Fusion pacing with biventricular, left ventricular-only and multipoint pacing in cardiac resynchronisation therapy: Latest evidence and strategies for use

Despite advances in the field of cardiac resynchronisation therapy (CRT), response rates and durability of therapy remain relatively static. Optimising device timing intervals may be the most common modifiable factor influencing CRT efficacy after implantation. This review addresses the concept of fusion pacing as a method for improving patient outcomes with CRT. Fusion pacing describes the delivery of CRT pacing with a programming strategy to preserve intrinsic atrioventricular (AV) conduction and ventricular activation via the right bundle branch. Several methods have been assessed to achieve fusion pacing. QRS complex duration (QRSd) shortening with CRT is associated with improved clinical response. Dynamic algorithm-based optimisation targeting narrowest QRSd in patients with intact AV conduction has shown promise in people with heart failure with left bundle branch block. Individualised dynamic programming achieving fusion may achieve the greatest magnitude of electrical synchrony, measured by QRSd narrowing

Contractile reserve as a predictor of prognosis in patients with non-ischaemic systolic heart failure and dilated cardiomyopathy: a systematic review and meta-analysis.

OBJECTIVE: Patients with non-ischaemic systolic heart failure (HF) and idiopathic dilated cardiomyopathy (DCM) are a heterogenous group with varied morbidity and mortality. Prognostication in this group is challenging. We performed a systematic review and meta-analysis to examine the significance of the presence of contractile reserve as assessed via stress imaging on mortality and hospitalisation. METHODS: A search for studies that non-invasively assessed contractile reserve in patients with DCM or non-ischaemic HF with reduced ejection fraction, stress imaging with follow-up data comparing outcomes. A range of imaging modalities and stressors were included. We examined primary endpoints of mortality and secondary endpoints of combined cardiovascular events including HF progression or hospitalisation. Our analysis compared endpoints in patients with contractile reserve and those without it. RESULTS: Nine prospective cohort studies were identified describing a total of 787 patients. These studies are methodologically but not statistically heterogenous (I2 = 31%). Using a random effect model, the presence of contractile reserve was associated with a significantly lower risk of mortality and cardiovascular events odds ratios of 0.20 (CI 0.11, 0.39) (P < 0.00001) and 0.13 (CI 0.04, 0.40) (P = 0.0004), respectively. CONCLUSION: Regardless of stressor and imaging modality and despite the significant methodological heterogeneity within the current data (imaging techniques and parameters), patients with non-ischaemic cardiomyopathy and reduced EF who demonstrate contractile reserve have a lower mortality, and lower events/hospitalisations. The presence of contractile reserve therefore offers a potential positive prognostic indicator when managing these patients

Noninvasive electrocardiographic imaging of dynamic atrioventricular delay programming in a patient with left bundle branch block

Introduction The response to cardiac resynchronization therapy (CRT) is determined by various factors, including left ventricular (LV) lead location, atrioventricular (AV) delay, and inter-/intraventricular delays. Advances in quadripolar lead technology and device algorithms have improved patient response, yet selection of optimal settings remains challenging. Studies have shown acute improvement in electrical synchrony with manual AV optimization by fusion optimized intervals1,2; automated device algorithms, for example AdaptivCRT (Medtronic, Minneapolis, MN),3 SmartDelay (Boston Scientific, Marlborough, MA),4 and SyncAVTM (Abbott, Sylmar, CA)5; and pacing from multiple LV lead electrodes with MultiPoint Pacing (MPP).6,7 The aim of this clinical case report was to evaluate the acute benefits of SyncAV Plus in the new-generation, Bluetooth-enabled GallantTM CRT device (Abbott, Sylmar, CA). SyncAV Plus continually programs the paced AV delay shorter than the intrinsic PR interval by a programmable offset (% of PR duration) to synchronize intrinsic and ventricular paced activation wavefronts. Twelve-lead electrocardiogram (ECG) and noninvasive electrocardiographic imaging (ECGi) epicardial mapping analyses were performed to characterize the impact of SyncAV Plus on electrical synchrony during a range of CRT programming strategies, including biventricular (BiV) pacing, MPP, LV-only pacing, and LV-only pacing with MPP

Acute breathlessness with frank hemoptysis following catheter ablation for atrial fibrillation, a cause not so obvious.

All clinicians prescribing amiodarone require knowledge of the challenging diagnosis and management of amiodarone-induced pulmonary toxicity (APT), which is potentially fatal. APT should be considered early in all patients presenting with new respiratory symptoms and concurrent amiodarone therapy. Drug cessation and corticosteroid therapy can be highly effective once recognized

Post-operative cardiac implantable electronic devices in patients undergoing cardiac surgery: a contemporary experience.

This is a pre-copyedited, author-produced version of an article accepted for publication in EP Europace,, following peer review. The version of record: Peter Henry Waddingham, Jonathan M Behar, Neil Roberts, Gurpreet Dhillon, Adam J Graham, Ross J Hunter, Carl Hayward, Mehul Dhinoja, Amal Muthumala, Rakesh Uppal, Edward Rowland, Mark J Earley, Richard J Schilling, Simon Sporton, Martin Lowe, Amer Harky, Oliver R Segal, Pier D Lambiase, Anthony W C Chow, Post-operative cardiac implantable electronic devices in patients undergoing cardiac surgery: a contemporary experience, EP Europace, , euaa241, https://doi.org/10.1093/europace/euaa241 is available online at: https://doi.org/10.1093/europace/euaa241.AIMS: Optimum timing of pacemaker implantation following cardiac surgery is a clinical challenge. European and American guidelines recommend observation, to assess recovery of atrioventricular block (AVB) (up to 7 days) and sinus node (5 days to weeks) after cardiac surgery. This study aims to determine rates of cardiac implantable electronic devices (CIEDs) implants post-surgery at a high-volume tertiary centre over 3 years. Implant timing, patient characteristics and outcomes at 6 months including pacemaker utilization were assessed. METHODS AND RESULTS: All cardiac operations (n = 5950) were screened for CIED implantation following surgery, during the same admission, from 2015 to 2018. Data collection included patient, operative, and device characteristics; pacing utilization and complications at 6 months. A total of 250 (4.2%) implants occurred; 232 (3.9%) for bradycardia. Advanced age, infective endocarditis, left ventricle systolic impairment, and valve surgery were independent predictors for CIED implants (P < 0.0001). Relative risk (RR) of CIED implants and proportion of AVB increased with valve numbers operated (single-triple) vs. non-valve surgery: RR 5.4 (95% CI 3.9-7.6)-21.0 (11.4-38.9) CIEDs. Follow-up pacing utilization data were available in 91%. Significant utilization occurred in 82% and underutilization (<1% A and V paced) in 18%. There were no significant differences comparing utilization rates in early (≤day 5 post-operatively) vs. late implants (P = 0.55). CONCLUSION: Multi-valve surgery has a particularly high incidence of CIED implants (14.9% double, 25.6% triple valve). Age, left ventricle systolic impairment, endocarditis, and valve surgery were independent predictors of CIED implants. Device underutilization was infrequent and uninfluenced by implant timing. Early implantation (≤5 days) should be considered in AVB post-multi-valve surgery