Management of a patient with multiple device replacements and extractions: When the leadless pacemaker is a viable solution

Leadless pacemaker (LPs) is a safe device and the implantation rates of this device is increasing. The device extraction and replacement are today a challenging procedures especially in case of infections, fragile and older patients or in unfavorable venous anatomy; LPs can be a valid alternative strategy in these cases. We report a case of management of a patient with multiple previous device replacements and extractions, with malfunction of transvenous pacemaker and with a fibrous membrane between the walls of the ventricular lead and the superior vena cava (SVC), who underwent a successful LP implantation

Direct Oral Anticoagulants in the Setting of Catheter Ablation of Atrial Fibrillation: State of art

Atrial fibrillation (AF) represents the arrhythmia of greatest clinical impact and catheter ablation of AF (CAAF) has become the most effective strategy for rhythm control in selected patients. Therefore, appropriate anticoagulation strategies are of paramount importance for patients undergoing CAAF, especially those at high risk, such those with high CHA2DS2VASc scores. Optimal management of anticoagulation before, during, and after CAAF is crucial. Several studies have evaluated the use of different anticoagulation strategies in the periprocedural period. Randomized controlled trial seem to suggest that in patients undergoing CAAF, uninterrupted (or minimally interrupted) direct oral anticoagulants (DOACs) provides an alternative to continuous vitamin K antagonists strategy, with low thromboembolic and bleeding risk

A possible easy way to predict response to cardiac resynchronization therapy: The role of QRS Index

Background: Some studies have evaluated the role of QRS duration (QRSd) as predictor of response to Cardiac Resynchronization Therapy (CRT). However, their results are still not entirely clear. The goal of our study was to determine the correlation between the relative change in QRS narrowing index (QI) compared to clinical outcome and prognosis in patients who underwent CRT implantation. Methods: We collected clinical and echocardiographic data of 115 patients in whome a CRT device was implanted in accordance with current guidelines. QRS duration before and after CRT implantation and QI were measured. Results: After 6 months, a signifi cant improvement in all echocardiographic parameters was detected. QI was correlated to reverse remodelling (r = +0.19; 95% CI: 0.006 to 0.35, p = 0,049). The value of QI that predicted best LV reverse remodelling after 6 months of CRT was 12.25% (sensitivity = 65,5%, specifi city = 75%, area under the curve = 0.737, p = 0,001). Independent predictors of QI are sex, serum creatinine and eGFR measured at baseline and LVEF pre-CRT performed by echocardiography. We observed an betterment in their HF clinical composite score and NYHA class at 12 months. We have also investigated the clinical outcomes and the possible sex differences related to QI. Conclusions: Patients with a larger QI after CRT initiation showed greater echocardiographic reverse remodelling and better outcome from death or cardiovascular hospitalization. QI seems to be an easy-to- measure variable that could be used or evaluated to predict CRT response but further studies are needed

Chronic Apical and Nonapical Right Ventricular Pacing in Patients with High-Grade Atrioventricular Block: Results of the Right Pace Study

Objective. The aim of the study was to compare the two approaches to chronic right ventricular pacing currently adopted in clinical practice: right ventricular apical (RVA) and non-RVA pacing. Background. Chronic RVA pacing is associated with an increased risk of atrial fibrillation, morbidity, and even mortality. Non-RVA pacing may yield more physiologic ventricular activation and provide potential long-term benefits and has recently been adopted as standard procedure at many implanting centers. Methods. The Right Pace study was a multicenter, prospective, single-blind, nonrandomized trial involving 437 patients indicated for dual-chamber pacemaker implantation with a high percentage of RV pacing. Results. RV lead-tip target location was the apex or the interventricular septum. RVA (274) and non-RVA patients (163) did not differ in baseline characteristics. During a median follow-up of 19 months (25th–75th percentiles, 13–25), 17 patients died. The rates of the primary outcome of death due to any cause or hospitalization for heart failure were comparable between the groups (log-rank test, p=0.609), as were the rates of the composite of death due to any cause, hospitalization for heart failure, or an increase in left ventricular end-systolic volume ≥ 15% as compared with the baseline evaluation (secondary outcome, p=0.703). After central adjudication of X-rays, comparison between adjudicated RVA (239 patients) and non-RVA (170 patients) confirmed the absence of difference in the rates of primary (p=0.402) and secondary (p=0.941) outcome. Conclusions. In patients with indications for dual-chamber pacemaker who require a high percentage of ventricular stimulation, RVA or non-RVA pacing resulted in comparable outcomes. This study is registered with ClinicalTrials.gov (identifier: NCT01647490)

Magnitude of QRS duration reduction after biventricular pacing identifies responders to cardiac resynchronization therapy

Background Several studies have investigated the association between native QRS duration (QRSd) or QRS narrowing and response to biventricular pacing. However, their results have been conflicting. The aim of our study was to determine the association between the relative change in QRS narrowing index (QI) and clinical outcome and prognosis in patients who undergo cardiac resynchronization therapy (CRT) implantation. Methods and results We included 311 patients in whom a CRT device was implanted in accordance with current guidelines for CRT. On implantation, the native QRS, the QRSd and the QI during CRT were measured. After 6 months, 220 (71%) patients showed a 10% reduction in LVESV. The median [25th–75th] QI was 14.3% [7.2–21.4] and was significantly related to reverse remodeling (r = + 0.22; 95%CI: 0.11–0.32, p = 0.0001). The cut-off value of QI that best predicted LV reverse remodeling after 6 months of CRT was 12.5% (sensitivity = 63.6%, specificity = 57.1%, area under the curve = 0.633, p = 0.0002). The time to the event death or cardiovascular hospitalization was significantly longer among patients with QI > 12.5% (log-rank test, p = 0.0155), with a hazard ratio (HR) of 0.3 [95%CI: 0.11–0.78]. In the multivariate regression model adjusted for baseline parameters, a 10% increment in QI (HR = 0.61[0.44–0.83], p = 0.002) remained significantly associated with CRT response. Conclusions Patients with a larger decrease in QRSd after CRT initiation showed greater echocardiographic reverse remodeling and better outcome from death or cardiovascular hospitalization. QI is an easy-to-measure variable that could be used to predict CRT response at the time of pacing site selection or pacing configuration programming