Background: The in-hospital management of patients with cardiac implantable electronic devices (CIEDs) changed early in the COVID-19 pandemic. Routine in-hospital controls of CIEDs were converted into remote home monitoring (HM). The aim of our study was to investigate the impact of the lockdown period on CIEDs patients and its influence on in-hospital admissions through the analysis of HM data. Methods: We analysed data recorded from 312 patients with HM during the national quarantine related to COVID-19 and then compared data from the same period of 2019. Results: We observed a reduction in the number of HM events in 2020 when compared to 2019. Non-sustained ventricular tachycardia episodes decreased (18.3% vs. 9.9% p = 0.002) as well as atrial fibrillation episodes (29.2% vs. 22.4% p = 0.019). In contrast, heart failure (HF) alarm activation was lower in 2019 than in 2020 (17% vs. 25.3% p = 0.012). Hospital admissions for critical events recorded with CIEDs dropped in 2020, including those for HF. Conclusions: HM, combined with telemedicine use, has ensured the surveillance of CIED patients. In 2020, arrhythmic events and hospital admissions decreased significantly compared to 2019. Moreover, in 2020, patients with HF arrived in hospital in a worse clinical condition compared to previous months.
Background Conduction System Pacing (CSP) includes both His Bundle Pacing (HBP) and Left Bundle Branch Pacing (LBBP). It guarantees physiological cardiac activation and it is essential to avoid pacing-induced dyssynchrony. Markedly dilated atria, up-grading to CRT, and congenital cardiopathies still represent complex anatomical scenarios in which the available tools could often result inadequate and graved by suboptimal results. Objective To evaluate the feasibility and effectiveness of 3D electro-anatomical mapping (EAM) to guide CSP (both HBP and LBBP) in patients with characteristics that allows “a priori” classification as complex anatomical scenario with low probability of success using only fluoroscopic guidance and available tools. Left atrium area >40 cm2; post-PICM up-grading and congenital heart disease were considered signs of anatomical complexity. Methods and results The study includes 25 patients (19 males, mean age 76–11 years; mean baseline EF 34.2–12.6%; 17 BBB; 5 post-PICM up-grading), candidates for CSP. 16 and 9 were respectively implanted with PM and ICD (13/12 dual/three-chamber devices). CARTO system was used in 6 ptss and EnsiteTM Precision in 19. EAM involved reconstruction of the right atrium and sub-tricuspid septum with the use of a decapolar catheter. Several “tags” have been placed on the His signals, in order to reconstruct the “His Cloud” and distinguish within it the proximal, medium, and distal area (Fig. 1). The sub-tricuspid septum was always reconstructed so that intra-procedurally operator could easily move from HBP to LBBP based on electrical parameters or paced QRS morphology. The mapping catheter was removed after the mapping phase and replaced with the pacing lead. Both exposed fixed screw 3830 leads and standard stylet-driven leads were used. HBP was achieved in 10 pts and LBBP in 13 pts. Three failures were resolved by CS lead implant. The time spend for His cloud mapping was 18±7 min. The mean threshold was 1.1±0.5 V; sensing 11.6±9.3 mV and impedance 786±339 ohm. Baseline QRS 155±19 ms and paced QRS 119±7 ms. In cases of LBBP we were also able to measure on the EAM map the depth of the catheter within the septum, resulting in 11.5±3.1 mm and the distance of the initial screw site from the His of 26.5±10.3 mm. Conclusions The electro-anatomical mapping allows the accurate reconstruction of “His cloud” by properly distinguishing proximal, middle, distal His. The sub-tricuspid zone of the interventricular septum is also reconstructed in high definition, so that intra-procedurally it is possible to easily move from HBP to LBBP and vice-versa based on the electrical parameters and paced QRS morphology. This method appears safe and effective even in complex cardiac anatomies possibly saving time and fluoroscopy use. The tags on the His cloud and sub-tricuspid septum can satisfactorily guide lead placement with high reproducibly. Funding Acknowledgement Type of funding sources: None. Figure 1. 3D-EAM used to guide HBP implant
Background Conduction system pacing (CSP)is becoming increasingly popular thanks to the ability to both maintain physiological electrical activation in patients with narrow QRS and restore ventricular synchrony in patients with bundle branch block (BBB). The Selectra3D introducer is a new tool able to support the correct positioning and screwing of the catheter on the bundle of His (HBP) or on the left branch (LBBP). It does exist in 3 different shapes: S, M, L (Fig. 1) based on the radius of main curvature. The internal diameter of 7.3 Fr allows it to support both the 3830 lumen-less catheter historically used for CSP, as well as standard 6Fr stylet-driven leads. Objective To evaluate the effectiveness of the Selectra3D introducer for CSP (including both HBP and LBBP), considering the procedural success rate and the lead stability (stability of electrical parameters or need for implant revision) in the medium-term follow-up. Methods and results The Selectra3D introducer was used in 56 patients' candidates for CSP (mean age 80±6 years). Pacing indications included A-V block in 21 patients, AF with slow ventricular response in 9 patients; SND in 8 patients and HF and severe ventricular dysfunction in 18 patients (of which 4 were PICM). The mean baseline EF was 40±15%. A PM was implanted in 40 patients and an ICD in 16. A standard stylet-driven lead was used in 48 cases, a fixed exposed screw lead was used in 8 patients. HBP was obtained in 21 cases and LBBP in 30 cases, while in 5 cases (8.9%) neither HBP nor LBBP could be obtained. Implants were performed via a left-sided approach in 55 cases and a right-sided approach in 1 case. The baseline QRS duration was 144±38 ms and the paced QRS duration was 118±21 ms. The electrical parameters were optimal with sensing 8.7±8 mV; impedance 625±276 ohm; threshold 1±0.5 V. During follow-up, 2 lead dislodgement (3.9%) (1 HBP and 1 LBBP) were recorded, both within 7 days after implantation. All the others showed stability of the electrical parameters at a mean follow-up of 8.4±4.2 months. Conclusions The new Selectra3D introducer supports effectively and safely the lead implant on conduction system catheters (HBP and LBBP), allowing the implant of both exposed fixed screw leads and standard stylet-driven leads, leading to procedural success>90%. The electrical parameters were optimal at implantation and remained stable during follow-up. Funding Acknowledgement Type of funding sources: None. Figure 1
Funding Acknowledgements Type of funding sources: None. Background Left Bundle Branch Pacing (LBBP) ensures physiologic ventricular activation. Growing experiences are rising on its applicability . Different tools available allow successful implant in different cardiac anatomies. Objective To analyse implant success rate and acute electrical parameters in LBBP guided by C315 fixed curve sheath or Selectra3D sheath. Methods 151 patients (mean age 79.8±8.3 years; 51% males) received LBBP. Pacing indication: AV block 50%, SND 12%, slow AF12%, ablate&pace 9%; HF 14%, revision of previous lead 1%. Coronary disease was present in 31%; hypertension in 93%, diabetes in 30%, severe valvular disease in 5%, persistent AF in 31% pts. Average QRS duration was 136±34 ms. Basal mean EF 52±12%. Different criteria for successful LBBP were analyzed (table 1). Results The lead was successfully implanted in the left bundle in 97.3% pts. In 60.5% pts guided by the C315 Medtronic fixed curve sheath while in 39.5% pts by the Selectra3D (40-S, 55-M, 65-L) Biotronik sheaths. 93 (63%) pts received 3830 fixed screw lead, 51 (35%) pts received Solia S 60 stylet-driven lead and 3 (2%) patients received Tendril 58 cm stylet-driven lead. All different criteria analysed to define successful LBBP were comparable in the C315 and Selectra 3D group (table 1). In 61% pts LBBP was the first choice, in 39% LBBP was aimed after unsatisfactory HBP (His threshold>2V or paced QRS>140 ms). The LBBP lead was connected to the RV port in 67% DR and 18% SR PMs; to the LV port in the 22 CRT devices. Mean fluoroscopy time was 10±6 min including implant of all leads, without differences between implants. Electrical parameters were highly favourable in all patients (mean threshold 0.73±0.27V and mean sensing 11±5.8 mV) without differences between the 2 sheaths. Pacing impedance was significantly lower in the Selectra 3D group. Paced QRS duration was 114±15 ms (112±14 vs 116±16 ms; P 0.180). Implant failure were 4 (2 due to severe tricuspid regurgitation and 2 to severe dilated atria). Conclusion LBBP is highly reliable in clinical practice. The different sheath available lead to successfully perform the implant in different cardiac anatomies. In our experience there was no differences in technical acute outcome between implant guided by C315 Medtronic sheath and Selectra3D Biotronik sheath.
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