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Advances in Cardiac Pacing and Cardiac Resynchronization Therapy

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (31 July 2023) | Viewed by 16752

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Dr. François Regoli

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Guest Editor

1. Service of Cardiology, Regional Hospital of Bellinzona and Valleys (ORBV), Via Ospedale 12, CH 6500 Bellinzona, Switzerland
2. Division of Cardiology, Cardiocentro Ticino Institute, Via Tesserete 48, CH-6900 Lugano, Switzerland
Interests: pacing therapies in heart failure; cardiac resynchronization therapy; ICD therapies; atrial fibrillation; imaging in interventional electrophysiology

Special Issue Information

Dear Colleagues,

The field of cardiac pacing has undergone many important changes in recent years. Leadless technologies are now widely available both as single-chamber pacing devices and also as single-chamber devices with atrial-sensing capability. Furthermore, mapping studies on conduction system disturbances and the characterization of different patterns of interventricular conduction delays—specifically, left bundle branch blocks—have unveiled important new information on how to target the ventricular conduction system to deliver clinically effective pacing (CSP). The potential clinical impact of these novel pacing strategies appears to be very promising.

Several therapeutic developments in cardiology have had an impact on cardiac pacing and cardiac resynchronization therapy (CRT) indications. The relatively high rate of atrio-ventricular (AV) block use following transcatheter aortic valve implantation (TAVI) represents a new and expanding area of research. Patients treated with TAVI are often elderly, frail, and present with multiple comorbidities, including heart failure. Risk stratification for AV block use following TAVI, and the choice of the most adequate pacing strategy in this setting, represent only some of the many clinical challenges in this area. On another note, heart failure medical therapies have evolved in recent years, redefining optimal medical therapy goals and, therefore, potentially delaying cardiac resynchronization therapy (CRT) in patients. These developments, coupled with the important progress made in CSP, are redefining the role of CRT in the treatment of selected patients with heart failure.

Through contributions from leading experts on cardiac pacing and CRT, the present edition provides an updated view on the current state of cardiac pacing therapies and offers valuable insight into the future direction of this field.

Dr. François Regoli
Guest Editor

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Keywords

leadless pacing
pacing in TAVI patients
pacing in heart failure
His-bundle pacing
conduction system pacing
cardiac resynchronization therapy

Published Papers (12 papers)

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Editorial

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4 pages, 384 KiB

Open AccessEditorial

Reducing CIED-Related Morbidity: “LESS Is More”

by François D. Regoli

J. Clin. Med. 2022, 11(16), 4782; https://doi.org/10.3390/jcm11164782 - 16 Aug 2022

Cited by 1 | Viewed by 888

Abstract

In recent years, the rate of pacemaker implantations has continued to rise throughout Europe [...] Full article

(This article belongs to the Special Issue Advances in Cardiac Pacing and Cardiac Resynchronization Therapy)

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Research

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9 pages, 1492 KiB

Open AccessArticle

Feasibility and Safety Study of Concomitant Left Bundle Branch Area Pacing and Atrioventricular Node Ablation with Same-Day Hospital Dismissal

by Zhigang Liu and Xiaoke Liu

J. Clin. Med. 2023, 12(22), 7002; https://doi.org/10.3390/jcm12227002 - 09 Nov 2023

Cited by 1 | Viewed by 752

Abstract

Background: Left bundle branch area pacing (LBBAP) has rapidly emerged as a promising modality of physiologic pacing and has demonstrated excellent lead stability. In this retrospective study, we evaluate whether this pacing modality can allow concomitant atrioventricular node (AVN) ablation and same-day dismissal. Methods: Twenty-four consecutive patients (female 63%, male 37%) with an average age of 78 ± 5 years were admitted for pacemaker (75%)/defibrillator (25%) implantations and concomitant AVN ablation. Device implantation with LBBAP was performed first, followed by concomitant AVN ablation through left axillary vein access to allow for quicker post-procedure ambulation. The patients were discharged on the same day after satisfactory post-ambulation device checks. Results: LBBAP was successful in 22 patients (92% in total, 20 patients had an LBBP and two patients had a likely LBBP), followed by AVN ablation from left axillary vein access (21/24, 88%). All patients had successful post-op chest x-rays, post-ambulation device checks, and were discharged on the same day. After a mean follow up of three months, no major complications occurred, such as LBBA lead dislodgement requiring a lead revision. The LBBA lead pacing parameters immediately after implantation vs. three-month follow up were a capture threshold of 0.8 ± 0.3 [email protected] ms vs. 0.6 ± 0.3 [email protected] ms, sensing 9.9 ± 3.9 mV vs. 10.4 ± 4.1 mV, and impedance of 710 ± 216 ohm vs. 544 ± 110 ohm. The QRS duration before and after AVN ablation was 117 ± 32 ms vs. 123 ± 14 ms. Mean LVEF before and three months after the implantation was 44 ± 14% vs. 46 ± 12%. Conclusion: LBBA pacing not only offers physiologic pacing, but also allows for a concomitant AVN ablation approach from the left axillary vein and safe same-day hospital dismissal. Full article

(This article belongs to the Special Issue Advances in Cardiac Pacing and Cardiac Resynchronization Therapy)

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10 pages, 1127 KiB

Open AccessArticle

Long-Term Performance of Epicardial versus Transvenous Left Ventricular Leads for Cardiac Resynchronization Therapy

by Gijs E. de Maat, Bart A. Mulder, Martijn E. Van de Lande, Rajiv S. Rama, Michiel Rienstra, Massimo A. Mariani, Alexander H. Maass and Theo J. Klinkenberg

J. Clin. Med. 2023, 12(18), 5766; https://doi.org/10.3390/jcm12185766 - 05 Sep 2023

Cited by 1 | Viewed by 996

Abstract

Aims: to study the technical performance of epicardial left ventricular (LV) leads placed via video assisted thoracic surgery (VATS), compared to transvenously placed leads for cardiac resynchronization therapy (CRT). Methods: From 2001 until 2013, a total of 644 lead placement procedures were performed for CRT. In the case of unsuccessful transvenous LV lead placement, the patient received an epicardial LV lead. Study groups consist of 578 patients with a transvenous LV lead and 66 with an epicardial LV lead. The primary endpoint was LV-lead failure necessitating a replacement or deactivation. The secondary endpoint was energy consumption. Results: The mean follow up was 5.9 years (epicardial: 5.5 ± 3.1, transvenous: 5.9 ± 3.5). Transvenous leads failed significantly more frequently than epicardial leads with a total of 66 (11%) in the transvenous leads group vs. 2 (3%) in the epicardial lead group (p = 0.037). Lead energy consumption was not significantly different between groups. Conclusions: Epicardial lead placement is feasible, safe and shows excellent long-term performance compared to transvenous leads. Epicardial lead placement should be considered when primary transvenous lead placement fails or as a primary lead placement strategy in challenging cases. Full article

(This article belongs to the Special Issue Advances in Cardiac Pacing and Cardiac Resynchronization Therapy)

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11 pages, 1452 KiB

Open AccessFeature PaperArticle

Transvenous Lead Extraction during Cardiac Implantable Device Upgrade: Results from the Multicenter Swiss Lead Extraction Registry

by Andreas Haeberlin, Fabian Noti, Alexander Breitenstein, Angelo Auricchio, Tobias Reichlin, Giulio Conte, Catherine Klersy, Moreno Curti, Etienne Pruvot, Giulia Domenichini, Beat Schaer, Michael Kühne, Michal Gruszczynski, Haran Burri, Richard Kobza, Christian Grebmer and François D. Regoli

J. Clin. Med. 2023, 12(16), 5175; https://doi.org/10.3390/jcm12165175 - 08 Aug 2023

Viewed by 714

Abstract

Background: Device patients may require upgrade interventions from simpler to more complex cardiac implantable electronic devices. Prior to upgrading interventions, clinicians need to balance the risks and benefits of transvenous lead extraction (TLE), additional lead implantation or lead abandonment. However, evidence on procedural outcomes of TLE at the time of device upgrade is scarce. Methods: This is a post hoc analysis of the investigator-initiated multicenter Swiss TLE registry. The objectives were to assess patient and procedural factors influencing TLE outcomes at the time of device upgrades. Results: 941 patients were included, whereof 83 (8.8%) had TLE due to a device upgrade. Rotational mechanical sheaths were more often used in upgraded patients (59% vs. 42.7%, p = 0.015) and total median procedure time was longer in these patients (160 min vs. 105 min, p < 0.001). Clinical success rates of upgraded patients compared to those who received TLE due to other reasons were not different (97.6% vs. 93.0%, p = 0.569). Moreover, multivariable analysis showed that upgrade procedures were not associated with a greater risk for complications (HR 0.48, 95% confidence interval 0.14–1.57, p = 0.224; intraprocedural complication rate of upgraded patients 7.2% vs. 5.5%). Intraprocedural complications of upgraded patients were mostly associated with the implantation and not the extraction procedure (67% vs. 33% of complications). Conclusions: TLE during device upgrade is effective and does not attribute a disproportionate risk to the upgrade procedure. Full article

(This article belongs to the Special Issue Advances in Cardiac Pacing and Cardiac Resynchronization Therapy)

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11 pages, 920 KiB

Open AccessFeature PaperArticle

Peri-Procedural Management of Direct-Acting Oral Anticoagulants (DOACs) in Transcatheter Miniaturized Leadless Pacemaker Implantation

by François Diederik Regoli, Ardan M. Saguner, Angelo Auricchio, Andrea Demarchi, Elena Pasotti, Giulio Conte, Maria Luce Caputo, Tardu Özkartal and Alexander Breitenstein

J. Clin. Med. 2023, 12(14), 4814; https://doi.org/10.3390/jcm12144814 - 21 Jul 2023

Viewed by 821

Abstract

Introduction: Data on peri-operative management of direct-acting oral anticoagulants (DOACs) during transcatheter pacing leadless system (TPS) implantations remain limited. This study aimed to evaluate a standardized DOAC management regime consisting of interruption of a single dose prior to implantation and reinitiation within 6–24 h; also, patient clinical characteristics associated with this approach were identified. Method: Consecutive patients undergoing standard TPS implantation procedures from two Swiss tertiary centers were included. DOAC peri-operative management included the standardized approach (Group 1A) or other approaches (Group 1B). Results: Three hundred and ninety-two pts (mean age 81.4 ± 7.3 years, 66.3% male, left ventricular ejection fraction 55.5 ± 9.6%) underwent TPS implantation. Two hundred and eighty-two pts (71.9%) were under anticoagulation therapy; 192 pts were treated with DOAC; 90 pts were under vitamin-K antagonist. Patients treated with DOAC less often had structural heart disease, diabetes mellitus, and advanced renal failure. The rate of major peri-procedural complications did not differ between groups 1A (n = 115) and 1B (n = 77) (2.6% and 3.8%, p = 0.685). Compared to 1B, 1A patients were implanted with TPS for slow ventricular rate atrial fibrillation (AF) (p = 0.002), in a better overall clinical status, and implanted electively (<0.001). Conclusions: Standardized peri-procedural DOAC management was more often implemented for elective TPS procedures and did not seem to increase bleeding or thromboembolic adverse events. Full article

(This article belongs to the Special Issue Advances in Cardiac Pacing and Cardiac Resynchronization Therapy)

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9 pages, 775 KiB

Open AccessArticle

Risk of Pacing-Induced Cardiomyopathy in Patients with High-Degree Atrioventricular Block—Impact of Right Ventricular Lead Position Confirmed by Computed Tomography

by Patricia Zerlang Fruelund, Anders Sommer, Jens Brøndum Frøkjær, Søren Lundbye-Christensen, Tomas Zaremba, Peter Søgaard, Claus Graff, Søren Vraa, Aksayan Arunanthy Mahalingasivam, Anna Margrethe Thøgersen, Michael Rangel Pedersen and Sam Riahi

J. Clin. Med. 2022, 11(23), 7228; https://doi.org/10.3390/jcm11237228 - 05 Dec 2022

Cited by 3 | Viewed by 1433

Abstract

Prospective studies applying fluoroscopy for assessment of right ventricular (RV) lead position have failed to show clear benefits from RV septal pacing. We investigated the impact of different RV lead positions verified by computed tomography (CT) on the risk of pacing-induced cardiomyopathy (PICM). We retrospectively included 153 patients who underwent routine fluoroscopy-guided pacemaker implantation between March 2012 and May 2020. All patients had normal pre-implant left ventricular ejection fraction (LVEF). Patients attended a follow-up visit including contrast-enhanced cardiac CT and transthoracic echocardiography. Patients were classified as septal or non-septal based on CT analysis. The primary endpoint was PICM (LVEF < 50% with ≥10% decrease after implantation). Based on CT, 48 (31.4%) leads were septal and 105 (68.6%) were non-septal. Over a median follow-up of 3.1 years, 16 patients (33.3%) in the septal group developed PICM compared to 31 (29.5%) in the non-septal group (p = 0.6). Overall, 13.1% deteriorated to LVEF ≤ 40%, 5.9% were upgraded to cardiac resynchronization therapy device, and 14.4% developed new-onset atrial fibrillation, with no significant differences between the groups. This study demonstrated a high risk of PICM despite normal pre-implant left ventricular systolic function with no significant difference between CT-verified RV septal or non-septal lead position. Full article

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8 pages, 856 KiB

Open AccessArticle

Early Experience with the Biotronik Protego ICD Lead

by Thomas Seiler, Christian Grebmer, Gabriela Hilfiker, Richard Kobza and Benjamin Berte

J. Clin. Med. 2022, 11(23), 7070; https://doi.org/10.3390/jcm11237070 - 29 Nov 2022

Viewed by 1372

Abstract

Background: In the last decade, newer generation ICD leads have been developed based on mechanistic insides of priorly failing leads. The aim of our study was to assess the long-term performance and mechanisms of failure of the 2013-introduced Biotronik Protego ICD lead in a real-world population. Methods: All patients, who underwent implantation of a Protego ICD lead at the Heart Centre Lucerne (Lucerne, Switzerland) between November 2013 and March 2017, were followed up with semi-annual device-controls. The primary endpoint was defined as lead failure, secondary endpoints compromised all-cause death, (in)appropriate shocks and the need for reintervention. Results: A total of 64 patients (mean age 66.7 ± 8.7 years, 30% female) underwent implantation of a Protego ICD lead: 78% for primary prevention, 53% had underlying ischemic heart disease, and 40.6% had a dilated cardiomyopathy (DCM). Mean left ventricular ejection fraction (LVEF) was 32.6 ± 10.5%. A total of 24 patients were treated with cardiac resynchronization therapy (CRT), and their baseline LVEF improved from 27.8 ± 7.3% before to 39.8 ± 12.5 after implantation (p < 0.001). Mean time to follow-up was 5.5 ± 0.9 years. Overall, 14 patients (26.6%) suffered from at least one episode of sustained ventricular tachycardia; in total 10 patients (15.6%) died. Two patients experienced lead failure due to lead fracture after 5.5 and 5.7 years, which was clinically apparent by an abrupt rise in lead impedance (>2000 Ω) and by repetitive inappropriate shocks, respectively. Conclusions: In this retrospective observational study, the calculated annual lead failure rate of the Biotronik Protego ICD lead was 0.59% per patient—thus, the durability and long-term performance seem to be promising. Full article

(This article belongs to the Special Issue Advances in Cardiac Pacing and Cardiac Resynchronization Therapy)

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10 pages, 1585 KiB

Open AccessArticle

The Effects of His Bundle Pacing Compared to Classic Resynchronization Therapy in Patients with Pacing-Induced Cardiomyopathy

by Rafal Gardas, Krzysztof S. Golba, Tomasz Soral, Jolanta Biernat, Piotr Kulesza, Mateusz Sajdok and Kamil Zub

J. Clin. Med. 2022, 11(19), 5723; https://doi.org/10.3390/jcm11195723 - 27 Sep 2022

Cited by 6 | Viewed by 1311

Abstract

Pacing-induced cardiomyopathy (PICM) is among the most common right ventricular pacing complications. Upgrading to cardiac resynchronization therapy (CRT) is the recommended treatment option. Conduction system pacing with His bundle pacing (HBP) has the potential to restore synchronous ventricular activation and can be an alternative to biventricular pacing (BVP). Patients with PICM scheduled for a system upgrade to CRT were included in the prospective cohort study. Either HBP or BVP was used for CRT. Electrocardiographic, clinical, and echocardiographic measurements were recorded at baseline and six-month follow-up. HBP was successful in 44 of 53 patients (83%). Thirty-nine patients with HBP and 22 with BVP completed a 6-month follow-up. HBP led to a higher reduction in QRS duration than BVP, 118.3 ± 14.20 ms vs. 150.5 ± 18.64 ms, p < 0.0001. The improvement in New York Heart Association (NYHA) class by one or two was more common in patients with HBP than those with BiV (p = 0.04). Left ventricular ejection fraction (LVEF) improved in BVP patients from 32.9 ± 7.93% to 43.9 ± 8.07%, p < 0.0001, and in HBP patients from 34.9 ± 6.45% to 48.6 ± 7.73%, p < 0.0001. The improvement in LVEF was more considerable in HBP patients than in BVP patients, p = 0.019. The improvement in clinical outcomes and left ventricle reverse remodeling was more significant with HBP than BVP. HBP can be a valid alternative to BVP for upgrade procedures in PICM patients. Full article

(This article belongs to the Special Issue Advances in Cardiac Pacing and Cardiac Resynchronization Therapy)

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10 pages, 254 KiB

Open AccessArticle

Step by Step through the Years—High vs. Low Energy Lead Extraction Using Advanced Extraction Techniques

by David Zweiker, Basma El Sawaf, Giuseppe D’Angelo, Andrea Radinovic, Alessandra Marzi, Luca R. Limite, Antonio Frontera, Gabriele Paglino, Michael Spartalis, Donah Zachariah, Kenzaburo Nakajima, Paolo Della Bella and Patrizio Mazzone

J. Clin. Med. 2022, 11(16), 4884; https://doi.org/10.3390/jcm11164884 - 19 Aug 2022

Cited by 3 | Viewed by 1276

Abstract

Background: Limited data is available about the outcome of TLE in patients with vs. without high energy leads in the last decade. Methods: This is an analysis of consecutive patients undergoing TLE at a high-volume TLE centre from 2001 to 2021 using the stepwise approach. Baseline characteristics, procedural details and outcome of patients with high energy lead (ICD group) vs. without high energy lead (non-ICD group) were compared. Results: Out of 667 extractions, 991 leads were extracted in 405 procedures (60.7%) in the ICD group and 439 leads in 262 procedures (39.3%) in the non-ICD group. ICD patients were significantly younger (median 67 vs. 74 years) and were significantly less often female (18.1% vs. 27.7%, p < 0.005 for both). Advanced extraction tools were used significantly more often in the ICD group (73.2% vs. 37.5%, p < 0.001), but there were no significant differences in the successful removal (98.8% vs. 99.2%) or complications (4.7% vs. 3.1%) between the groups (p > 0.2 for both). Discussion: Using the stepwise approach, overall procedural success was high and complication rate was low in a high-volume centre. In patients with a high energy lead, the TLE procedure was more complex, but outcome was similar to comparator patients. Full article

(This article belongs to the Special Issue Advances in Cardiac Pacing and Cardiac Resynchronization Therapy)

Review

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11 pages, 1181 KiB

Open AccessReview

Conduction System Pacing versus Conventional Biventricular Pacing for Cardiac Resynchronization Therapy: Where Are We Heading?

by Giulia Domenichini, Mathieu Le Bloa, Cheryl Teres Castillo, Denis Graf, Patrice Carroz, Ciro Ascione, Alessandra Pia Porretta, Patrizio Pascale and Etienne Pruvot

J. Clin. Med. 2023, 12(19), 6288; https://doi.org/10.3390/jcm12196288 - 29 Sep 2023

Cited by 1 | Viewed by 2341

Abstract

Over the last few years, pacing of the conduction system (CSP) has emerged as the new standard pacing modality for bradycardia indications, allowing a more physiological ventricular activation compared to conventional right ventricular pacing. CSP has also emerged as an alternative modality to conventional biventricular pacing for the delivery of cardiac resynchronization therapy (CRT) in heart failure patients. However, if the initial clinical data seem to support this new physiological-based approach to CRT, the lack of large randomized studies confirming these preliminary results prevents CSP from being used routinely in clinical practice. Furthermore, concerns are still present regarding the long-term performance of pacing leads when employed for CSP, as well as their extractability. In this review article, we provide the state-of-the-art of CSP as an alternative to biventricular pacing for CRT delivery in heart failure patients. In particular, we describe the physiological concepts supporting this approach and we discuss the future perspectives of CSP in this context according to the implant techniques (His bundle pacing and left bundle branch area pacing) and the clinical data published so far. Full article

(This article belongs to the Special Issue Advances in Cardiac Pacing and Cardiac Resynchronization Therapy)

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12 pages, 1970 KiB

Open AccessReview

Conduction System Pacing Today and Tomorrow

by Andreas Haeberlin, Siro Canello, Andreas Kummer, Jens Seiler, Samuel H. Baldinger, Antonio Madaffari, Gregor Thalmann, Adrian Ryser, Christoph Gräni, Hildegard Tanner, Laurent Roten, Tobias Reichlin and Fabian Noti

J. Clin. Med. 2022, 11(24), 7258; https://doi.org/10.3390/jcm11247258 - 07 Dec 2022

Cited by 3 | Viewed by 2607

Abstract

Conduction system pacing (CSP) encompassing His bundle (HBP) and left bundle branch area pacing (LBBAP) is gaining increasing attention in the electrophysiology community. These relatively novel physiological pacing modalities have the potential to outperform conventional pacing approaches with respect to clinical endpoints, although data are currently still limited. While HBP represents the most physiological form of cardiac stimulation, success rates, bundle branch correction, and electrical lead performance over time remain a concern. LBBAP systems may overcome these limitations. In this review article, we provide a comprehensive overview of the current evidence, implantation technique, device programming, and follow-up considerations concerning CSP systems. Moreover, we discuss ongoing technical developments and future perspectives of CSP. Full article

(This article belongs to the Special Issue Advances in Cardiac Pacing and Cardiac Resynchronization Therapy)

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Other

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13 pages, 4316 KiB

Open AccessSystematic Review

Effect of Digitalis on ICD or CRT-D Recipients: A Systematic Review and Meta-Analysis

by Wen Zhuo, Hualong Liu, Linghua Fu, Weiguo Fan and Kui Hong

J. Clin. Med. 2023, 12(4), 1686; https://doi.org/10.3390/jcm12041686 - 20 Feb 2023

Viewed by 1391

Abstract

Background: Digitalis has been widely utilized for heart failure therapy and several studies have demonstrated an association of digitalis and adverse outcome events in patients receiving implantable cardioverter defibrillators (ICDs) or cardiac resynchronization therapy defibrillators (CRT-Ds). Hence, we conducted this meta-analysis to assess the effect of digitalis on ICD or CRT-D recipients. Methods: We systematically retrieved relevant studies using the Cochrane Library, PubMed, and Embase database. A random effect model was used to pool the effect estimates (hazard ratios (HRs) and 95% confidence intervals (CIs)) when the studies were of high heterogeneity, otherwise a fixed effect model was used. Results: Twenty-one articles containing 44,761 ICD or CRT-D recipients were included. Digitalis was associated with an increased rate of appropriate shocks (HR = 1.65, 95% CI: 1.46–1.86, p < 0.001) and a shortened time to first appropriate shock (HR = 1.76, 95% CI: 1.17–2.65, p = 0.007) in ICD or CRT-D recipients. Furthermore, the all-cause mortality increased in ICD recipients with digitalis therapy (HR = 1.70, 95% CI: 1.34–2.16, p < 0.01), but the all-cause mortality was unchanged in CRT-D recipients (HR = 1.55, 95% CI: 0.92–2.60, p = 0.10) or patients who received ICD or CRT-D therapy (HR = 1.09, 95% CI: 0.80–1.48, p = 0.20). The sensitivity analyses confirmed the robustness of the results. Conclusion: ICD recipients with digitalis therapy may tend to have higher mortality rates, but digitalis may not be associated with the mortality rate of CRT-D recipients. Further studies are required to confirm the effects of digitalis on ICD or CRT-D recipients. Full article

(This article belongs to the Special Issue Advances in Cardiac Pacing and Cardiac Resynchronization Therapy)

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