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Left bundle branch block (LBBB) and atrioventricular (AV) conduction abnormalities requiring permanent pacemaker (PPM) implantation occur frequently following transcatheter aortic valve replacement (TAVR). The resultant left ventricular (LV) dyssynchrony may be associated with adverse clinical events.The purpose of this study was to assess the adverse outcomes associated with LV dyssynchrony due to high-burden right ventricular (RV) pacing or permanent LBBB following TAVR in patients with preserved left ventricular ejection fraction (LVEF).Consecutive TAVR patients at the University of Michigan from January 2012 to June 2017 were included. Pre-existing cardiac implantable electronic device, previous LBBB, LVEF50%, or follow-up period1 year were excluded. The primary outcome was all-cause mortality. Secondary outcomes included cardiomyopathy (defined as LVEF ≤45%), a composite endpoint of cardiomyopathy or all-cause mortality, and the change in LVEF at 1-year follow-up.A total of 362 patients were analyzed (mean age 77 years). LV dyssynchrony group (n = 91 [25.1%]) included 56 permanent LBBB patients, 12 permanent LBBB patients with PPM, and 23 non-LBBB patients with PPM and high-burden RV pacing. Remaining patients served as control (n = 271 [74.9%]). After adjusted analysis, LV dyssynchrony had significantly higher all-cause mortality (adjusted hazard ratio [HR] 2.16; 95% confidence interval [CI] 1.07-4.37) and cardiomyopathy (adjusted HR 14.80; 95% CI 6.31-14.69). The LV dyssynchrony group had mean LVEF decline of 10.5% ± 10.2% compared to a small increase (0.5% ± 7.7%) in control.Among TAVR patients with preserved LVEF and normal AV conduction, development of postprocedural LV dyssynchrony secondary to high-burden RV pacing or permanent LBBB was associated with significantly higher risk of death and cardiomyopathy at 1-year follow-up.

Transseptal puncture (TSP) is routinely performed for left atrial ablation procedures. The use of a three-dimensional (3D) mapping system or intracardiac echocardiography (ICE) is useful in localizing the fossa ovalis and reducing fluoroscopy use. We aimed to compare the safety and efficacy between 3D mapping system-guided TSP and ICE-guided TSP techniques.We conducted a prospective observational study of patients undergoing TSP for left atrial catheter ablation procedures (mostly atrial fibrillation ablation). Propensity scoring was used to match patients undergoing 3D-guided TSP with patients undergoing ICE-guided TSP. Logistic regression was used to compare the clinical data, procedural data, fluoroscopy time, success rate and complications between the groups.65 patients underwent 3D-guided TSP, and 151 propensity score-matched patients underwent ICE-guided TSP. The TSP success rate was 100% in both 3D-guided and ICE-guided group. Median needle time was 4.00 min (IQR 2.57-5.08) in patients with 3D-guided TSP compared to 4.02 minutes (IQR 2.83-6.95) in those with ICE-guided TSP (p = 0.22). Mean fluoroscopy time was 0.2 minutes (IQR 0.1-0.4) in patients with 3D-guided TSP compared to 1.2 minutes (IQR 0.7-2.2) in those with ICE-guided TSP (p0.001). There were no complications related to TSP in both groups.3D mapping-guided TSP is as safe and effective as ICE-guided TSP without additional cost. This article is protected by copyright. All rights reserved.

While ICD therapy reduction programming strategies are recommended in current multi-society guidelines, concerns remain about a possible trade-off between the benefits of ICD therapy reduction and failure to treat episodes of ventricular arrhythmias. The study is to evaluate the outcomes of primary prevention patients followed in centers with high and low concordance with the 2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement and 2019 focused update on optimal ICD programming and testing guidelines.Consecutive patients with primary prevention ICD implantation from two centers between 2014 and 2016 were included. One center was classified as high guideline concordance center (HGC) with 47% (146/310) of patients with initial ICD concordant with the guidelines, and the other center was classified as low guideline concordance center (LGC) with only 1% (2/178) of patients with guideline-concordant initial ICD programming. Cox proportional hazard models were used to assess risk of first ICD therapy (ATP or shock), first ICD shock, and mortality.A total of 488 patients were included (mean age, 66 ± 13 years). During a mean follow-up of 1.9 ± 0.9 years, patients followed at HGC were 63% less likely to receive any ICD therapy (adjusted HR [aHR] 0.37, 95% CI 0.42-0.99). There were no significant differences in the rate of first ICD shock (aHR 0.72, 95% CI 0.34-1.52) or mortality (aHR 1.19, 95% CI, 0.47-3.05).Compared to primary prevention patients followed at LGC, primary prevention ICD patients followed at HGC received a significantly lower rate of ICD therapy, mainly from ATP reduction, without a difference in mortality during follow-up.

Objective: Long-term right ventricular pacing has been associated with an increased risk of heart failure and cardiomyopathy. The pathophysiology of cardiomyopathy associated with right ventricular pacing remains unclear. We aim to evaluate the burden and short-term outcomes of ventricular dyssynchrony after immediate permanent pacemaker implantation. Materials and Methods: This prospective cohort study examined consecutive patients who had permanent pacemaker implantation at Vajira Hospital in 2019. Left ventricular systolic function, specifically left ventricular ejection fraction (LVEF) and echocardiographic ventricular dyssynchrony parameters were assessed. The endpoints included the prevalence of ventricular dyssynchrony, new-onset cardiomyopathy, heart failure, and death. The correlation between QRS complex duration, the burden of ventricular pacing, and echocardiographic ventricular dyssynchrony was measured. Results: Thirty-six consecutive patients underwent pacemaker implantation. The prevalence of mechanical ventricular dyssynchrony was 22.2% using the interventricular conduction delay method, 41.7% using LV pre-ejection period method, and 11.1% using the septal posterior wall motion abnormality method. Electrical ventricular dyssynchrony was 86.1% and new-onset cardiomyopathy was 17.1% after 3 months of permanent pacemaker implantation. The right ventricular pacing of more than 20% was significantly associated with cardiomyopathy (p < 0.022) and heart failure (log-rank, p = 0.049) within 3 months. But heart failure was not associated with mechanical ventricular dyssynchrony parameters (log-rank, p = 0.610; hazard ratio [HR], 1.53; 95% confidence interval [CI], 0.29 - 7.96; p = 0.613 for IVMD and log-rank, p = 0.398; HR, 0.04; 95% CI, 0.01 - 3316.7 for SPWMD). Conclusion: Mechanical and electrical ventricular dyssynchrony are common findings in right ventricular pacing. High-burden right ventricular pacing after 3 months of permanent pacemaker implantation is often associated with cardiomyopathy and heart failure, but mechanical and electrical ventricular dyssynchrony does not predict a short-term decline in left ventricular systolic function and heart failure.

Vajira Medical Journal, 66, 2, 125-136

BACKGROUND Lead damage is a complication caused by lead manipulation or heating damage from conventional electrocautery (EC) after cardiovascular implantable electronic device (CIED) replacement. Application of electrical plasma (PEAK PlasmaBlade) is a new technology that reportedly reduces this risk. OBJECTIVES This study was designed to compare the effect of EC versus PEAK PlasmaBlade on lead parameters and complications after generator replacement procedures. METHODS We retrospectively studied 410 consecutive patients (840 leads) who underwent CIED replacement using EC (EC group) and 410 consecutive patients (824 leads) using PEAK PlasmaBlade (PlamaBlade group). Pacing lead impedance, incidence of lead damage, and complications were compared between both groups. RESULTS Lead impedance increased in 393 leads (46.8%) in the EC group versus 282 leads (34.2%) in the PlasmaBlade group (p

BACKGROUND Implanted defibrillators are capable of recording activity data based on company-specific proprietary algorithms. This study aimed to determine the prognostic significance of baseline and decline in device-derived activity level across different device companies in the real world. METHODS We performed a retrospective cohort study of patients (n = 280) who underwent a defibrillator implantation (Boston, Medtronic, St. Jude, and Biotronik) for primary prevention at the University of Michigan from 2014 to 2016. Graphical data obtained from device interrogations were retrospectively converted to numerical data. The activity level averaged over a month from a week postimplantation was used as baseline. Subsequent weekly average activity levels (SALs) were standardized to this baseline. SAL below 59.4% was used as a threshold to group patients. All-cause mortality and death/heart failure were the primary end-points of this study. RESULTS Fifty-six patients died in this study. On average, they experienced a 50% decline in SAL prior to death. Patients (n = 129) who dropped their SAL below threshold were more likely to be older, male, diabetic, and have more symptomatic heart failure. They also had a significantly increased risk of heart failure/death (hazard ratio [HR] 3.6, 95% confidence interval [95% CI] 2.3-5.8, P

Inappropriate therapy is a common adverse effect in patients with an implantable cardioverter-defibrillator (ICD) that may be prevented by appropriate programming.The purpose of this study was to assess the outcomes of device programming based on a 2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement and a 2019 focused update on optimal ICD programming and testing.Consecutive patients who underwent ICD insertion for primary prevention from 2014-2016 at 3 centers were included in the retrospective analysis. Patients were classified into 2 groups based on the tachycardia programming at the time of implant: guideline concordant group (GC) and non-guideline concordant group (NGC). Kaplan-Meier analysis and Cox proportional hazard models were used to estimate freedom from ICD therapy (antitachycardia pacing or shock), ICD shock, and death.A total of 772 patients were included in the study (mean age 63.3 ± 13.8 years). Of this total, 258 patients (33.4%) were in the GC group and 514 patients (66.6%) were in the NGC group. During mean follow-up of 2.02 ± 0.91 years, guideline concordant programming was associated with a 53% reduction in ICD therapy (P .01) and 50% reduction in ICD shock (P = .02). There were no significant differences in mortality (6% in GC group vs11% in NGC group; P = .22).Only one-third of the studied population had an ICD device programmed in concordance with current guidelines. ICD programming based on the current guidelines was associated with a significantly lower rate of ICD therapy and shock without changes in mortality during intermediate-term follow-up.

Lipid accumulation product (LAP) is a novel biomarker of central lipid accumulation related to the risk of diabetes and cardiovascular disease (CVD). Consistent with physiologic observations, an alternative index uses waist circumference (WC) and fasting triglycerides (TG) concentrations to describe lipid over accumulation. Objective: Explore the association of LAP with anthropometric parameters and subclinical atherosclerosis in perimenopausal/menopausal women with no evidence of established CVD.Explore the association of LAP with anthropometric parameters and subclinical atherosclerosis in perimenopausal/menopausal women with no evidence of established CVD.The study was an observational cross-sectional study and included 130 perimenopausal/menopausal participants. The anthropometric parameters used were height, weight, and WC. Laboratory lipid profile and LAP were calculated. High-resolution B-mode ultrasonography was performed to measure carotid intima media thickness (CIMT) and to search for carotid atherosclerosis.One hundred thirty perimenopausal/menopausal women were studied. About 22.3% had an abnormal CIMT. The percentages of normal weight, generalized obesity, and central obesity among study participants were 30.7%, 14.0%, and 55.3%, respectively. LAP was not correlated with CIMT and atherosclerosis. WC and waist-hip ratio (WHR) were correlated with CIMT but were not correlated with atherosclerosis. The other parameters of LAP and body mass index were not predictive of carotid atherosclerosis. Systolic blood pressure, diastolic blood pressure, fasting blood sugar, TG, and highdensity lipoprotein cholesterol were higher with LAP equal or greater than 34.5 than with LAP lower than 34.5. However, CIMT was not statistically different between the two LAP groups (p = 0.99).Central lipid distribution in perimenopausal/menopausal women using anthropometric phenotype WC and WHR was correlated with higher CIMT values. Both LAP index and anthropometric phenotype were not helpful for identifying subclinical atherosclerosis defined by CIMT measurement equal or greater than 0.9 mm.