"Ablate and Pace" with Conduction System Pacing: Concomitant versus Delayed Atrioventricular Junction Ablation

Objectives: Conduction system pacing (CSP) and atrioventricular junction ablation (AVJA) improve the outcomes in patients with symptomatic, refractory atrial fibrillation (AF). In this setting, AVJA can be performed simultaneously with implantation or in a second procedure a few weeks after implantation. Comparison data on these two alternative strategies are lacking. Methods: A prospective, multicentre, observational study enrolled consecutive patients with symptomatic, refractory AF undergoing CSP and AVJA performed in a single procedure or in two separate procedures. Data on the long-term outcomes and healthcare resource utilization were prospectively collected. Results: A total of 147 patients were enrolled: for 105 patients, CSP implantation and AVJA were performed simultaneously (concomitant AVJA); in 42, AVJA was performed in a second procedure, with a mean of 28.8 ± 19.3 days from implantation (delayed AVJA). After a mean follow-up of 12 months, the rate of procedure-related complications was similar in both groups (3.8% vs. 2.4%; p = 0.666). Concomitant AVJA was associated with a lower number of procedure-related hospitalizations per patient (1.0 ± 0.1 vs. 2.0 ± 0.3; p < 0.001) and with a lower number of hospital treatment days per patient (4.7 ± 1.8 vs. 7.4 ± 1.9; p < 0.001). Conclusions: Concomitant AVJA resulted as being as safe as delayed AVJA and was associated with a lower utilization of healthcare resources.

Complications of left bundle branch area pacing compared with biventricular pacing in candidates for resynchronization therapy: Results of a propensity score-matched analysis from a multicenter registry

BACKGROUND

Cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) is a well-established therapy in patients with reduced left ventricular ejection fraction, heart failure, and left bundle branch block. Left bundle branch area pacing (LBBAP) has recently been shown to be a feasible and effective alternative to BVP. Comparative data on the risk of complications between LBBAP and BVP among patients undergoing CRT are lacking.

OBJECTIVE

The aim of this study was to compare the long-term risk of procedure-related complications between LBBAP and BVP in a cohort of patients undergoing CRT.

METHODS

This prospective, multicenter, observational study enrolled 668 consecutive patients (mean age 71.2 ± 10.0 years; 52.2% male; 59.4% with New York Heart Association class III-IV heart failure symptoms) with left ventricular ejection fraction 33.4% ± 4.3% who underwent BVP (n = 561) or LBBAP (n = 107) for a class I or II indication for CRT. Propensity score matching for baseline characteristics yielded 93 matched pairs. The rate and nature of intraprocedural and long-term post-procedural complications occurring during follow-up were prospectively collected and compared between the 2 groups.

RESULTS

During a mean follow-up of 18 months, procedure-related complications were observed in 16 patients: 12 in BVP (12.9%) and 4 in LBBAP (4.3%) (P = .036). Compared with patients who underwent LBBAP, those who underwent BVP showed a lower complication-free survival (P = .032). In multivariate analysis, BVP resulted an independent predictive factor associated with a higher risk of complications (hazard ratio 3.234; P = .042). Complications related to the coronary sinus lead were most frequently observed in patients who underwent BVP (50.0% of all complications).

CONCLUSION

LBBAP was associated with a lower long-term risk of device-related complications compared with BVP in patients with an indication for CRT.

Ablate and pace: Comparison of outcomes between conduction system pacing and biventricular pacing

BACKGROUND

Conduction system pacing (CSP), including His-bundle pacing (HBP) and left bundle branch area pacing (LBBAP), have been proposed as alternatives to biventricular pacing (BVP) in patients scheduled for ablate and pace (A&P) strategy. The aim of this study was to compare the clinical outcomes, including the rate and nature of device-related complications, between BVP and CSP in a cohort of patients undergoing A&P.

METHODS

Prospective, multicenter, observational study, enrolling consecutive patients undergoing A&P. The risk of device-related complications and of heart failure (HF) hospitalization was prospectively assessed.

RESULTS

A total of 373 patients (75.3 ± 8.7 years, 53.9% male, 68.9% with NYHA class ≥III) were enrolled: 263 with BVP, 68 with HBP, and 42 with LBBAP. Baseline characteristics of the three groups were similar. Compared to BVP and HBP, LBBAP was associated with the shortest mean procedural and fluoroscopy times and with the lowest acute capture thresholds (all p < .05). At 12-month follow-up LBBAP maintained the lowest capture thresholds and showed the longest estimated residual battery longevity (all p < .05). At 12-months follow-up the three study groups showed a similar risk of device-related complications (5.7%, 4.4%, and 2.4% for BVP, HBP, and LBBAP, respectively; p = .650), and of HF hospitalization (2.7%, 1.5%, and 2.4% for BVP, HBP, and LBBAP, respectively; p = .850).

CONCLUSIONS

In the setting of A&P, CSP is a feasible pacing modality, with a midterm safety profile comparable to BVP. LBBAP offers the advantage of reducing procedural times and obtaining lower and stable capture thresholds, with a positive impact on the device longevity.

Impact of atrioventricular junction ablation and CRT-D on long-term mortality in patients with left ventricular dysfunction, permanent, refractory atrial fibrillation and narrow QRS: results of a propensity matched analysis

INTRODUCTION

In patients with symptomatic permanent atrial fibrillation (PEAF) and narrow QRS, atrio-ventricular junction ablation (AVJA) plus cardiac resynchronization therapy (CRT) is superior to medical therapy in reducing heart failure (HF) hospitalization and all-cause mortality. To compare the mortality of a population of patients with HF, reduced EF (rEF) and PEAF treated with AVJA plus CRT with that of a contemporary cohort of patients in sinus rhythm (SR) with similar baseline characteristics.

METHODS AND RESULTS

In this prospective, multicentre, observational study, all-cause mortality in a group of consecutive patients undergoing AVJA and implantable cardioverter-defibrillator (ICD) combined with CRT implantation for HFrEF, narrow QRS, and PEAF with uncontrolled ventricular rate was compared with that of a contemporary cohort of patients in SR undergoing ICD implantation (not combined with CRT) for HFrEF and narrow QRS. Individual 1:1 propensity matching of baseline characteristics was performed. A total of 824 patients were enrolled. Propensity matching yielded 107 matched pairs. After a median follow-up of 52 months, all-cause mortality was similar in patients treated with AVJA plus CRT and in the control group (p=0.434). In AVJA plus CRT patients, mortality was significantly lower than in control group patients with a history of paroxysmal/persistent AF (n=45, p=0.020), and similar to that of patients without a history of AF (n=62, p=0.459).

CONCLUSIONS

After adjustment for patient characteristics, the long-term prognosis of patients with HFrEF, narrow QRS and PEAF who underwent AVJA plus CRT was similar to that of a population of patients in SR with similar characteristics. This article is protected by copyright. All rights reserved.

The relationship between anatomy and electrical parameters in His bundle pacing

Background

The relationship between anatomy and electrical parameters of His bundle (HB) pacing has not been extensively studied.

Purpose

To characterize the anatomical location of the HB lead tip and its relationship with acute electrical parameters.

Methods

Consecutive patients who underwent HB lead implantation, guided by standard fluoroscopy and electrophysiology, were prospectively enrolled. The relationship between HB lead tip and tricuspid valve plane (TVP) was assessed with post-procedure transthoracic echocardiography.

Results

Twenty-five patients were studied. In 11 patients (44%), the HB lead tip did not cross the TVP (A group): in 7 cases it was screwed in the right atrium at a mean distance of −6.1 mm from the TVP and, in 4 cases, at the level of the tricuspid annulus. In the remaining 14 patients (56%), the lead tip crossed the TVP (V group): it was screwed in the right ventricle at a mean distance of 9.3 mm from the TVP. A and V groups had comparable HB capture thresholds (1.6±1 V vs 1.7±0.7 V, 1 ms pulse-width; p=0.66); selective HB capture was significantly more represented in the A group (91% vs 21%; p=0.001). Significantly higher R-wave amplitudes were seen in the V group (6.7±3 vs 2.5±1.7 mV; p=0.0004), and they positively correlated with the distance from the TVP (p=0.0038). Atrial oversensing was never observed.

Conclusion

In a consecutive cohort of HBP recipients, the rate of patients who had an effective HB capture in the atrium was substantial and was characterized by different electrophysiological properties than in the ventricle.

Funding Acknowledgement

Type of funding sources: None.

The relationship between anatomy and electrical parameters in His bundle pacing: A transthoracic echocardiography evaluation

PURPOSE

The implantation site of the His bundle (HB) lead may influence pacing parameters. Our aim was to characterize the anatomical location of the HB lead tip and its relationship with acute electrical parameters.

METHODS

Consecutive patients who underwent HB lead implantation, guided by standard fluoroscopy and electrophysiology, were prospectively enrolled. The relationship between HB lead tip and tricuspid valve plane (TVP) was assessed with post-procedure transthoracic echocardiography.

RESULTS

Twenty-five patients were studied. In 11 patients (44%), the HB lead tip did not cross the TVP (A group): in 7 cases it was screwed in the right atrium at a mean distance of -6.1 mm from the TVP and, in 4 cases, at the level of the tricuspid annulus. In the remaining 14 patients (56%), the lead tip crossed the TVP (V group): it was screwed in the right ventricle at a mean distance of 9.3 mm from the TVP. A and V groups had comparable HB capture thresholds (1.6 ± 1 V vs 1.7 ± 0.7 V, 1 ms pulse-width; p = 0.66); selective HB capture was significantly more represented in the A group (91% vs 21%; p = 0.001). Significantly higher R-wave amplitudes were seen in the V group (6.7 ± 3 vs 2.5 ± 1.7 mV; p = 0.0004), and they positively correlated with the distance from the TVP (p = 0.0038). Atrial oversensing was never observed.

CONCLUSION

In a consecutive cohort of HB pacing recipients, the rate of patients who had an effective HB capture in the atrium was substantial and was characterized by different electrophysiological properties than in the ventricle.

Is His-optimized superior to conventional cardiac resynchronization therapy in improving heart failure? Results from a propensity-matched study

BACKGROUND

His bundle pacing (HBP), alone or optimized in association with coronary sinus pacing (HBP+LV) has recently been proposed as an alternative to conventional cardiac resynchronization therapy (CRT). However, there is lack of controlled studies that assessed clinical outcome.

METHODS

We did a single-center, propensity-score matched, case-control study of comparison of HBP and HBP+LV versus conventional CRT in patients with heart failure (HF) and standard indications for CRT. The study group patients were consecutively enrolled in the year 2019. The control group patients were selected, by propensity score matching, among those CRT implantations performed in the years 2015-2018.

RESULTS

There were 27 patients in each group. In the active group, 12 (44%) patients received HBP alone and 12 (44%) patients HBP+LV pacing. HBP failed in three (11%) patients. In the control group, conventional CRT was achieved in 26 (96%) patients and failed in one. Paced QRS width was shorter in the active than in the control group (128 ± 18 vs. 148 ± 27 ms, p = .004). During a mean of 9.6 months of follow-up, a composite clinical outcome of death, hospitalization for HF or worsening HF occurred in three (11%) in the active group and in four (15%) in the control group, p = .58. No difference was also observed with softer endpoints: NYHA class (1.9 ± 0.7 vs. 2.1 ± 0.7), subjective improvement (74% vs. 74%) and LV ejection fraction (40.7% vs. 40.7%).

CONCLUSION

Compared with conventional CRT, a shorter QRS width can be obtained with HBP alone or in association with coronary sinus pacing but we were unable to show a better clinical outcome. There is urgent need for large, randomized trials.

Left bundle branch area pacing in a young athlete with progressive cardiac conduction (Lev-Lenegre) disease

We present the case of a professional soccer player affected by right bundle branch block and symptomatic 2:1 atrio-ventricular block during effort, due to progressive cardiac conduction disease (Lev-Lenegre disease), who received successful left bundle branch area pacing after a failed attempt at His bundle pacing. The electrocardiographic outcome of paced QRS was consistent with a rapid electrical activation of the left ventricle through the Purkinje system. The pursue of physiological pacing was preferred over conventional, given the young age of our patient and the expectedly high burden of stimulation, to reduce the long-term risk of pacing-induced cardiomyopathy.

Anterior Mitral Valve Aneurysm Is an Uncommon Complication of Aortic Valve Infective Endocarditis: A Case Report

Patient: Male, 62

Final Diagnosis: Mitral valve aneurysm complicating aortic valve endocarditis

Symptoms: Fever

Medication: —

Clinical Procedure: Combined aortic valve and mitral valve replacement

Specialty: Cardiology