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Background Cardiac resynchronisation therapy (CRT) in patients with permanent atrial fibrillation (AF) is usually less effective than in sinus rhythm patients. Recent evidence has shown that His bundle pacing (HBP) might be a valuable alternative to conventional pacing systems resulting in more physiologic electrical activation of the heart. Currently, there is a need to identify the optimal way of CRT + HBP programming in patients with congestive heart failure (CHF) and permanent AF to achieve high cardiac output and improve physical capacity and survival. Purpose The aim of this study was to evaluate the impact of CRT + HBP programming on cardiac output in the early post-operative measurements. Methods We included consecutive patients with: 1. permanent AF, 2. CHF in NYHA class III-IV, 3. bundle branch block with QRS >130 ms or QRS During the early post-operative phase, we aimed to optimize CRT + HBP settings in order to achieve the highest cardiac output assessed by repeated echocardiographic measurements of aortic velocity time integral at various pacing programs (Table 1). Then, we selected the optimal pacing settings of CRT + HBP for each individual patient. Results Study included 17 consecutive patients aged 71.5±6.3 years, 12 were male. Mean LVEF was 24% and median NYHA class was III. The most efficacious method of pacing in terms of aortic VTI was HBP combined with left ventricular pacing (LV) which resulted in median VTI of 22.5. HBP + LV was superior to right ventricular pacing (RV): VTI of 22.5 vs 18.5, P=0.003 and outperformed biventricular pacing: VTI 22.5 vs 18.7, P=0.019. Detailed results are shown in Figure 1. Conclusion His bundle pacing coupled with LV pacing proved to be the most advantageous pacing program setting with regard to cardiac output and it performed significantly better than RV pacing only or biventricular pacing. Our observation supports the use of His bundle pacing in CRT systems in patients with CHF and permanent AF. Figure 1 Funding Acknowledgement Type of funding source: None

A single-chamber ICD is a standard method for primary SCD prophylaxis. In patients with chronic atrial fibrillation it does not contribute to the regularization of heart rate, which is crucial for proper treatment. Moreover, to avoid the deleterious effect of right ventricular pacing only minority of the patients with single chamber ICD get the appropriate, recommended dose of beta-blockers. The aim of our study was to assess the efficacy of direct His-bundle pacing in a population of patients with congestive heart failure and chronic atrial fibrillation using upgrade from single chamber to dual-chamber ICD and atrial channel to perform the His-bundle pacing Methods The study population included 39 patients (37 men, 2 women) aged 67.2±9.3 years, with CHF and chronic AF implanted primarily with single chamber ICD with established pharmacotherapy and stable clinical status. Results The echocardiography measurements at baseline and during follow-up were presented in the table: During short period (3–6 months) of follow-up the mean values of EF and LV dimensions significantly improved. This was also accompanied by functional status improvement. Conclusions His-bundle-based pacing in CHF-chronic AF patients contributes to significant echocardiographic and clinical improvement. Standard single-chamber ICD implantation in CHF-chronic AF patients yields only SCD prevention without influence on remodeling process. The physiological pacing contributes to better pharmacotherapy. Funding Acknowledgement Type of funding source: None

Background In patients undergoing permanent DDD cardiac pacing, the maintenance of atrial contractility is important to ensure adequate ventricular filling and to guarantee an optimal ventricular ejection capacity. Atrial fibrillation (AF) is a major risk factor for thromboembolic events and is associated with increased cardiovascular and all-cause mortality. Purpose To analyse the risk factors for development of permanent AF in patients with DDD pacemaker and determine its association with all-cause mortality in long-term follow-up. Methods Retrospectively collected records comprised all consecutive patients who underwent primary DDD pacemaker implantation at single-centre between 1984–2014. Patients who were lost to follow-up after hospital discharge were excluded from analysis. Follow-up was completed on 31st August 2016. Definition of permanent AF was the occurence of AF which persisted until the end of follow-up. Data on patients' survival status and deceased patients' dates of death were collected from the national death registration system. Information of death date was available as of 31st August 2016. The endpoint was all-cause mortality. Results We included a total of 3771 patients and 24,432 patient-years of follow-up and exluded 157 (4%) patients who were lost to follow-up after hospital discharge. Mean follow-up was 78±62 months (max. 370 months), 1761 (47%) were female. Paroxysmal AF prior to DDD pacemaker implantation was detected in 1276 patients (34%). During entire follow-up 717 (19%) patients developed permanent AF in a mean period of 55±50 months. Analysis of risk factors for development of permanent AF is presented in Figure. Cox proportional hazards model with time-dependent covariate showed that development of permanent AF significantly increased mortality during follow-up (HR = 1.885, 95% CI, 1.654–2.148, P Permanent AF risk factors Conclusions Female sex protected against permanent AF development, whereas age at implantation, history of paroxysmal AF and apical position of RV lead increased the risk. Permanent AF was significantly increasing the all-cause mortality, even after adjustment for age at implant and gender. Acknowledgement/Funding None

The heart rate regularization is crucial for proper treatment of patients with atrial fibrillation and congestive heart failure. The standard resynchronization can be applied, but in patients with narrow QRS this procedure is of no use. The aim of our study is to assess the efficacy of direct His-bundle pacing in patients with congestive heart failure and chronic atrial fibrillation using dual chamber ICD implanted for prevention of sudden cardiac death. Methods The study population included 78 patients with CHF and chronic AF: group A - 56 pts treated with direct His-bundle pacing using atrial port of dual chamber ICD and group B - 22 patients implanted with single chamber ICD as recommended by the guidelines. The patients in group B constituting clinical controls were derived from the Heart Failure Outpatients Clinic with established clinical status and pharmacotherapy. Results The demographic data, clinical characteristics and echocardiography measurements at baseline and during follow-up were presented in the table: Table 1 Group A Group B P value Age (years) 69.7±6.9 66.7±11.3 n.s. Sex (% of male sex) 84.0 86.4 n.s. Ventricular pacing (%) – 46.3±31.2 – His-bundle pacing (%) 81.7±9.2 – – pre post pre post pre vs. post LVEDD (mm) 66.9±4.9 59.9±4.7 64.8±8.0 64.7±8.1 During 12-months of follow-up the mean values of NYHA functional class, EF and LV dimensions did not change in group B but significantly improved in group A. The physiological His-bundle based pacing enabled optimal beta-blocker dosing. The studied groups had no tachyarrhythmia at baseline so the presumable atrial fibrillation-related harm depends on the rhythm irregularity. Conclusions His-bundle-based pacing in CHF-chronic AF patients contributes to significant echocardiographic and clinical improvement. Standard single-chamber ICD implantation in CHF-chronic AF patients yields only SCD prevention without influence on remodeling process. The CHF-patients with narrow QRS and chronic AF benefit from substantially higher beta-blockade which can be instituted in His-bundle pacing group.

Objective The aim of this study was to evaluate the incidence of venous stenosis and occlusion (VSO) in patients referred for transvenous lead extraction (TLE) with regard to the indications for this treatment and to analyse the influence of VSO on efficacy, complications and technical challenges of TLE procedures. Methods The material consists of 133 consecutive TLE procedure records. The contrast venography examination of the ipsilateral access vein was performed prior to the operation. The whole study population was divided into two subgroups, based on the presence (subgroup I) or absence (subgroup II) of VSO. Results Phlebography was performed in 133 patients with age ranging from 25.7 to 86.1 years, 44 female (33.1%). The VSO was confirmed in 48 (36.1%) patients - subgroup I. Most of the patients were referred to TLE due to non-infectious reasons (100 pts-75.2%). The absence of VSO was observed substantially more frequently in patients with diabetes (P = 0.02). Procedural success rate reached 93.3% in subgroup I and 98.8% in subgroup II (P = 0.1). There was no significant difference in the use of advanced tools and alternative access sites. Conclusion The presence of VSO can be expected in one third of patients referred for lead extraction. There is no association between indication for TLE (infected or noninfected lead extraction) and the incidence of VSO. Diabetes proved to have a protective effect on venous patency in the previously mentioned group. VSO does not influence the effectiveness, safety, and the use of additional tools during TLE procedures.

We present a complication of the infected pacing system extraction by lobular pneumonia in a 73-year-old female patient. The pacing system involved DDD pacemaker, atrial and ventricular endocardial leads implanted 12 year beforehand. The defect of the atrial lead emerged during the pacemaker replacement 4 years ago. The diagnosis of the injury cause and its reparation were not undertaken at that time. An interruption of the atrial lead which resulted in the formation of a loop inside the cardiac chamber was found when purulant pacemaker pocket infection had been diagnosed. The patient was referred for the pacing system extraction after preoperative specific antibiotic treatment. After a long-lasting, difficult, two-step leads extraction procedure, pneumonia developed. An echocardiogram revealed enlargement of the right atrium and ventricle, with elevated pulmonary artery pressure up to 40 mmHg. An atypical chest X-ray with the presence of a large pleural liquid volume led to the work-up of hemorrhagic complications and postponed the antithrombotic therapy. With the delay of 1.5 month the pulmonary scintigraphy showed features of pulmonary embolism. The embolism was most likely caused by a vegetation mobilized from the endocardial lead and/or endocardium during the extraction maneuvers. Before the surgery, the vegetations attached to the leads or to the endocardium had not been visualized. Anticoagulant therapy with antivitamins K was successful, which resulted in the pulmonary pressure normalization. The patient has remained in a good condition for the next 3 months of follow-up.