Background: The Rheos(R) System (CVRx, Minneapolis, MN, USA) is an implantable device used to lower blood pressure in patients with resistant hypertension by stimulation of the carotid baroreceptors. It is unknown if interaction might exist between Rheos and conventional pacemakers.Methods: Compatibility of the Rheos device was tested in four patients with preexisting pacemakers. Intra- and postoperative testing was completed with pacemaker and Rheos settings programmed to provoke interaction. Intracardiac electrograms were printed to determine interaction with the pacemaker.Results: No interaction was observed at maximum atrial and ventricular sensitivity settings and maximum bilateral Rheos output settings.Conclusion: Concomitant device therapy with Rheos device and pacemakers can be achieved without interaction. (PACE 2011; 34:354-356)

Introduction: CHF Patients often have sleep-disordered breathing (SDB), particularly central sleep apnea and Cheyne-Stokes respiration (CSR) related to poor cardiac function. Obstructive sleep apnea is commonly linked to obesity. Increasingly, a category described as "complex SDB" is being recognized, representing an overlap of obstructive and central apnea and may often prevent diagnosing patients by those distinct phenotypes. As part of the APNEA-CHF trial evaluating effects of CRT on SDB, this study describes complex SDB in CRT recipients. Methods: CRT indicated patients were enrolled consecutively at 6 sites in the US. After implantation, patients were screened by full polysomnography (PSG) and manually scored by a core lab using nasal cannula, thorax & abdomen effort, and EEG to classify apneas as obstructive or central. Apnea hypopnea indices (AHI) were calculated separately for obstructive (oAHI) and central (cAHI) events. cAHI% and oAHI% were calculated as a percentage of the total AHI. Results: Of 50 patients screened by PSG; 37 (74%) had AHI ≥ 15. CAHI% ranged continuously from 0 to 90% in these 37 patients (see figure). All patients were NYHA class III, with baseline characteristics: age = 62 ± 11Yr, BMI = 32 ± 6kg/m2, LVEF = 22 ± 6%, AHI = 43 ± 21/Hr, cAHI = 12 ± 14/Hr, oAHI = 30 ± 21/Hr, F/M = 3/34, Ischemic/Non-Ischemic = 15/22, QRS width = 154 ± 26s. Conclusions: SDB was very common in CRT patients. Much of this is neither pure obstructive nor central but complex, requiring detailed diagnosis. Concomitant obesity and poor cardiac function may have contributed to complexity of SDB. Further study is required to ascertain the implications of complex SDB within a HF population.

Tabled 13 Month DataAll Patients (n = 20)ATR Patients (n = 5)VF Patients (n = 2)# Single PVC/d2978 ± 42212336 ± 21301995 ± 1755# double PVC/d150 ± 305292 ± 542101 ± 116# nonsustained VT episode/d105 ± 445410 ± 8862 ± 2% Time of PSG study with SpO2 < 85%3.4 ± 9.08.2 ± 17.85.4 ± 7.6Sleep Efficiency (%)75.3 ± 9.880.5 ± 871.9 ± 0.5 Open table in a new tab

Tabled 1ParametersBaseline3 MonthDelta (Baseline - 3 Month)p valueVE/VCO2 Slope36.9 ± 10.033.3 ± 7.7−3.6 ± 10.40.12peak VO2 (ml/kg/min)13.8 ± 4.215.0 ± 4.21.1 ± 3.50.15SDANN (ms)62.8 ± 28.779.2 ± 30.116.3 ± 27.6<0.05HRV footprint (%)29.3 ± 15.338.8 ± 11.99.5 ± 10.1<0.01NYHA3.0 ± 0.02.3 ± 0.5−0.7 ± 0.5<0.01QoL52.8 ± 25.434.3 ± 22.9−18.5 ± 24.1<0.01AHI (/Hr)43.4 ± 22.642.0 ± 25.8−1.4 ± 20.40.76CAHI (/Hr)14.2 ± 15.78.8 ± 7.8−5.4 ± 15.70.12CAHI%(%)32.8 ± 27.122.9 ± 17.8−9.9 ± 23.90.07Sleep Efficiency (%)67.8 ± 13.974.7 ± 9.56.9 ± 13.80.03Circulation Delay (s) – Central SDB24.1 ± 6.123.0 ± 5.3−1.2 ± 5.60.20Circulation Delay (s) – Obstructive SDB20.9 ± 5.420.7 ± 4.1−0.2 ± 5.20.90 Open table in a new tab

Objectives: While defibrillation energy requirements (DERs) have been extensively studied in patients receiving conventional defibrillators, the DERs of patients receiving cardiac resynchronization therapy with defibrillation capability (CRT‐D) devices have not been well described. The purpose of this analysis was to characterize DERs (defined as true threshold or the presence of appropriate safety margins) in patients undergoing implant of a CRT‐D and to determine whether DERs in this population were similar to those reported for patients undergoing implantation of conventional defibrillators.

Objectives: While defibrillation energy requirements (DERs) have been extensively studied in patients receiving conventional defibrillators, the DERs of patients receiving cardiac resynchronization therapy with defibrillation capability (CRT-D) devices have not been well described. The purpose of this analysis was to characterize DERs (defined as true threshold or the presence of appropriate safety margins) in patients undergoing implant of a CRT-D and to determine whether DERs in this population were similar to those reported for patients undergoing implantation of conventional defibrillators. Methods: Data were analyzed retrospectively from the VENTAK CHF/CONTAK CD biventricular pacing study. An appropriate safety margin of at least 10 J was verified with at least two successful conversions with 21 J or less. Multivariate logistic regression was performed to determine baseline predictors of failed DER testing. Results: Of 501 patients enrolled, 444 (89%) had successful DER test outcomes. Of the remaining 57 patients, 34 converted with energies >= 21J, and 23 had their testing terminated prematurely or were not tested, primarily due to patient condition. Larger left ventricular internal dimension in diastole (P = 0.003) and prolonged procedure time (P = 0.01) were significant predictors of higher energy requirements. Few significant complications arose from DER testing. Conclusions: DER testing can be accomplished safely and successfully in the majority of CRT-D patients. However, safety margins cannot be ascertained in a significant number of these patients. Left ventricular inner diameter in diastole (LVIDd) and prolonged procedure time may predict higher DERs, and could be used to anticipate the need for a high-energy device or inclusion of a subcutaneous array.

In the normal heart, stimulation spreads rapidly via the His-Purkinje system causing synchronous contraction of the ventricles. With conventional bi-ventricular pacing that attempts to restore synchronus contraction, the left ventricle (LV) is excited from a single site. We theorized that exciting the LV from two sites would further improve intra-ventricular synchrony.

Despite an array of treatment modalities, the overall prognosis for patients with severe heart failure remains bleak. Biventricular pacing, or cardiac resynchronization therapy, is gaining increasing acceptance as a compelling treatment for those individuals with advanced heart failure (New York Heart Association functional class III or IV). This article provides a brief description of the atrial and ventricular conduction disturbances common in patients with advanced heart failure. Current indications for therapy are outlined, as are recent results of cardiac resynchronization therapy trials. The implant procedure is described to provide a comprehensive overview of this innovative approach to re-establishing normal electromechanical activity and synchronous right and left ventricular contractions. Patient care, before and after device implant, is also summarized. The focus on patient education throughout this article may allow it to serve as a reference for health care providers involved in the care of patients with severe heart failure.

Patients with ICDs are commonly advised to quit industrial jobs because of concerns that strong electromagnetic fields operating in the industrial environment might interfere with ICD functions. This study was done to assess interactions between industrial equipment and ICDs, and to devise a simple low risk screening protocol. We studied 18 patients carrying nine different ICD models who were met at their workplace by a clinical technician and were asked to walk through their workplace and perform typical duties while sensing status was monitored by listening to the ICD's beeper. All devices were interrogated at the completion of testing. At follow-up, patients were contacted by phone and were asked about employment status and history of ICD discharges or syncope. One hundred eighty-four contacts with 114 types of industrial equipment in 13 different industrial facilities (including 31 contacts with arc welding machines) were monitored. Interference with ICD's function occurred in only one contact (0.5%), when ICD therapy was temporarily suspended while a worker was attaching a huge electromagnet to a crane. At follow-up 46.0 +/- 6.0 months after testing, 7 patients (41%) are still holding the same job, 7 have retired because of reasons unrelated to their ICD, and 3 patients were transferred to a nonindustrial job. None of the patients had either an ICD shock or syncope during work. The use of a simple screening procedure can safely identify sources of electromagnetic interference that may affect ICD operation, and can predict long-term safety of working in an industrial workplace for ICD patients.

GIUDICI, M., et al. : Mapping the Coronary Sinus and Great Cardiac Vein. The purpose of this study was to develop a better understanding of the pacing and sensing characteristics of electrodes placed in the proximal cardiac veins. A detailed mapping of the coronary sinus (CS) and great cardiac vein (GCV) was done on 25 patients with normal sinus rhythm using a deflectable electrophysiological catheter. Intrinsic bipolar electrograms and atrial and ventricular pacing voltage thresholds were measured. For measurement purposes, the GCV and the CS were each subdivided into distal (D), middle (M), and proximal (P) regions, for a total of six test locations. Within the CS and GCV, the average atrial pacing threshold was always lower ( P < 0.05 ) than the ventricle with an average ventricular to atrial ratio > 5, except for the GCV‐D. The average atrial threshold in the CS and GCV ranged from 0.2– to 1.0‐V higher than in the atrial appendage. Diaphragmatic pacing was observed in three patients. Atrial signal amplitude was greatest in the CS‐M, CS‐D, and GCV‐P and smaller in the CS‐P, GCV‐M, and GCV‐D. Electrode spacing did not significantly affect P wave amplitude, while narrower electrode spacing attenuated R wave amplitude. The average P:R ratio was highest with 5‐mm‐spaced electrodes compared to wider spaced pairs. The P:R ratio in the CS was higher (P < 0.05) than in all positions of the GVC. It is possible to pace the atrium independent of the ventricle at reasonably low thresholds and to detect atrial depolarization without undue cross‐talk or noise using closely spaced bipolar electrode pairs. The areas of the proximal, middle, and distal CS produced the best combination of pacing and sensing parameters.