Search Results (139)

Background: Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of severe aortic valve stenosis (AS). Balloon post-dilatation (PD) remains an important procedural step to optimize valve function by resolving incomplete valve expansion, which may lead to paravalvular regurgitation and other potentially adverse effects. There are only limited data on the predictors, incidence, and clinical impact of PD during TAVI. Methods: This retrospective, single-center study analyzed 585 patients who underwent TAVI (2016–2022). Pre-procedural evaluations included transthoracic echocardiography and CT angiography to assess key parameters, including the aortic valve calcium score (AVCS); aortic valve calcium density (AVCd); aortic valve maximal systolic transvalvular flow velocity (AV Vmax); and aortic valve mean systolic pressure gradient (AV MPG). We identified imaging predictors of PD and evaluated associated clinical outcomes by analyzing procedural endpoints (according to VARC-3 criteria) and long-term survival. Results: PD was performed on 67 out of 585 patients, with elevated AV Vmax (OR: 1.424, 95% CI: 1.039–1.950; p = 0.028) and AVCd (OR: 1.618, 95% CI: 1.227–2.132; p = 0.001) emerging as a significant independent predictor for PD in TAVI. Kaplan–Meier survival analysis revealed no significant differences in short- and mid-term survival between patients who underwent PD and those who did not. Interestingly, patients requiring PD exhibited a lower incidence of adverse events regarding major vascular complications, permanent pacemaker implantations and stroke. Conclusions: The study highlights AV Vmax and AVCd as key predictors of PD. Importantly, PD was not associated with increased procedural adverse events and did not predict adverse events in this contemporary cohort. Full article

Background and Clinical Significance: Evaluating wide complex rhythms in patients with permanent pacemakers can be a diagnostic challenge, particularly when the rhythm is irregular. While pacemaker-mediated rhythms are typically regular and predictable, the appearance of wide complex irregular rhythms raises concerns ranging from lead malfunction to life-threatening arrhythmias, such as ventricular tachycardia. Understanding the interplay between intrinsic cardiac activity and device function is crucial for timely and accurate diagnosis in this increasingly common clinical scenario. Case presentation: We report on a 74-year-old female with a VVI pacemaker implanted for binodal disease, who presented with intermittent palpitations and an irregular rhythm. The patient has a recent history of falling on her right shoulder, which is also the site of the device implantation. We used a clinical step-by-step approach to rule out pacemaker malfunction and to establish the need for an unscheduled device interrogation. Conclusions: This case presentation highlights the important role of clinical reasoning and the approach to such a patient, especially when a key method of pacemaker evaluation, such as device interrogation, is not readily available. Full article

Loop diuretics like furosemide are commonly used in heart failure (HF) treatment, but their effects on disease progression are still unclear. Furosemide treatment accelerates HF deterioration in a swine model, but the mechanism of acceleration is poorly understood. We hypothesized that furosemide activates inflammatory signaling in the failing left ventricular (LV) myocardium, leading to adverse remodeling of the extracellular matrix (ECM). A total of 14 Yorkshire pigs underwent permanent transvenous pacemaker implantation and were paced at 200 beats per minute; 9 non-instrumented pigs provided controls. Seven paced animals received normal saline, and seven received furosemide at a dose of 1 mg/kg intramuscularly. Weekly echocardiograms were performed. Furosemide-treated animals reached the HF endpoint a mean of 3.2 days sooner than saline-treated controls (mean 28.9 ± 3.8 SEM for furosemide and 32.1 ± 2.5 SEM for saline). The inflammatory signaling protein transforming growth factor-beta (TGF-β) and its downstream proteins were significantly (p ≤ 0.05) elevated in the LV after furosemide treatment. The regulatory factors in cell proliferation, mitogen-activated protein kinase signaling pathway proteins, and matrix metalloproteinases were elevated in the furosemide-treated animals (p ≤ 0.05). Our data showed that furosemide treatment increased ECM remodeling and myocardial fibrosis, reflecting increased TGF-β signaling factors, supporting prior results showing worsened HF. Full article

Background: The increasing use of technologies operating between 10 and 200 kHz, such as RFID, wireless power transfer systems, and induction cooktops, raises concerns about electromagnetic interference (EMI) with cardiac implantable electronic devices (CIEDs). The mechanisms of interaction within this frequency range have been only partially addressed by both the scientific and regulatory communities. Methods: A physical twin of a pacemaker/implantable defibrillator (PM/ICD) was developed to experimentally assess voltages induced at the input stage by low-to-mid-frequency magnetic fields. The setup simulates the two sensing modalities programmable in PMs/ICDs and allows for the analysis of different implant configurations, lead geometries, and positions within a human body phantom. Results: Characterization of the physical twin demonstrated its capability to reliably measure induced voltages in the range of 5 mV to 1.5 V. Its application enabled the identification of factors beyond the implant’s induction area that contribute to the induced voltage, such as the electrode-tissue interface and body-induced currents. Conclusions: This physical twin represents a valuable tool for experimentally validating the mechanisms of EMI in CIEDs, providing insights beyond current standards. The data obtained can serve as a reference for the validation of numerical models and patient-specific digital twins. Moreover, it offers valuable information to guide future updates and revisions of international electromagnetic compatibility standards for CIEDs. Full article

The axillary and cephalic veins are commonly utilized for transvenous pacemaker lead access. They typically advance to the heart through the subclavian, brachiocephalic, and superior vena cava veins. Anatomical variations such as a persistent left superior vena cava (PLSVC) may pose a challenge, necessitating an alternative approach for lead placement. This anomaly can often be identified during venographic contrast imaging or by visualizing atypical venous courses during the procedure. Another challenge occurs when the venous pathway is tortuous. Careful monitoring during the procedure is crucial to ensure that the lead follows the intended path. If not, the lead may inadvertently enter a collateral, such as the inferior thyroid vein, which drains into the internal jugular or left brachiocephalic vein. Despite these deviations, the lead may eventually reach the heart, although via an unusual course. If such a lead is left in place, even in the absence of immediate complications, long-term outcomes are unpredictable and carry the risk of unforeseen complications. Full article

Background/Objectives: A significant subset of congenital heart disease (CHD) patients undergo a transvenous pacemaker (PM)/implantable cardioverter defibrillator (ICD) lead extraction (TLE) in their lifetime. We aimed to report on the outcome and complexity of TLEs in CHD patients for whom a powered mechanical sheath was used. Methods: This retrospective study included 175 consecutive TLEs performed at our centre. Overall, 13 TLEs in CHD patients and 162 TLEs in non-CHD patients were performed. A total of 264 leads were extracted. Results: CHD patients were younger than non-CHD patients at the time of their first lead implant (21.2 ± 17 vs. 57.1 ± 18 years; p < 0.01) and at the time of lead extraction (33.38 ± 13 vs. 63.31 ± 16 years; p < 0.01). The leads extracted from CHD patients were significantly older than the leads extracted from non-CHD patients (median: 8.0 vs. 4.0 years; p < 0.01). CHD patients and non-CHD patients did not differ in terms of the procedural (92% vs. 87%; p = 0.581) and clinical success rates (100% vs. 91%; p = 0.269). The two patient groups did not differ in terms of their procedural complication rate (0% vs. 11%; p = 0.191). There were no differences in the extraction techniques used, i.e., rotational mechanical sheaths were used in 61% of CHD extractions and in 38% of non-CHD extractions; p = 0.11. Conclusions: TLEs that use rotational mechanical sheaths as an advanced technique can be safely and effectively performed in CHD patients. The outcome and complexity of TLEs in CHD patients are comparable with those in non-CHD patients that undergo this procedure. Full article

Background and Objectives: When pacemakers were first introduced, their indications and implantation techniques were quite limited. Over 400,000 permanent pacemakers are implanted annually worldwide, mostly under local anesthesia (LA), which is preferred for its hemodynamic stability. However, inadequate LA often leads to excessive use of local anesthetics or analgesics. This study evaluates the efficacy of combining interscalene brachial plexus block (ISB) and superficial cervical plexus block (SCPB) as regional anesthesia (RA) techniques during permanent pacemaker implantation compared to LA. Materials and Methods: A total of 42 patients were divided into RA and LA groups. The RA group underwent ISB and SCPB under ultrasound guidance, while the LA group received traditional local anesthetic methods. Results: The RA group exhibited superior pain control, reduced analgesic requirements, and higher satisfaction rates compared to the LA group. Ultrasound guidance enhanced block success rates and minimized complications. Conclusions: ISB and SCPB offer a superior alternative to LA for pacemaker implantation, especially in patients with anxiety or insufficient LA response. Full article

Atrial fibrillation (AF) is a leading cause of stroke, heart failure, and cardiovascular morbidity, yet its pathophysiology remains incompletely understood. Among various molecular regulators, microRNAs (miRNAs) have emerged as promising biomarkers for AF detection and burden monitoring. However, the optimal sample type for miRNA analysis remains unclear, posing a challenge for biomarker standardization. This study aimed to assess whether miRNA expression profiles remain consistent across plasma and blood cells, with a focus on identifying miRNAs with a strong predictive potential for AF burden. This exploratory study recruited patients diagnosed with sick sinus syndrome who had undergone permanent pacemaker implantation. Participants were stratified into three groups based on AF status: no AF (n = 2), paroxysmal AF (PaAF; n = 2), and persistent AF (PerAF; n = 2) for white blood cell (WBC) samples, and pooled plasma samples from no AF (n = 3 pools) and PerAF (n = 3 pools). Using an miRNA microarray analysis, miR-1-3p was consistently downregulated in both WBC and plasma samples of patients with AF, showing significant decreases (fold-change in WBC: PaAF 0.22, PerAF 0.20; plasma PerAF 0.28) and highlighting its potential as a circulating biomarker for AF burden. Additional differentially expressed miRNAs, including miR-451a and miR-382-5p, exhibited sample-dependent variations, underscoring the importance of validating miRNA expression across multiple biological compartments. The study highlights the need for mechanistic investigations to determine whether miR-1-3p directly contributes to AF pathogenesis or serves as a downstream consequence of atrial remodeling. These findings reinforce the potential of miR-1-3p as a reliable circulating biomarker for AF, offering new avenues for non-invasive monitoring and risk stratification. Future research should explore the role of miR-1-3p in AF-related molecular pathways and its applicability as a therapeutic target. Full article

Background: Salmonella enterica serovar Infantis (S. Infantis) is a widespread pathogen in agriculture, causing epidemics in chicken flocks. Despite being primarily an animal pathogen, it may pose significant health risks to immunocompromised individuals. Methods: This report describes the first known case of cardiac device-related infective endocarditis (CDRIE) attributed to S. Infantis, highlighting its emerging pathogenic potential. It also reviews the literature for microbiologic and epidemiologic perspectives. Results: A 61-year-old male with a history of high-grade multiple myeloma presented with nonspecific symptoms, including low-grade fever and exertional dyspnoea. Blood cultures identified a pure culture of S. Infantis, and transoesophageal echocardiography revealed vegetations on pacing leads. Following pacemaker extraction and appropriate antimicrobial therapy, the patient’s condition temporary improved, but later deteriorated due to the progression of underlying malignancy. Conclusions: This case underscores the importance of considering S. Infantis in the differential diagnosis of endocarditis in immunocompromised patients, along with the critical need for stringent food safety measures to mitigate infection risks from contaminated poultry products. Full article

Background/Objective: Previous studies have indicated a higher incidence of complications associated with dual-lead devices compared to single-lead devices. This retrospective study aimed to investigate the effect of lead count and other factors on peri/postoperative complications for new pacemaker (PM) or implantable cardioverter-defibrillator (ICD) implantations in a representative German cohort. Methods: In accordance with quality assurance (QS) requirements, all hospitals in Germany collect patient-specific data on cardiac device implantation. We utilized the QS database from North Rhine-Westphalia to analyze data from 169,547 patients who underwent PM (n = 137,208) or ICD (n = 32,339) implantation between 2010 and 2014. The primary endpoint was the incidence of perioperative complications in the PM and ICD groups, analyzed separately for single- and dual-lead systems. Regression analysis was performed to identify specific risk factors and the effect of lead number on complications. Results: In the PM group, patients with dual-lead devices experienced significantly more complications than those with single-lead devices (3.27% vs. 2.85%, p < 0.001), largely driven by lead dislocations. In the ICD group, no significant difference in complication rates was observed between single-lead and dual-lead devices (1.39% vs. 1.46%, p = 0.635). The risk of complications was over twice as high for PM implantation compared to ICD implantation (3.17% vs. 1.42%). Patients with intrahospital complications faced a significantly higher risk of mortality than those without complications (PM: 4.5% vs. 1.6%; ICD: 3.9% vs. 0.5%). Independent risk factors for complications and mortality were identified in both groups, with a notable increase in the risk of intrahospital mortality associated with complications. Conclusions: Complications of dual-lead PM implantations are higher than single-lead procedures, mostly due to lead dislocations. Such a difference, though, was not observed in ICD implantations. Our findings may help optimize procedural strategies to improve patient safety, especially in PM implantations. Full article

Conduction system pacing started with His bundle pacing (HBP) and then rapidly switched gears into left bundle branch pacing (LBBP). We describe our center’s experience with LBBP using either lumenless leads (LLLs) or stylet-driven leads (SDLs). Patients who were admitted to two tertiary centers between 1 April 2021 and 30 June 2024 and met the guidelines for pacing were recruited and prospectively followed up. A total of 124 patients underwent permanent pacemaker (PPM) implantation using the LBBP technique with a mean follow-up of 19.7 ± 13.3 months. In total, 90 patients were implanted with LLLs and 34 with SDLs. There was no significant difference in the procedural time and final paced QRS duration, but fluoroscopy time was significantly longer in the SDLs (26.2 ± 17.7 min vs. 17.5 ± 13.0 min, respectively, p = 0.026). The on-table impedance values were also significantly higher in the LLLs, and this persisted throughout the follow-up. There were no differences in the rates of complications. The success of conduction system pacing implantation with SDLs and LLLs is comparable with reasonable safety and reliable outcomes. Good pre-implant patient selection will contribute to improved outcomes. Full article

Bicuspid aortic valve (BAV) is the most common congenital heart disease, affecting 0.5–2% of the population and often leading to early aortic valve degeneration. While surgical aortic valve replacement (SAVR) remains the gold standard for treating severe bicuspid aortic stenosis (AS), transcatheter aortic valve implantation (TAVI) is emerging as a viable alternative in selected BAV anatomies. Initial experiences with first-generation transcatheter heart valves (THVs) showed the feasibility of this technique, but were associated with lower device success rates and higher complications, such as paravalvular leak (PVL) and pacemaker implantation. Advancements in second- and third- generation THVs, together with better pre-procedural imaging assessment and growing operator experience, have significantly enhanced TAVI outcomes in BAV patients, with results now comparable to those seen in tricuspid aortic valves (TAVs). Proper patient selection, pre-procedural sizing, and device implantation are key to improving TAVI success in BAV. Recent registry data on contemporary THV platforms demonstrate improved procedural success, hemodynamic performance, and the safety of TAVI in BAV. However, higher rates of PVL, pacemaker implantation, and strokes remain concerns. Ongoing advancements in THV design and procedural techniques will further enhance outcomes for this challenging population. Up to the present, there are no dedicated THVs for BAV, but the latest-generation THVs offer promising results. Full article

Adult congenital heart disease (ACHD) represents a significant portion of congenital anomalies, and with improved treatments leading to an increased life expectancy, its prevalence has been increasing over the past few decades. Nonetheless, a considerable number of patients with ACHD require cardiac rhythm management devices during their lifetime. Traditionally, transvenous pacemaker placement has been the standard mode of treatment for these patients. However, some patients with ACHD have anatomical barriers that obscure this mode of treatment. Leadless pacing systems (LPSs) have changed the field of pacing. Currently, two different LPSs are available. In a real-world setting, implanting an LPS in patients after tricuspid valve (TV) surgery seems to be a straightforward procedure with a low risk of complications, with patients showing no valvular dysfunction after the intervention. LPS implantation is an option to avoid device-related complications in patients with previous TV surgery. Moreover, it has been demonstrated that even the jugular approach seems as safe as the femoral approach and could be considered an alternative implantation method for LPSs. The Aveir VR leadless pacemaker is a helix LPS with unique features, such as its capacity as a dual-chamber leadless pacemaker, the ability to map electrical parameters before releasing the device, and its possibility of being retrievable. Hereby, we present the case of Ebstein’s anomaly, atrial septal defect closure, and previous TV surgery with symptomatic intermittent advanced atrioventricular block. This case illustrates that a transjugular approach for LPSs is also feasible in patients with ACHD. Full article

Background: In patients requiring dual-chamber pacemaker (DDD) implantation, optimal atrial lead position remains a matter of debate. While most centers prefer implantation in the right atrial appendage position (Non-BB-P), due to a speculated favorable impact on atrial conduction characteristics, often, a Bachman bundle pacing (BB-P) is recommended. However, data investigating clinical outcomes in these patients are still rare. Methods: To evaluate this issue, in this retrospective single-center study, one-year clinical follow-up, pacemaker interrogations and available echocardiography findings in 301 consecutive patients (BB-P: age 76 ± 10 years, 46.7% female, n = 169; Non-BB-P: 77.6 ± 9 years, 50% female, n = 132, p = n.s.) scheduled for dual-chamber implantation were analyzed. Results: During follow-up, the incidence of atrial fibrillation (AF) remained similar in both groups (BB-P: 38.3%, n = 154 vs. Non-BB-P: 34.2%, n = 117 p = n.s.). However, we detected significantly more mode switch episodes in the BB-P group (BB-P: 51.9%, n = 154 vs. Non-BB-P: 38.8%, n = 116, p = 0.032). Furthermore, left ventricular functional parameters, including left ventricular ejection fraction (BB-P: 57.1 ± 8.4%, n = 60 vs. Non-BB-P: 56.0 ± 9.6, n = 45 p = n.s.) and incidence of diastolic dysfunction (BB-P: 55.2%, n = 67 vs. Non-BB-P: 38.3%, n = 47, p = n.s.), as well as the rate of left (BB-P: 58.8%, n = 68 vs. Non-BB-P: 42.0%, n = 50, p = n.s.) and right atrial dilatation (BB-P: 27.9%, n = 68 vs. Non-BB-P: 28.0%, n = 50 p = n.s.), were not significantly affected by the atrial lead position. However, stimulated p-waves were significantly shorter in BB-P vs. Non-BB-P (BB-P: 132.9 ± 23.7 ms, n = 127 vs. Non-BB-P: 139.6 ± 23.4 ms, n = 93, p = 0.031). Conclusions: In patients requiring dual-chamber implantation, the position of the atrial lead significantly altered atrial conduction, but this did not seem to affect left ventricular function parameters or the occurrence of atrial fibrillation within our follow-up period. Interestingly, we even detected more mode switch episodes in the BB-P group, hinting at an even proarrhythmic potential of BB-P. On the other hand, we found a decreased ventricular stimulation percentage in BB-P vs. Non-BB-P. Further studies should investigate the impact of Bachmann bundle pacing on clinical outcomes. Full article

Background/Objectives: PRKAG2 syndrome (PS) is a rare genocopy of hypertrophic cardiomyopathy (HCM). Our goal was to expand knowledge about PS by analyzing patient clinical, imaging, and follow-up data. Methods: The study included carriers of likely pathogenic or pathogenic PRKAG2 variants identified in the years 2011–2022. Cardiac involvement was assessed by electrocardiography, echocardiography, cardiac magnetic resonance imaging, and endomyocardial biopsy (EMB). We recorded concomitant diseases and cardiac events, including the implantation of electronic cardiac devices, arrhythmia, heart failure (HF), and death. Results: Seven patients from four families (median age 43 years) with PRKAG2 variants: Phe293Leu, Val336Leu, Arg302Gln, and His530Arg were included. At the first evaluation, 3 carriers were in New York Heart Association (NYHA) functional class II–III, while the remaining were in NYHA class I. Left ventricular hypertrophy (LVH) was present in 5 patients; 2 had ventricular pre-excitation, one was in atrial flutter and pacemaker-dependent; 2 had bradycardia. Two female carriers had concomitant chronic renal disease. In the EMB of one of the patients, staining for glycogen deposits was positive. Furthermore, we provide a link between the Val336Leu PRKAG2 variant and autophagy identified on EMB. After a median follow-up of 13.1 years, 6 carriers had LVH, 3 required admission for HF, and 1 had sustained ventricular tachycardia with subsequent cardioverter defibrillator implantation, and despite this, died suddenly; there were two de novo pacemaker implantations due to symptomatic bradycardia. Conclusions: PR is a distinctive disorder with an early onset of arrhythmic events, often leading to HF. Full article