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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.

Increased heart rate at rest (HR) is a risk factor of sudden cardiac death (SCD) and cardiovascular mortality.Retrospective assessment of increased HR influence on mortality and ventricular tachycardia followed by adequate ICD intervention.350 patients (52 female, 298 male), mean age 65.1+/-10.1 years (22-89 years) with ICD without resynchronization function implanted between 2008 and 2010 were examined. ECGs at rest were used to determine HR. In case of atrial fibrillation, mean value of 2 shortest and longest RR intervals was calculated to determine HR.During the mean observation period of 387+/-300 days, 73 patients (66 male, 7 female), mean age 63.7+/-12.2 years (22-89) had an arrhythmial/intervention, and 46 patients (9 male, 37 feamle), mean age 68.8+/-10.3 years (43-86) died. To optimize sensitivity and specificity of HR, cut off point was established using ROC curve (79/min). Number of patients with HR79/min was significantly higher (64.7% vs 19,1%, p0.022) in the group of patients with arrhyth-mialintervention vs no arrhythmial/intervention, and in dead vs alive patients (73.9% vs 19.5%, p0,001). Kaplan-Meier univariate analysis proved, that HRor =79/min was an important factor increasing probability of survival (p0.001) and arrhythmial/intervention free live (p0.012). HR79/ min particularly predisposed to fast ventricular arrhythmias and interventions - CV (p0.092). In Cox multivariate analysis, HRor =79/min was a protective factor only in death risk (HR=0.2362, 95%CI=0.1094-0.5099, p0.0002).An important factor increasing probability of survival without ventricular arrhythmia or death was a mean heart rate below 79/min. The cycle length of the baseline rhythm determine the arrhythmia cycle length.

There is no research on the change of quality of life and NYHA classification after pacing system upgrade performed as a treatment of advanced heart failure during a long observation period in a particular population of patients with long-term apical right ventricular pacing, permanent atrial fibrillation and complete atrio-ventricular block. The aim of the study was evaluation of changes in quality of life and NYHA class in group of patients in which upgrade from right ventricular apical pacing to biventricular or bifocal right ventricular pacing was done.Evaluation of quality of life was performed in a chosen group of 27 patients (20 males, mean age 71.2) who completed the 12-month observation period. Quality of life was assessed by the Short Form-36 (SF-36) questionnaire. The first examination was carried out before the planned pacing system upgrade, that is, when advanced heart failure appeared in the course of permanent atrial fibrillation and right ventricular apical pacing present for a long time (on average 7.7 years). The change of quality of life after 12-month period of upgrade pacing system was analyzed. A comparison of patient's self assessment (as far as physical aspect of quality of life is concerned - Physical Component Summary - PCS) with doctor's interview concerning NYHA classification was performed. Additionally quality of life pointed out by a patient was analyzed in relation to the diseases most common in this population: hypertension, diabetes mellitus and renal failure. Because the questionnaires were completed by the patients personally without the third party, the assessment referred to mistakes in filling in the questionnaires (quantity of missed questions and incorrect marking the answers by adding individual comments) in relation to patients' age.In 12-month follow-up after pacing system upgrade, improvement of quality of life was found in 48.1% of patients. Assessment of physical aspect of quality of life was possible due to SF-36. Improvement occurred in 55.5% of patients, however in relation with NYHA classification improvement appeared in 51.8% of patients. Improvement in NYHA was in significant correlation with improvement in physical aspect of life (p = 0.025), especially in the subgroup treated by pacing system upgrade to bifocal right ventricular pacing (p = 0.0066). In the subgroup with improvement, hypertension and diabetes were less frequent, however frequency of renal failure was greater, than in the subgroup without quality of live improvement. Both before and after pacing system upgrade, there was no significant connection (only a trend) between the number of mistakes done during self-completion of the questionnaires and patients' age.In 12-month follow-up after pacing system upgrade, improvement of quality of life was found in 48.1% of patients. There exists a significant correlation between the improvement of physical efficiency in NYHA class and the improvement in physical aspect of quality of life in patients' self assessment (p = 0.025). In the subgroup treated by pacing system upgrade to bifocal right ventricular pacing this correlation is especially strong (p = 0.0066).

Cardiac resynchronization therapy (CRT) is an acknowledged treatment for advanced heart failure in acquired dilated cardiomyopathy, resistant to pharmacotherapy. Although there are no therapeutic standards regarding heart failure originating from congenital heart defects with systemic right ventricle, a number of CRT implantations by transvenous approach in congenitally corrected transposition of the great arteries (CCTGA) have been reported since 2001, even though none of them expressly referred to a case concomitant with dextrocardia and situs inversus anomaly. We present a 57 year-old patient with dextrocardia and CCTGA, who underwent surgical closure of interatrial and interventricular septal defects at the age of 19, and in whom a VVI pacemaker was subsequently implanted at age 36. A three-lead CRT system was implanted by transvenous approach. Imaging techniques, including multi-slice computed tomography, targeted to pacing system and unusual anatomical relationships were applied. Within a 20-month follow-up, a significant improvement of functional NYHA class, systemic right ventricle ejection fraction and exercise capability were observed. Entirely transvenous CRT system implantation is feasible in patients with dextrocardia and CCTGA, and has substantial potential for long-term benefits.

Although transvenous pacing is a safe treatment modality for bradyarrhythmias, serious thrombotic and embolic complications are reported to occur in 0.6-3.5% of cases. We describe a case of pacemaker-associated thrombosis, with an axillary and subclavia veins thrombosis. The patient was treated with subcutaneous heparin which proved successful as the sole treatment.

We describe a case of percutaneous removal of endocardial implantable cardioverter-defibrillator lead displaced to the right pulmonary artery. The procedure was performed from two accesses; from the lower one (femoral) and then, due to technical problems, from the upper one (subclavian). In the last stage the flattened Dotter's basket was introduced to the heart inside the Byrd dilator and then fastened to the described lead as the external 'splint'. This solution is an alternative to the recommended use of the internal metal leader with anchoring function in case of significant malformation of the internal lumen of the lead. The procedure we describe is an example of the sort of individual, original solution indispensable for the efficient and safe removal of untypically displaced leads.

We describe a method of regaining venous access to the heart in a patient with permanent atrial stimulation, in whom the pacing system upgrade to the atrio-ventricular one was necessary. However, left subclavian vein occlusion was found. We used an existing lead as a conduit. During such treatment the lead was removed. After a recanalisation the therapeutic aim was achieved - there were two new leads implanted.

The expanding number of patients treated with pacing, especially resynchronisation therapy and pacing system upgrades as well as leads remaining inactive, and prolonged life expectancy are the causes of an increase of the number of electrodes in pacemaker patients. The growing problem with endocardial lead infections and excess leads has made percutaneous lead removal technology widespread as it is less invasive than cardiosurgery.We present our experience in percutaneous lead removal in a single reference centre in Poland.During 2.5 years, 236 leads in 120 patients were removed. The criterion for inclusion in the present analysis was the age of the oldest lead:12 months in pacemaker patients and6 months in patients with implantable cardioverter-defibrillators (ICD). All patients admitted to the hospital for lead removal underwent a percutaneous procedure. The age of the patients ranged from 18 to 87 (mean 65.7) years. The leads were removed using the Lead Extraction System (Cook) with the rotational cutting force only, notlaser or RF energy.Indications for lead removal were: local (pocket) infection (47%), endocarditis (27%) and lead excess (26%). Seventy six percent of patients had at least two pacemaker/ICD-related procedures whereas 24% had only one implantation procedure in the past. The median time from the preceding procedure was 12 months. In 38 patients there were 60 inactive electrodes. The majority of patients had two (62%) or three (19%) leads, followed by 12% with one lead and 7% of patients with more than three leads. In 27.5% of patients leads from the coronary sinus were removed. The complication rate was 4%.Percutaneous lead removal procedures are performed in Poland for class I and II indications according to NASPE classification. In many cases patients had multiple leads, including in the coronary sinus. The majority of patients had two or more interventions in the past.

A case of 72 year old-male with cor triatriatum sinister, permanent atrial fibrillation and symptomatic bradycardia is presented. Patient was scheduled for pacemaker implantation. A preoperative evaluation with transesophageal echocardiography revealed a nonrestrictive membrane in left atrium, normal right superior vena cava and absence of persistent left superior vena cava and other cardiac anomalies. A right ventricular pacemaker lead was implanted through left subclavian approach. Preoperative evaluation shortened a radiation exposure and procedure time.

We present a 59 year old patient with advanced heart failure who underwent lead extraction. The lead was implanted 11 years ago, and 2 years later looped spontaneously following its fracture. The transvenous extraction process through inferior vena cava was complicated by knotting of the inactive lead over the active ventricular lead. The patient was pacemaker-dependent. Finally, the old lead was successfuly explanted. The active intact lead was used to create resynchronisation system.

A 61-year-old patient with a 20-year history of permanent pacemaker implantation and half--a-year cardiac resynchronization therapy using a left ventricular lead placed via surgical approach was admitted for extraction of an old coiled right ventricular lead, which triggered ventricular arrhythmia and created a risk of pulmonary embolism. The lead was extracted via the left femoral vein in two stages: untying a loop on the lead using a pig-tail catheter and Dotter basket followed by traction and dissection of adhesions using a Byrd dilator sheath. Dissection of the old lead from the active right ventricular one posed special technical problems.

Pacemaker dependency (PD) can be defined as the risk of serious injury or death from sudden pacemaker failure, an event more dangerous than progressive rate decrease. The aim of this study was to evaluate the incidence of PD during long-term follow-up after pacing system implantation.The study included 3638 patients (mean age 65.3 +/- 10.2 years). Indications for pacing were sick sinus syndrome (SSS) in 1315 patients, atrioventricular block (AVB) in 1482, AVB and SSS in 478 and atrial fibrillation (AF) with bradycardia in 363 patients. The mean follow-up was 4.8 +/- 1.8 years. Pacemaker dependency was defined as the absence of an intrinsic rhythm of 30 beats/min during back-up pacing and after switching off the pacemaker. If any significant symptoms of bradycardia developed or if the underlying rhythm did not appear (asystole5 s) the pacing was restarted. Pacemaker dependency was observed in 76 (2.1%) of the 3638 patients . In this subgroup pacing indications were SSS in 8 (0.6%) of 1315 patients, AVB in 52 (3.5%) of 1482, SSS and AVB in 15 (3.1%) of 478 and AF with bradycardia in 1 (0.3%) of 363. Patients with AVB had a significantly higher incidence of PD than patients with SSS or AF (p0.001, p0.005, respectively). A total of 139 patients suffered from myocardial infarction and 106 patients had a temporary pacing prior to pacemaker implantation. The majority of these patients were pacemaker dependent (p0.001).In our study PD occurred very rarely, being found in 2.1% of all patients. Patients with AVB have a significantly higher incidence of PD than patients with SSS or AF. Temporary pacing prior to pacemaker implantation and previous myocardial infarction indicate patients at risk of PD development. (Cardiol J 2007; 14: 83-86).