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Cardiac implantable electronic device (CIED)-related infections are a major complication of CIED therapy and associated with high morbidity and mortality. The aim of the present study was to evaluate the incidence of lead erosion as one cause of the CIED-related infections and to provide detailed information about the therapy of two cases of lead erosion. We retrospectively screened the database of a large clinic specialized on patients with CIED (HIZ BERLIN Herzschrittmacher- und ICD-Zentrum, Berlin, Germany) for cases of lead erosion between 2015 and 2020. A total of 5971 outpatients were treated at the HIZ BERLIN - including 4782 patients with a one- or two-chamber pacemaker, 837 patients with an implantable cardioverter defibrillator (ICD) and 352 patients with a biventricular device for cardiac resynchronization therapy (CRT). The incidence of lead erosion was 0.033%. As one of the two patients, who suffered from lead erosions, had no signs of systemic infection, the patient received local therapy with an antimicrobial mesh and intravenous antibiotics. After twelve months, he showed a good clinical outcome without ongoing or recurring infection. In conclusion, the incidence of lead erosion is low. In case of lead erosions without signs of systemic infection, an antimicrobial mesh might be implanted as an off-label use in patients that decline complete device removal., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Right ventricular (RV) pacing is the standard treatment for symptomatic bradycardia. RV pacing is known to cause dyssyncrony. New treatment options like His bundle pacing enhance the focus on left ventricular dysfunction in patients with pacemakers., Objectives: The aim of this cross-sectional study was to obtain a real-life picture of the patients in a representative cohort of outpatients with permanent pacemakers. The prevalence and causes of left ventricular dysfunction (LVD) were explored., Methods: In total, 1869 patients of a pacemaker outpatient clinic were screened for left ventricular systolic dysfunction by transthoracic echocardiography. All patients were interviewed for symptoms and cardiologist care. Percentages of RV pacing and underlying cardiac disease were recorded., Results: A left ventricular ejection fraction (LVEF) under 45% was found in 207 (11.1%) of all patients. Predictive factors for a reduced LVEF were a high pacing rate and long-term pacing. LVD due to RV pacing was diagnosed in 3.4% of all patients. Only 845 patients (45%) reported that they regularly visited a cardiologist., Conclusion: There is a high prevalence of unknown LVD in a typical pacemaker cohort. Therefore, regular echocardiographic examinations should be performed in outpatients of pacemaker clinics.

Aims: Optimization of the AV-interval (AVI) in DDD pacemakers improves cardiac hemodynamics and reduces pacemaker syndromes. Manual optimization is typically not performed in clinical routine. In the present study we analyze the prevalence of E/A wave fusion and A wave truncation under resting conditions in 160 patients with complete AV block (AVB) under the pre-programmed AVI. We manually optimized sub-optimal AVI., Methods: We analyzed 160 pacemaker patients with complete AVB, both in sinus rhythm (AV-sense; n = 129) and under atrial pacing (AV-pace; n = 31). Using Doppler analyses of the transmitral inflow we classified the nominal AVI as: a) normal, b) too long (E/A wave fusion) or c) too short (A wave truncation). In patients with a sub-optimal AVI, we performed manual optimization according to the recommendations of the American Society of Echocardiography., Results: All AVB patients with atrial pacing exhibited a normal transmitral inflow under the nominal AV-pace intervals (100%). In contrast, 25 AVB patients in sinus rhythm showed E/A wave fusion under the pre-programmed AV-sense intervals (19.4%; 95% confidence interval (CI): 12.6-26.2%). A wave truncations were not observed in any patient. All patients with a complete E/A wave fusion achieved a normal transmitral inflow after AV-sense interval reduction (mean optimized AVI: 79.4 ± 13.6 ms)., Conclusions: Given the rate of 19.4% (CI 12.6-26.2%) of patients with a too long nominal AV-sense interval, automatic algorithms may prove useful in improving cardiac hemodynamics, especially in the subgroup of atrially triggered pacemaker patients with AV node diseases.

Background: Postoperative lead perforation is a life-threatening complication of cardiac pacing. Identification of precipitating factors for this serious complication may help to anticipate a specific risk profile and to minimize the incidence., Methods: We conducted a retrospective tertiary referral center analysis to clarify clinical, anatomical, and technical characteristics related to pacemaker (PM) and cardioverter/defibrillator lead perforation. We examined the baseline characteristics and the symptoms. In a subgroup, we investigated the myocardial thickness on contrast-enhanced cardiac computed tomography., Results: We enrolled 26 patients. Female gender appears to put patients at slightly increased risk for lead perforation. In a majority active fixation leads were used. Symptoms occurred in 72%. Pericardial effusion and tamponade were present in 38% and 19%, respectively. Sensing was compromised in 65%. A high pacing threshold or exit block occurred in 92%. Myocardial thickness did not differ between patients with or without perforation. In 96%, the perforation was treated by transvenous withdrawal., Conclusion: Chest pain, phrenic stimulation, bad sensing, or exit block early after PM implantation must prompt radiological and echocardiographic evaluation. A missing pericardial effusion particularly late after implantation does not rule out a perforation. Especially active fixating leads have a higher risk of perforation. With cardiac surgery in standby transvenous withdrawal is a safe way to treat lead perforation., (©2014 Wiley Periodicals, Inc.)

Introduction: Atrioventricular (AV) block is a frequent complication of transcatheter aortic valve implantation (TAVI). TAVI is routinely performed under anticoagulation using heparin, which potentially may lead to an increased bleeding rate in patients who undergo permanent pacemaker (PPM) implantation immediately after TAVI. As the number of TAVI procedures continues to rise, data on the optimal management of TAVI-related AV block are needed. Therefore, the aim of our study was to analyze PPM implantation-related complications after TAVI., Methods: We retrospectively collected data on PPM implantations after TAVI in our center from January 2010 to December 2012. In total, we included 30 patients who received a PPM for TAVI-related AV block. Twelve patients (group A) underwent PPM implantation on the day of TAVI. In 18 patients (group B), PPM implantation was performed at least 1 day after TAVI (3.8 ± 4.5 days). Since all patients undergoing TAVI receive dual antiplatelet therapy (DA-therapy), we compared all implantations after TAVI with a historic patient cohort that underwent PPM implantation under DA-therapy., Results: Procedure times, fluid loss via drainage systems, and drainage times were neither significantly different between groups A and B nor between all PPM implantations after TAVI compared to the historic control group., Conclusion: PPM implantation immediately after TAVI is safe and can be performed without increased rate of complications., (©2013, The Authors. Journal compilation ©2013 Wiley Periodicals, Inc.)

Background: Cardiac device infections are serious complications that require aggressive treatment strategies, including interventional or surgical lead extraction., Methods: Here we describe the long-time follow-up of vacuum-assisted closure (V.A.C.) treatment in five patients with local cardiac device infection (LDI). In these patients the device was removed, the electrodes were shortened, and a V.A.C. treatment was applied. The primary endpoint was defined as time to re-LDI., Results: Three patients had LDI of a pacemaker pocket, whereas two presented with an infection of their ICD pocket. The V.A.C. treatment was applied for 34.4 ± 17.9 days. The mean hospitalization time was 38.6 ± 19.2 days. The follow-up period was assessed for 34.6 ± 19.2 months. Only one patient developed re-LDI, 69 days after removal of the device. The other four patients did not show any signs of reinfection during the follow-up period. None of the five patients sustained serious adverse events., Conclusions: V.A.C. treatment may be an option for selected patients with LDI who refuse a laser-guided lead extraction or surgical removal of the electrodes as the primary therapy., (©2012, The Authors. Journal compilation ©2012 Wiley Periodicals, Inc.)

Background: Device implantations in patients on dual antiplatelet-therapy (DA-therapy) continue to rise. The aim of our study was to compile and analyze data on complications of antiarrhythmia device implantation under DA-therapy., Methods: We prospectively collected data on all device implantations in our department from January 2008 until February 2009. The control group was comprised of patients on acetylsalicylic acid alone or no antiplatelet medication at all (318 subjects). The DA-therapy group consisted of 109 patients of whom 71 were analyzed retrospectively (implantations from 2002 to 2007)., Results: Procedure times were significantly longer in DA-therapy patients receiving a pacemaker for the first time. In contrast, procedure times did not differ significantly between the two study groups for implantable cardioverter defibrillator (ICD) implantations and for pacemaker replacements. Fluid losses via drainage systems and drainage times were significantly increased in the DA-therapy group as compared with the control group after pacemaker but not after ICD implantations. Importantly, there were no significant differences in complication rates, particularly the hematoma rate, between the DA-therapy and the control group., Conclusions: When drainage systems are used, antiarrhythmia device implantation is safe and can be performed without significantly increased risk of clinically relevant hematoma in patients on continued DA-therapy. (PACE 2010; 394-399).

Heart failure and atrial fibrillation often coexist, especially with increasing degree of heart failure severity. Under this constellation, the advantage of cardiac resynchronization therapy (CRT) is still under discussion and displayed as an unresolved problem in the guidelines for cardiac stimulation and resynchronization. If ventricular desynchronization can be documented and response to CRT can be expected, the challenge is to interoperatively seek the best left ventricular electrode position and to postoperatively optimize the device in order to achieve the best therapy performance. This situation encourages the development of individualized methods and to utilize innovative apparatus features in order to consolidate individual decisions and to optimize CRT in heart failure with atrial fibrillation.

Aims: Recommendations for programming the rate-adaptive AV delay in CRT., Methods and Results: In cases of continual biventricular pacing, the optimal AV delay in CRT (AVD(opt)) is the net effect of the pacemaker-related interatrial conduction time (IACT), duration of the left-atrial electromechanical action (LA-EAC(long)), and the duration of the left-ventricular latency period (S(V)-EAC(short)). It can be calculated by AVD(opt) = IACT+LA-EAC(long)-S(V)-EAC(short). We measured these three components in 20 CRT-ICD patients during rest and submaximal ergo metric exercise (71 +/- 9 W) resulting in a 22.5 +/- 9.6 bpm rate increase. IACT and S(V)-EAC(short) did not reveal significant differences. LA-EAC(long), however, varied significantly by -10.7 +/- 16.1 ms (P = 0.008) during exercise. In contrast to AVD(optVDD), there was a significant difference in AVD(optDDD) of -8.8 +/- 14.5 ms (P = 0.014) between the resting and submaximal exercise conditions. In DDD pacing, AVD(opt) was shortened by 2.6 ms/10 bpm., Conclusion: In consideration of the findings of the studies performed to date, the rate-adaptive AV delay should be deactivated.

Background: Pacemaker-induced superior vena cava (SVC) syndrome is a rare but serious complication of permanent pacemaker implantation. Because of its rarity, little is known about the long-term prognoses of such patients., Methods: Five patients, mean age 62 +/- 11.4 years, with pacemaker-induced SVC syndrome for more than 10 years were investigated. The clinical evaluation included: exercise testing, thrombophilia lab tests, and a chest CT., Results: Two of the patients manifested complications of SVC syndrome which included thoracoabdominal subcutaneous collaterals. One of these patients simultaneously developed an increase in the pacing threshold which required the implantation of epicardial leads. Three of the five patients had normal age-adjusted VO(2) AT und VO(2) max. Four of the patients were both heterozygous for a polymorphism of PAI-1 and were homozygous for a polymorphism of t-PA. One of these patients also was heterozygous for a polymorphism of factor V and glycoprotein IIb/IIIa. The chest CTs revealed extensive and varying collateral circulation patterns in all of the patients., Conclusions: The development of pacemaker-induced SVC syndrome is the result of various predisposing factors including thrombophilia. Many patients retain normal age-adjusted cardiopulmonary capacity and demonstrate stable clinical findings on the long-term as the result of the development of extensive collateral vessel systems. The most serious complication was the combination of SVC syndrome and the simultaneous malfunctioning of one of the leads requiring implantation of a new lead.

Aims: We prospectively evaluated results from cardiopulmonary exercise testing for chronotropic incompetence (CI) in a cohort of 292 pacemaker patients. In addition, we evaluated comorbidity and antiarrhythmic patient data as indicators of CI., Methods and Results: On the basis of exercise stress testing and application of the definition of CI by Wilkoff, 51% of our cohort was categorized as having CI. Indications for pacemaker implant for this patient group were 42% atrioventricular block, 56% sinus node disease, and 59% atrial fibrillation. Maximum oxygen uptake (VO(2) max) and exercise duration were significantly reduced among CI pacemaker patients, whereas oxygen uptake at the anaerobic threshold remained unchanged. The following clinical characteristics were significant predictors of CI: existence of coronary artery disease (P = 0.038), presence of an acquired valvular heart disease (P = 0.037), and former cardiac surgery (P = 0.041). Age, gender, arterial hypertension, cardiomyopathy, congenital heart disease, left ventricular ejection fraction, and time period between stress-exercise examination and pacemaker implantation were not significant predictors of CI. Chronic antiarrhythmic therapy with digitalis (P = 0.013), beta blockers (P = 0.036), and amiodarone (P = 0.045) were significant predictors of CI. In contrast, medication with class I and IV antiarrhythmics had no significant correlation with CI., Conclusion: We found the following characteristics predictive of CI in this pacemaker patient population: VO(2) max, existence of coronary artery disease or acquired valvular heart disease, previous cardiac surgery, as well as medication with digitalis, beta blockers, and amiodarone.

This case report describes a transient pacemaker exit block due to subcutaneous emphysema following pneumothorax. Pneumothorax after pacemaker implantation is rare, but development of subcutaneous emphysema under such circumstances is even more uncommon. Exit block develops only with the use of unipolar leads; with implantation of bipolar leads, this complication cannot occur.

Piezoelectric activity-based rate responsive pacemakers are commonly implanted with the sensor facing inward. This study was conducted to assess the safe and effective rate response of an activity-based rate responsive pacemaker implanted with the sensor facing outward. A comparison were made to a previously studied patient group with sensor facing inward. Patient and pacemaker data was collected at predischarge and 2-month follow-up. Two-minute hall walks in conjunction with programmer-assisted rate response assessment were utilized to standardize initial rate response parameter settings for both patient groups. At 2-month follow-up, sensor rate response to a stage 3 limited CAEP protocol was recorded. Adequate sensor rate response was achieved for both patient groups. No difference was noted in reported patient complications for both groups. A statistically significant difference in programmed rate response curve setting and activity threshold for the two groups was noted at 2-month follow-up. Adequate sensor rate response was achieved for a patient population implanted with an activity-based rate responsive pacemaker with sensor facing outward. In this orientation, one higher rate response curve setting and an activity threshold one value more sensitive were required on average when compared to the normal sensor orientation group.