Background Transcatheter tricuspid valve replacement (TTVR) has emerged as a therapeutic option for patients with symptomatic severe tricuspid regurgitation. Right ventricular (RV) leads from pre-existing cardiac implantable electronic devices are entrapped during TTVR device implantation. Case Summary An 83-year-old woman with a dual-chamber cardiac implantable electronic device underwent TTVR in 2022. The procedure resulted in entrapment of the RV lead. After TTVR, the increase in lead impedance raised concern for lead failure, prompting consideration of a leadless pacemaker. During this procedure, the entrapped lead was extracted without causing malposition of the TTVR device. Discussion Extraction of entrapped leads after TTVR may be feasible in experienced centers after cautious deliberation. Nevertheless, pre-emptive lead extraction should be considered to minimize the risk of unsuccessful extraction or serious complications. Take-Home Message Extraction of entrapped RV leads without causing TTVR device malposition may be feasible, and leadless pacemakers can be considered a technically viable alternative for RV pacing in TTVR.

BACKGROUND:While interventional strategies have expanded the options for long term rhythm restoration, rate control continues to play a pivotal role in the treatment of atrial arrhythmias; however, pharmacologic strategies alone often fail in achieving effective rate control. AIMS:To examine long-term outcomes in patients who have undergone atrioventricular node ablation (AVNA) for the management of symptomatic atrial arrhythmias. METHODS:This observational Study Assessed Patients Who Underwent AVNA For Rate Control of Atrial Fibrillation (AF) Or Atrial Tachycardia (AT) Between April 2014 and February 2022. Clinical data, along with follow-up information including cardiac device interrogation were analyzed. A composite safety endpoint, Encompassing Heart Failure (HF) Rehospitalization, lead revision, device infection, or upgrade for cardiac resynchronization therapy (CRT), was evaluated. Additionally, structured patient interviews were conducted to assess quality of life outcomes. RESULTS:192 patients (76 females (39.6%), mean age 73.7 ± 10 years) were included into the study. Patients suffered from paroxysmal AF in 10 cases (5.2%), persistent AF in 138 cases (71.9%) and AT in 44 cases (22.9%). Acute AVNA was successful in all patients. Two pseudoaneurysms at the femoral puncture site occurred as the only periprocedural complications. Mean follow-up duration was 907.0 ± 609.7 days. Persistent complete AV block was present in 191 patients (99.5%) during follow-up. The composite safety endpoint occurred in 58 (30.2%) patients. Quality of life significantly improved in most patients with a relevant regression in EHRA and NYHA scores. CONCLUSION:AVNA is effective and safe in an all-comer patient population with high success rates in terms of rate control, QOL improvement and a favorable safety profile during long-term observation.

BACKGROUND:The prognostic relevance of implantable cardioverter defibrillator (ICD) in patients with end-stage heart failure (HF) with left ventricular assist device (LVAD) remains controversial. OBJECTIVES:To evaluate the prognostic impact of ongoing use of ICD and associated complications in HF-patients with LVAD-implantation. METHODS:We retrospectively analyzed all consecutive patients (n = 351) who underwent LVAD-implantation and follow up between 2009 and 2021. Patients were categorized according to the presence (n = 254) or absence (n = 97) of ICD. To reduce baseline imbalances between groups, propensity score matching (PSM) was performed, yielding two matched cohorts of 79 patients each. The primary endpoint was a composite of all-cause mortality and heart transplantation. Secondary endpoints included all-cause mortality, heart transplantation, and ICD-related complications. RESULTS:Median age was 58 [49-65] years, and 85% were male. Median follow-up duration was 3.6 [2.6-5.7] years. The primary endpoint revealed significantly less events in the ICD cohort (44.3% vs. 59.5% (HR 0.6 95%CI [0.40; 0.97], p = 0.035)). The difference was driven by a higher rate of all-cause mortality (22.08% vs. 41.8%, p = 0.008), while the heart transplantation rate was similar (17.7% vs. 21.5%, p = 0.98). ICD-related complications occurred in 20.4% of all ICD-patients, including 27 lead revisions, 8 complete system removals due to infection, 13 inadequate shocks and 4 hematoma evacuations. CONCLUSION:ICD therapy was associated with lower mortality in this single-center LVAD-cohort. However, this finding contrasts with recent meta-analytic. Given the substantial burden of ICD-related complications, ICD-management after LVAD-implantation should be individualized according to arrhythmic risk, pacing requirements, procedural risk, and patient preferences.

The coronary sinus and its tributaries constitute the anatomical foundation for successful cardiac resynchronization therapy. Despite the emergence of conduction system pacing as a physiological alternative, conventional transvenous CRT retains its important role—not all clinical scenarios can be addressed by left bundle branch area or His bundle pacing alone. Understanding coronary venous anatomy therefore remains essential for every implanting physician. This review provides a clinically oriented analysis of coronary venous anatomy as it pertains to left ventricular lead implantation.We examine the embryological origins of the coronary sinus, explaining why variants such as persistent left superior vena cava and obstructive Thebesian and Vieussens valves occur. The gross anatomy section details coronary sinus dimensions, ostial localization, and tributary classification using attitudinally correct nomenclature. Microanatomical considerations include wall thickness gradients, subepicardial adipose tissue thickness, and myocardial sleeve distribution.We review imaging modalities—fluoroscopy, computed tomography, and magnetic resonance imaging—emphasizing their complementary roles in preprocedural planning and real-time guidance. Catheter and wire handling techniques are discussed, from cannulation strategies to lead delivery. Electrophysiological parameters including Q-LV and S-QRS intervals are examined in the context of anatomical lead positioning.Finally, we analyze how anatomy influences outcomes, complications, and non-response. Understanding the coronary venous system transforms cardiac resynchronization therapy from a technical procedure into an anatomically informed intervention where success depends on matching therapeutic goals with individual patient anatomy.

To compare the prevalence and progression of tricuspid regurgitation (TR) after the implantation of right-ventricular pacing cardiac implantable electronic devices (CIEDs) versus biventricular pacing devices. TR in patients with CIEDs is often linked to mechanical interference from leads, but studies show TR can also progress with leadless pacemakers, suggesting a direct effect of pacing. We conducted a retrospective analysis of 549 patients who received a pacemaker (PM), implantable cardioverter defibrillator (ICD), or cardiac resynchronization therapy (CRT) device. Follow-ups were conducted after one year and at least three years with aggregate interrogation and transthoracic echocardiography performed. Patients were categorized into two groups: right-ventricular (RVall) pacing and biventricular (BiV) pacing. Median age was 68 [57–76] years, with 419 (76.3

AIMS:Left bundle branch area pacing (LBBAP) has emerged as an alternative to cardiac stimulation via right ventricular pacing and cardiac resynchronization therapy using coronary sinus leads. The approach utilizes dedicated three-dimensional guiding catheters for lead placement. Our objective was to evaluate the feasibility and safety of a simplified approach of implantation of an LBBAP electrode without a dedicated guiding catheter. METHODS:This was a prospective single-center proof-of-concept evaluation. Patients with an indication for dual-chamber pacemaker implantation were consecutively enrolled. All patients received ventricular lead placement with a commercially available stylet-driven pacemaker lead. LBBAP was attempted without the use of a dedicated guiding catheter but with the help of a manually three-dimensionally pre-curved stylet. RESULTS:A total of 24 patients were analyzed. Procedure and fluoroscopy durations were 61 ± 12 min and 7.4 ± 3.9 min, while LBBAP lead placement was successful in 19 patients (79%). In these patients, the V6-R-wave peak time was 74 ± 11 ms, the V1V6 interpeak interval was 51 ± 11 ms, and QRS width during unipolar stimulation was 123 ± 14 ms. No complications attributed to the transseptal route of the pacing lead occurred. After a mean follow-up of 104 ± 20 days, there was no significant change in QRS widths (123 ± 15 ms, p = 0.94), V6-R wave peak time (70 ± 11 ms, p = 0.3), and V1V6 interpeak interval (45 ± 10 ms; p = 0.12). CONCLUSION:Implantation of an LBBAP electrode without the use of a dedicated three-dimensional sheath is feasible and safe in a high proportion of patients. Further studies are necessary to define the impact of this technique for potential use in clinical routine.

The authors report for the first time to their knowledge, implantation of a standard implantable cardioverter-defibrillator lead for permanent delivery of left bundle branch area pacing. Implantation was successful and safe in 11 of 12 patients, with adequate defibrillation testing, good electrical and electrocardiographic parameters, and uneventful device-related short-term follow-up.

Graphical Abstract Implantation in a patient with transcatheter tricuspid valve annuloplasty (A), transcatheter valve replacement (B, C), and a combination of transcatheter annuloplasty and edge-to-edge repair (D). LAO, left anterior oblique; PM, pacemaker; RAO, right anterior oblique; TR, tricuspid regurgitation.

Permanent pacemaker implantation (PMI) is associated with increased morbidity after transcatheter aortic valve replacement (TAVR). Cardiac resynchronization-therapy (CRT) is recommended for patients if left ventricular ejection fraction (LVEF) is ≤ 40

Abstract Background Interest in conduction system pacing (CSP) has increased in recent years. For left bundle branch area pacing (LBBAP), 4F and 6F pacing leads have been shown to be effective and safe. No information is available on the potential use of ICD leads for LBBAP. Aim The objective of the study was to demonstrate the feasibility of implanting an ICD lead in the LBBAP position to reduce the number of leads for CRT-D therapy. Patients and Methods We implanted the 7F ICD lead in the LBBAP position through a new 10F CSP delivery sheath in ten consecutive patients. Periprocedural data, QRS morphology and degree of QRS reduction were analyzed. Results Ten consecutive patients (one female) aged 69.5±9.2 years were treated with the above-mentioned method. Eight patients had ischemic cardiomyopathy and two patients had nonischemic cardiomyopathy. All patients had a CRT-D indication. Eight patients had a wide QRS complex with complete LBB and a QRS complex of 184.8±25.8 ms. Two patients had a narrow QRS complex but first-degree AV block with a PR interval greater than 240 ms. Left ventricular ejection fraction was 31.8±8.6%. Operative and fluoroscopy times were 103.6±30.3 minutes and 10.5±6.1 minutes, respectively. On average, 1.7 ± 0.6 screwing attempts were required per patient. The intraprocedural LBBAP threshold was 0.78±0.6V/1.0ms, the impedance was 530.8±86.5 ohm, and the R-wave amplitude was 9±3.3mV. The unipolar paced QRS complex was 123.6±15.9ms, the bipolar paced QRS complex was 129.5±12.8ms, and the bipolar paced QRS complex on the next day was 133.3±11.7. The mean duration from stimulus to R-wave peak in lead V6 was 82.9 ± 19.7 ms. The R-wave interpeak interval between leads V6 and V1 was 43.4 ± 9.7 ms. All but one patient received an effective defibrillation threshold test at 30J (n=8) and 36J (n=1). One patient was not tested during the procedure due to high risk. Conclusion This first-in-human study of ICD lead implantation in the LBBAP position demonstrated its feasibility and efficacy in achieving conduction system stimulation. This approach may lead to a reduction in the number of leads implanted for cardiac resynchronization therapy. Figure 1. A- RAO view, angiography of the RV for verification of the TVA-summit. B- LAO view, angiography from the CSP- sheath after reaching final position of the LBBAP lead (right sided interventricular septum - yellow dotted line). C – 12 lead ECG (speed 50mm/sec) demonstrating paced and native QRS complexes. D – Fluoroscopy in RAO view, final result. E – Fluoroscopy in LAO view, final result. F – Transthoracic echocardiography the next day (4Ch view) demonstrates optimal LBBAP lead position.. RAO – right anterior oblique; LAO – left anterior oblique; TVA – tricuspid valve anulus; CSP – conduction system pacing; LBBAP – left bundle branch area pacing.Figure 1.

Atrioventricular (AV)‐node ablation (AVNA) is a common therapy option for rate control strategy of permanent atrial fibrillation (AF). We hypothesized that isolation of the AV nodal isolation (AVNI) is associated with a more frequent preservation of an adequate escape rhythm compared to AVNA.

Background:Cardiac resynchronization therapy (CRT) by implantation of an endocardial coronary sinus (CS) pacing lead is an established heart failure therapy. The recent European Society of Cardiology (ESC) guidelines on cardiac pacing and CRT recommend conduction system pacing (CSP) as a potential bail-out therapy in patients with previously unsuccessful CS-lead implantation. We present a case in which unsuccessful implantation of a CS pacing and ineffective QRS correction by His-bundle pacing (HBP) was overcome by left-bundle branch pacing (LBBP) to achieve cardiac resynchronization. Case summary:The patient had to undergo revision of a CS lead for CRT due to rising pacing thresholds and pacing impedance. CS-lead implantation was omitted by a stenotic posterolateral CS branch. HBP did not lead to adequate QRS correction. The patient underwent successful LBB lead implantation as bail-out therapy. After LBBP lead implantation electrocardiographic and echocardiographic parameters were evident of effective CRT. Discussion:Conduction system pacing may be an alternative to CS pacing for CRT in heart failure patients, which is endorsed by the current European guidelines. LBBP may overcome limitations of HBP and provide an alternative to other strategies such as surgical implantation of epicardial left-ventricular pacing leads. Further studies are needed to fully clarify the role of LBBP for heart failure treatment.

AbstractAimsBaroreflex activation therapy (BAT) is an innovative treatment option for advanced heart failure (HFrEF). We analysed patients' BAT acceptance and the outcome of BAT patients compared with HFrEF patients solely treated with a guideline‐directed medical therapy (GDMT) and studied effects of sacubitril/valsartan (ARNI).MethodsIn this prospective study, 40 HFrEF patients (71 ± 3 years, 20% female) answered a questionnaire on the acceptance of BAT. Follow‐up visits were performed after 3, 6, and 12 months. Primary efficacy endpoints included an improvement in QoL, NYHA class, LVEF, HF hospitalization, NT‐proBNP levels, and 6MHWD.ResultsTwenty‐nine patients (73%) showed interest in BAT. Ten patients (25%) opted for implantation. BAT and BAT + ARNI patients developed an increase in LVEF (BAT +10%, P‐value (P) = 0.005*; BAT + ARNI +9%, P = 0.049*), an improved NYHA class (BAT −88%, P = 0.014*, BAT + ARNI −90%, P = 0.037*), QoL (BAT +21%, P = 0.020*, BAT + ARNI +22%, P = 0.012*), and reduced NT‐proBNP levels (BAT −24%, P = 0.297, BAT + ARNI −37%, P = 0.297). BAT HF hospitalization rates were lower (50%) compared with control group patients (83%) (P = 0.020*).ConclusionsAlthough BAT has generated considerable interest, acceptance appears to be ambivalent. BAT improves outcome with regard to LVEF, NYHA class, QoL, NT‐proBNP levels, and HF hospitalization rates. BAT + ARNI resulted in more pronounced effects than ARNI alone.

The cover image is based on the Original Article AV-node isolation as an alternative to AV-node ablation in patients undergoing pace & ablate strategy by Lisa Lemke et al., .

In den vergangenen Jahren wurden zwei wesentliche internationale Experten-Empfehlungen zum Sondenmanagement kardialer implantierbarer elektronischer Devices (CIED) überarbeitet. So veröffentlichte zum einen die Heart Rhythm Society (HRS) 2017 einen Expertenkonsensus zum Thema Sondenmanagement unter Einschluss der Aspekte Haltbarkeit, Fehlfunktionen und Rückrufe, der Indikationen von Revisionseingriffen, des periprozeduralen Managements, einschließlich der personellen und logistischen Voraussetzungen von Sondenextraktionen, und gab zudem Empfehlungen zur Qualitätssicherung und zum Datenmanagement. Zum anderen publizierte die European Heart Rhythm Association (EHRA) 2018 Empfehlungen zum Design von klinischen Studien und Registern und forderte zudem eine intensivere wissenschaftliche Aufarbeitung der Sondenextraktionsprozeduren und benannte bestehende Wissenslücken („gaps in evidence“). Beide Manuskripte ergänzen sich thematisch und verfolgen das gemeinsame Ziel einer flächendeckenden qualitativ hochwertigen klinischen Versorgung sowie einer zukünftig fundierteren Aufarbeitung offenstehender wissenschaftlicher Fragen. Die gewählten Schwerpunkte adressieren explizit nicht ausschließlich Elektroden-revidierende Zentren, sondern alle in die Behandlung von CIED-Patienten involvierten Ärzte. Der vorliegende Kommentar der Arbeitsgemeinschaft Herzrhythmusstörungen der DGTHG fasst die wesentlichen Empfehlungen der beiden Stellungnahmen zusammen, erläutert Hintergründe und diskutiert kritisch kontroverse Auffassungen.

In the past few years two major international expert recommendations on lead management of cardiac implantable electronic devices (CIED) have been revised. Accordingly, in 2017 an expert consensus on lead management under the patronage of the Heart Rhythm Society (HRS) was published. It focused mainly on aspects of durability, malfunctions and recalls, indications for revision interventions, periprocedural management including personnel and logistic requirements for lead removal. Additionally, the recommendations on quality assurance and data management were addressed as well. Subsequently, the European Heart Rhythm Association (EHRA) published expert recommendations in 2018, which mainly dealt with the design of clinical studies and registries and requested a comprehensive analysis of lead extraction procedures and specified existing gaps in evidence. The papers complemented each other in terms of content and had a common denominator for high-quality clinical care that was based on well-supported clinical evidence. Importantly, both consensus statements address, besides lead extraction centers, explicitly all physicians involved in the treatment of CIED patients. The present comments by the Working Group on Heart Rhythm Disorders of the German Society for Thoracic, Cardiac and Vascular Surgery (DGTHG) summarizes the most important recommendations of the two statements, explains the background and discusses critical controversies.

We report the case of an 88-year-old man who developed a mid-left-ventricular (LV) obstruction caused by apical pacing to manage thirddegree atrioventricular block. The flow generated by the obstruction was directed toward the LV apex and appeared from late systole to early diastole. The obstruction appeared to result from earlier contraction at the apex compared with the midventricular portion of the LV, which was followed by an also earlier apical relaxation. The obstruction was eliminated by using a second right-ventricular midseptally attached electrode combined with a sequential septo-apical pacing (septal stimulation 40 ms before apical pacing).

AIMS Pacing the specific conduction system like the Bundle of His (HB) can lead to more physiologic activation patterns compared to traditional right ventricular apical pacing. The aim of this study was to estimate the feasibility and value of electroanatomical mapping (EAM) for HB pacing during the learning curve and its impact on procedural outcome. METHODS AND RESULTS Fifteen consecutive patients were treated using EAM of the His bundle region before implantation. Voltage and activation maps of HB potentials were performed. The activation time from His potential to R wave (ECG-reference) was measured and correlated to the HV interval. The atrial and ventricular potentials were blended so the active window could only see the His potential. After completing the activation map, it was transformed into a peak-to-peak voltage map of the HB. With reversed black and white colour scale, the exact point of the maximal His signal amplitude was visualized. Procedural data for the implantation were analysed using this innovative approach. The average total procedural time and fluoroscopy time was 88.2 ± 19.1 min and 10.9 ± 4.5 min, respectively. The 3D mapping time was 18.4 ± 5.1 min. The 13.9 ± 5.1 His potential points were needed in average to complete the map. No periprocedural complications were seen in this cohort. In 86.7% of cases, His bundle pacing was successful. The average threshold for the His bundle stimulation and the R-wave amplitude was 1.62 ± 1 V (@1.0 ms) and 4.8 ± 3.2 mV, respectively. The pacing impedance was 513.5 ± 102.8 Ω. Average paced QRS complex width was 116.9 ± 20.3ms. On average 2.6 ± 1.6 lead positions were targeted to find the optimal pacing site. CONCLUSION Electroanatomical mapping-guided implantation of His-bundle leads can facilitate the identification of optimal pacing sites and allow to minimize procedure and fluoroscopy times even during the phase of the learning curve.