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Left ventricular assist devices (LVAD) are used in the treatment of advanced left ventricular heart failure. LVAD can serve as a bridge to orthotopic heart transplantation or as a destination therapy in cases where orthotopic heart transplantation is contraindicated. Ventricular arrhythmias are frequently observed in patients with LVAD. This problem is further compounded as a result of diagnostic difficulties arising from presently available electrocardiographic methods. Due to artifacts from LVAD-generated electromagnetic fields, it can be challenging to assess the origin of arrhythmias in standard ECG tracings. In this article, we will review and discuss common mechanisms, diagnostics methods, and therapeutic strategies for ventricular arrhythmia treatment, as well as numerous problems we face in LVAD implant patients.

His-bundle pacing (HBP) is a relatively new method of cardiac pacing, with recent studies showing an association between HBP and a lower risk of developing right ventricular heart failure compared to classical pacing methods. However, HBP is also associated with a higher risk of lead dislodgement, undersensing, and loss of capture. As such, a detailed assessment of pacing effectiveness in pacemaker patients is vital. In the presented case, an electrocardiogram (ECG) recording seems to present successful selective His-bundle pacing, while pacemaker follow-up demonstrated the loss of ventricular capture. In conclusion, patients receiving HBP should undergo ECG alongside pacing parameter analysis and pacing electrograms, as differences in successful and unsuccessful pacing ECG can be very subtle., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2023. Published by Elsevier Inc.)

Background: Driveline infections in continuous-flow left ventricular assist devices (cf-LVAD) remain the most common adverse event. This single-center retrospective study investigated the risk factors, prevalence and management of driveline infections., Methods: Patients treated after cf-LVAD implantation from December 2014 to January 2020 were enrolled. Baseline data were collected and potential risk factors were elaborated. The multi-modal treatment was based on antibiotic therapy, daily wound care, surgical driveline reposition, and heart transplantation. Time of infection development, freedom of reinfection, freedom of heart transplantation, and death in the follow-up time were investigated., Results: Of 75 observed patients, 26 (34.7%) developed a driveline infection. The mean time from implantation to infection diagnosis was 463 (±399; range, 35-1400) days. The most common pathogen was Staphylococcus aureus (n = 15, 60%). First-line therapy was based on antibiotics, with a primary success rate of 27%. The majority of patients (n = 19; 73.1%) were treated with surgical reposition after initial antibiotic therapy. During the follow-up time of 569 (±506; range 32-2093) days, the reinfection freedom after surgical transposition was 57.9%. Heart transplantation was performed in eight patients due to resistant infection. The overall mortality for driveline infection was 11.5%., Conclusions: Driveline infections are frequent in patients with implanted cf-LVAD, and treatment does not efficiently avoid reinfection, leading to moderate mortality rates. Only about a quarter of the infected patients were cured with antibiotics alone. Surgical driveline reposition is a reasonable treatment option and does not preclude subsequent heart transplantation due to limited reinfection freedom., (© 2021. The Author(s).)

Exacerbation of chronic heart failure (HF) is the most common cause of hospitalization in adults, which is associated with high morbidity and mortality rates, mainly due to HF exacerbation or sudden cardiac death (SCD). A novelty in the treatment of HF with reduced left ventricular ejection fraction (HFrEF) in recent years has been the approval of sacubitril / valsartan, a drug belonging to angiotensin receptor-neprilysin inhibitors (ARNIs). Sacubitril / valsartan significantly reduces the severity of HF symptoms as well as the risk of hospitalization and death and is characterized by a good safety profile. Therefore, it has a strong position in the guidelines of international cardiac societies. However, the precise mechanism underlying the beneficial effects of ARNIs on cardiovascular mortality is unknown. The advantages of ARNIs are likely to result from improved left ventricular ejection fraction, reduced myocardial remodeling, and increased natriuretic peptide availability. Therefore, sacubitril / valsartan may exhibit antiarrhythmic properties and reduce the risk of ventricular arrhythmias and SCD in patients with HFrEF. Importantly, the improvement of the function and electrical stabilization of cardiomyocytes may translate into a reduced risk of appropriate and inappropriate implantable cardioverter‑defibrillator interventions and improvement in the percentage of biventricular pacing. In this expert opinion of the Heart Rhythm and Heart Failure Sections of the Polish Cardiac Society, we summarize and discuss the current knowledge on the effect of sacubitril / valsartan on the occurrence of ventricular arrhythmias and the risk of SCD in patients with chronic HFrEF.

Introduction: New pacing technologies offer a greater choice of left ventricular pacing sites and greater personalization of cardiac resynchronization therapy (CRT). The effects on cardiac function of novel pacing configurations are often compared using multi-beat averages of acute hemodynamic measurements. In this analysis of the iSpot trial, we explore whether this is sufficient., Materials and Methods: The iSpot trial was an international, prospective, acute hemodynamic trial that assessed seven CRT configurations: standard CRT, MultiSpot (posterolateral vein), and MultiVein (anterior and posterior vein) pacing. Invasive and noninvasive blood pressure, and left ventricular (LV) dP/dt max were recorded. Eight beats were recorded before and after an alternation from AAI to the tested pacing configuration and vice-versa. Eight alternations were performed for each configuration at each of the five atrioventricular delays., Results: Twenty-five patients underwent the full protocol of eight alternations. Only four (16%) patients had a statistically significant >3 mm Hg improvement over conventional CRT configuration (posterolateral vein, distal electrode). However, if only one alternation was analyzed (standard multi-beat averaging protocol), 15 (60%) patients falsely appeared to have a superior nonconventional configuration. Responses to pacing were significantly correlated between the different hemodynamic measures: invasive systolic blood pressure (SBP) vs noninvasive SBP r = 0.82 (P < .001); invasive SBP vs LV dP/dt r = 0.57, r 2  = 0.32 (P < .001)., Conclusions: Current standard multibeat acquisition protocols are unfortunately unable to prevent false impressions of optimality arising in individual patients. Personalization processes need to include distinct repeated transitions to the tested pacing configuration in addition to averaging multiple beats. The need is not only during research stages but also during clinical implementation., (© 2019 Wiley Periodicals, Inc.)

Background: Multiple randomised clinical trials have proven that cardiac resynchronisation therapy (CRT) reduces morbidity and mortality in appropriately selected patients with congestive heart failure and is recommended for such patients as per the European Society of Cardiology guidelines., Aim: In this paper we compare the indications and demographics in cardiac resynchronisation recipients in Poland and other European countries., Methods: In 2015 and 2016, physicians from 42 European countries participated in the second edition of the European Cardiac Resynchronisation Therapy Survey. For 14 months, 288 implanting centres gathered data regarding demography, indications, implanting methods, and guidance compatibility from 11,088 patients receiving CRT., Results: The survey revealed that a vast group of patients were eligible for CRT implantation (although some of them with rela-tively weak guidance recommendations) and showed essential variety in clinical practice when national data were benchmarked., Conclusions: The population of CRT recipients in Poland and other European countries did not differ in terms of demographic and clinical characteristics. In most cases, indications for CRT were in accordance with the guidelines; however some devices were implanted in patients beyond the guideline recommendations. For these procedures, the decision regarding CRT im-plantation relies mainly on the physicians' experience.

Identification of demographic and clinical factors which influence prognosis is crucial in patients with heart failure and cardiac resynchronization therapy (CRT)., Materials and Methods: The study included 223 patients with CRT (177 males), mean age 64.6±9.7 years, including 98 patients (43.9%) with defibrillation function (CRT-D) and 58 (26.0%) with permanent atrial fibrillation (AF). Of 223, n=72 patients (32.3%) had CRT implanted after the age of 70. The mean follow-up was 37±19 months. Mortality rates and other clinical factors according to age were assessed in multivariable analysis of CRT patients follow-up., Results: Total mortality was 30.9%. Mortality rate was similar in subjects aged ≤70 and >70 (HR:1.41, 95%CI:0.70-2.82). The female gender was the strongest clinical factor of best prognosis (HR:0.12,95%CI:0.03-0.59, p=0.0088). Lower mortality was also associated with higher left ventricular ejection fraction (HR:0.94,95%CI:0.90-0.98, p=0.0031). Coronary disease (HR:2.09,95%CI:1.10-3.99, p=0.0245), chronic kidney disease (HR:3.00, 95%CI:1.47-6.12, p=0.0024)and higher NYHA class (HR:2.28, 95%CI:1.18-4.40, p=0.0137) were factors of increased mortality. For patients >70 years old, gender was not a survival determining factor and mortality was lower in regard to hypertension or permanent AF. Only chronic kidney disease was significantly associated with higher mortality in patients >70 years old (HR:6.74, 95%CI:1.90-23.9). The use of defibrillation function had no influence on survival rate at any age., Conclusions: In patients with cardiac resynchronization therapy female gender was not associated with mortality and was the factor of better prognosis. For subjects aged >70 a worse prognosis was related to renal insufficiency., (© 2018 MEDPRESS.)

Introduction: Recent efforts to increase CRT response by multiSPOT pacing (MSP) from multiple bipols on the same left ventricular lead are still inconclusive., Aim: The Left Ventricular (LV) MultiSPOTpacing for CRT (iSPOT) study compared the acute hemodynamic response of MSP pacing by using 3 electrodes on a quadripolar lead compared with conventional biventricular pacing (BiV)., Methods: Patients with left bundle branch block (LBBB) underwent an acute hemodynamic study to determine the %change in LV+dP/dtmax from baseline atrial pacing compared to the following configurations: BiV pacing with the LV lead in a one of lateral veins, while pacing from the distal, mid, or proximal electrode and all 3 electrodes together (i.e. MSP). All measurements were repeated 4 times at 5 different atrioventricular delays. We also measured QRS-width and individual Q-LV durations., Results: Protocol was completed in 24 patients, all with LBBB (QRS width 171±20 ms) and 58% ischemic aetiology. The percentage change in LV+dP/dtmax for MSP pacing was 31.0±3.3% (Mean±SE), which was not significantly superior to any BiV pacing configuration: 28.9±3.2% (LV-distal), 28.3±2.7% (LV-mid), and 29.5±3.0% (LV-prox), respectively. Correlation between LV+dP/dtmax and either QRS-width or Q-LV ratio was poor., Conclusions: In patients with LBBB MultiSPOT LV pacing demonstrated comparable improvement in contractility to best conventional BiV pacing. Optimization of atrioventricular delay is important for the best performance for both BiV and MultiSPOT pacing configurations., Trial Registration: ClinicalTrials.gov NTC01883141.

Unlabelled: Cardiac resynchronization therapy with defibrillator function (CRT-D) along with an optimal medical therapy improves symptoms, cardiac efficiency, quality of life (QoL) and prognosis in patients with heart failure (CHF). The aim of the study was to assess effects of hospital-based and home-based/telemonitoring exercise training., Methods: The prospective, randomized study was conducted in 52 patients (pts), aged 45-75years (mean 62±9.3), with CHF of ischemic or another etiology, NYHA class III and implanted CRT-D. Group CRT-Ex (n=26) underwent initial exercise training in the hospital setting and continued training program at home with telemonitoring 5 times a week for 8weeks. The CRT-control group (n=26) consisted of patients who had hospital rehabilitation, but no training program after discharge., Results: No differences between the groups in CHF etiology, comorbidities, medical therapy and in any of spiroergometry (CPX) parameters at baseline were observed. After 3-4months the CRT-Ex group achieved better results in VO2 peak, VCO2 peak and treadmill test duration. But after 12months the measurements returned to the baseline values. No significant differences were observed directly between two groups in distances of 6-MWT at baseline, at 3-4months and at 12months. Echocardiographic evaluation showed significant reduction of left ventricular dimensions and improvement in the left ventricular ejection fraction (EF), in both groups (25.3±7.4% to 28.9±9.1%, CRT-Ex group, p=0.0213 and 24.9±7.2% to 31.7±10.6%, CRT-Control group, p=0.0001). Significant improvement in all domains of QoL was observed in the CRT-Ex group, while the CRT-Control pts declared only higher energy levels and less pain. Intensity of telemonitoring guided home-based exercise training was low. In the 12- and 18-months follow-up there were no differences in the ICD-interventions, mortality or hospitalization rates between the groups., Conclusions: A structured exercise training program in the hospital and home-based with telemonitoring was safe option of additional treatment and improved directly physical fitness and, quality of life in patients with NYHA III CHF and CRT-D. However these effects haven't been sustained in longer period of time and had no impact on prognosis., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Still increasing life expectancy in patients with implanted devices and large number of leads more and more often induce the need to cure the treatment complications or to change especially to cardiac resynchronization therapy (CRT). In order to prevent further complications, the possibility of damaged or redundant leads extraction should be taken into consideration. The aim of the paper was to assess the effectiveness and safety of transvenous lead extraction (TLE) with co-implantation of resynchronization systems., Methods and Results: Between 2008 and March 2013, the system removal with TLE was conducted in 246 patients. In 38 patients (11 women, 28.9%), aged 43-79 (mean 65 years), it was combined with co-implantation of CRT-pacemaker or defibrillator (CRT-P/D). Indications for TLE covered: lead failure in 21 (55.3%) patients, redundant leads in 6 (15.8%), and the occluded venous system in 7 (18.4%). The up-grade of the pacemaker or defibrillator system to CRT-D was performed in 19 cases, CRT-P/D revision in next 19. Together 32 defibrillation leads and 42 pacing leads (27 left ventricular leads, and 1 epicardial lead) were implanted. The intended clinical target--an effective resynchronization therapy--was obtained in all patients. There was no case of death or severe complications. In 2 cases of venous occlusion, the implantation on the contralateral side was required., Conclusions: TLE enables effective resynchronization therapy also in the case of the presence of too many leads, occlusion of the venous system or lead failure. Significant technical problems can occur especially in patients with venous system occlusion.

Introduction: Right ventricular pacing (RVP) causes ventricular desynchronization and may lead to the development of heart failure (HF). Prolongation of atrioventricular delay (AVD) in DDDR pacemakers reduces unnecessary RV stimulation. The aim of the study was to verify the influence of RVP reduction on HF symptoms., Methods: The study comprised 31 patients (17 men, mean age: 71.6 ± 8 yrs) with DDDR pacemaker implanted due to sinus node dysfunction (SND). At baseline, 28 patients did not present any symptoms of HF. Three patients were in NYHA class II. Patients were randomized either to 150 ms AVD or to minimizing right ventricular pacing (MRVP). Crossing over to the alternate mode took place after 4 months. Cardiopulmonary exercise test (CPX), echocardiography (ECHO) and BNP measurements were done before pacemaker implantation, after 4 and 8 months., Results: The percentage of RVP was significantly higher in 150 ms AVD than in MRVP: 81.7 ± 22.6 versus 14.2±20.5%, P < 0.0001. Patients with 150 ms mode had worse CPX parameters than those with MRVP mode: peak oxygen uptake was 14.2±4.3 versus 19.9±6.3 ml/kg per min, P = 0.0001, higher BNP concentrations: 72.3±48.3 versus 49.4±43.9 pg/ml, P = 0.001 and worse left ventricle [LV] function: ejection fraction: 53.2±6.7 versus 57.3±5.5%, P < 0.0001; LV diastolic diameter: 4.86±0.52 versus 4.66±0.5 cm, P < 0.01., Conclusion: Predominant RVP in patients without symptoms of HF at baseline may be responsible for worse performance in cardiopulmonary exercise test, higher BNP concentrations and impairment of LV function. Specific DDDR pacemaker programming promotes intrinsic AV conduction and may prevent the development of pacing-induced HF., (©2013, Wiley Periodicals, Inc.)

Cardiac resynchronization therapy (CRT) has become a recommended method for patients with congestive heart failure (CHF) and cardiac dyssynchrony. In some cases, CRT implantation procedure can be complicated because of anatomic and technical reasons. Some reports describe balloon angioplasty of stenotic heart veins as a method to achieve the target vessel. We present a case of a 58-year-old male with permanent atrial fibrillation and CHF who was referred for CRT. During the implantation of the pacemaker, the diaphragmatic obstacle in coronary sinus (CS) has been passed after many attempts using a balloon catheter with no inflation. The aim of the report is to discuss, in short, the real necessity of venous angioplasty in the CS bed during CRT implantation.

Background: Cardiac resynchronisation therapy (CRT) has become a valuable therapeutic tool in patients with advanced chronic heart failure (CHF). The search for optimal methods for the assessment of CRT efficacy is still underway., Aim: To evaluate the impact of implantation of CRT devices in patients with CHF on adaptation of circulatory and respiratory systems to maximal exercise assessed by cardiopulmonary exercise tests (CPX) and 6-minute walking tests (6MWT)., Methods: We investigated 27 patients (22 males, 5 females, 61.2+/-9.1 years) with a CRT device implanted due to advanced CHF, which resulted from ischaemic or dilated cardiomyopathy. All patients before implantation underwent echocardiography, CPX with expired gas analysis and 6MWT. Investigations were repeated at 3-6 months after CRT implantation. In CPX we evaluated peak oxygen uptake (peak VO2), oxygen pulse, maximal minute ventilation-carbon dioxide production (VE/VCO2 (max)), and its slope (VE/VCO2 slope) and VE/VO2 slope, VO2 in anaerobic threshold (AT), and cardiac and respiratory reserve. In 6MWT we evaluated walking distance and heart rate and blood pressure response to exercise., Results: We noted statistically higher mean peak VO2 after CRT implantation in the studied group: 11.34+/-3.38 vs. 14.56+/-3.99 ml/kg/min (p<0.0001) and 1.01 +/-0.44 vs. 1.4+/-0.55 l/min (p=0.003) and higher values of expired CO2: 1.00+/-0.43 vs. 1.43+/-0.67 l/min (p=0.004). The O2 pulse rose from 9.65+/-3.39 to 13.23+/-5.43 ml/beat (p=0.015). We also observed a significant reduction of VE/VCO2 slope from 42.34+/-13.35 before CRT to 34.77+/-6.04 after CRT (p=0.0196) and a significant decrease of VE/VO2 slope from 41.32 +/-15.46 to 34.01+/-6.27 (p=0.037). VE/VCO2 (max) fell from 58.02+/-15.86 to 50.1+/-13.14 (p=0.009). Patients estimated their dyspnoea on the Borg scale at peak exercise at 4.75+/-0.75 points before CRT and at 3.67+/-1.15 points (p=0.002) after CRT. Patients could walk a longer distance during 6MWT than before CRT (367+/-154.9 vs. 231.1+/-170.3 m, p<0.001)., Conclusions: Cardiac resynchronisation therapy improves exercise tolerance measured by means of CPX and 6MWT, improves respiratory system efficiency and restores its adaptive mechanisms during exercise in patients with advanced CHF. Better exercise adaptation after CRT may be objectively measured with CPX parameters, and correlates with improvement of clinical symptoms. CPX seems to be a very helpful tool in assessing the results of CRT.

Background: Cardiac resynchronisation therapy (CRT) is often recommended for the treatment of patients with severe heart failure and cardiac dyssynchrony. The procedure efficacy should be evaluated not only by objective criteria and clinical end points, but also by patients' subjective opinion of their everyday functioning., Aim: To assess the quality of life (QoL) in patients treated with CRT., Methods: The study comprised 26 CRT patients: 18 males and 8 females, aged 63.3+/-9.5 (34-75) years. The QoL was evaluated by NHP questionnaires twice: before CRT implantation and 15+/-4 months (mean) after the procedure., Results: There was a significant improvement in the mean values of energy (2.9 vs. 2; p <0.01), physical mobility (4.3 vs. 3; p <0.05) and emotional reactions (5.2 vs. 3.7; p <0.05) following CRT. However, some aspects of everyday functioning did not improve after CRT. They included looking after the home (66.7 vs. 66.7%) and sex life (54.2 vs. 70.8%). An improvement was observed in home life (33.3 vs. 20.8%) and social life (61.5 vs. 50%)., Conclusions: Cardiac resynchronisation therapy improves patients' QoL. The psycho-social condition of CRT patients needs further, larger studies and should be taken into account by attending health professionals.

Background: Benefits of cardiac resynchronisation therapy (CRT) for survival in selected congestive heart failure (CHF) patients have been acknowledged by the 2005 ESC guidelines., Aim: To analyse mortality in CRT pacing only (CRT-P) patients during at least one-year follow-up., Methods: This was a prospective, multi-site, at least one-year observational study on mortality and mode of death in patients who received CRT-P due to commonly accepted indications. One-year follow-up data (or earlier death) were available for 105 patients (19 females, 86 males) aged 60.6+/-9.8 years (35-78). Baseline NYHA class was 3.2+/-0.4 (3-4). Coronary artery disease (CAD) was the underlying aetiology of CHF in 57 (54%) patients and 48 (46%) patients had CHF due to non-coronary factors., Results: Mean follow-up duration was 730 days (360-1780), median 625. There were 21 (20%) deaths: 5 (24%) sudden cardiac deaths (SCD), 13 (62%) deaths due to heart failure (HFD) and 3 (14%) other deaths. Thirteen (62%) patients died within the first year of observation. All SCD occurred in this period. Mean time to death was 303+/-277 days (19-960) to HFD - 339+/-313 days (19-960) and to SCD - 208+/-127 days (31-343). There were no significant differences between survivors and non-survivors with respect to left ventricular ejection fraction (LVEF) (25+/-10 vs. 20+/-8%), 6-minute walk test (6 min WT) (276+/-166 vs. 285+/-163 m) and LV diastolic diameter (LVEDD) (71+/-9 vs. 78+/-10 mm) (all NS). The SCD and HFD patients had similar age (62.0+/-5.4 vs. 56.6+/-13.2 years), gender (80 vs. 83% males), NYHA class (3.1+/-0.2 vs. 3.5+/-0.3), LVEF (22+/-9 vs. 17+/-5%), LVEDD (86+/-10 vs. 79+/-9 mm), 6 min WT (270+/-142 vs. 292+/-188 m) (NS). In 4 patients from the SCD group CHF was of non-coronary aetiology and only in 1 patient from the HFD group (p=0.003). The values of LVEF, LVEDD and NYHA class in HFD patients who died during the first year after implantation, compared with those who died later, were similar., Conclusions: Sudden cardiac death probability in the studied CRT-P population was the highest during the first year after implantation. Afterwards, the risk of HFD started to increase. Thus, in all patients eligible for CRT prophylactic defibrillation function should be considered.