refractory atrial fibrillation the ablate and pace (A&P) strategy (pacemaker implantation followed by atrio-ventricular junction ablation (AVJA)) is superior to medical therapy in improving quality of life and prognosis. Despite its well-proven benefits, this invasive therapeutic option is still underutilized in clinical practice. The choice of pacing modality (right ventricular pacing, biventricular pacing, BVP, or conduction system pacing, CSP) is crucial and can have significant clinical implications. In particular, in recent years CSP is emerging as an alternative to BVP, showing a good effectiveness and safety profile. Other important aspects are the timing of ablation, the approach used for AVJA, and the correct device programming after AVJA.

AREAS COVERED

This article reviews the currently available evidence on this therapeutic strategy with a particular focus on its impact on patient outcome, recognized indications, technical considerations, and future perspectives.

EXPERT OPINION

With the availability of more robust evidence confirming the better effectiveness and safety profile of CSP compared to conventional pacing modalities, in the next few years CSP will become the standard pacing modality in candidates for A&P. The routine adoption of this pacing modality could lead to a wider use of A&P in clinical practice.

Is conduction system pacing more effective than right ventricular pacing in reducing atrial high-rate episodes in patients with heart failure and preserved ejection fraction?

Background

The relationship between conduction system pacing (CSP) and the incidence of atrial fibrillation (AF) in patients with heart failure and preserved ejection fraction (HFpEF) remains uncertain. This study aims to investigate the occurrence of atrial high-rate episodes (AHREs) following CSP in patients with HFpEF, in comparison to right ventricular pacing (RVP).

Methods

Patients with HFpEF who received dual-chamber pacemakers for atrioventricular block were retrospectively enrolled from January 2018 to January 2023. Both new-onset and progressive AHREs were recorded, along with other clinical data, including cardiac performance and lead outcomes.

Results

A total of 498 patients were enrolled, comprising 387 patients with RVP and 111 patients with CSP, with a follow-up duration of 44.42 ± 10.41 months. In patients without a prior history of AF, CSP was associated with a significantly lower incidence of new-onset AHREs when the percentage of ventricular pacing was ≥20% (9.52% vs. 29.70%, P = 0.001). After adjusting for confounding factors, CSP exhibited a lower hazard ratio for new-onset AHREs compared to RVP (HR 0.336; [95% CI: 0.142-0.795]; P = 0.013), alongside left atrial diameter (LAD) (HR 1.109; [95% CI: 1.048-1.173]; P < 0.001). In patients with a history of AF, the progression of AHREs in CSP and RVP did not differ significantly (32.35% vs. 34.75%, P = 0.791). Cardiac performance metrics, including left ventricular end-diastolic diameter (LVEDD) (49.09 ± 4.28 mm vs. 48.08 ± 4.72 mm; P = 0.015), LAD (40.68 ± 5.49 mm vs. 39.47 ± 5.24 mm; P = 0.001), and NYHA class (2.31 ± 0.46 vs. 1.59 ± 0.73; P < 0.001), improved obviously following CSP, while LVEDD (48.37 ± 4.57 mm vs. 49.30 ± 5.32 mm; P < 0.001), LAD (39.77 ± 4.58 mm vs. 40.83 ± 4.80 mm; P < 0.001), NYHA class (2.24 ± 0.43 vs. 2.35 ± 0.83; P = 0.018), and left ventricular ejection fraction (LVEF) (57.41 ± 2.42 vs. 54.24 ± 6.65; P < 0.001) deteriorated after RVP.

Conclusion

Our findings suggest that CSP may be associated with improvements in cardiac performance and a reduction in new-onset AHREs compared to RVP in patients with HFpEF. However, prospective randomized trials are anticipated to confirm these potential benefits.

Differences in pacemaker programming between electrophysiology specialists and other physicians

BACKGROUND

Appropriate programming of cardiovascular implantable electronic devices (CIED) is essential to ensure adequate function and avoid harmful effects. In underdeveloped countries, CIED monitoring and programming are often performed by physicians involved in their implantation. However, many of them often do not have sufficient training in CIED programming.

OBJECTIVE

We aimed to assess the differences in pacemaker programming between electrophysiology (EP) specialists and other physicians.

METHODS

We retrospectively reviewed changes in pacemaker programming performed by an EP specialist in patients who attended for pacemaker evaluation and reported previous follow-ups by a non-EP specialist.

RESULTS

Among 58 patients (26 males), 41 patients (71%) had programming errors and required setting modifications. The rate adaptative pacing function (R-mode) was incorrectly deactivated in 9 patients (15%) and improperly activated in 2 patients (3%). Unnecessary ventricular stimulation was detected in 23 patients (40%) with a pacing burden of 60% (32-95%). The lower rate limit was unnecessarily high in 12 patients (21%). Atrial or ventricular pacing output was inappropriate in 15 patients (26%) and was consequently modified (4 patients unnecessarily high, 9 patients below requirements). The auto-adapted pacing output was switched off in 17 of 18 patients (16 due to physician's preference, and 1 due to algorithm inaccuracy). The programmed sensitivity was inaccurate in 2 patients (3%). In 2 patients (3%) switching from DDDR to VVIR mode was required.

CONCLUSION

We found a high prevalence of errors in pacemaker programming by non-EP specialists. An EP specialist should always be responsible for CIED follow-up.

Rate and nature of complications with leadless transcatheter pacemakers compared with transvenous pacemakers: results from an Italian multicentre large population analysis

AIMS

The safety and efficacy of leadless intracardiac-permanent pacemaker (L-PM) have been demonstrated in multiple clinical trials, but data on comparisons with conventional transvenous-permanent pacemaker (T-PM) collected in a consecutive, prospective fashion are limited. The aim of this analysis was to compare the rate and the nature of device-related complications between patients undergoing L-PM vs. T-PM implantation.

METHODS AND RESULTS

Prospective, multicentre, observational project enrolling consecutive patients who underwent L-PM or T-PM implantation. The rate and nature of device-related complications were analysed and compared between the two groups. Individual 1:1 propensity matching of baseline characteristics was performed. A total of 2669 (n = 665 L-PM) patients were included and followed for a median of 39 months, L-PM patients were on average older and had more co-morbidities. The risk of device-related complications at 12 months was significantly lower in the L-PM group (0.5% vs. 1.9%, P = 0.009). Propensity matching yielded 442 matched pairs. In the matched cohort, L-PM patients trended toward having a lower risk of overall device-related complications (P = 0.129), had a similar risk of early complications (≤30 days) (P = 1.000), and had a significantly lower risk of late complications (>30 days) (P = 0.031). All complications observed in L-PM group were early. Most (75.0%) of complications observed in T-PM group were lead- or pocket-related.

CONCLUSION

In this analysis, the risk of device-related complications associated with L-PM implantation tended to be lower than that of T-PM. Specifically, the risk of early complications was similar in two types of PMs, while the risk of late complications was significantly lower for L-PM than T-PM.

Leadless transcatheter pacemaker: Indications, implantation technique and peri-procedural patient management in the Italian clinical practice

BACKGROUND

Safety and efficacy of leadless pacemakers (L-PM) have been demonstrated in multiple clinical trials, but real-world data on patient selection, implantation technique, and peri-procedural patient management in a clinical practice setting are lacking.

METHODS

Consecutive patients undergoing L-PM implantation in 14 Italian centers were followed in a prospective, multicentre, observational project. Data on baseline patient characteristics, clinical indications, implantation procedure, and peri-procedural patient management were collected. The rate and nature of device-related complications were also recorded.

RESULTS

A total of 782 L-PM patients (68.4% male, 75.6 ± 12.4 years) were included in the analysis. The main patients-related reason leading to the choice of implanting a L-PM rather than a conventional PM was the high-risk of device infection (29.5% of cases). The implantation success rate was 99.2%. The median duration of the procedure was 46 min. In 90% of patients the device was implanted in the septum. Of patients on oral anticoagulant therapy (OAT) (n = 498) the implantation procedure was performed without interrupting (17.5%) or transiently interrupting OAT without heparin bridging (60.6%). During a median follow-up of 20 months major device-related complications occurred in 7 patients (0.9%): vascular access-site complications in 3 patients, device malfunction in 2 patients, pericardial effusion/cardiac tamponade in one patient, device migration in one patient.

CONCLUSIONS

In the real world setting of Italian clinical practice L-PM is often reserved for patients at high-risk of infection. The implantation success rate was very high and the risk of major complications was low. Peri-procedural management of OAT was consistent with available scientific evidence.

Safety and efficacy profile of an indigenous developed CHARAK DDDR 747R dual-chamber rate-responsive pacemaker

Aim:

The purpose of this study was to assess the safety and performance of the domestically manufactured Charak DDDR 747R (Pacetronix Ltd, Indore, India) pacemaker device.

Materials and Methods:

This was a prospective, controlled, single-center study conducted between March 2016 and August 2017. Eligible patients were implanted with a Charak DDDR 747R pacemaker with parameters set as specified on the packaging material unless otherwise advised by the physician. Patients were evaluated before discharge and at the 18-month follow-up. Data such as patient age, gender, and medical history were collected to determine patient eligibility for study participation, monitoring of study progress, and data analysis.

Results:

A total of 35 patients were analyzed. Males comprised 45.7% and females comprised 54.3% of patients. The average pacing threshold was threshold (atrium) was 1.05 V and the average pacing threshold (ventricle) was 1.07 V. The average impedance (atrium) was 641.09 Ω and the average impedance (ventricle) was 719.31 Ω. No serious adverse events were documented during the follow-up. One death occurred; however, this was not device-related.

Conclusions:

As per study findings, the Charak DDDR 747R, an indigenous pacemaker, is safe and effective in the Indian population. Durable lead parameters were obtained during the study which remained stable over time referring the same. Future larger studies are needed to confirm the preliminary data obtained from our study.

Leadless pacemaker versus transvenous single-chamber pacemaker therapy: peri-procedural aspects, utilization of medical resources and patient acceptance

BACKGROUND

Leadless pacemaker (L-PM) have been developed in order to overcome the lead- and pocket-related complications associated with transvenous pacemaker (T-PM). The impact of L-PM implantation on the utilization of medical resources, patient comfort and therapy acceptance could differ from that of T-PM.

RESEARCH DESIGN AND METHODS

Prospective, single-center study enrolling 243 consecutive patients undergoing PM implantation. Propensity matching for baseline characteristics yielded 77 matched pairs. Procedural data, patient acceptance (assessed by Florida Patient Acceptance Survey, FPAS) and quality of life (QoL) (assessed at the baseline, 1 week, 3 and 6 months) were compared between the two groups (L-PM and T-PM).

RESULTS

The implantation procedure was longer in L-PM than T-PM patients (42.2±16.3 vs. 28.9±11.9 minutes; p<0.001). L-PM was associated with lower intra- and post-operative pain intensity (all p<0.05), shorter hospitalization (3.2±0.5 vs. 3.5±1.1 days; p=0.034), greater patient acceptance (FPAS score: 58.7±7.1 vs. 40.5±4.1; p<0.001), and better QoL on both physical and mental health scales (all p<0.05).

CONCLUSIONS

Although L-PM implantation takes longer than T-PM, it is better tolerated and accepted by patients and is associated with a better QoL.

Prevention of long-lasting atrial fibrillation through antitachycardia pacing in DDDR pacemakers

OBJECTIVE

The MINERVA trial showed that in pacemaker patients with atrial fibrillation (AF) history, DDDRP pacing combining three algorithms - (a) atrial antitachycardia pacing with Reactive ATP enabled, (b) atrial preventive pacing and (c) managed ventricular pacing (MVP)-may effectively delay progression to persistent/permanent AF compared with standard DDDR pacing. We performed a comparative non-randomised evaluation to evaluate if Reactive ATP can be the main driver of persistent/permanent AF reduction independently on preventive pacing.

METHODS

Thirty-one centres included consecutive dual-chamber pacemaker patients with AF history. Reactive ATP was programmed in all patients while preventive atrial pacing was not enabled. These patients were compared with the three groups of MINERVA randomised trial (Control DDDR, MVP, and DDDRP). The main endpoint was the incidence of AF longer than 7 consecutive days.

RESULTS

A total of 146 patients (73 years old, 54% male) were included and followed for a median observation period of 31 months. The 2-year incidence of AF > 7 days was 12% in the Reactive ATP group, very similar to that found in the DDDRP arm of the MINERVA trial (13.8%, P = .732) and significantly lower than AF incidence found in the MINERVA Control DDDR arm (25.8%, P = .012) and in the MINERVA MVP arm (25.9%, P = .025).

CONCLUSIONS

In a real-world population of dual-chamber pacemaker patients with AF history, the use of Reactive ATP is associated with a low incidence of persistent AF, highlighting that the positive results of the MINERVA trial were related to the effectiveness of Reactive ATP rather than to preventive pacing.

Optimizing single-chamber pacing in dogs Part 1: Rate determinations, rate interventions and hysteresis

Determining ideal pacing rates to meet physiological needs and optimizing programming to prevent unnecessary right ventricular pacing in dogs requires an understanding of heart rate profiles and applicable pacing technology. The heart rate and rhythm of the dog is complex necessitating investigation of rate requirements of activity and circadian influences. Overlaying this information are a multiplicity of other factors such as age, breed, temperament, cardiovascular disease and underlining rhythm disorders that contribute to the difficulty in making general conclusions. However, all such information permits better implementation of programming options with the goal of better outcomes. In this review (Part 1 of a two-part review) instantaneous heart rate, rolling average heart rate, simple average heart rate, heart rate tachograms, RR interval tachograms (2D, 3D and dynamic), and Poincaré plots (2D, 3D and dynamic) are discussed as they apply to decisions in the determination and examination of pacing rates for dogs programmed in the VVI pacing mode (Ventricular paced, Ventricular sensed, Inhibited pacing). The applicable pacing operations available for three pacemaker companies are reviewed (Abbott, Biotronik/Dextronix, and Medtronic). The programmable options considered include: slowest pacing rate without additional features to extend the pacing interval, sleep/rest rate preferences, hysteresis to lengthen pacing interval following intrinsic beats, and intermittent increases in pacing following abrupt loss of intrinsic rhythm. Recommendations are suggested for follow-up of individual dogs with examination of pacing statistics and Holter monitoring.

Optimizing single-chamber pacing in dogs. Part 2: Rate adaptive pacing

Proper programming of pacemakers for dogs in the rate adaptive mode requires an understanding of the rate requirements for each individual and the interplay of programmable features. The specific advantages and disadvantages of the rate adaptive mode should be considered on a case by case basis. Fundamentally, two components are linked in the implementation of rate adaptive pacing: (1) sensing the need for a change in rate and (2) responding with the appropriate alteration in pacing rate. The programming interaction of these two components are interdependent and affected by the rates programmed. These features may be adjusted manually or automatically. In this review (Part 2 of a two-part review) the considerations required to program each aspect that optimizes the pacing rate profile are reviewed. These include the lower rate, upper sensor rate, activities of daily life rate, sensor threshold, acceleration and deceleration, slope, activities of daily life zone, exertion zone, automatic versus manual adjustments and closed loop stimulation. The programming features of pacemakers manufactured by three companies are summarized (Abbott, formerly St. Jude; Biotronik/Dextronix; Medtronic). Means of assessing the success of pacemaker programing is examined through examples of pacemaker data, Holter analysis, Poincaré plots and tachograms. Finally, the questions and considerations for rate adaptive pacing in dogs that demand investigation are proposed.

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.

Cardiac Stimulation in the Third Millennium: Where Do We Head from Here?

Over the years, pacemakers have evolved from a life-saving tool to prevent asystole to a device to treat heart rhythm disorders and heart failure, aiming at improving both cardiac function and clinical outcomes. Cardiac stimulation nowadays aims to correct the electrophysiologic roots of mechanical inefficiency in different structural heart diseases. This has led to awareness of the concealed risks of customary cardiac pacing that can inadvertently cause atrioventricular and inter-/intra-ventricular dyssynchrony, and has promoted the development of new pacing modalities and the use of stimulation sites different from the right atrial appendage and the right ventricular apex. The perspective of truly physiologic pacing is the leading concept of the continued research in the past 30 years, which has made cardiac stimulation procedure more sophisticated and challenging. In this article, we analyze the emerging evidence in favor of the available strategies to achieve an individualized physiologic setting in bradycardia pacing.

Pacing devices to treat bradycardia: current status and future perspectives

Introduction: Cardiac stimulation evolved from life-saving devices to prevent asystole to the treatment of heart rhythm disorders and heart failure, capable of remote patient and disease-progression monitoring. Cardiac stimulation nowadays aims to correct the electrophysiologic roots of mechanical inefficiency in different structural heart diseases.Areas covered: Clinical experience, as per available literature, has led to awareness of the concealed risks of customary cardiac pacing, that can inadvertently cause atrio-ventricular and inter/intra-ventricular dyssynchrony. New pacing modalities have emerged, leading to a new concept of what truly represents 'physiologic pacing' beyond maintenance of atrio-ventricular coupling. In this article we will analyze the emerging evidence in favor of the available strategies to achieve an individualized physiologic setting in bradycardia pacing, and the hints of future developments.Expert opinion: 'physiologic stimulation' technologies should evolve to enable an effective and widespread adoption. In one way new guiding catheters and the adoption of electrophysiologic guidance and non-fluoroscopic lead implantation are needed to make His-Purkinje pacing successful and effective at long term in a shorter procedure time; in the other way leadless stimulation needs to upgrade to a superior physiologic setting to mimic customary DDD pacing and possibly His-Purkinje pacing.

Change in the use of remote monitoring of cardiac implantable electronic devices in Italian clinical practice over a 5-year period: results of two surveys promoted by the AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

AIMS

The aim of this study was to evaluate the use of remote monitoring in Italian clinical practice and its trend over the last 5 years.

METHODS

In 2012 and 2017, two surveys were conducted. Both were open to all Italian implanting centres and consisted of 25 questions on the characteristics of the centre, their actual use of remote monitoring, applied organizational models and administrative and legal aspects.

RESULTS

The questionnaires were completed by 132 and 108 centres in 2012 and 2017, respectively (30.6 and 24.7% of all Italian implanting centres). In 2017, significantly fewer centres followed up fewer than 200 patients by remote monitoring than in 2012, while more followed up more than 500 patients (all P < 0.005). In most of the centres (77.6%) that responded to both surveys, the number of patients remotely monitored significantly increased from 2012 to 2017.In both surveys, remote monitoring was usually managed by physicians and nurses. Over the period, primary review of transmissions by physicians declined, while it was increasingly performed by nurses; the involvement of technicians rose, while that of manufacturers' technical personnel decreased. The percentage of centres in which transmissions were submitted to the physician only in critical cases rose (from 28.3 to 64.3%; P < 0.001). In 86.7% of centres, the lack of a reimbursement system was deemed the main barrier to implementing remote monitoring.

CONCLUSION

In the last 5 years, the number of patients followed up by remote monitoring has increased markedly. In most Italian centres, remote monitoring has increasingly been managed through a primary nursing model. The lack of a specific reimbursement system is perceived as the main barrier to implementing remote monitoring .

Impact of COVID-19 pandemic on the clinical activities related to arrhythmias and electrophysiology in Italy: results of a survey promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

COVID-19 outbreak had a major impact on the organization of care in Italy, and a survey to evaluate provision of for arrhythmia during COVID-19 outbreak (March-April 2020) was launched. A total of 104 physicians from 84 Italian arrhythmia centres took part in the survey. The vast majority of participating centres (95.2%) reported a significant reduction in the number of elective pacemaker implantations during the outbreak period compared to the corresponding two months of year 2019 (50.0% of centres reported a reduction of > 50%). Similarly, 92.9% of participating centres reported a significant reduction in the number of implantable cardioverter-defibrillator (ICD) implantations for primary prevention, and 72.6% a significant reduction of ICD implantations for secondary prevention (> 50% in 65.5 and 44.0% of the centres, respectively). The majority of participating centres (77.4%) reported a significant reduction in the number of elective ablations (> 50% in 65.5% of the centres). Also the interventional procedures performed in an emergency setting, as well as acute management of atrial fibrillation had a marked reduction, thus leading to the conclusion that the impact of COVID-19 was disrupting the entire organization of health care, with a massive impact on the activities and procedures related to arrhythmia management in Italy.

Risk of syncopal recurrences in patients treated with permanent pacing for bradyarrhythmic syncope: role of correlation between symptoms and electrocardiogram findings

Aims 

To evaluate the risk of syncopal recurrences after pacemaker implantation in a population of patients with syncope of suspected bradyarrhythmic aetiology.

Methods and results 

Prospective, multicentre, observational registry enrolling 1364 consecutive patients undergoing pacemaker implantation for syncope of bradyarrhythmic aetiology (proven or presumed). Before pacemaker implantation, all patients underwent a cardiac work-up in order to establish the bradyarrhythmic aetiology of syncope. According to the results of the diagnostic work-up, patients were divided into three groups: Group A, patients in whom a syncope-electrocardiogram (ECG) correlation was established (n = 329, 24.1%); Group B, those in whom clinically significant bradyarrhythmias were detected without a documented syncope-ECG correlation (n = 877, 64.3%); and Group C, those in whom bradyarrhythmias were not detected and the bradyarrhythmic origin of syncope remained presumptive (n = 158, 11.6%). During a median follow-up of 50 months, 213 patients (15.6%) reported at least one syncopal recurrence. Patients in Groups B and C showed a significantly higher risk of syncopal recurrences than those in Group A [hazard ratios (HRs): 1.60 and 2.66, respectively, P &lt; 0.05]. Failure to establish a syncope-ECG correlation during diagnostic work-up before pacemaker implantation was an independent predictor of syncopal recurrence on multivariate analysis (HR: 1.90; P = 0.002).

Conclusion

In selecting patients with syncope of suspected bradyarrhythmic aetiology for pacemaker implantation, establishing a correlation between syncope and bradyarrhythmias maximizes the efficacy of pacing and reduces the risk of syncopal recurrences.

Occurrence of atrial fibrillation in pacemaker patients and its association with sleep apnea and heart rate variability

AIMS

Sleep apnea (SA) is a risk factor for atrial fibrillation (AF) occurrence. Sympathovagal imbalance is a mechanism that predisposes to the development of AF and that occurs in SA. Some pacemakers can detect SA events and continuously measure a time domain measure of heart rate variability (HRV), i.e. the standard deviation of 5-min median atrial-atrial sensed intervals (SDANN). We evaluated the association between the occurrence of AF and device-detected SA and SDANN in patients who received pacemakers.

METHODS

We enrolled 150 consecutive patients undergoing implantation of a dual-chamber pacemaker, capable of SA and SDANN estimation. The SA was defined as severe if the Respiratory Disturbance Index was ≥30 episodes/h for at least one night during the first week after implantation.

RESULTS

Sixteen patients in permanent AF were excluded from our analysis. During follow-up, AF (cumulative device-detected AF duration > 6 h/day) occurred in 24(18%) patients out of the remaining 134 patients. Severe SA was detected in 84 patients. SDANN values were available in 74 patients and the median value was 76 ms [25°-75°percentile:58-77]. The risk of AF was higher in patients with severe SA (log-rank test; p = .033). The presence of either or both conditions (severe SA and SDANN < 76 ms) was associated with shorter time to AF event (p = .042) and was an independent predictor of AF (hazard ratio: 2.37; 95%CI:1.08 to 5.21; p = .033).

CONCLUSION

In pacemaker patients, device-diagnosed severe SA and reduced SDANN are associated with a higher risk of AF.

Lead choice in cardiac implantable electronic devices: an Italian survey promoted by AIAC (Italian Association of Arrhythmias and Cardiac Pacing)

Background: Few data are available regarding lead preferences of electrophysiologists during cardiac implantable electronic devices (CIEDs) implantation. Aim of this survey is to evaluate the leads used, and the reasons behind these choices, in a large population of implanters. Methods: A questionnaire was sent to all 314 Italian centers with experience in CIED implantation. Results: 103 operators from 100 centers (32% of centers) responded. For atrium, passive leads represented first choice for pacemakers and defibrillators (71% and 64% of physicians, respectively), mainly for safety. For right ventricle, active fixation was preferred (61% and 93% operators in pacemaker and defibrillator patients), for higher versatility in positioning and lower dislodgement risk. For left ventricular stimulation, quadripolar leads were preferred by more than 80% of respondents, for better phrenic nerve and myocardial threshold management; active-fixation leads represent a second choice, in order to prevent or manage dislodgement (78% and 17% of respondents, respectively), but 44% of operators considered them dangerous. Conclusions: The choice of leads is heterogeneous. Trends are toward active-fixation right ventricular leads and passive-fixation atrial leads (particularly in pacemaker patients, considered frailer). For left ventricular stimulation, operators' majority want to disposition all kind of leads, although quadripolar leads are the favorites.

EHRA White Paper: knowledge gaps in arrhythmia management-status 2019

Clinicians accept that there are many unknowns when we make diagnostic and therapeutic decisions. Acceptance of uncertainty is essential for the pursuit of the profession: bedside decisions must often be made on the basis of incomplete evidence. Over the years, physicians sometimes even do not realize anymore which the fundamental gaps in our knowledge are. As clinical scientists, however, we have to halt and consider what we do not know yet, and how we can move forward addressing those unknowns. The European Heart Rhythm Association (EHRA) believes that scanning the field of arrhythmia / cardiac electrophysiology to identify knowledge gaps which are not yet the subject of organized research, should be undertaken on a regular basis. Such a review (White Paper) should concentrate on research which is feasible, realistic, and clinically relevant, and should not deal with futuristic aspirations. It fits with the EHRA mission that these White Papers should be shared on a global basis in order to foster collaborative and needed research which will ultimately lead to better care for our patients. The present EHRA White Paper summarizes knowledge gaps in the management of atrial fibrillation, ventricular tachycardia/sudden death and heart failure.