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In patients with persistent left superior vena cava (PLSVC), transvenous device implantation for cardiac resynchronization therapy (CRT) may be challenging. We present a complex case with successful, high-density electroanatomic mapping (EAM) guided corrective His bundle pacing (CHBP) following failed CRT upgrade in a patient with PLSVC, congenital heart disease, and pacing-associated heart failure. CHBP restored physiological conduction in left bundle branch block with complete conduction block leading to clinical improvement and cardiac remodeling. The presented case supports the growing evidence that EAM-guided CHBP may be considered a feasible alternative to conventional CRT when venous anatomy is not favorable for left ventricular lead implantation.

The inSighT study was designed to determine the prevalence of ischemic changes as recorded by implantable cardioverter-defibrillator (ICD) ST deviations in intracardiac electrocardiograms (EGM) over the 24 h preceding malignant ventricular arrhythmias (VT/VF).The study enrolled patients with known coronary artery disease (CAD) or high risk of future development of CAD implanted with an ICD equipped with an ST monitoring feature (Ellipse™/Fortify Assura™, St. Jude Medical). Device session records were collected at each in-clinic follow-up. EGM ST levels of the beats over the 15 minutes prior to VT/VF events were compared using a t test with those from a baseline period of 23-24 h prior to the VT/VF event. All events with p .05 were visually inspected to confirm they were evaluable; additional criteria for exclusion from further analysis included inappropriate therapy, aberrant conduction, and occurrence of VT/VF within 24h prior to the current event.The study enrolled 481 ICD patients (64 ± 11 years, 83% male) in 14 countries and followed them for 15±5 months. A total of 165 confirmed VT/VF episodes were observed, of which 71 events (in 56 patients, 34% of all patients with VT/VF) were preceded by significant (p .05) ST-segment changes unrelated to known non-ischemic causes. None of the analyzed demographic and clinical factors proved to be associated with greater odds of presenting with ST-segment changes prior to VT/VF episode.In this exploratory study, characteristic ST-segment changes, likely representative of ischemic events, were observed in 34% of all patients with VT/VF episodes.

Introduction The clinical benefit of invasive therapy in elderly patients with acute coronary syndrome (ACS) remains unclear. Furthermore, the decision-making process to treat this growing patient group is also debatable. The purpose of this study was to assess the association between elderly ACS patients, the treatment choice and their in-hospital outcomes after non-ST- elevation (NSTE)-ACS in a consecutive series of patients >75 years of age. Methods and Results Consecutive patients >75 years presenting with NSTE-ACS in our hospital between July 2017 and July 2018 were included during the first 2 days of hospital admission. Demographic data, prior medical history and present medical condition were documented. During day 0 and day 2, geriatric assessments ( Clinical Frailty Scale [CFS], Barthel index, Charlson comorbidity index, “timed up and go” test [TUG], Mini-Mental Status Test [MMS], Geriatric D epression Scale [GDS], SF-36 for quality of life, instrumental activities of daily living [IADL], Killip- score, Grace- score and Euro- score) were conducted. After 6 months, patients were re-evaluated. In 106 patients (mean age 81.9±5.3 years, 57% male gender), 68 patients (64%) were treated interventionally, and 38 patients had conservative treatment (36%). Patients treated with intervention were significantly younger (80.9±4.7 years vs 83.5±6.0 years, p=0.015), had a lower rate of prior cerebral events (17.6% vs 26.3%; p=ns) and suffered more often from chronic obstructive pulmonary disease (17.6% vs 34.2%; p=0.050). All other demographic variables were comparable between both groups. The composite clinical endpoint (death, re-infarction, bleeding) was reached in 7 patients (10.3%) of the invasive and in 2 patients (5.3%) of the conservative group. They were not significantly different between both groups. A frailty index, consisting of commonly used parameters of functional impairment in elderly patients, namely, MMS ≤2 at baseline, IADL ≤7, CFS ≥7 and age ≥85 years, significantly predicted conservative treatment. Conclusion Effective revascularization techniques are still underused in patients of older age in the case of ACS. For decision-making, geriatric tests alone may not predict treatment in those patients, but the combination of different tests may better predict treatment and perhaps the clinical outcomes in those patients. Furthermore, frail patients are at higher risk for not receiving guideline recommended therapy.

Background Currently, several geographies around the world remain underrepresented in medical device trials. The PANORAMA 2 study was designed to assess contemporary region-specific differences in clinical practice patterns of patients with cardiac implantable electronic devices (CIEDs). Methods In this prospective, multicenter, observational, multinational study, baseline and implant data of 4,706 patients receiving Medtronic CIEDs (Medtronic plc, Minneapolis, MN, USA; either de novo device implants, replacements, or upgrades) were analyzed, consisting of: 54% implantable pulse generators (IPGs), 20.3% implantable cardiac defibrillators (ICDs), 15% cardiac resynchronization therapy -defibrillators, and 5.1% cardiac resynchronization therapy -pacemakers, from 117 hospitals in 23 countries across four geographical regions between 2012 and 2016. Results For all device types, in all regions, there were fewer females than males enrolled, and women were less likely to have ischemic cardiomyopathy. Implant procedure duration differed significantly across the geographies for all device types. Subjects from emerging countries, women, and older patients were less likely to receive a magnetic resonance imaging-compatible device. Defibrillation testing differed significantly between the regions. European patients had the highest rates of atrial fibrillation (AF), and the lowest number of implanted single-chamber IPGs. Evaluation of stroke history suggested that the general embolic risk is more strongly associated with stroke than AF. Conclusions We provide comprehensive descriptive data on patients receiving Medtronic CIEDs from several geographies, some of which are understudied in randomized controlled trials. We found significant variations in patient characteristics. Several medical decisions appear to be affected by socioeconomic factors. Long-term follow-up data will help evaluate if these variations require adjustments to outcome expectations.

We present a case of successful interventional laser-assisted extraction of an endovascularly trapped long-term implanted ventriculoatrial shunt in a patient with shunt-associated septicemia. This approach is based on modified techniques for explantation of pacemaker leads and might be considered an additional option for extraction of otherwise nonremovable trapped endovascular catheters in experienced centers.

Aims Oesophagogastroduodenoscopy (OGD) after catheter ablation (CA) of atrial fibrillation (AF) revealed a high rate of procedure related oesophageal lesions. We hypothesized that magnetically guided CA with careful radiofrequency energy titration at the posterior left atrial (LA) wall limits the incidence of oesophageal tissue damage. Methods and results As a part of the prospective "Remote MAGNetic catheter Ablation for Atrial Fibrillation" (MAGNA-AF) registry, 251 out of 266 consecutive patients underwent OGD after magnetically guided single-CA for AF. All detected pathologies were analysed. Simultaneous pacing and ablation from the tip of the magnetically guided catheter was found to be a safe and feasible method for energy titration. Post-interventional OGD documented midoesophageal tissue damage in four (1.6%) patients. Although a thermal origin of these injuries must be discussed, none of them was located at the anterior oesophageal wall. Risk factors for midoesophageal lesions were female gender and concomitant acetylsalicylic acid (ASA) treatment. Mechanical lesions in 16 patients were attributed to periprocedural transoesophageal echocardiography (TOE). There was no atrio-oesophageal fistula (AOF). Five hundred and one incidental pathologies were found endoscopically, most frequent axial oesophageal herniation (71%), oesophagitis (22%), and gastritis (57%). Conclusion Magnetically guided CA for AF with careful energy titration at the posterior LA wall and no oesophageal temperature monitoring is not associated with an increased incidence of oesophageal thermal injury. The routine use of periprocedural TOE may cause a low rate of mechanical oesophageal lesions but reliably prevents major complications like transient ischaemic attack, stroke, or cardiac tamponade. An observed high prevalence of upper digestive system inflammation (63%) may further support the recommendation for a routine post-interventional treatment with a proton-pump-inhibitor.

The use of different three-dimensional electro-anatomical mapping (3D-EAM) systems for right-sided arrhythmia ablation may have a distinct effect on procedure duration and radiation exposure. We evaluated 355 consecutive patients undergoing routine typical atrial flutter ablation at two centers.

Electrophysiology procedures (EP) are traditionally performed under fluoroscopic guidance. The use of different three-dimensional electro-anatomical mapping (3D-EAM) systems for right-sided arrhythmia ablation may differently effect procedure duration and radiation exposure. We evaluated 301

Apart from monitoring shock efficacy, proof of flawless detection of induced ventricular fibrillation (VF) is a decisive argument in favor of implantable cardioverter defibrillator (ICD) testing. On the other hand, it has been observed that undersensing of VF is extremely rare with good sensing of the intrinsic R wave of ≥ 5-7 mV. The case presented here shows limitations in both argumentations: Neither optimal R wave sensing during sinus rhythm nor repeated ICD testing could rule out or predict multiple erroneous detections of clinical VF episodes. This must be taken into consideration in the current discussion on the necessity of defibrillation testing. Further optimization of sensing technology should be a focus in the development of modern ICD systems so as to improve the safety and efficacy of ICD therapy.

The need for implantable cardioverter-defibrillator (ICD) defibrillation testing (DT) and subsequent intraoperative system modifications is discussed controversially. The study’s goal was to prove that consequent abdication of intraoperative DT does not impair defibrillation efficacy and does not increase the rate of postoperative system revisions. In a prospective single-center observational study, 609 out of 648 consecutive patients underwent transvenous ICD implantation (left-sided, active can, dual coil lead, and biphasic shock waveform) waiving intraoperative DT. Defibrillation efficacy was validated prior to hospital discharge (PHD) by applying two 10 J safety margin (SM) shocks. Following “schockless” implantation 580 out of 609 patients (95.2 %) met a 10 J SM with default programming. Shock path reversal provided 10 J SM in 13 out of 29 cases with initially failed DT. In four patients (0.7 %) maximum energy shocks were ineffective. There was no morbidity or mortality related to DT. The total rate of surgical ICD revisions was 1.8 %. Routine ICD implantation without intraoperative DT does not lead to an increased rate of postoperative system modifications and does not decrease defibrillation efficacy as tested PHD.

Aims Follow-up of the ever-increasing numbers of patients with implantable cardiac devices places a heavy burden on clinical departments. Device automaticity may alleviate the follow-up burden by minimizing the time for physician involvement. The aim of the prospective, multicentre AUTOMATICITY registry was to examine the performance of a subset of programmed automatic algorithms during patient follow-up and their acceptance by implanting physicians. Methods and results The clinical use of automatic algorithms from the InsigniaTM pacemakers (PM; Boston Scientific, St Paul, MN, USA) was evaluated: atrial and ventricular AutoSense (sensitivity adjustment), ventricular Automatic Capture (threshold verification and output setting), AutoLifeStyleTM (sensor settings adjustment). The objective of the study was to assess the reprogramming rates within 12 months of implant, the reasons for reprogramming and relationship to adverse events. A total of 960 patients were enrolled in the study. The proportion of patients free from any algorithm reprogramming at 12 months was 86.1%. A total of 2736 algorithms were activated at enrolment, with 156 (5.7%) being reprogrammed in 115 patients at 12 months for any reason. Forty-nine reprogrammings (1.8%) were unintentional or related to changes in device settings such that the algorithm was no longer available, 33 (1.2%) were due to suspected sensing issues, and 22 (0.8%) were assumed related to the algorithm. The individual 12-month reprogramming-free rates were: ventricular AutoSense 94.3%, Atrial AutoSense 93.3%, AutoLifeStyleTM 93.9%, and Automatic Capture 95.9%. Conclusion The results of the AUTOMATICITY registry show that automatic measurement of key settings and automatic adjustment to optimal programming is feasible and safe. The simplicity of PM follow-up and avoidance of frequent reprogramming may contribute to a more effective use of hospital time and resources.

A 9-year-old girl presented with systemic infection related to a Port-a-Cath system (PAC); therefore, the urgent removal of the PAC was indicated. However, the catheter was trapped and not extractable by conventional means. Using existing comprehensive experience in the removal of pacemaker and implantable cardioverter defibrillator leads, the entrapped PAC was successfully extracted by laser technique, thus avoiding open heart surgery.

A 9-year-old girl presented with systemic infection related to a Port-a-Cath system (PAC); therefore, the urgent removal of the PAC was indicated. However, the catheter was trapped and not extractable by conventional means. Using existing comprehensive experience in the removal of pacemaker and implantable cardioverter defibrillator leads, the entrapped PAC was successfully extracted by laser technique, thus avoiding open heart surgery.