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Copyright of Anaesthesiologie & Intensivmedizin is the property of DGAI e.V. - Deutsche Gesellschaft fur Anasthesiologie und Intensivmedizin e.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Zeitschrift für Herz-, Thorax- und Gefaesschirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

A 50-year-old male patient with cardiomyopathy (New York Heart Association Class IV, left ventricle ejection fraction of 15%, left bundle branch block, intermittent supraventricular tachycardia, tricuspid regurgitation, and mitral regurgitation) was qualified for a cardiac resynchronization therapy with defibrillator (CRT-D) procedure. CRT-D has become an integral part of systolic heart failure therapy. It can minimize rehospitalization, improve the exercise capacity and well-being of the patient, and potentially decrease mortality. After the CRT-D implantation, electrocardiographic changes were found to be reverted. No hospitalization was reported at 2-year follow-up. The patient survived and regained his quality of life.

Background When cardiac implantable electronic device infection occurs, standard therapy is usually total system extraction. Transvenous lead extraction is preferable to open heart surgical extraction, unless contraindicated because of the presence of very large vegetations on the intravenous leads according to the European Society of Cardiology guidelines. Extraction of transvenous leads with vegetations risks distal embolism resulting in obstruction and/or infection in the pulmonary arteries. Catheter aspiration of vegetations or thrombi has been performed prior to transvenous lead extraction using a partial veno-venous extracorporeal bypass circuit. We report the use of a single-access aspiration system using the Inari FlowTriever 24 French system to debulk a defibrillator lead before percutaneous extraction. Case summary A 79-year-old male presented with fever 18 years after his first implantable cardioverter defibrillator implant and 9 years after his most recent pulse generator change. Two large vegetations were identified on his transvenous defibrillator lead on the atrial aspect, near the tricuspid annulus, which were aspirated using the Inari Medical 24Fr FlowTriever aspiration catheter. We describe anatomical considerations during the approach and a technique to localize the vegetations based on a combination of fluoroscopy and transoesophageal echocardiogram guidance. Discussion This case demonstrates the safe and effective use of the Inari Medical 24Fr FlowTriever aspiration catheter in debulking a defibrillator lead before transvenous lead extraction. This method uses a single venous puncture and is not dependent on extracorporeal bypass. Apart from reducing complexity, this technique may be advantageous in patients where anticoagulation needs to be minimised. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) may be asymptomatic and the extensive monitoring capabilities of cardiac implantable electronic devices (CIEDs) revealed asymptomatic atrial tachi-arrhythmias of short duration (minutes-hours) occurring in patients with no prior history of AF and without AF detection at a conventional surface ECG. Both the terms "AHRE" (Atrial High-Rate Episodes) and subclinical AF were used in a series of prior studies, that evidenced the association with an increased risk of stroke. Two randomized controlled studies were planned in order to assess the risk-benefit profile of anticoagulation in patients with AHRE/subclinical AF: the NOAH and ARTESiA trials. The results of these two trials (6548 patients enrolled, overall) show that the risk of stroke/systemic embolism associated with AHRE/subclinical AF is in the range of 1–1.2 % per patient-year, but with an important proportion of severe/fatal strokes occurring in non-anticoagulated patients. The apparent discordance between ARTESiA and NOAH results may be approached by considering the related study-level meta-analysis, which highlights a consistent reduction of ischemic stroke with oral anticoagulants vs. aspirin/placebo (relative risk [RR] 0.68, 95 % CI 0.50–0.92). Oral anticoagulation was found to increase major bleeding (RR 1.62, 95 % CI 1.05–2.5), but no difference was found in fatal bleeding (RR 0.79, 95 % CI 0.37–1.69). Additionally, no difference was found in cardiovascular death or all-cause mortality. Taking into account these results, clinical decision-making for patients with AHRE/subclinical AF at risk of stroke, according to CHA 2 DS 2 -VASc, can now be evidence-based, considering the benefits and related risks of oral anticoagulants, to be shared with appropriately informed patients. [ABSTRACT FROM AUTHOR]

Abstract Introduction COVID‐19 drastically impacted the landscape of the United States’ medical system. Limited data is available on the nationwide implantation trends in Cardiac Resynchronization Therapy Defibrillator (CRT‐D) devices before and during the pandemic. We aimed to explore the impact of the COVID‐19 pandemic on CRT‐D insertion rates and adverse outcomes related to delays in care. Methods and Results We conducted a retrospective cross‐sectional analysis using the National Inpatient Sample database between 2017 and 2020. Variables were identified using their ICD‐10 codes. Inclusion criteria: age ≥ 18 years, presenting for a nonelective admission, primary diagnosis of hypertensive heart disease, hypertensive heart, chronic kidney disease, or heart failure, and underwent insertion of a CRT‐D. Between 2017 and 2020, CRT‐D devices were inserted during 23,635 admissions. On average, 6198 devices were implanted yearly from 2017 to 2019, with only 5040 devices being implanted in 2020. Additionally, reduced implantation rates were noted for every cohort of hospital size, location, and teaching status during this year. The year 2020 also had the highest average death rate at 1.39%, but this difference was statistically insignificant (adjusted Wald test p = .767), and COVID‐19 was not associated with an increased risk of inpatient mortality (OR 0.22, 95% CI 0.03–1.82, p = .162). Conclusion The COVID‐19 pandemic has affected all facets of the healthcare system, especially surgical volume rates. CRT‐D procedures significantly decreased in 2020. This is the first retrospective study highlighting the trend of reduced rates of CRT‐D implantation as a response to the COVID‐19 pandemic.

Introduction: COVID-19 drastically impacted the landscape of the United States' medical system. Limited data is available on the nationwide implantation trends in Cardiac Resynchronization Therapy Defibrillator (CRT-D) devices before and during the pandemic. We aimed to explore the impact of the COVID-19 pandemic on CRT-D insertion rates and adverse outcomes related to delays in care. Methods and Results: We conducted a retrospective cross-sectional analysis using the National Inpatient Sample database between 2017 and 2020. Variables were identified using their ICD-10 codes. Inclusion criteria: age ≥ 18 years, presenting for a nonelective admission, primary diagnosis of hypertensive heart disease, hypertensive heart, chronic kidney disease, or heart failure, and underwent insertion of a CRT-D. Between 2017 and 2020, CRT-D devices were inserted during 23,635 admissions. On average, 6198 devices were implanted yearly from 2017 to 2019, with only 5040 devices being implanted in 2020. Additionally, reduced implantation rates were noted for every cohort of hospital size, location, and teaching status during this year. The year 2020 also had the highest average death rate at 1.39%, but this difference was statistically insignificant (adjusted Wald test p = .767), and COVID-19 was not associated with an increased risk of inpatient mortality (OR 0.22, 95% CI 0.03-1.82, p = .162). Conclusion: The COVID-19 pandemic has affected all facets of the healthcare system, especially surgical volume rates. CRT-D procedures significantly decreased in 2020. This is the first retrospective study highlighting the trend of reduced rates of CRT-D implantation as a response to the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Aims Catheter ablation (CA) of ventricular tachycardia (VT) has become an important tool to improve clinical outcomes in patients with appropriate transvenous implantable cardioverter defibrillator (ICD) shocks. The aim of our analysis was to test whether VT ablation (VTA) impacts long-term clinical outcomes even in subcutaneous ICD (S-ICD) carriers. Methods and results International Subcutaneous Implantable Cardioverter Defibrillator (iSUSI) registry patients who experienced either an ICD shock or a hospitalization for monomorphic VT were included in this analysis. Based on an eventual VTA after the index event, patients were divided into VTA+ vs. VTA− cohorts. Primary outcome of the study was the occurrence of a combination of device-related appropriate shocks, monomorphic VTs, and cardiovascular mortality. Secondary outcomes were addressed individually. Among n = 1661 iSUSI patients, n = 211 were included: n = 177 experiencing ICD shocks and n = 34 hospitalized for VT. No significant differences in baseline characteristics were observed. Both the crude and the yearly event rate of the primary outcome (5/59 and 3.8% yearly event rate VTA+ vs. 41/152 and 16.4% yearly event rate in the VTA−; log-rank: P value = 0.0013) and the cardiovascular mortality (1/59 and 0.7% yearly event rate VTA+ vs. 13/152 and 4.7% yearly event rate VTA−; log-rank P = 0.043) were significantly lower in the VTA + cohort. At multivariate analysis, VTA was the only variable remaining associated with a lower incidence of the primary outcome [adjusted hazard ratio 0.262 (0.100–0.681), P = 0.006]. Conclusion In a real-world registry of S-ICD carriers, the combined study endpoint of arrhythmic events and cardiovascular mortality was lower in the patient cohort undergoing VTA at long-term follow-up. ClinicalTrials.gov identifier NCT0473876. [ABSTRACT FROM AUTHOR]

Objectives: To determine the annual numbers of first ICD insertions in New South Wales during 2005–2020; to examine health outcomes for people who first received ICDs during this period. Study design: Retrospective cohort study; analysis of linked administrative health data. Setting, participants: All first insertions of ICDs in NSW, 2005–2020. Main outcome measures: Annual numbers of first ICD insertions, and of emergency department presentations and hospital re‐admissions 30 days, 90 days, 365 days after first ICD insertions; all‐cause and disease‐specific mortality (to ten years after ICD insertion). Results: During 2005–2020, ICDs were first inserted into 16 867 people (18.5 per 100 000 population); their mean age was 65.7 years (standard deviation, 13.5 years; 7376 aged 70 years or older, 43.7%), 13 214 were men (78.3%). The annual number of insertions increased from 791 in 2005 to 1256 in 2016; the first ICD insertion rate increased from 15.5 in 2005 to 18.9 per 100 000 population in 2010, after which the rate was stable until 2019 (19.8 per 100 000 population). Of the 16 778 people discharged alive from hospital after first ICD insertions, 54.4% presented to emergency departments within twelve months, including 1236 with cardiac arrhythmias (7.4%) and 434 with device‐related problems (2.6%); 56% were re‐admitted to hospital, including 1944 with cardiac arrhythmias (11.5%) and 2045 with device‐related problems (12.1%). A total of 5624 people who received first ICDs during 2005–2020 (33.3%) died during follow‐up (6.7 deaths per 100 person‐years); the survival rate was 94.4% at one year, 76.5% at five years, and 54.2% at ten years. Conclusions: The annual number of new ICDs inserted in NSW has increased since 2005. A substantial proportion of recipients experience device‐related problems that require re‐admission to hospital. The potential harms of ICD insertion should be considered when assessing the likelihood of preventing fatal ventricular arrhythmia. [ABSTRACT FROM AUTHOR]

Background: The Virtual Reality Headset (VRH) is a device aiming at improving patient's comfort by reducing pain and anxiety during medical interventions. Its interest during cardiac implantable electronic devices (CIED) implant procedures has not been studied. Methods: We randomized consecutive patients admitted for pacemaker or Implantable Cardioverter Defibrillator (ICD) at our center to either standard analgesia care (STD-Group), or to VRH (VRH-Group). Patients in the STD-Group received intra-venous paracetamol (1 g) 60 min before the procedure, and local anesthesia was performed with lidocaine. For patients of the VRH-Group, VRH was used on top of standard care. We monitored patients' pain and anxiety using numeric rating scales (from 0 to 10) at the time of sub-cutaneous pocket creation, and during deep axillary vein puncture. Patient comfort during the procedure was assessed using a detailed questionnaire. Morphine consumption was also assessed. Results: We randomized 61 patients to STD-Group (n = 31) or VRH-Group (n = 30). Pain and anxiety were lower in the VRH-Group during deep venous puncture (3.0 ± 2.0 vs. 4.8 ± 2.2, p = 0.002 and 2.4 ± 2.2 vs. 4.1 ± 2.4, p = 0.006) but not during pocket creation (p = 0.58 and p = 0.5). Morphine consumption was lower in the VRH-Group (1.6 ± 0.7 vs. 2.1 ± 1.1 mg; p = 0.041). Patients' overall comfort during procedure was similar in both groups. Conclusion: VRH use improved pain and anxiety control during deep venous puncture compared to standard analgesia care, and allowed morphine consumption reduction. However, pain and anxiety were similar at the time of sub-cutaneous pocket creation. [ABSTRACT FROM AUTHOR]

This study aimed to characterise the level of access to magnetic resonance imaging (MRI) in Australian hospitals for patients with MR-conditional and non-MR-conditional cardiac implantable electronic devices (CIED), and to identify any barriers impeding this access. All Australian Tertiary Referral Public Hospitals (n=38) were surveyed with a mixed qualitative and quantitative questionnaire. Provision of MRI to patients with MR-conditional and non-MR-conditional CIEDs; patient monitoring strategies during scan and personnel in attendance; barriers impeding MRI access. Of the 35 (92%) hospitals that completed the survey, a majority (85.7%) scan MR-conditional CIEDs, while a minority (8.6%) scan non-MR-conditional CIEDs. MR-conditional device scanning is often limited to non-pacing dependent patients, excluding implantable cardioverter–defibrillators. In total, 21% of sites exclude thoracic MR scans for CIED patients. Although most centres scan on 1.5 Tesla (T) machines (59%), 10% scan at 3T and 31% scan at both strengths. Sites vary in patient monitoring strategies and personnel in attendance; 80% require staff with Advanced Cardiac Life Support to be present. Barriers to service expansion include an absence of national guidelines, formal training, and logistical device support. Most surveyed Australian hospitals offer MRI for patients with MR-conditional CIEDs, however many still have exclusions for particular patient groups or scan requests. Only three surveyed sites offer MRI for patients with non-MR-conditional CIEDs in Australia. A national effort is needed to address the identified barriers including the development of national guidelines, formal training, and logistical support. [ABSTRACT FROM AUTHOR]

Defibrillators are used to restore coordinated electromechanical activity in the heart by applying a controlled electric shock to the myocardium. Essential components are needed within the electrical circuits to deliver a safe and effective shock including a capacitor, an inductor, and a transformer. Understanding the function of each component will enhance the user's application of this crucial device in clinical practice. Equally, recognizing the significant effect from the type of waveform used on determining the success of defibrillation is essential knowledge. Furthermore, appropriate perioperative management of implantable cardiac defibrillators is needed to ensure patient safety. [ABSTRACT FROM AUTHOR]

Copyright of Herzschrittmachertherapie und Elektrophysiologie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Cardiac pacemaker implantation after orthotopic heart transplantation declined dramatically after development of the bicaval anastomosis technique. However, much less is known about the rate, indications, and predictors of device implantation procedures with the current surgical technique. The purpose of this study was to evaluate the indications, patient characteristics, incidence, and survival related to cardiac implantable electronic device (CIED) implantation after heart transplantation. This was a single-center study of 399 consecutive adult recipients of orthotopic heart transplants with bicaval anastomosis from 1991 to 2017. The primary end point was freedom from pacemaker or implantable cardioverter-defibrillator (ICD) implantation, and the secondary end point was all-cause mortality. At the time of transplantation, the mean age of recipients was 50 ± 12 years and that of donors 31 ± 12 years. CIEDs were implanted in 8% of recipients (n = 31): 11 pacemakers (35%) for sinus node dysfunction, 17 (55%) for high-grade heart block, and 3 ICDs (10%) for the primary prevention of sudden cardiac death. Early CIED implantation (<30 days) was rare and absent for sinus node dysfunction. The risk for CIED implantation increased progressively during follow-up (0–30 years; median 11 years), with low-, moderate-, and high-risk periods between 0 and 10, between 10 and 20, and between 20 and 30 years, respectively. Recipients receiving CIEDs survived longer after transplantation (21 years vs 13 years; P <.01). Recipients receiving pacemakers for heart block were more likely to receive older donor hearts at the time of transplantation. The risk of pacemaker implantation increases progressively, while ICD implantation is rare. Donor age is the predominant risk factor for subsequent heart block. Early sinus node dysfunction requiring permanent pacing is rare. [ABSTRACT FROM AUTHOR]

The approach/type of an implantable cardioverter defibrillator (ICD) is determined by the underlying cardiac anatomy, venous access, and pre-existing cardiac implantable electronic devices. We describe a case of subcutaneous ICD implantation in an adult with congenital heart disease (CHD) with a pre-existing inframammary transvenous pacemaker. This was preferred over adding a defibrillator coil to existing pacing leads, extraction/replacement of pacing system, or a sternotomy/epicardial ICD placement. The procedure was accomplished uneventfully with successful defibrillation threshold testing. Innovative approaches are required to manage arrhythmias in adults with CHD, with shared decision making playing a critical role.

Background: Anomalous left brachiocephalic vein (ALBCV) is a rare venous anomaly. Double Left brachiocephalic vein is the rarest type of ALBCV anomaly. Case report: Here we report a case of gentleman with post myocardial infarction ventricular tachycardia who underwent ICD implantation, where we could not place the lead initially through left side. CT angiography revealed presence of a duplicated circumaortic left BCV. It's cranial limb coursing normally anterior to arch and compressed at its confluence with RBCV and the caudal limb with a subaortic course draining into the RSVC. We report this first case of double LBCV along with right sided aortic arch and aberrant origin of LSCA arising from Kommerel's diverticulum. Conclusion: This case highlights that interventional cardiologists should be aware of these venous anomalies for proper planning and implantation of CIED successfully via transvenous approach.

Cardiac implantable electronic devices (CIEDs) improve quality of life and prolong survival, but there are additional considerations for cardiovascular imaging after implantation—both for standard indications and for diagnosing and guiding management of device-related complications. This clinical consensus statement (part 2) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients after implantation of conventional pacemakers, cardioverter defibrillators, and cardiac resynchronization therapy (CRT) devices. The document summarizes the existing evidence regarding the role and optimal use of various cardiac imaging modalities in patients with suspected CIED-related complications and also discusses CRT optimization, the safety of magnetic resonance imaging in CIED carriers, and describes the role of chest radiography in assessing CIED type, position, and complications. The role of imaging before and during CIED implantation is discussed in a companion document (part 1). [ABSTRACT FROM AUTHOR]

More than 500 000 cardiovascular implantable electronic devices (CIEDs) are implanted in the European Society of Cardiology countries each year. The role of cardiovascular imaging in patients being considered for CIED is distinctly different from imaging in CIED recipients. In the former group, imaging can help identify specific or potentially reversible causes of heart block, the underlying tissue characteristics associated with malignant arrhythmias, and the mechanical consequences of conduction delays and can also aid challenging lead placements. On the other hand, cardiovascular imaging is required in CIED recipients for standard indications and to assess the response to device implantation, to diagnose immediate and delayed complications after implantation, and to guide device optimization. The present clinical consensus statement (Part 1) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients undergoing implantation of conventional pacemakers, cardioverter defibrillators, and resynchronization therapy devices. The document summarizes the existing evidence regarding the use of imaging in patient selection and during the implantation procedure and also underlines gaps in evidence in the field. The role of imaging after CIED implantation is discussed in the second document (Part 2). [ABSTRACT FROM AUTHOR]

Subcutaneous implantable cardioverter defibrillators (S-ICDs) are being used with increased frequency in children and patients with congenital heart disease. Vascular access complexities, intracardiac shunts, and specific anatomies make these devices particularly appealing for some of these patients. Alternative screening, implantation, and programming techniques should be considered based on patient size, body habitus, anatomy, procedural history, and preference. Appropriate and inappropriate shock rates are generally comparable to those seen with transvenous devices. Complications such as infection can occur, although their severity is likely to be less than that seen with transvenous devices. Technical advances are likely to further broaden S-ICD applicability. [ABSTRACT FROM AUTHOR]

Infection is the most dreaded complication of cardiac implantable electronic devices (CIEDs), particularly in patients undergoing high-risk procedures (eg, generator change, device upgrade, lead/pocket revision). The purpose of this study was to describe the impact of chlorhexidine gluconate (CHG) pocket lavage in high-risk procedures. Patients from a prospective multicenter registry undergoing high-risk procedures were included. CHG lavage was performed by irrigating the generator pocket with 20 cc of 2% CHG without alcohol followed by and normal saline (NS) irrigation. Only NS irrigation was performed in the comparison group. The primary efficacy outcome was CIED-related infection at 12 months. The primary safety outcome was any CHG-associated adverse event. The secondary outcome was CIED infection during long-term follow-up. Propensity score matching (PSM) analysis was performed for the primary efficacy outcome. A total of 1504 patients were included. At 12-month follow-up, the primary efficacy outcome occurred in 4 of 904 CHG (0.4%) and 14 of 600 NS (2.3%) subjects (log-rank P =.005). On multivariate analysis, the use of CHG irrigation was associated with a lower risk of infection at 1-year follow-up (Cox proportional hazard ratio [HR] 0.138; 95% confidence interval [CI] 0.04–0.45; P =.001). This effect persisted during long-term follow-up. PSM demonstrated a significant reduction in CIED-related infection for the CHG group (0.2% vs 2.5%; Cox proportional HR 0.08; 95% CI 0.01–0.59; P =.014). No adverse events were associated with the use of CHG. CHG lavage during high-risk procedures was associated with a reduction in CIED-related infections without any adverse events reported. The benefits of CHG lavage were observed even during long-term follow up and in PSM analysis. [Display omitted] [ABSTRACT FROM AUTHOR]

Risk stratification for sudden death should be discussed with patients with congenital heart disease at each stage of personal and cardiac development. For most patients, risk is low through teenage years and the critical factors to consider are anatomy, ventricular function, and symptoms. By adulthood, these are supplemented by screening for atrial arrhythmias, ventricular arrhythmias, and pulmonary hypertension. Therapies include medication, ablation, and defibrillator placement. [ABSTRACT FROM AUTHOR]

Pediatric patients with congenital heart disease present unique challenges when it comes to cardiac implantable electronic devices. Pacing strategy is often determined by patient size/weight and operator experience. Anatomic considerations, including residual shunts, anatomic obstructions and barriers, and abnormalities in the native conduction system, will affect the type of CIED implanted. Given the young age of patients, it is important to have an "eye on the future" when making pacemaker/defibrillator decisions, as one can expect several generator changes, lead revisions, and potential lead extractions during their lifetime. [ABSTRACT FROM AUTHOR]

The article describes the case of a 55-year-old man with arrhythmogenic cardiomyopathy with biventricular involvement who was referred for subcutaneous defibrillator (S-ICD) removal and dual chamber implantable cardioverter defibrillator (ICD) implanation. Topics discussed include his left ventricular ejection fraction on echocardiography, his medical therapy, and advantage of antitachycardia pacing (ATP) offered by transvenous ICDs over S-ICDs.

BackgroundIn the US, 1.4 million people have implanted ICDs for reducing the risk of sudden death due to ventricular arrhythmias. Cardiac MRI (cMR) is of particular interest in the ICD patient population as cMR is the optimal imaging modality for distinguishing cardiac conditions that predispose to sudden death, and it is the best method to plan and guide therapy. However, all ICDs contain a ferromagnetic transformer which imposes a large inhomogeneous magnetic field in sections of the heart, creating large image voids that can mask important pathology. A shim system was devised to resolve these ICD issues. A shim coil system (CSS) that corrects ICD artifacts over a user-selected Region-of-Interest (ROI), was constructed and validated.MethodsA shim coil was constructed that can project a large magnetic field for distances of ~15 cm. The shim-coil can be positioned safely anywhere within the scanner bore. The CSS includes a cantilevered beam to hold the shim coil. Remotely controlled MR-conditional motors allow 2 mm-accuracy three-dimensional shim-coil position. The shim coil is located above the subjects and the imaging surface-coils. Interaction of the shim coil with the scanner’s gradients was eliminated with an amplifier that is in a constant current mode. Coupling with the scanners’ radio-frequency (rf) coils, was reduced with shielding, low-pass filters, and cable shield traps. Software, which utilizes magnetic field (B0) mapping of the ICD inhomogeneity, computes the optimal location for the shim coil and its corrective current. ECG gated single- and multiple-cardiac-phase 2D GRE and SSFP sequences, as well as 3D ECG-gated respiratory-navigated IR-GRE (LGE) sequences were tested in phantoms and N = 3 swine with overlaid ICDs.ResultsWith all cMR sequences, the system reduced artifacts from >100 ppm to

(1) Introduction: Digitalis use in patients with severe heart failure is controversial. We assessed the effects of digitalis therapy on mortality in a large, observational study in recipients of cardiac resynchronization therapy (CRT). (2) Methods: Consecutive patients receiving a CRT-defibrillator in three European tertiary referral centers were enrolled and followed-up for a mean 37 months ± 28 months. Digitalis use was assessed at the time of CRT implantation. A multivariate Cox-regression model and propensity score matching were used to determine all-cause mortality as the primary endpoint. CRT-response (defined as improvement of ≥1 NYHA class), echocardiographic improvement (defined as improvement of LVEF of ≥ 5%) and incidence of ICD shocks and rehospitalization were assessed as secondary endpoints in a subgroup of patients. (3) Results: The study comprised 552 CRT-recipients with standard indications, including 219 patients (40%) treated with digitalis. Compared to patients without digitalis, they had more often atrial fibrillation, poorer LVEF and a higher NYHA class (all p ≤ 0.002). Crude analysis of all-cause mortality demonstrated a similar relative risk of death for patients with and without digitalis (HR = 1.14; 95% CI 0.88–1.5; p = 0.40). After adjustment for independent predictors of mortality, digitalis therapy did not alter the risk for death (adjusted HR = 1.04; 95% CI 0.75–1.45; p = 0.82). Furthermore, in comparison to 286 propensity-score-matched patients, mortality was not affected by digitalis intake (propensity-adjusted HR = 1.11; 95% CI 0.72–1.70; p = 0.64). A CRT-response was predominant in digitalis non-users, concerning both improvement of HF symptoms and LVEF (NYHA p < 0.01; LVEF p < 0.01), while patients on digitalis had more often ventricular tachyarrhythmias requiring ICD shock (p = 0.01); although, rehospitalization for cardiac reasons was significantly lower among digitalis users compared to digitalis non-users (HR = 0.58; 95% C. I. 0.40–0.85; p = 0.01). (4) Conclusions: Digitalis therapy had no effect on mortality, but was associated with a reduced response to CRT and increased susceptibility to ventricular arrhythmias requiring ICD shock treatment. Although, digitalis administration positively altered the likelihood for cardiac rehospitalization during follow-up.

Background: Most recent cardiac implantable electronic devices (CIEDs) can safely undergo a cardiovascular magnetic resonance (CMR) scan under certain conditions, but metal artifacts may degrade image quality. The aim of this study was to assess the overall diagnostic yield of CMR and the extent of metal artifacts in a multicenter, multivendor study on CIED patients referred for CMR. Methods: We analyzed 309 CMR scans from 292 patients (age 57 ± 16 years, 219 male) with an MR-conditional pacemaker (n = 122), defibrillator (n = 149), or loop recorder (n = 38); CMR scans were performed in 10 centers from 2012 to 2020; MR-unsafe implants were excluded. Clinical and device parameters were recorded before and after the CMR scan. A visual analysis of metal artifacts was performed for each sequence on a segmental basis, based on a 5-point artifact score. Results: The vast majority of CMR scans (n = 255, 83%) were completely performed, while only 32 (10%) were interrupted soon after the first sequences and 22 (7%) were only partly acquired; CMR quality was non-diagnostic in 34 (11%) scans, poor (<1/3 sequences were diagnostic) in 25 (8%), or acceptable (1/3 to 2/3 sequences were diagnostic) in 40 (13%), while most scans (n = 201, 68%) were of overall good quality. No adverse event or device malfunctioning occurred, and only nonsignificant changes in device parameters were recorded. The most affected sequences were SSFP (median score 0.32 [interquartile range 0.07–0.91]), followed by GRE (0.18 [0.02–0.59]) and LGE (0.14 [0.02–0.55]). ICDs induced more artifacts (median score in SSFP images 0.87 [0.50–1.46]) than PMs (0.11 [0.03–0.28]) or ILRs (0.11 [0.00–0.56]). Moreover, most artifacts were located in the anterior, anteroseptal, anterolateral, and apical segments of the LV and in the outflow tract of the RV. Conclusions: CMR is a versatile imaging technique, with a high safety profile and overall good image quality even in patients with MR-conditional CIEDs. Several strategies are now available to optimize image quality, substantially enhancing overall diagnostic yield. [ABSTRACT FROM AUTHOR]

Cardiac screening has increasingly become a standard part of preventive care for elite athletes in cricket and many other sports around the world. Ideally, a cardiac screening program should be supported by a range of other strategies across the sporting organization focused on quality of care for athletes and prevention of other cardiac emergencies. This narrative review aimed to present key strategies for the successful implementation of cardiac screening and prevention of other cardiac emergencies in the setting of elite cricket. It builds on previous recommendations and adds updated evidence, including cricket-specific evidence. We present key strategies for the prevention of cardiac emergencies in elite cricket. These are cardiac screening, including electrocardiogram (ECG) interpreted by a physician with expertise in athlete ECGs, regular auditing of the cardiac screening program and ongoing quality improvement, building required sports cardiology infrastructure; cardiovascular awareness across the organization, and cardiac emergency preparation, including access to automated external defibrillators (AEDs), cardiopulmonary resuscitation (CPR) training, and prematch medical briefings. Some of these strategies may also be appropriate for nonelite matches but would need to be tailored according to the resources available. The ultimate aim is to provide better cardiac care for cricketers, staff, and the broader community. [ABSTRACT FROM AUTHOR]

BACKGROUND: Clinical features among patients with refractory out-of-hospital cardiac arrest (OHCA) and initial shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia are not well-characterized. METHODS: We compared clinical characteristics and coronary angiographic findings between patients with refractory OHCA (incessant ventricular fibrillation/pulseless ventricular tachycardia after =3 direct-current shocks) and those without refractory OHCA. RESULTS: Between 2014 and 2018, a total of 204 patients with ventricular fibrillation/pulseless ventricular tachycardia OHCA (median age 62; males 78%) were divided into groups with (36%, 74/204) and without refractory arrest (64%, 130/204). Refractory OHCA patients had longer cardiopulmonary resuscitation (23 versus 15 minutes), more frequently required =450 mg amiodarone (34% versus 3.8%), and had cardiogenic shock (80% versus 55%) necessitating higher adrenaline dose (4.0 versus 1.0 mg) and higher rates of mechanical ventilation (92% versus 74%; all P<0.01). Of 167 patients (82%) selected for coronary angiography, 33% (n=55) had refractory OHCA (P=0.035). Significant coronary artery disease (=1 major vessel with >70% stenosis) was present in >70% of patients. Refractory OHCA patients frequently had acute coronary occlusion (64% versus 47%), especially left circumflex (20% versus 6.4%) and graft vessel (7.3% versus 0.9%; all P<0.05) compared with those without refractory OHCA. Refractory OHCA group had higher in-hospital mortality (45% versus 30%, P=0.036) and greater new requirement for dialysis (18% versus 6.3%, P=0.011). After adjustment, refractory OHCA was associated with over 2-fold higher odds of in-hospital mortality (odds ratio, 2.28 [95% CI, 1.06-4.89]; P=0.034). CONCLUSIONS: Refractory ventricular fibrillation/pulseless ventricular tachycardia OHCA was associated with more intensive resuscitation, higher rates of acute coronary occlusion, and poorer in-hospital outcomes, underscoring the need for future studies in this extreme-risk subgroup. [ABSTRACT FROM AUTHOR]

Indications for cardiac implantable electronic devices (CIEDs) are increasing. Almost one-third of device-related infections are endocarditis. Transvenous lead extraction (TLE) has emerged as an effective and safe approach for treating device-related infections and complications. Multiple types of extraction tools are being used worldwide. Our goal is to evaluate the safety and effectiveness of TLE using non-powered extraction tools. The study included patients between October 2018 and July 2022 requiring TLE according to EHRA expert consensus recommendations on lead extraction. A total of 88 consecutive patients were included. Indications for TLE included device-related infections in 74% of the patients. Of those, 32% had device-related endocarditis with or without sepsis. Staphylococcus Aureus was the most frequent pathogen in patients with endocarditis and positive bacteremia, and 57% had negative bloodstream cultures. A total of 150 cardiac pacing and defibrillator leads were targeted for extraction. The mean dwell time for leads was 6.92 ± 4.4 years; 52.8% were older than 5 years, 15.8% were older than ten years, and the longest lead dwell time was 26 years. Patients' age varied between 18 and 98, with a mean age of 66 ± 16 years. Sixty-seven percent of patients were males. Using only non-powered extraction tools, we report 93.3% complete lead removal and 99% clinical success with partial extraction. We report no procedure-related death nor major complications. Minor complication incidence was 6.8%, and all complications resolved spontaneously. The 30-day mortality rate was 3.4%. TLE using non-powered extraction tools is safe and effective even without surgical backup on site. [ABSTRACT FROM AUTHOR]

• Heart failure (HF) is associated with a substantial risk of hospitalizations and adverse outcomes. • In patients with cardiac implantable electronic devices (CIEDs) there is the possibility of multiparametric remote monitoring of HF. • Several CIEDs parameters may result in multiparametric scores predicting patients' risk of worsening HF. • Patients can be managed days or weeks before overt decompensation, at the time of CIEDs pre-clinical alerts. • Decision making on clinical, laboratory or instrumental checks is needed in order to assess the need for escalating HF medications after a remote monitoring alert. In this review we focus on heart failure (HF) which, as known, is associated with a substantial risk of hospitalizations and adverse cardiovascular outcomes, including death. In recent years, systems to monitor cardiac function and patient parameters have been developed with the aim to detect subclinical pathophysiological changes that precede worsening HF. Several patient-specific parameters can be remotely monitored through cardiac implantable electronic devices (CIED) and can be combined in multiparametric scores predicting patients' risk of worsening HF with good sensitivity and moderate specificity. Early patient management at the time of pre-clinical alerts remotely transmitted by CIEDs to physicians might prevent hospitalizations. However, it is not clear yet which is the best diagnostic pathway for HF patients after a CIED alert, which kind of medications should be changed or escalated, and in which case in-hospital visits or in-hospital admissions are required. Finally, the specific role of healthcare professionals involved in HF patient management under remote monitoring is still matter of definition. We analyzed recent data on multiparametric monitoring of patients with HF through CIEDs. We provided practical insights on how to timely manage CIED alarms with the aim to prevent worsening HF. We also discussed the role of biomarkers and thoracic echo in this context, and potential organizational models including multidisciplinary teams for remote care of HF patients with CIEDs. [ABSTRACT FROM AUTHOR]

Diagnosis and risk stratification of rare genetic heart diseases remains clinically challenging. In many cases, there are few data and insufficient numbers to support randomized controlled trials. While implantable cardioverter defibrillator (ICD) use is vital to protect higher-risk individuals from life-threatening ventricular arrhythmias, low-risk individuals also require protection from unnecessary ICDs and their associated complications. Once an ICD has been implanted, appropriate device programming is essential to ensure maximal protection while balancing the risks of inappropriate therapy. [ABSTRACT FROM AUTHOR]

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Introduction: Use of sodium glucose cotransporter 2 inhibitors (SGLT2i) was associated with a reduction in atrial fibrillation hospitalizations. Therefore, we aim to evaluate the effects of SGLT2i on atrial tachy‐arrhythmias (ATA) in patients with cardiac implantable electronic devices (CIEDs). Methods: All 13 888 consecutive patients implanted with a CIED in two tertiary medical centers were enrolled. Treatment with SGLT2i was assessed as a time dependent variable. The primary endpoint was the total number of ATA. Secondary endpoints included total number of ventricular tachy‐arrhythmias (VTA), ATA and VTA, and death. All events were independently adjudicated blinded to the treatment. Multivariable propensity score modeling was performed. Results: During a total follow‐up of 24 442 patient years there were 62 725 ATA and 10 324 VTA events. Use of SGLT2i (N = 696) was independently associated with a significant 22% reduction in the risk of ATA (hazard ratio [HR] = 0.78 [95% confidence interval {CI} = 0.70–0.87]; p <.001); 22% reduction in the risk of ATA/VTA (HR = 0.78 [95% CI = 0.71–0.85]; p <.001); and with a 35% reduction in the risk of all‐cause mortality (HR = 0.65 [95% CI = 0.45–0.92]; p =.015), but was not significantly associated with VTA risk (HR = 0.92 [95% CI = 0.80–1.06]; p =.26). SGLT2i were associated with a lower ATA burden in heart failure (HF) patients but not among diabetes patients (HF: HR = 0.68, 95% CI = 0.58–0.80, p <.001 vs. Diabetes: HR = 0.95, 95% CI = 0.86–1.05, p =.29; p <.001 for interaction between SGLT2i indication and ATA burden). Conclusion: Our real world findings suggest that in CIED HF patients, those with SGLT2i had a pronounced reduction in ATA burden and all‐cause mortality when compared with those not on SGLT2i. [ABSTRACT FROM AUTHOR]

Guidelines are important tools to guide the diagnosis and treatment of patients to improve the decision-making process of health professionals. They are periodically updated according to new evidence. Four new Guidelines in 2021, 2022 and 2023 referred to pediatric pacing and defibrillation. There are some relevant changes in permanent pacing. In patients with atrioventricular block, the heart rate limit in which pacemaker implantation is recommended was decreased to reduce too-early device implantation. However, it was underlined that the heart rate criterion is not absolute, as signs or symptoms of hemodynamically not tolerated bradycardia may even occur at higher rates. In sinus node dysfunction, symptomatic bradycardia is the most relevant recommendation for pacing. Physiological pacing is increasingly used and recommended when the amount of ventricular pacing is presumed to be high. New recommendations suggest that loop recorders may guide the management of inherited arrhythmia syndromes and may be useful for severe but not frequent palpitations. Regarding defibrillator implantation, the main changes are in primary prevention recommendations. In hypertrophic cardiomyopathy, pediatric risk calculators have been included in the Guidelines. In dilated cardiomyopathy, due to the rarity of sudden cardiac death in pediatric age, low ejection fraction criteria were demoted to class II. In long QT syndrome, new criteria included severely prolonged QTc with different limits according to genotype, and some specific mutations. In arrhythmogenic cardiomyopathy, hemodynamically tolerated ventricular tachycardia and arrhythmic syncope were downgraded to class II recommendation. In conclusion, these new Guidelines aim to assess all aspects of cardiac implantable electronic devices and improve treatment strategies.

Implantable cardioverter defibrillators (ICDs) have a long history and have progressed significantly since the 1980s. They have become an essential part of the prevention of sudden cardiac death, with a proven survival benefit in selected patient groups. However, with more recent trials and with the introduction of contemporary heart failure therapy, there is a renewed interest and new questions regarding the role of a primary prevention ICD, especially in patients with heart failure of non-ischaemic aetiology. This review looks at the history and evolution of ICDs, appraises the traditional evidence for ICDs and looks at issues relating to patient selection, risk stratification, competing risk, future directions and a proposed contemporary ICD decision framework.

Short-duration and high-amplitude electric pulses have recently been used for two different biological tasks: stimulating physiological actions such as heart rate or defibrillation and invoking cell annihilation, as in cancer treatment or atrial fibrillation ablation, by electroporation. However, the physics behind the influence of such pulses has been controversial due to the linear methods used in the analyses. We present the results of a simple nonlinear model to study this situation. Results for the specific nonlinear model show that, below a certain pulse duration, stimulating threshold levels increase rapidly, while the delivered energies reach the lowest plateau. This renders former energy estimates based on linear models, which show a distinct minimum in the calculated delivered energy at a certain amplitude which is invalid for the real nonlinear case. It is notable that these results explain why short high-amplitude pulses are more beneficial to the patient than lower and longer ones in pacing. However, these pulses should not be too high, since no additional energy reduction is achieved and electroporation processes could occur. To further reduce the tissue burden, a train of pulses is necessary, but delivered energies become higher. Considering this case, we clarify the difficulty of reaching threshold at the end of the nth pulse for n > 2 not previously reached and find the “best” conditions for such a train of pulses.

Ventricular arrhythmias (VAs) are a group of heart rhythm disorders that can be life‐threatening and cause significant morbidity. VA in the presence of structural heart disease (SHD) has distinct prognostic implications and requires a comprehensive and multifaceted approach for investigation and management. Early specialist referral should be considered for all patients with VA. Particular urgency is recommended in patients with syncope, nonsustained/sustained VA on Holter monitor and SHD on cardiac imaging because of the heightened risk of sudden cardiac death. Comprehensive phenotyping is recommended for most patients with VA, encompassing noninvasive cardiac functional testing, multimodality imaging and genetic testing in select circumstances. Management of idiopathic VA is guided heavily by symptom burden and the presence of ventricular systolic impairment. In SHD, guideline‐directed heart failure therapy and device implantation are critical considerations. Whilst commonly used and well‐established, antiarrhythmic drugs can be hampered by toxicity and failure of adequate arrhythmia control. Catheter ablation is increasingly being considered a feasible first‐line alternative to medical therapy, where outcomes are influenced by disease aetiology and scar burden in SHD. Catheter ablation is associated with reduced arrhythmia recurrence and burden and improved quality of life at follow‐up. [ABSTRACT FROM AUTHOR]

BackgroundVest Prevention of Early Sudden Death Trial did not demonstrate a significant reduction in arrhythmic death with the wearable cardioverter-defibrillator (WCD), but compliance with the device may have substantially affected the results. ThePletcher influence of WCD compliance on outcomes has not yet been fully evaluated.MethodsUsing linear and pooled logistic models, we performed as-treated analyses omitting person-time in the hospital and adjusted for correlates of WCD compliance. To assess the impact of early stopping of WCD, we performed a per-protocol Kaplan-Meier analysis, censoring after the last day the WCD was worn. Interactions of potential effect modifiers with treatment assignment and WCD compliance on outcomes were investigated. Finally, we used linear models to identify predictors of WCD compliance.ResultsA per-protocol analysis demonstrated a significant reduction in total (P

Abstract Introduction Rapid-cycle deliberate practice (RCDP) is a simulation-based educational strategy that consists of repeating a simulation scenario a number of times to acquire a planned competency. When the objective of a cycle is achieved, a new cycle initiates with increased skill complexity. There have been no previous randomized studies comparing after-event debriefing clinical manikin-based simulation to RCDP in adult cardiopulmonary resuscitation (CPR). Methods We invited physicians from the post-graduate program on Emergency Medicine of the Hospital Israelita Albert Einstein. Groups were randomized 1:1 to RCDP or after-event debriefing simulation prior to the first station of CPR training. During the first 5 min of the pre-intervention scenario, both groups participated in a simulated case of an out-of-hospital cardiac arrest without facilitator interference; after the first 5 min, each scenario was then facilitated according to group allocation (RCDP or after-event debriefing). In a second scenario of CPR later in the day with the same participants, there was no facilitator intervention, and the planned outcomes were evaluated. The primary outcome was the chest compression fraction during CPR in the post-intervention scenario. Secondary outcomes comprised time for recognition of the cardiac arrest, time for first verbalization of the cardiac arrest initial rhythm, time for first defibrillation, and mean pre-defibrillation pause. Results We analyzed data of three courses conducted between June 2018 and July 2019, with 76 participants divided into 9 teams. Each team had a median of 8 participants. In the post-intervention scenario, the RCDP teams had a significantly higher chest compression fraction than the after-event debriefing group (80.0% vs 63.6%; p = 0.036). The RCDP group also demonstrated a significantly lower time between recognition of the rhythm and defibrillation (6 vs 25 s; p value = 0.036). Conclusion RCDP simulation strategy is associated with significantly higher manikin chest compression fraction during CPR when compared to an after-event debriefing simulation.