Aims:A novel therapy offering cardiac resynchronization therapy (CRT) with an additional lead placed in His bundle has been reported in a few case reports and case series as improving the hemodynamical and clinical condition of patients with permanent atrial fibrillation (AF) in whom other therapeutic methods have not been successful. Methods:Fourteen consecutive patients with permanent AF, heart failure (HF), bundle branch block (BBB) with QRS complex width >130 ms, and impaired left ventricular ejection fraction (LVEF) underwent implantation of implantable cardioverter defibrillator (ICD)/CRT systems with His bundle pacing (HBP). During the follow-up, we assessed the efficacy of ICD/CRT systems with HBP in HF treatment. Results:The study cohort consisted of 14 patients with the mean age of 67.35 ± 10 years. The mean duration of QRS was 159.2 ± 28.6 ms, mean LVEF was 24.36 ± 10.7%, and mean follow-up duration was 14.4 months. One patient died due to HF aggravation during the follow-up. In the remaining 13 patients, the mean LVEF significantly improved from 24% to 38%, P = 0.0015. The left ventricular end-diastolic dimension decreased from 72 mm to 59 mm, P < 0.001; left ventricular end-systolic dimension decreased from 59 mm to 47 mm, P = 0.0026. The mean QRS duration shortened from 159 ms to 128 ms, P = 0.016. The mean percentage of HBP reached 97%. As a result, 92.3% of patients demonstrated significant improvement in the New York Heart Association functional class, P < 0.001. Conclusion:The use of atrial channel for HBP, choice of optimal ICD/CRT pacing configuration, and optimization of pharmacological therapy resulted in a substantial narrowing of QRS width and clinical improvement in left ventricular mechanical function during the follow-up. K E Y W O R D Satrial fibrillation, bundle branch block, cardiac resynchronization therapy, His bundle pacing, pacemaker 1 BACKGROUND Cardiac resynchronization therapy (CRT) is an acknowledged therapeutic choice for patients with sinus rhythm, congestive heart failure (HF) in the New York Heart Association (NYHA) class II-IV, wide QRS > 130 ms, and reduced left ventricular ejection fraction (LVEF) ≤35%, who remain symptomatic despite optimal medical therapy. 1,2 CRT in patients with permanent atrial fibrillation (AF) is usually less effective compared to patients in sinus rhythm. 1-3 The reasons for a less favorable response to CRT in that population are complex. 4 The greatest magnitude of benefit from CRT tends to be observed in those who are paced at >98% of the time.The findings from the RAFT-AF study showed that it was challenging to achieve the appropriate target of biventricular pacing in patients with permanent AF to the extent that only one-third of the study population reached nearly 100% pacing. 5 Irregular and fast ventricular response in AF induces changes in the myocardium referred to as a tachycardiomyopathy 6 and is increasing the risk of inappropriate therapies from implantable cardioverter defibrillator (ICD). 7 Additionally, patients with CRT derive ...

Objective The aim of this study was to evaluate the incidence of venous stenosis and occlusion (VSO) in patients referred for transvenous lead extraction (TLE) with regard to the indications for this treatment and to analyse the influence of VSO on efficacy, complications and technical challenges of TLE procedures. Methods The material consists of 133 consecutive TLE procedure records. The contrast venography examination of the ipsilateral access vein was performed prior to the operation. The whole study population was divided into two subgroups, based on the presence (subgroup I) or absence (subgroup II) of VSO. Results Phlebography was performed in 133 patients with age ranging from 25.7 to 86.1 years, 44 female (33.1%). The VSO was confirmed in 48 (36.1%) patients - subgroup I. Most of the patients were referred to TLE due to non-infectious reasons (100 pts-75.2%). The absence of VSO was observed substantially more frequently in patients with diabetes (P = 0.02). Procedural success rate reached 93.3% in subgroup I and 98.8% in subgroup II (P = 0.1). There was no significant difference in the use of advanced tools and alternative access sites. Conclusion The presence of VSO can be expected in one third of patients referred for lead extraction. There is no association between indication for TLE (infected or noninfected lead extraction) and the incidence of VSO. Diabetes proved to have a protective effect on venous patency in the previously mentioned group. VSO does not influence the effectiveness, safety, and the use of additional tools during TLE procedures.

(Cardiol J 2014; 21, 1: 47-52)

Incorrect implantation of a ventricular pacemaker (PM) lead into the left ventricle (LV) is a known problem associated with permanent pacing. The optimal management of such cases identified late has not been clearly established. Generally acceptable management options are: open-chest cardiac surgery using cardio-pulmonary bypass, chronic anticoagulation and antiplatelet-drugs therapy. Rarely, the problem is solved by percutaneous LV lead extraction. We present a case of a patient with DDD pacing and ventricular lead implanted incorrectly into the LV apex region via an atrial septal defect eight years ago. Chronic PM pocket infection developed after replacement of the device. Both leads were extracted percutaneously, and the embolic protection system (Filter-Wire EZ, Boston Scientific) was used to reduce cerebral circulation embolism. The hardest connective tissue adhesions affecting the lead and the anodal ring were found in the LV. Less dense surrounding fibrous tissue around the lead was present at all levels of the venous course of the lead and in the right atrium. Very small fragments of apparently connective tissue remnants were found in cerebral circulation protection filters, and had been removed after the procedure. We conclude that old, permanently implanted LV leads may be extracted percutaneously, especially when there is an increased risk of cardiac surgery, or where the patient's consent for surgical treatment is lacking. In order to perform the procedure it is recommended to establish a cerebral protection system and intraoperative transoesophageal echocardiography which are mandatory for successful lead removal.

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