Search Results (231)

Background and Objectives: Cardiac implantable electronic device (CIED) infections remain among the most serious complications of pacemaker, implantable cardioverter-defibrillator, and cardiac resynchronization therapy procedures. They are associated with substantial morbidity, mortality, prolonged hospitalization, system extraction, long-term antimicrobial therapy, and increased healthcare costs. As most infections arise from perioperative contamination or procedure-related complications, prevention has become a major priority in contemporary electrophysiology practice. This review aimed to summarize current evidence on the prevention of CIED infections, with particular emphasis on modifiable risk factors and perioperative preventive measures. Materials and Methods: A focused narrative review was undertaken using targeted searches of PubMed/MEDLINE and Scopus, supplemented by major international guideline and consensus documents, with priority given to contemporary guidelines, randomised trials, meta-analyses, and major observational studies relevant to CIED infection prevention. Results: Prevention of CIED infection requires a structured, multifactorial approach spanning the entire procedural pathway. Key preventive strategies include careful reassessment of device indication, individualized device selection, correction of modifiable risk factors, postponement of elective implantation in the presence of active infection, appropriate perioperative antibiotic prophylaxis, and optimized management of anticoagulant and antiplatelet therapy to minimize pocket hematoma. Additional relevant measures include meticulous skin antisepsis, limitation of temporary invasive devices and unnecessary hardware, appropriate venous access selection, careful generator pocket creation and wound closure, and avoidance of early reintervention whenever feasible. Antibacterial envelopes may reduce major CIED infections in selected high-risk patients, whereas routine escalation of preventive measures without proven benefit is not supported. Conclusions: CIED infection prevention is inherently multifactorial and depends on the consistent application of evidence-based measures before, during, and after device implantation. Rigorous control of modifiable risk factors, prevention of pocket hematoma, appropriate antimicrobial prophylaxis, and meticulous procedural technique remain the cornerstones of effective infection prevention in patients undergoing CIED procedures. Full article

Background: Left bundle branch area pacing (LBBaP) has emerged as a physiological alternative to conventional biventricular pacing (BiVP) for cardiac resynchronization therapy (CRT). We aimed to compare long-term clinical, electrical, and echocardiographic outcomes of LBBaP versus BiVP in patients with heart failure with reduced ejection fraction (HFrEF). Methods: In this single-center retrospective study, 271 consecutive patients undergoing CRT implantation were included (LBBaP, n = 68; BiVP, n = 203). Outcomes included electrical resynchronization parameters, echocardiographic reverse remodeling, heart failure hospitalization, and all-cause mortality during a median follow-up of 41 months. Results: LBBaP achieved greater electrical resynchronization, with shorter postprocedural QRS duration (144 vs. 153 ms; p = 0.005) and shorter left ventricular activation time compared with BiVP. LBBaP was associated with lower radiation exposure (124 vs. 244 mGy; p < 0.001) and lower pacing thresholds. At 6 months, LVEF was higher in the LBBaP group (37.7% vs. 33.0%; p = 0.005), and heart failure hospitalization occurred less frequently (22.6% vs. 36.7%; p = 0.042). Long-term all-cause mortality did not differ between groups (p = 0.289). In multivariable analysis, baseline renal dysfunction and heart failure hospitalization within 6 months independently predicted mortality. Conclusions: In patients with HFrEF undergoing CRT, LBBaP provides superior electrical resynchronization and greater reverse remodeling compared with BiVP. Although associated with improved short-term clinical outcomes, long-term survival appears primarily determined by comorbid conditions rather than pacing modality. Full article

Background: Cardiac resynchronization therapy (CRT) improves outcomes in heart failure (HF) patients with reduced left ventricular ejection fraction (LVEF) and a wide QRS complex. However, up to 30–50% of patients fail to respond. The QRS Index, which quantifies QRS shortening after CRT, has emerged as a potential predictor of response. We aimed to perform a systematic review and meta-analysis to evaluate the association between QRS Index and CRT response. Methods: We searched PubMed, Scopus and Cochrane for studies reporting QRS Index values in CRT responders and non-responders. Studies defining response based on clinical, echocardiographic, or combined criteria were included. Heterogeneity was assessed using the I² statistic, and a random-effects model was applied. A meta-regression analysis explored the relationship between baseline echocardiographic parameters and QRS Index. Results: Nine studies with 1274 patients met the inclusion criteria, with 760 (59%) classified as responders and 514 (41%) as non-responders. The weighted mean ± standard deviation was 16.14 ± 13.19 in responders and 7.22 ± 14.96 in non-responders. The QRS Index was significantly higher in the responder group compared to non-responders (mean difference: 8.76; 95% CI: 6.45–11.06; I² = 45%; p < 0.00001). Meta-regression revealed that lower left ventricular end-systolic volume (LVESV) values were associated with even higher QRS Index in responders compared to non-responders (β = −0.0483; 95% CI: −0.0938; −0.0029, p = 0.0372). Conclusions: QRS Index is significantly higher in CRT responders, supporting its role as a predictor of response. Further studies are needed to standardize its clinical use and assess its prognostic impact. Full article

Background: Resynchronization therapy has become a cornerstone in patients with heart failure (HF). Recent advancements in this field have led to the development of the so-called “left bundle branch area pacing” (LBBAP), a form of pacing where a single ventricular catheter directly addresses the left bundle for a more physiological stimulation. The current literature provides encouraging evidence regarding this topic, but there is still limited data for the older population, particularly those aged ≥75 years. This review aims to clarify how LBBAP has been explored in this cohort and if its application could be safe and effective even in the most advanced stages of life. Methods: A search of articles from PubMed was conducted. Patients were considered older if above 75 years of age. Data regarding Italian statistics were obtained from national registries. Results: The current literature supports the safety and effectiveness of LBBAP in older patients across different indications, with outcomes comparable to those reported in younger patients and a suggested cost-effectiveness. Conversely, data regarding patients affected by cardiac amyloidosis are still inconclusive. Conclusions: LBBAP represents a valuable resource for patients of all ages, but frailty is a major issue in the older population that needs to be addressed. The potential integration of this technology with defibrillator capabilities will enable an even more extensive application in the near future. Full article

Background and Objectives: Upgrades to cardiac resynchronization therapy (CRT) account for approximately one quarter of all CRT indications. Although recent clinical trials have demonstrated significant clinical benefits of upgrade procedures, data on the long-term clinical effects of CRT upgrades remain limited. This study aimed to evaluate long-term clinical, echocardiographic, and device-related outcomes after CRT upgrade and to determine predictors of left ventricular reverse remodelling. Materials and Methods: A total of 97 patients underwent CRT upgrade at a tertiary referral centre, including 57 patients upgraded to CRT with pacemaker (CRT-P) and 40 to CRT with defibrillator (CRT-D). Results: During a 5-year follow-up period, 46 patients (47%) died from any cause. Appropriate device therapy was recorded in 13 (33%) CRT-D patients. The composite endpoint of death or time to first appropriate shock occurred in 25 (63%) CRT-D patients compared with 21 (37%) CRT-P patients (p = 0.013). Patients with CRT-P demonstrated a significantly greater improvement in left ventricular ejection fraction (LVEF) than those with CRT-D (15% vs. 9%, p < 0.003). Greater LVEF improvement was observed in patients with non-ischemic compared with ischemic cardiomyopathy (17% vs. 10%, p < 0.01). In multivariable analysis, pacemaker-induced cardiomyopathy (PICMP) was identified as a predictor of left ventricular (LV) reverse remodelling. Conclusions: In this prospective, non-randomized cohort, CRT upgrade was associated with long-term clinical and echocardiographic improvement. Differences observed between CRT-P and CRT-D groups should be interpreted cautiously, as the study was not designed for direct comparison. PICMP was independently associated with LV reverse remodelling. Full article

Background: Cardiac resynchronization therapy (CRT) can be an effective form of heart failure (HF) management among congenital heart disease (CHD) patients (pts) with and without surgically repaired defects. However, very long-term results are limited. Recently, CRT has been implicated to be proarrhythmic among older CRT recipients. This issue is largely unknown among younger CHD-CRT pts. This study presents up to a 20-year (y) continuous review of any arrhythmia (Arr) burden associated with CRT among CHD-HF pts. Methods: From 1999 to 2024, outcomes of 45 CHD-HF pts (NYHA II-IV) (age 4–57 y [mean 26]; 31% female) were compared between those on established medical management (MM) (n = 18) and CRT recipients (n = 27) followed continuously for 1–20 years. Pre-existing and any de novo Arr that occurred following CRT were documented. Clinical assessments were continuous. Results: Follow-up was for 1 to 20 y (mean 7.5 y ± 0.7 sem). Patient demographics (CRT vs. MM groups) were comparable. Pre-existing Arr were found in 16 pts (38%) from both groups: accelerated junction (one CRT), atrial flutter (one CRT; two MM), and ventricular tachycardia (six CRT; six MM). During follow-up, outcomes included 14 pt deaths and 7 heart transplants (HTs). Of these, pre-existing Arr were causative among three CRT recipients: two ≤ 2 y and one > 5 y after CRT. There were no new-onset Arr in any pt groups. CRT significantly improved patient survival free from HT or death at 10 y (44 vs. 13% [p < 0001]). Conclusion: When applied effectively, CRT benefits CHD-HF pts without causing additional arrhythmias. However, pre-existing Arr remain a concern reflecting persistently adverse intrinsic myocellular issues among CHD-HF pts. Full article

Cardiac resynchronization therapy (CRT) is a cornerstone intervention for patients with heart failure (HF) and electrical dyssynchrony, improving quality of life, functional capacity, and survival. Beyond mechanical synchrony, mounting evidence suggests CRT exerts systemic and myocardial cardiometabolic benefits. CRT acutely enhances mechanical efficiency and shifts substrate utilization toward greater oxidation of fatty acids and ketones, effects that correlate with long-term reverse remodeling on cardiac magnetic resonance imaging. Earlier metabolomic profiling demonstrated that CRT normalizes circulating energy metabolites, improving Krebs cycle intermediates and substrate balance between glucose and lipids, while baseline metabolite patterns may differentiate responders from non-responders. These metabolic adaptations accompany favorable changes in diastolic performance, right ventricular function, and ventriculo-arterial coupling. In parallel, improved splanchnic perfusion and reduced congestion may ameliorate gut dysbiosis and endotoxemia, mitigating systemic inflammation. Collectively, these findings position CRT as a therapy capable of both mechanical and metabolic restoration in advanced HF. In this review, we discuss the emerging data on how CRT reconditions myocardial energy metabolism, influences ventricular–arterial interactions, and modulates peripheral and gut-derived metabolic pathways. Full article

Background/Objectives: Cardiac resynchronization therapy (CRT) is a cornerstone treatment for heart failure with reduced ejection fraction (HFrEF), yet many patients remain symptomatic despite long-term electrical optimization. Although sacubitril/valsartan (ARNI) is central to guideline-directed medical therapy (GDMT), data on its late initiation in patients with chronic CRT are scarce. This study evaluated the impact of delayed ARNI initiation on clinical status, functional capacity, and cardiac remodelling in a real-world CRT population. Methods: We performed a single-centre, retrospective observational study including 76 HFrEF patients with chronic CRT who started ARNI between 2022 and late 2024. Patients underwent standardized assessment at baseline (T0) and after 12 ± 3 months (T1), including clinical evaluation, 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12), symptom-limited bicycle exercise testing, and comprehensive echocardiography. The primary endpoint was change in quality of life (QoL). Secondary endpoints included exercise capacity, echocardiographic reverse remodelling, NYHA class, loop diuretic dose, and device-detected arrhythmias. Dose–response and multidimensional response patterns were explored. Results: KCCQ-12 increased from 52.96 ± 16.33 to 75.55 ± 18.12 (Δ +22.59 ± 13.22, p < 0.001), with 89.5% achieving a clinically meaningful improvement. Exercise duration and peak workload improved significantly. LVEF increased from 35.08 ± 6.96% to 43.18 ± 8.42% (Δ +8.11%, p < 0.001), with reductions in left ventricular and atrial volumes. Loop diuretic dose decreased (median −10 mg/day furosemide equivalent, p < 0.001), and 26.3% discontinued diuretics. A lower prevalence of device-detected arrhythmias was observed at follow-up, from 34.2% to 6.6% (p < 0.001). Higher ARNI doses were associated with greater likelihood of clinical, functional, and structural response. Longer CRT duration reduced the probability of structural remodelling but not symptomatic or functional benefit. Conclusions: In patients with long-standing CRT, delayed ARNI initiation was associated with improvements in QoL, exercise capacity, cardiac remodelling, congestion status, and electrical stability. These findings suggest that CRT is not a therapeutic ceiling and that late ARNI initiation remains a valuable component of comprehensive GDMT. Full article

Cardiac contractility modulation (CCM) is a bioelectronic therapy that delivers precisely timed electrical signals during ventricular refractoriness to modulate myocardial contractility without triggering depolarization. Unlike pacing-based therapies, CCM does not initiate a new depolarization but instead modulates intracellular signaling pathways to enhance myocardial contractility without increasing myocardial oxygen consumption. CCM therefore represents a myocardial conditioning strategy distinct from cardiac resynchronization therapy, conduction system pacing, or neuromodulation. Experimental and translational studies demonstrate that repeated CCM delivery induces sustained myocardial adaptations, including improvements in excitation–contraction coupling, molecular signaling pathways, and structural remodeling that extend beyond transient hemodynamic effects. Across clinical investigations, CCM has been associated with meaningful improvements in exercise tolerance, health-related quality of life, and functional status in carefully selected populations. Observational data further suggest a potential reduction in heart failure-related hospitalizations when therapy is applied within evidence-aligned indications. Recent technological developments—including simplified ventricular lead configurations, rechargeable compact generators, and integrated CCM–defibrillator platforms—have reduced procedural complexity and may broaden clinical applicability, particularly in patients with concomitant implantable cardioverter–defibrillator indications. This review synthesizes mechanistic insights, clinical evidence, patient selection principles, and practical considerations to define the evolving role of CCM within contemporary heart failure care pathways. Full article

Cardiac pacing has undergone a significant transformation in the last decade. Leadless pacing (LP), once only a conceptual idea stemming from the early interest in eliminating lead-related complications of transvenous pacemakers, has now become a reality in clinical practice. Since the introduction of the first human single-chamber asynchronous leadless ventricular pacing in 2012, atrioventricular-synchronized single- or dual-chamber leadless pacing systems have been approved for clinical use since 2020. Leadless cardiac resynchronization therapy (CRT) has shown optimistic results in case series and awaits its full utility in real-world clinical practice. With the successful feasibility study of leadless conduction system pacing, we are eagerly awaiting long-term safety and efficacy data on a large scale. Another important frontier is the development of self-rechargeable LP, which may be an ideal pacemaker for the future and may reduce the burden of multiple device replacements as batteries near the end-of-service. Totally extravascular percutaneous leadless pericardial micro-pacemaker system implantation is under development. In this state-of-the-art review, we examine the evolution of cardiac pacing, emphasizing the development and utility of LP to meet maximum physiological pacing needs, optimize atrioventricular synchrony and cardiac resynchronization, and broaden its indications. Full article

Background/Objectives: Reduced-ejection-fraction heart failure (HFrEF) constitutes a challenge due to its high morbidity and mortality. The use of sacubitril/valsartan (angiotensin receptor–neprilysin inhibitors [ARNI]) and SGLT2 inhibitors (SGLT2i) represents a change in management approach with a demonstrated association with positive ventricular remodeling and a reduction in cardiovascular events. We describe the clinical and therapeutic course of patients with HFrEF in a specialized unit, comparing two consecutive periods (2011–2016 vs. 2017–2021), with emphasis on the impact of ARNI and SGLT2i upon clinical parameters and the use of devices. Methods: A retrospective, longitudinal observational study was carried out in 1363 outpatients with HFrEF, with at least two years of follow-up. Clinical characteristics, treatments, the evolution of left ventricular ejection fraction (LVEF), mortality, and the use of devices (implantable cardioverter–defibrillator [ICD], cardiac resynchronization therapy [CRT]) were evaluated. Results: A total of 1363 patients were analyzed, showing a significant therapeutic change in the 2017–2021 group with the incorporation of ARNI (40%) and SGLT2i (25%). This cohort achieved better ventricular recovery, with a significantly higher mean LVEF at one year compared to the 2011–2016 group (44.3% vs. 42.1%; p = 0.004). Regarding devices, ICD implantation rate decreased in the recent period (7.2% vs. 11.1%; p = 0.016), while CRT indication increased. Most importantly, all-cause mortality after two years fell from 9.4% to 5.9% (p = 0.023). Multivariate analysis confirmed that this survival improvement was independently associated with the study period (HR 1.57 for the earlier group) and was linked to the protective effect of contemporary pharmacological treatments. Conclusions: The systematic introduction of ARNI and SGLT2i in the treatment of HFrEF was associated with improved ventricular function, reduced need for device implantation, and lower mortality over the middle term in a real-life clinical setting. Full article

Background/Objectives: Sacubitril/Valsartan is a cornerstone therapy to improve outcomes in patients with heart failure with reduced ejection fraction (HFrEF). This study aimed to investigate the effect of Sacubitril/Valsartan on cardiac autonomic balance using physiological sensor data obtained from implantable cardioverter-defibrillators (ICDs) or cardiac resynchronization therapy defibrillators (CRT-Ds). Methods: This observational study involved 54 ICD and CRT-D patients who initiated Sacubitril/Valsartan therapy to treat HFrEF. The evaluated key parameters included heart rate variability (HRV), 24 h mean heart rate (24 h-HR), and nocturnal heart rate (nHR). Device electrical parameters and ventricular arrhythmias were also assessed. The data were collected by remote monitoring and averaged over a 7-day window at baseline (before treatment) and at 3 and 12 months after treatment initiation. Results: Sacubitril/Valsartan significantly improved HRV at 3 months (from 78.6 ms [interquartile range: 54.2–104.6] to 80.8 ms [60.8–108.0]; p = 0.041), reduced 24 h-HR (from 73.2 bpm [67.3–77.7] to 69.9 bpm [64.2–75.7]; p = 0.016), and reduced nHR (from 63.0 bpm [58.1–70.0] to 60.4 bpm [56.0–68.6]; p = 0.028). No significant changes in HRV, 24 h-HR, and nHR were observed between 3- and 12-month follow-up. The device electrical parameters were not influenced by the treatment. While the overall ventricular arrhythmia burden did not change post-treatment, patients with pre-treatment arrhythmias experienced a significant reduction in episodes from 2.97 (pre-treatment) to 0.82 (post-treatment) events per 100 patient years (p = 0.008). Conclusions: Sacubitril/Valsartan therapy in HFrEF patients was associated with statistically significant changes in cardiac autonomic indices, including a small increase in HRV and a slight reduction in heart rate, mainly during the first three months of treatment. Full article

Background/Objectives: Heart failure is a major global health problem. Among the available treatment options, cardiac resynchronization therapy (CRT) has been shown to improve both quality of life (QoL) and mortality; however, not all patients respond adequately. Our study aimed to identify echocardiographic parameters that predict a positive response to CRT. Methods: A total of 33 patients (10 women and 23 men) were prospectively recruited, all met the standard criteria for CRT implantation. Biochemical, clinical, QoL, 6 min walk test, and echocardiographic evaluations were performed prior to CRT implantation and reassessed after 6 months. A ≥15% reduction in left ventricular end-systolic volume was taken as the defining parameter of positive response. Based on response level, patients were divided into two groups: responders and non-responders. Results: Comparing the overall population before and after CRT, a positive impact was observed on biochemical, electrocardiographic, and echocardiographic parameters. Fourteen patients (42%) were classified as responders and nineteen (58%) as non-responders. Only two basal echocardiographic parameters showed significant baseline differences between groups: Global Longitudinal Strain (GLS) and the Kapetanakis index. ROC curve analysis showed that baseline GLS and Kapetanakis index had excellent discriminative ability for predicting CRT response. Also, binary logistic regression analysis identified the association of GLS and Kapetanakis index with CRT response. Finally, Rho Spearman analysis showed a positive correlation between the degree of response to CRT and the QoL, (ρ) of 0.663 with p = 0.001. Conclusions: Our findings confirm the overall clinical, biochemical, echocardiographic, and QoL benefits of CRT. In addition, two echocardiographic parameters proved to be potential response predictors. Full article

The role of cardiac implantable electronic devices (CIEDs), including implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) devices, in patients supported with left ventricular assist devices (LVADs) remains controversial. Although ICDs clearly reduce the risk of sudden cardiac death (SCD) and improve outcomes in advanced heart failure (HF), their benefit in patients with continuous-flow mechanical circulatory support is less certain. Initial small studies involving LVAD patients, particularly those with older pulsatile devices, suggested that ICDs confer a survival benefit during LVAD support. However, more recent evidence has been inconsistent. Some studies show modest protection against arrhythmic death, whereas others show no improvement in overall mortality. Similarly, CRT does not appear to offer significant additional hemodynamic benefits after LVAD implantation, and current evidence does not strongly support its routine continuation. Device-related complications—including lead failure, infection, electromagnetic interference, and inappropriate shocks—are major clinical concerns that can offset potential benefits. Accordingly, current guidelines recommend maintaining pre-existing ICD or CRT devices in LVAD patients but do not endorse the routine implantation of new devices after LVAD placement. The existing evidence highlights the need for a nuanced and individualized approach to CIED therapy in patients with LVAD. Future research should focus on randomized trials, registry-based analyses, and the exploration of novel technologies such as leadless pacing, subcutaneous ICDs, and advanced programming algorithms. Patient-centered outcomes, particularly quality of life and ethical considerations—such as ICD deactivation in end-of-life scenarios—must be considered in decision-making in this evolving field. Full article

Background: Globalization, increased mobility, changes in dietary habits, and a growing number of immunocompromised patients have heightened exposure to rare or opportunistic pathogens. Here, we present a case of cardiac implantable electronic device-related infective endocarditis (CIED-IE) caused by Bacillus cereus bacteremia originating in the gastrointestinal tract. Case presentation: A 66-year-old female, who had a cardiac resynchronization pacemaker (CRT-P) implanted in 2017 due to second-degree atrioventricular block and left bundle branch block, had undergone device replacement due to battery depletion 4 months earlier and was scheduled for transvenous lead extraction (TLE) due to generator pocket infection. During the TLE procedure, transoesophageal echocardiography revealed vegetations on the leads and in the right atrium. Standard empirical therapy covering methicillin-resistant Staphylococci and Gram-negative bacteria was administered, including oritavancin and gentamicin. Surprisingly, intraoperative samples cultured B. cereus, a Gram-positive, spore-forming rod that usually causes food poisoning through contamination of rice and other starchy foods. B. cereus is generally resistant to β-lactam antibiotics except for carbapenems but is susceptible to glycopeptides. The oritavancin treatment was extended to four fractionated doses (1200, 800, 800, and 800 mg) administered at 7-day intervals. To eradicate bacteria in the gastrointestinal tract, oral vancomycin (125 mg 4 times a day) was added. After 4 weeks of effective antibiotic therapy, a CRT-P with a left bundle branch area pacing lead was reimplanted on the right subclavian area, with no recurrence of infection during the 3-month follow-up. Clinical discussion: In the patient, a diet high in rice and improper storage of rice dishes, together with habitual constipation, were identified as risk factors for the development of invasive Bacillus cereus infection. However, the long half-life lipoglycopeptide antibiotic, oritavancin, administered weekly, proved effective in treating CIED-IE. Conclusions: Infection with rare or opportunistic microorganisms may require extended microbiological diagnostics and non-standard antibiotic therapy; therefore, the medical history should consider risk factors for such infections. Full article