Chemotherapy-induced cardiomyopathy (CHIC) represents a growing clinical challenge due to the increasing use of cardiotoxic treatments. These therapies can lead to progressive myocardial dysfunction, ultimately resulting in heart failure. Cardiac resynchronization therapy (CRT) has been widely investigated in selected patients with chronic heart failure; however, those with CHIC remain underrepresented in CRT trials. Current evidence is largely based on retrospective and observational studies, with MADIT-CHIC being the only prospective trial to date. No randomized controlled trials are currently available. Despite encouraging findings, existing data remain limited by small sample sizes and short follow-up durations. In particular, the impact of CRT on left ventricular dyssynchrony, arrhythmic burden, and long-term survival in this population has not been fully elucidated. A multidisciplinary cardio-oncology approach is essential not only for the comprehensive management of these complex patients, but also to guide appropriate timing of CRT implantation. Further research is warranted to refine patient selection criteria and to fully assess the long-term benefits and risks of CRT in patients with CHIC.

BACKGROUND Repeated procedures involving the cardiac implant-able electronic device (CIED) pocket increase the infection risk, and the extent of pocket adhesions may prolong the procedure time. Few data on pocket histology at the time of CIED replacement are available.OBJECTIVE The purpose of this study was to describe CIED pocket histology in a cohort of patients undergoing CIED replacement or upgrade.METHODS All consecutive patients undergoing CIED replacement or upgrade at our center between November 2019 and May 2020 were enrolled. Subclinical pocket infection was ruled out by physical inspection and laboratory parameters before the procedure. Pocket tissue specimens from the anterior and posterior pockets were ob-tained intraoperatively. A systematic histological analysis of capsular thickness, fibrous connective tissue, neovascularization, inflammation, and calcifications was performed.RESULTS Thirty patients (6 women, 20%) were enrolled. The mean capsular thickness was 0.8 & PLUSMN; 0.3 mm in the anterior wall and 1.1 & PLUSMN; 0.4 mm in the posterior wall. Subcapsular fibrosis was mild and multifocal in the anterior wall and moderate and focal in the poste-rior wall. Neovascularization was focal in most cases, and vessel re-modeling mainly involved the tunica media. Chronic inflammation was usually mild and nongranulomatous, and in a quarter of cases, subacute exudative fibrous inflammation was detected in the poste-rior pocket wall.CONCLUSION The CIED pocket is a histopathologically dynamic environment, given the coexistence of both a subacute foreign body response and fibrous tissue growth, implying continuous re-modeling due to an injury-repair mechanism. Strategies to interact with foreign body response might minimize inflammatory pocket ac-tivity, especially device encapsulation by tight fibrous tissue, and possibly complications related to repeated CIED procedures.

Abstract Funding Acknowledgements Type of funding sources: None. Background FDG-PET/CT clinical use for cardiovascular implantable electronic device (CIED) infection is of relevant importance, since it provides information about presence and extension of the infection. However, asymptomatic patients with incidental FDG uptake on CIED are challenging. Purpose The primary objective of this observational study was to assess the diagnostic role of FDG PET/CT in patients without a suspicious of CIED infection. The secondary objective was to identify qualitative and semiquantitative predictors of CIED infection. Methods From 2017 to 2019 all FDG-PET/CT scans of CIED patients were analysed, the indications were a suspicious of CIED or non-cardiovascular infection, or oncological follow up. Four expert nuclear medicine physicians blindly reviewed all scans, focusing on FDG uptake in pocket and/or in extracardiac lead parts. They reported standardized uptake values (SUV), liver and blood pool target-to-background ratios, metabolic tumour volume (MTV). 6 months follow up after PET/CT scan was performed for eventual CIED extraction because of infection. Results 320 FDG-PET/CT scans were considered. Median age was 74 [33-94] years, 219/320 (68%) males. 122/320 (38%) scans presented FDG uptake around pocket and/or extracardiac lead parts; and 65/320 (20%) scans reported suspicious uptake. We identified these cut-off criteria as predictors of CIED extraction: TARGET SUV max >2.6 (sensitivity 71%, specificity 89%), LIVER-TARGET SUV max >1.3 (sensitivity 68%, specificity 89%). Both these values also demonstrated to be good predictors of CIED infection after 6 months follow up (p<0,001). Conclusion FDG-PET/CT uptake in asymptomatic CIED patients is underestimated and may be related to subtle CIED infection. By introducing high-specific SUV cut-off values, a considerable impact on patient management is expected.

Cancer therapy-induced cardiotoxicity is an emerging clinical and healthcare issue. Myocardial dysfunction and heart failure are mostly responsible for increased cardiovascular mortality in cancer disease survivors. Several imaging surveillance techniques have been proposed for early diagnosis of cancer therapy-induced cardiac dysfunction. Our aim was to provide an update of radionuclide angiography applications in this field. Radionuclide angiography is widely used to assess left ventricular ejection fraction (LVEF) throughout cancer treatment, especially in patients with limited acoustic window. Additional prognostic data may be provided by phase analysis and diastolic function evaluation. Low LVEF and high approximate entropy at baseline seem to be predictors for cancer therapy-induced cardiac dysfunction. A decrease in peak filling rate and/or an increase in time to peak filling rate may be observed in patients undergoing anthracycline and/or trastuzumab administration. Diastolic function impairment may precede or not LVEF decrease. In conclusion, recent studies have provided novel insights into the possible role of radionuclide angiography in the early detection of cancer therapy cardiotoxicity. While interpreting the results of a radionuclide angiography examination, an integrated approach combining the evaluation of LVEF, LV diastolic function, and phase analysis may be useful to improve risk stratification of cancer patients treated with cardiotoxic agents.

Abstract Background Extravascular (EV) implantable cardiac defibrillators (ICD) with substernal lead have recently proved to be a safe and effective alternative to conventional transvenous (TV) and subcutaneous defibrillators (S-ICDs) 1, owing to the possibility to deliver antitachycardia and asystole pacing while saving intravascular hardware. However, inappropriate shock delivery occurred in 9.7% of patients, and P-wave oversensing accounted for 42% of inappropriate shocks in the EV ICD Pivotal Study. Purpose to investigate the difference of lead placement in patients with and without P-wave oversensing. Method 17 patients undergoing implantation as part of the EV ICD Pivotal Study received the substernal lead placement based on computer tomography imaging (CT) and following the protocol recommendations. Lead placement beyond the left lateral sternum border was attempted whenever possible, based on CT guidance. P-wave detectability (P detected visually but non sensed by the device) on the sensing vector and P-wave oversensing by the device were investigated at each follow-up. The distance of sensing ring electrodes (R1 and R2) from the mid-spine line (line connecting the spinous processes from cervical to lumbar vertebral processes) was measured in each patient on the posterior-anterior chest radiogram. Results Mean age, BMI, NYHA class and left ventricular ejection fraction (LVEF) were respectively 53±9yrs, 25.3 ±6 kg/m2, 2 ±0.7, and 39±14%. The main aetiology was non-ischemic cardiomyopathy (12/17), including 3 arrhythmogenic cardiomyopathy patients and one with hypertrophic cardiomyopathy. The implantation was successful in 16 (6 females) out of 17 patients without any complication, with one implant failure due to inadequate sensing (0,5 mV) despite several attempts at tunnelling in different locations (rightward and leftward of the sternum). One patient with P-wave detectability had lead dislodgement after 2 weeks, and underwent repositioning to a more leftward location, where P-wave was not detectable. Only one patient had P-wave oversensing at follow-up, and received inappropriate shocks (Figure A); the remaining 15 patients neither had detectable P-wave on the sensing vector nor inappropriate shocks (Figure B). The median sensing amplitude at implantation was 2,7±1.4 mV and 2.6±1.2 mV along a 18±4 months follow-up, with R1-R2 being the final sensing vector chosen for 14/16 and R2-Can for 2/16 patients. The distance of R1 and R2 from the mid-spine line was significantly longer in patients with detectable P-wave compared to those without (37±13mm vs 18 mm and 30±15 vs 16 mm, respectively). Conclusions Placement of the EV ICD lead leftward to the left sternum border is safe, and prevents P-wave detection. The mid-spine line represents an easy landmark to guide lead placement during implantation. R1 distance ≥ 25 mm and R2 distance ≥ 20 mm from the mid-spine line provide a reliable marker of freedom from P-wave oversensing.Figure AFigure B

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiac implantable electronic device (CIED) procedures, characterized by reopening of the CIED pocket, increase infectious risk. In particular, pocket adhesions’ debridement may prolong procedure time, increasing the infectious risk. Nowadays, only few data are available on pocket histology at CIED reopening procedures. Purpose The aim of this study was to describe CIED pocket histology in a cohort of patients undergoing CIED replacement or upgrade. Methods All patients undergoing CIED replacement or upgrade at our center between November 2019 and May 2020 were enrolled. Subclinical pocket infection was ruled out by physical inspection and laboratory parameters. Pocket tissue specimens from anterior and posterior pocket wall were obtained. A systematic histological analysis of capsular thickness, fibrotic tissue, neovascularization, inflammation, and calcifications was performed. Results 30 patients (80% male) were enrolled. Mean capsular thickness of anterior and posterior wall was 0.8±0.3 mm and 1.1±0.4 mm, respectively. Subcapsular fibrosis was mild and multifocal in the anterior wall, and moderate and focal in the posterior. Neovascularization was mainly focal, and in most cases vessel remodelling involved the tunica media. Chronic inflammation was usually mild and non-granulomatous, and in a quarter of cases subacute exudative inflammation was detected in the posterior pocket wall. Conclusion CIED pocket is an histopathologically dynamic environment, characterized by the coexistence of a subacute foreign body response and a fibrous tissue growth, that produces a continuous remodelling due to injury-repair mechanisms. Strategies to reduce foreign body response might minimize inflammatory pocket activity, especially device encapsulation by fibrotic tissue, and simplify CIED reopening procedures. This can impact on CIED replacement or upgrade complications and infectious risk.

Abstract Background Extravascular (EV) implantable cardiac defibrillators (ICD) with substernal lead have recently proved to be a safe and effective alternative to conventional transvenous (TV) and subcutaneous defibrillators (S-ICD), owing to the possibility to deliver antitachycardia and asystole pacing while saving intravascular hardware. The proposed implantation technique for EV-ICDs is a subcutaneous pocket along the mid axillary line, although an intermuscular ICD placement can potentially reduce the risk of pocket complications, device migration and improve patient comfort and aesthetic outcomes. Purpose exploring the safety and feasibility of extravascular ICDs implantation with a substernal coil and an intermuscular generator placement. Methods Seventeen patients with a class I or IIa ICD indication either for primary (14/17) or secondary (3/17) prevention underwent EV-ICD implantation in our centre as part of the EV ICD Pivotal Study from May 2021 to November 2022. Access and tunnelling along the retrosternal space were performed based on current standard recommendations for EV-ICDs implantation. An intermuscular pocket for generator placement was obtained between the latissimus dorsi and the serratus anterior muscles beyond the left mid-axillary line. Results Mean age, BMI, NYHA class and left ventricular ejection fraction (LVEF) were respectively 53±9yrs, 25.3 ±6 kg/m2, 2 ±0.7, and 39±14%. The main aetiology was non ischemic cardiomyopathy (12/17), including 3 arrhythmogenic cardiomyopathy patients and one with hypertrophic cardiomyopathy. The implantation was successful in 16 (6 females) out of 17 patients, with one implant failure due to inadequate sensing (0,5 mV); the median sensing amplitude was 2,3 mV (min = 1,3 mV; max = 5,8 mV), with R1R2 being the final sensing vector chosen for 14/16 and R2-Can for 2/16. Defibrillation Testing (DFT) was performed in all patients: a 15 J shock terminated induced ventricular fibrillation (VF) in 12/16 patients, 20 J terminated VF in 3, a single patient had VF terminated at 30 J. No patient had infection or skin erosion or complained pain/discomfort at the pocket site along an 18±4 months follow-up. Only 1/16 patients had ventricular tachycardia at follow-up, successfully treated by the device. Conclusions Intermuscular placement of the EV ICD may be a feasible and reliable alternative to a subcutaneous one in terms of defibrillation efficacy, enabling patient comfort and aesthetic acceptance in thin-habit or young patients. Additional long-term data and larger patient cohorts are required to confirm its advantage compared to the subcutaneous placement.

Abstract Background Subcutaneous ICDs (S-ICD) are a valuable option in sudden cardiac death prevention. The main advantage over conventional transvenous ICDs is the absence of intravascular hardware for patients without the need for cardiac stimulation, resynchronization therapy or anti-tachycardia pacing. The claim of reduced lead-related complications has on the contrary been challenged by recent warnings of unexpected lead fracture. Moreover, concerns related to premature battery depletion (PBD) leading to unanticipated device replacement are increasing. Purpose To evaluate retrospectively the incidence of unanticipated S-ICD premature battery depletion in a single-centre experience. Method 168 consecutive patients implanted with S-ICD from February 2015 to November 2022 in our tertiary cardiology centre were included in this study. 4 patients moved to other sites and were thus lost to follow-up, leaving a total of 164 patients. PBD was defined as the occurrence of battery depletion requiring generator replacement earlier than 60 months post-implantation in the absence of therapy being delivered, or as a result of manufacturer recommendations. Results Most patients were implanted for primary prevention (101 patients, 60%). The main aetiology was hypertrophic cardiomyopathy (47 patients, 28%), followed by arrhythmogenic (35, 21%) and dilated idiopathic cardiomyopathy (24, 14%). Mean age and left ventricular ejection fraction at baseline were 46±18yrs and 51±16%, respectively. Over a total follow up period of 44±25 months, at 58±17 months following implantation 19 (11,6%) patients needed early replacement due to PBD, while 2 (1.2%) patients had lead fracture after respectively 41 and 26 months, for a total of 12,8% of patients with system-related complications. In addition to those patients requiring early replacement due to PBD or lead fracture, two underwent S-ICD extraction due to infection. Analysis of freedom from unanticipated PBD per year of implantation showed higher rates in years 2016 and 2017, with 67% and 27% of all implanted patients, respectively (Figure 1). Conclusions In this study, the incidence of PBDs appear to be higher than reported in literature though confined to a limited device series. However, if on the contrary the trend should remain remarkably high, that would not only endanger patients health due to repeated replacements, but also pose a huge economic burden to health systems.

Relatively few data are available on long-term survival and incidence of ventricular arrhythmias in cardiac resynchronization therapy (CRT) patients. We investigated long-term outcomes of CRT patients with non-ischemic dilated cardiomyopathy stratified as responders or non-responders according to radionuclide angiography. Fifty patients with non-ischemic dilated cardiomyopathy undergoing CRT were assessed by equilibrium Tc99 radionuclide angiography with bicycle exercise at baseline and after 3 months. Intra- and interventricular dyssynchrony were derived by Fourier phase analysis. Patient clinical outcome was assessed after 10 years. At 3 months, 50% of patients were identified as CRT responders according to an increase in LV ejection fraction ≥ 5%. During a follow-up of 109 ± 48 months, 30% of patients died and 6% underwent heart transplantation. Age and history of paroxysmal atrial fibrillation were found to be predictors of all-cause mortality. CRT responders showed lower risk of death from cardiac causes than non-responders. At follow-up, 38% of patients presented at least one episode of sustained ventricular tachycardia, with a similar percentage between responders and non-responders. At long-term follow-up, non-ischemic CRT recipients identified as responders by radionuclide angiography were found to be at lower risk of worsening heart failure death than non-responders. Long-term risk for sustained ventricular arrhythmia was similar between CRT responders and non-responders.

The current narrative review provides an update of available knowledge on venous access techniques for cardiac implantable electronic device implantation, with a focus on axillary vein puncture. Lower procedure-related and lead-related complications have been reported with extrathoracic vein puncture techniques compared with intrathoracic accesses. In particular, extrathoracic lead access through the axillary vein seems to be associated with lower complication incidence than subclavian vein puncture and higher success rate than cephalic vein cutdown. In literature, many techniques have been described for axillary vein access. The use of contrast venography-guided puncture has facilitated the diffusion of the axillary vein approach for device implantation. Venography may be particularly useful in specific demographic and clinical device implantation contexts. Ultrasound-guided or microwire-guided vascular access for lead positioning can be considered a valid alternative to venography, although current applications for axillary vein puncture need further evaluations.

Herpes zoster in COVID-19-positive patients Dear Editor, The new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has recently been declared a pandemic by the World Health Organization (WHO). The disease was defined as COVID-19 (Coronavirus Disease 2019) and principally affects the respiratory tract with a clinical scenario ranging from common cold to severe pneumonia. Diagnosis of COVID-19 disease is made on the grounds of clinical signs (fever, malaise, fatigue, dry cough, rhinorrhea, ageusia, anosmia, anorexia, and dyspnea), vital signs (fever >37.5°C, pulse oximetry saturation <98%), and radiological findings (chest CT scan for the presence of ground glass opacity). The clinical scenario differs with most patients only needing supportive care, while others require admission to an intensive care unit (ICU) for invasive mechanical ventilation. In Italy, the first person-to-person transmission of the SARS-CoV-2 was recorded on February 21, 2020, and to date (04/28/2020) the number of COVID-19 positive subjects is more than 100,000. The number of people requiring hospitalization and ICU is 30,000 and 3,000, respectively. At the time of writing, the number of positive cases has peaked in Italy. However, little is known on the cutaneous manifestations of COVID-19-positive patients. We aim to expand our knowledge by reporting four zoster infections in COVID-19-positive patients observed between March and April 2020. Four cases were retrieved, three female, one male, median age 70.5 years (range 68– 74). Three were admitted to the ICU and required mechanical ventilation along with hydroxychloroquine and tocilizumab administration in one patient (for details, see Table 1). All three patients developed a necrotic herpes zoster on the second branch of the trigeminal nerve. The male patient featuring a cardiac transplant was treated with hydroxychloroquine and azithromycin and developed the disease on the dorsum with the classic herpes zoster features (Fig. 1). Despite the transplant and the immunosuppressive drug used, the patient showed a more indolent COVID-19 behavior and did not require hospitalization. The median time from COVID-19 and herpes zoster diagnosis was 5.5 days. All patients at the time of zoster diagnosis showed leukopenia (lymphocyte count

Objectives: To investigate cardiac implantable electrical device (CIED) first implants in patients with hypertrophic cardiomyopathy (HCM) in a Swedish tertiary university hospital. Design: Clinical and technical data on pacemaker, implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy (CRT) first implants performed in HCM patients at the Karolinska University Hospital from 2005 to 2016 were extracted from the Swedish Pacemaker and ICD Registry. Echocardiographic data were obtained by review of hospital recordings. Results: The number of first pacemaker implants in HCM patients was 70 (1.5% of total pacemaker implants). The mean age of HCM pacemaker patients was 71 +/- 10 years. Pacemaker implants were almost uniformly distributed between genders. Dual-chamber pacemakers with or without CRT properties were prevalent (6 and 93%, respectively). The number of first ICD implants in HCM patients was 99 (5.1% of total ICD implants). HCM patients receiving an ICD were 53 +/- 15 years and prevalently men (70%). Sixty-five (66%) patients were implanted for primary prevention. Dual-chamber ICDs with or without CRT were 21 and 65%, respectively. Obstructive HCM was present in 47% pacemaker patients and 25% ICD patients with available pre-implant echo. Conclusions: This retrospective registry-based study provides a picture of CIED first implants in HCM patients in a Swedish tertiary university hospital. ICDs were the most commonly implanted devices, covering 59% of CIED implants. HCM patients receiving a pacemaker or an ICD had different epidemiological and clinical profiles.

Nuclear imaging techniques like single-photon emission computed tomography (SPECT) and radionuclide angiography have wide applications in patients receiving a cardiac implantable electrical device (CIED), who cannot usually undergo cardiac magnetic resonance. Our aim was to provide an update of single-photon imaging clinical applications, with a specific focus on CIED recipients. SPECT imaging is commonly used in CIED patients to assess myocardial perfusion, but it can also be used to evaluate myocardial viability, which is an important predictor of LV function improvement by cardiac resynchronization therapy (CRT). Radionuclide angiography has shown higher temporal resolution and reproducibility than SPECT in the evaluation of cardiac function and dyssynchrony. Left ventricular dyssynchrony as assessed by radionuclide angiography with phase analysis may be reliably used for CRT patient selection and evaluation of CRT response. SPECT imaging with meta-iodo-benzyl-guanidine allows for cardiac sympathetic innervation examination, which may be used for prognostic stratification of heart failure patients and prediction of ventricular tachyarrhythmias. Finally, promising results in CIED infection diagnosis have been shown by SPECT with radiolabeled autologous white blood cells.

Cardiovascular imaging techniques, including echocardiography, nuclear cardiology, multi-slice computed tomography, and cardiac magnetic resonance, have wide applications in cardiac resynchronization therapy (CRT). Our aim was to provide an update of cardiovascular imaging applications before, during, and after implantation of a CRT device. Before CRT implantation, cardiovascular imaging techniques may integrate current clinical and electrocardiographic selection criteria in the identification of patients who may most likely benefit from CRT. Assessment of myocardial viability by ultrasound, nuclear cardiology, or cardiac magnetic resonance may guide optimal left ventricular (LV) lead positioning and help to predict LV function improvement by CRT. During implantation, echocardiographic techniques may guide in the identification of the best site of LV pacing. After CRT implantation, cardiovascular imaging plays an important role in the assessment of CRT response, which can be defined according to LV reverse remodeling, function and dyssynchrony indices. Furthermore, imaging techniques may be used for CRT programming optimization during follow-up, especially in patients who turn out to be non-responders. However, in the clinical settings, the use of proposed functional indices for different imaging techniques is still debated, due to their suboptimal feasibility and reproducibility. Moreover, identifying CRT responders before implantation and turning non-responders into responders at follow-up remain challenging issues.

Aims:Common methodologies for analysis of analogous data sets are needed for international comparisons of treatment and outcomes. This study tests using administrative hospital discharge (HD) databases in five European countries to investigate variation/trends in pacemaker (PM) and implantable cardioverter defibrillator (ICD) implant rates in terms of patient characteristics/management, device subtype, and initial implantation vs. replacement, and compares findings with existing literature and European Heart Rhythm Association (EHRA) reports.Methods and results:HD databases from 2008 to 2012 in Austria, England, Germany, Italy and Slovenia were interrogated to extract admissions (without patient identification) associated with PM and ICD implants and replacements, using direct cross-referencing of procedure codes and common methodology to compare aggregate data. 1 338 199 records revealed 212 952 PM and 62 567 ICD procedures/year on average for a 204.4 million combined population, a crude implant rate of about 104/100 000 inhabitants for PMs and 30.6 for ICDs. The first implant/replacement rate ratios were 81/24 (PMs) and 25/7 (ICDs). Rates have increased, with cardiac resynchronization therapy (CRT) subtypes for both devices rising dramatically. Significant between- and within-country variation persists in lengths of stay and rates (Germany highest, Slovenia lowest). Adjusting for age lessened differences for PM rates, scarcely affected ICDs. Male/female ratios remained stable at 56/44% (PMs) and 79/21% (ICDs). About 90% of patients were discharged to home; 85-100% were inpatient admissions.Conclusion:To aid in policymaking and track outcomes, HD administrative data provides a reliable, relatively cheap, methodology for tracking implant rates for PMs and ICDs across countries, as comparisons to EHRA data and the literature indicated.

: Cardiac resynchronization therapy (CRT) is an established treatment in patients with symptomatic drug-refractory heart failure and broad QRS complex on the surface ECG. Despite the presence of either mechanical dyssynchrony or viable myocardium at the site where delivering left ventricular pacing being necessary conditions for a successful CRT, their direct assessment by techniques of cardiovascular imaging, though feasible, is not recommended in clinical practice by the current guidelines. Indeed, even though there is growing body of data providing evidence of the additional value of an image-based approach as compared with routine approach in improving response to CRT, these results should be confirmed in prospective and large multicentre trials before their impact on CRT guidelines is considered.

Bradyarrhythmias, including sinus node dysfunction and atrioventricular (AV) conduction disturbances, are a common clinical finding among elderly people. Ageing is associated with increased fat and collagen deposition surrounding the sinus node, which may cause temporary failure of sinus impulse formation and propagation. Moreover, age-related fibrosis and calcification of the cardiac skeleton may determine different degrees of AV conduction disorders. Other causes of AV blocks are represented by neuromuscular disorders, sarcoidosis, amyloidosis, Lyme disease, and post-radiation therapy. Isolated congenital complete AV block is a rare disease associated with exposure to maternal autoantibodies. If reversible extrinsic causes of bradyarrhythmias or underlying treatable diseases are ruled out, cardiac pacing is usually the therapy of choice in symptomatic bradyarrhythmias. During the last 20 years, cardiac pacing has faced dramatic changes in terms of increased implant rates, technology development, and implementation of indications in clinical practice. While in the 1960s and 1970s only AV blocks were treated, today the majority of pacemakers are implanted for sinus node disease. After being introduced in the 1980s and 1990s, dual-chamber pacing has become the most adopted pacing modality in patients with sinus node disease or AV block.

Background: We compared clinical and technical outcome of CRT recipients treated either with a conventional 3 leads (3L) CRTD or with the new 2 leads (DX) CRTD that enables atrial signal detection by a floating dipole built on a pentafilar RV lead. Methods: Echocardiography and cardiopulmonary exercise tests were repeated either before CRTD implantation and between 6 and 12 months follow up in consecutively implanted patients who had a resting heart rate > 40 bpm at maximum tolerated beta-blocker dosage. HF status, reverse LV remodeling, exercise tolerance and chronotropic incompetence were assessed at 12 months FU. Device diagnostics were obtained twice yearly until December 2016. Results: 37 patients aged 66 (58-73) years were consecutively implanted in 2013-2014 according to current guidelines, 25 with a 3L CRTD and 12 with a DX CRTD. Beta-blocker dosage was similar, and no difference between the 2 groups was observed in terms of NYHA class improvement, LV reverse remodeling, peak cardiopulmonary performance and presence of chronotropic incompetence at 12 months follow up. There was no difference in: amount delivered CRT; occurrence of VT/VF; occurrence of AT/AF. No patients developed need of atrial stimulation at 3-years FU. Atrial undersensing never occurred in any patient, whereas Far-field R-wave oversensing was more common in 3L patient than in DX patients (8/25 vs none, P < 0.05). P wave amplitude was greater in DX vs 3L patients [5.1(3.7-9.2) vs 2.9(2-3.9) mV, P < 0.01]. Conclusion: CRT can be achieved with two leads-only in the majority of patients, provided that indication to atrial stimulation is ruled out. (C) 2017 Elsevier B.V. All rights reserved.

Despite established efficacy for cardiac implantable electrical devices (CIEDs), large differences in CIED implant rates have been documented across and within countries. The aim of this paper is to investigate the influence of socio-economic, epidemiological and supply side factors on CIED implant rates across 57 Regions in 5 EU countries and to assess the feasibility of using administrative data for this purpose. A total of 1 330 098 hospitalizations for CIED procedures extracted from hospital discharge databases in Austria, England, Germany, Italy and Slovenia from 2008 to 2012 was used in the analysis. Higher levels of tertiary education among the labour force and percent of aged population are positively associated with implant rates of CIED. Regional per capita GDP and number of implanting centres appear to have no significant effect. Institutional factors are shown to be important for the diffusion of CIED. Wide variation in CIED implant rates across and within five EU countries is undeniable. However, regional factors play a limited part in explaining these differences with few exceptions. Administrative databases are a valuable source of data for investigating the diffusion of medical technologies, while the choice of appropriate modelling strategy is crucial in identifying the drivers for variation across countries. © 2017 The Authors. Health Economics published by John Wiley & Sons, Ltd.