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Introduction: Electrophysiological testing has been proposed in the latest European Society of Cardiology (ESC) guidelines for cardiac pacing to identify left bundle branch block (LBBB) patients with infrahisian conduction delay (IHCD) after transcatheter aortic valve replacement (TAVR). While in general IHCD is defined by a His‐ventricular (HV) interval of >55 ms, a cut‐off of ≥70 ms to trigger pacemaker (PM) implantation has been proposed in the latest ESC guidelines. The ventricular pacing (VP) burden during follow‐up in such patients is largely unknown. As such, we aimed to assess the VP burden during follow‐up of patients receiving PM therapy for LBBB after TAVR based on an HV interval > 55 ms and ≥70 ms. Methods: All patients with new‐onset or pre‐existing LBBB after undergoing TAVR at a tertiary referral center underwent EP testing the day after TAVR. In patients with a prolonged HV interval (>55 ms), PM implantation was performed by a trained electrophysiologist in a standardized fashion. All devices were programmed to avoid unnecessary VP by specific algorithms (e.g., AAI‐DDD). Results: 701 patients underwent TAVR at the University Hospital of Basel. One hundred seventy‐seven patients presented with new‐onset or pre‐existing LBBB the day following TAVR and underwent EP testing. An HV interval > 55 ms was found in 58 patients (33%) and an HV interval ≥ 70 ms in 21 patients (12%). 51 patients (mean age 84 ± 6.2 years, 45% women) agreed to receive a PM, out of which 20 (39%) patients had an HV Interval over 70 ms. Atrial fibrillation was present in 53% of the patients. A dual chamber PM was implanted in 39 (77%), and a single chamber PC in 12 (23%) patients, respectively. Median follow‐up was 21 months. The median VP burden overall was 3%. The median VP burden was not significantly different between patients with an HV ≥ 70 ms (6.5 [0.8−52]) and those with an HV between 55 and 69 ms (2 [0−17], p =.23). 31% of patients demonstrated a VP burden < 1%, 27% 1%−5% and 41% > 5%. The median HV intervals in patients with VP burdens < 1%, 1%−5% and >5% were 66 (IQR 62−70) ms, 66 (IQR 63−74) ms and 68 (IQR 60−72) ms, respectively, p =.52. When only assessing patients with an HV interval 55−69 ms, 36% demonstrated a VP burden of <1%, 29% of 1%−5% and 35% of >5%. In patients with an HV Interval ≥ 70 ms, 25% demonstrated a VP burden < 1%, 25% of 1%−5% and 50% of >5% %, p =.64 (Figure). Conclusion: In patients with LBBB after TAVR and IHCD defined by an HV interval > 55 ms, VP burden is relevant in a non‐negligible amount of patients during follow‐up. Further studies are warranted to define the optimal cut‐off value for the HV interval or to develop risk models incorporating HV measurements and other risk factors to trigger PM implantation in patients with LBBB after TAVR. [ABSTRACT FROM AUTHOR]

Background: A pace and ablate strategy may be performed in refractory atrial fibrillation with rapid ventricular response. Objective: We aimed to assess sex-related differences in patient selection and clinical outcomes after pace and ablate. Methods: In a retrospective multicentre study, patients undergoing AV junction ablation were studied. Sex-related differences in baseline characteristics, all-cause mortality, heart failure (HF) hospitalizations, and device-related complications were assessed. Results: Overall, 513 patients underwent AV junction ablation (median age 75 years, 50% men). At baseline, men were younger (72 vs. 78 years, p < 0.001), more frequently had non-paroxysmal AF (82% vs. 72%, p = 0.006), had a lower LVEF (35% vs. 55%, p < 0.001) and more frequently had cardiac resynchronization therapy (75% vs. 25%, p < 0.001). Interventional complications were rare in both groups (1.2% vs. 1.6%, p = 0.72). Patients were followed for a median of 42 months in survivors (IQR 22–62). After 4 years of follow-up, the combined endpoint of all-cause death or HF hospitalization occurred more often in men (38% vs. 27%, p = 0.008). The same was observed for HF hospitalizations (22% vs. 11%, p = 0.021) and all-cause death (28% vs. 21%, p = 0.017). Sex category remained an independent predictor of death or HF hospitalization after adjustment for age, LVEF and type of stimulation. Lead-related complications, infections, and upgrade to ICD or CRT occurred in 2.1%, 0.2% and 3.5% of patients, respectively. Conclusions: Pace and ablate is safe with a need for subsequent device-related re-interventions in 5.8% over 4 years. We found significant sex-related differences in patient selection, and women had a more favourable clinical course after AV junction ablation. [ABSTRACT FROM AUTHOR]

Introduction: Cardiac resynchronization defibrillator (CRT‐D) as primary prevention is known to reduce mortality. At the time of replacement, higher age and comorbidities may attenuate the benefit of implantable cardioverter‐defibrillator (ICD) therapy. The purpose of this study was to evaluate the progression of comorbidities after implantation and their association with mortality following CRT‐D generator replacement. In addition, a risk score was developed to identify patients at high risk for mortality after replacement. Methods and Results: We identified patients implanted with a primary prevention CRT‐D (n = 648) who subsequently underwent elective generator replacement (n = 218) from two prospective ICD registries. The cohort consisted of 218 patients (median age: 70 years, male gender: 73%, mean left ventricular ejection fraction [LVEF]: 36 ± 11% at replacement). Median follow‐up after the replacement was 4.2 years during which 64 patients (29%) died and 11 patients (5%) received appropriate ICD shocks. An increase in comorbidities was observed in 77 patients (35%). The 5‐year mortality rate was 41% in patients with ≥2 comorbidities at the time of replacement. A risk score incorporating age, gender, LVEF, atrial fibrillation, anemia, chronic kidney disease, and history of appropriate ICD shocks at time of replacement accurately predicted 5‐year mortality (C‐statistic 0.829). Patients with a risk score of greater than 2.5 had excess mortality at 5‐year postreplacement compared with patients with a risk score less than 1.5 (57% vs. 6%; p <.001). Conclusion: A simple risk score accurately predicts 5‐year mortality after replacement in CRT‐D patients, as patients with a risk score of greater than 2.5 are at high risk of dying despite ICD protection. [ABSTRACT FROM AUTHOR]

The Heart Failure (HF) Meta-score may be useful in predicting prognosis in patients with primary prevention cardiac resynchronization defibrillators (CRT-D) considering the competing risk of appropriate defibrillator shock versus mortality. Data from 648 consecutive patients from two centers were used for the evaluation of the performance of the HF Meta-score. The primary endpoint was mortality and the secondary endpoint was time to first appropriate implantable cardioverter-defibrillator (ICD) shock or death without prior appropriate ICD shock. Fine-Gray model was used for competing risk regression analysis. In the entire cohort, 237 patients died over a median follow-up of 5.2 years. Five-year cumulative incidence of mortality ranged from 12% to 53%, for quintiles 1 through 5 of the HF Meta-score, respectively (log-rank P < 0.001). Compared with the lowest quintile, mortality risk was higher in the highest quintile (HR 6.9; 95%CI 3.7–12.8). The HF Meta-score had excellent calibration, accuracy, and good discrimination in predicting mortality (C -statistic 0.76 at 1-year and 0.71 at 5-year). The risk of death without appropriate ICD shock was higher in risk quintile 5 compared to quintile 1 (sub HR 5.8; 95%CI 3.1–11.0, P < 0.001). Our study demonstrated a good ability of the HF Meta-score to predict survival in HF patients treated with CRT-D as primary prevention. The HF Meta-score proved to be useful in identifying a subgroup with a significantly poor prognosis despite a CRT-D. • The Heart Failure Meta-score reliably predicts survival in patients who received a CRT-D as primary prevention of SCD. • The Heart Failure Meta-score is able to discriminate between patients with a low or high risk for mortality • The majority of patients died without experiencing an appropriate ICD shock • The Heart Failure Meta-score can be used to identify a subgroup with a significantly poor prognosis despite a CRT-D [ABSTRACT FROM AUTHOR]

Background To categorize indications of permanent pacemaker (PPM) implantation after transcatheter aortic valve implantation (TAVI), to determine predictors for conduction disturbances and to quantify the need for ventricular pacing during follow-up. Method We studied 97 patients (median age 83 years, 58% female) undergoing TAVI using the Medtronic CoreValve Revalving System (MCRS; Medtronic Inc., Minneapolis, MN, USA) or Edwards-Sapien Valve (Edwards Lifesciences, Irvine, CA, USA). During follow-up, no need for ventricular pacing was defined as <1% ventricular pacing and intrinsic 1:1 atrioventricular (AV) conduction. Results In the 35 patients (36.1%) undergoing PPM implantation three indication categories were identified: (1) high-grade AV block (Mobitz 2 or higher), (2) new-onset left bundle branch block (LBBB) with a prolonged PR interval, and (3) new-onset LBBB. The only independent predictors of high-grade AV block were the use of MCRS (odds ratio [OR] 79.25; 95% confidence interval [CI] 4.57-1373.31) and the presence of preprocedural right bundle branch block (OR 81.95; 95% 95% CI 8.72-770.46). Whereas high-grade AV block resolved only in 17% of cases, none of the patients receiving a PPM due to LBBB with or without PR prolongation required ventricular pacing during follow-up. Conclusion Our findings justify early PPM implantation in patients with high-grade AV block and may suggest a more conservative approach to PPM implantation in patients with new-onset LBBB after TAVI. [ABSTRACT FROM AUTHOR]

An episode of device related proarrhythmia observed with a dual chamber ICD is reported. Ventricular tachycardia was induced due to an inappropriate interaction of programmed device settings with automatic algorithms, including noncompetitive atrial pacing (NCAP), an algorithm used to prevent atrial tachyarrhythmias. [ABSTRACT FROM AUTHOR]