[Bachmann bundle pacing]. / Bachmann-Bündel-Pacing.

In pacemaker and ICD therapy, atrial leads are usually implanted in the right atrial appendage (RAA). This is easy but associated with a risk of negative hemodynamic and electrophysiological effects. Atrial depolarization, atrial contraction, and atrioventricular conduction can be delayed and desynchronized by RAA pacing leading to atrial fibrillation, pacing-induced long first-degree AV block, right ventricular pacing and the development of heart failure. High-septal atrial pacing near Bachmann's bundle that connects the right and left atrium can prevent the negative effects of RAA pacing and synchronize atrial excitation as demonstrated by the shortening of the PQ time and P wave duration during Bachmann bundle pacing. This review presents techniques to implant atrial leads at Bachmann's bundle. Apart from fluoroscopy in left anterior oblique projection, no additional effort compared to RAA implantation is required. Clinical studies on Bachmann bundle pacing are sparse; our own results suggest beneficial effects in patients with sick sinus syndrome and paroxysmal atrial fibrillation who receive atrial pacing for ≥50% of the time. Bachmann bundle pacing represents an interesting and simple option for atrial pacing. It is desirable to make this technique known to a wider spectrum of implanters and to generate more data on its clinical potential.

[Sudden cardiac death in diabetes mellitus]. / Plötzlicher Herztod bei Diabetes mellitus.

Sudden cardiac death (SCD) represents one of the most frequent causes of death in patients with diabetes. In contrast to patients without diabetes it has not been significantly reduced despite improvements in the treatment of acute myocardial infarction and long-term treatment of cardiovascular diseases as well as diabetes mellitus. Several mechanisms can be responsible for the high incidence of SCD in diabetics: 1. arrhythmogenic effects mediated via cardiac autonomic neuropathy, repolarization disturbances or sympathetic tone activation (hypoglycemia), 2. myocardial ischemia due to atherosclerosis, endothelial dysfunction, platelet aggregation or thrombophilic effects, 3. myocardial disease due to inflammation, fibrosis, associated hypertension or uremia and 4. potassium imbalance due to diabetic nephropathy or hypoglycemia. This review introduces concepts of mechanisms that are responsible for SCD in patients with diabetes. Treatment of patients with diabetes should primarily consider a systematic assessment of any deterioration of this chronic disease and of complications at an early stage. Cardiovascular drug treatment corresponds to that of non-diabetics. In antidiabetic treatment drugs with a low risk of hypoglycemia should be preferred. Treatment with implantable cardioverter defibrillators (ICD) also combined with cardiac resynchronization therapy () demonstrated a high life-saving potential particularly in patients with diabetes.

[Device therapy of chronic heart failure: Update 2015]. / Device-Therapie der chronischen Herzinsuffizienz: Update 2015.

Cardiac pacemakers, implantable cardioverter defibrillators (ICD) and systems for cardiac resynchronization therapy (CRT) represent an important component of heart failure therapy. Pacemakers only play a role in bradycardia-associated heart failure and require optimal programming to prevent ventricular desynchronization. Primary prophylactic ICD implantation is indicated in patients with a left ventricular ejection fraction of ≤ 35 %, clinical stages NYHA II-III and a life expectancy > 1 year. The CRT is indicated in patients with a left bundle branch block but only in individual cases for other QRS morphologies of < 150 ms duration. The combination of CRT with a pacemaker or defibrillator must be decided on an individual basis. Device therapy in heart failure should always include remote monitoring to detect events early and to implement treatment accordingly. New developments include quadripolar left ventricular leads and pacing from multiple sites simultaneously thus enabling better resynchronization. Stimulation for modulation of cardiac contractility and the autonomous nervous system are currently being clinically tested. The optimal utilization of device therapy improves the course of heart failure and prevents cardiac decompensation and fatalities.

[Surprising mechanism of highly symptomatic tachycardia in a young patient : Diagnosis and treatment]. / Überraschender Pathomechanismus hochsymptomatischer Tachykardien bei einem jugendlichen Patienten : Diagnostik und Therapie.

The diagnosis of paroxysmal tachycardia can be challenging in clinical practice because even with a typical patient history including palpitations, tachycardia, and an on/off phenomenon, 24 h Holter monitoring frequently fails to document the tachycardia. After unsuccessful 24 h Holter monitoring, we managed to document a very fast wide QRS complex tachycardia in a young patient by a mobile portable event monitor. Subsequent invasive electrophysiologic diagnostics followed by catheter ablation clarified the tachycardia mechanism and led to permanent elimination of the tachycardia.

Do gender differences exist in pacemaker implantation?--results of an obligatory external quality control program.

AIMS: The aim of the study was to evaluate the effects of patient gender onto primary pacemaker implantation, evaluating the database of the Institute of Quality Assurance Hessen in the federal state of Hessen, Germany. METHODS AND RESULTS: The database of the obligatory external quality control program for the years 2003-2006 was evaluated retrospectively. In 72 centres, 17 826 patients undergoing stationary primary pacemaker implantation have been registered. Male patients had more AV blocks when compared with women and less sick sinus syndrome and atrial fibrillation with bradycardia. In patients being 80 years and older, men received significantly more dual-chamber devices than women for the indications: AV block and sick sinus syndrome. In women, atrial pacing thresholds were significantly higher and P-wave amplitudes were significantly lower. Women had, independent from age or pacing system implanted, significantly more acute complications than men, with significant differences for pneumothorax and pocket haematoma. CONCLUSION: This large-scale real-life patient cohort of primary stationary pacemaker implantation showed that gender has an impact onto pacemaker implantation, with less favourable outcomes for women.

[Echocardiographic assessment of myocardial function during His bundle and right ventricular pacing]. / Echokardiographische Beurteilung der myokardialen Funktion unter His-Bündel- und rechtsventrikulärer Schrittmacherstimulation.

INTRODUCTION: In patients with pacemaker (PM) therapy, His bundle stimulation (HBS) may lead to a more synchronous activation of the left ventricle (LV) than conventional right ventricular stimulation (RVS). In this study, we investigated to which extent this effect can be objectified by means of contemporary echocardiographic functional imaging. METHODS: In all, 15 RVS patients (6 women, mean age 76.6 ± 4.1 years) and 15 HBS patients (6 women, mean age 74.6 ± 3.7 years) underwent echocardiography with and without cardiac pacing. Besides LV end-diastolic volume (EDV), ejection fraction (EF), and global strain (GLS), we measured global and regional myocardial work and LV efficiency based on noninvasive pressure-strain loops. RESULTS: In all HBS patients, optimization of PM settings resulted in immediate changes in myocardial function parameters. With pacing, RVS patients showed a higher decrease in EF and GLS than HBS patients. Global LV work and LV work efficiency decreased significantly only in RVS patients. CONCLUSION: Changes in regional and global myocardial function can by proven and quantified by functional echocardiography. In patients under PM therapy, HBS shows functional advantages in comparison to conventional RVS.

[17th part: Transvenous pacemaker implantation in corrected Fallot tetralogy with heart failure]. / 17. Folge: Transvenöse Schrittmacher-Implantation bei korrigierter Fallot-Tetralogie mit Herzinsuffizienz.

Implantation of transvenous pacemaker leads can be particularly--and unexpectedly--difficult in patients with corrected congenital heart disease. If the operation has been performed a long time ago, there are frequently no more reports about the exact intervention available. The present case illustrates the importance of the ECG and fluoroscopy during implantation in complex congenital heart disease.

Non-invasive risk stratification: prognostic implications of exercise testing.

The interpretation of exercise ECGs is frequently limited to an assessment of the ST segment for evaluation of ischemia. However, exercise testing represents a simple test of the complex interactions of the autonomous nervous system and provides a multitude of information with independent prognostic information. This overview summarizes available studies on the significance of chronotropic incompetence, exercise capacity, heart rate recovery after exercise, and the incidence of ventricular premature activity during or after exercise. These parameters express subclinical pathophysiological changes which cannot be identified by other means, e. g., coronary angiography or echocardiography. A reduced maximal heart rate under exercise may indicate a "blunted" sympathetic reaction as a protective myocardial reaction to an increase in left ventricular wall stretch in preclinical forms of heart failure. A reduced exercise capacity, measured in metabolic equivalents, METs, is one of the strongest predictors of cardiac and all cause mortality. A reduced heart rate recovery after exercise indicates an increased sympathetic tone or lack physiological increase in vagal tone; increased ventricular ectopy potentially identifies preclinical cardiomyopathy. This summary of study results aims at providing a new view on exercise testing that should lead to an improved understanding of relevant information included in the exercise ECG.

Stroke complicating congenital sick sinus syndrome.

We report the case of a patient with congenital sick sinus syndrome complicated by atrial fibrillation and embolic stroke 23 years after the initial diagnosis, at the age of 34 years. Treatment with a dual-chamber pacemaker and oral anticoagulation were initiated; further follow-up was uneventful but pacemaker diagnostics constantly documented asymptomatic recurrences of paroxysmal atrial fibrillation.

[Progression of heart failure during cardiac resynchronization therapy: what is the cause?]. / 15. Folge: Verschlechterung der Herzinsuffizienz unter kardialer Resynchronisationstherapie: Was ist der Grund?

A 74 year old patient with cardiac resynchronization therapy (CRT) since 12 months presents with cardiac decompensation and dyspnea NYHA III-IV after improvement of cardiac symptoms for 9 months. Her history is remarkable for left ventricular hypertrophy, aortic valve replacement 14 years earlier, a left ventricular ejection fraction of 35-40%, and permanent third degree AV block. The 12 lead standard ECG reveals the cause of cardiac deterioration which is confirmed by telemetry. This case demonstrates the importance of optimized programming of CRT systems which differs from conventional programming of dual-chamber devices in some aspects.

[16th part: ventricular lead position]. / 16. Folge: Ventrikuläre Elektrodenlage.

This case illustrates how the ventricular lead position can be defined exactly if different fluoroscopic views and a 12 lead ECG are available.

[Cardiac resynchronization therapy in patients with permanent atrial fibrillation--with or without atrial lead?]. / 14. Folge: Kardiale Resynchronisationstherapie bei Patienten mit permanentem Vorhofflimmern--mit oder ohne atriale Elektro.

A 59-year-old patient received a biventricular defibrillator for cardiac resynchronization therapy (CRT) due to severe heart failure and a left bundle branch block. He had suffered from mitral stenosis and had received valve replacement 16 years earlier. Because he had permanent atrial fibrillation since that time, no atrial lead was implanted. His symptoms improved with CRT until he received adequate shock therapy for a rapid ventricular tachyarrhythmia. After that his symptoms deteriorated again severely. The ECG recorded during an unscheduled follow-up visit 1 week after the shock explains the reason.

Use of telemedicine in the diagnosis of paroxysmal atrial fibrillation and to monitor the effect of antiarrhythmic drug therapy.

We present the case of a patient with highly symptomatic tachyarrhythmias for 2 years without any arrhythmia documentation despite numerous ECG and Holter registrations. By means of telemedicine, it was possible to document the arrhythmia--in this case atrial fibrillation--within 10 days and to start antiarrhythmic drug treatment with flecainide and metoprolol. This case demonstrates the diagnostic potential of telemedicine in patients with recurrent episodes of tachyarrhythmias in whom episodes are not sufficiently frequent to allow diagnosis by Holter monitoring. Telemedicine may also be advantageous for ECG monitoring during the early phase after cardioversion or initiation of specific antiarrhythmic pharmacotherapy in order to detect potential drug-induced proarrhythmic changes.

[Indication for cardiac resynchronization therapy: Consensus 2005]. / Indikation zur kardialen Resynchronisation: Konsensus 2005.

The indication for cardiac resynchronization therapy (CRT) using biventricular pacing or ICD systems has to be highly differentiated to optimize the proportion of patients who derive significant symptomatic benefit from this therapy, on the one hand, and to avoid this invasive treatment in patients with a low probability of clinical success of CRT, on the other hand. As a consensus in 2005, it can be put forward that there is sufficient evidence for an indication for CRT from clinical studies for the following characteristics: 1) Heart failure in NYHA functional class III or IV (if cardiac recompensation to class III is at least temporarily successful), 2) left ventricular ejection fraction < or =35%, 3) QRS duration >130 ms, particularly if left bundle branch block is present, 4) sinus rhythm. In addition, available data also suggest an indication for CRT in patients with atrial fibrillation if the other criteria listed above are met. The indication for CRT is unclear in patients with other intraventricular conduction delay (particularly right bundle branch block) while patients with left bundle branch block and a QRS duration of 120-130 ms seem to benefit if echocardiographic criteria demonstrate ventricular dyssynchrony. Since a multiplicity of echocardiographic criteria of ventricular dyssynchrony exists which is neither standardized nor evaluated in large-scale randomized trials, ventricular dyssynchrony on echocardiography alone cannot be regarded as an established indication for CRT without a QRS complex > or =120 ms. Similarly, whether heart failure in functional state NYHA II should be regarded as a CRT indication is currently being investigated in the randomized RAFT and MADIT-CRT trials.

[Difficult AV optimization in a patient with a biventricular implantable cardioverter defibrillator]. / 13. Folge: Schwierigkeiten bei der AV-Zeit-Optimierung einer Patientin mit biventrikulärem implantierbaren Kardioverter/Defibrillator.

This quiz presents the case of a patient who deteriorated clinically after AV delay optimization of a biventricular implantable cardioverter defibrillator. It illustrates that these complex devices require profound knowledge of their function.

Prevalence, characteristics and clinical implications of regular atrial tachyarrhythmias in patients with atrial fibrillation: insights from a study using a new implantable device.

OBJECTIVES: This study prospectively analyzed atrial tachyarrhythmia (AT) organization and antitachycardia pacing (ATP) success in patients with an implanted device for AT therapy. BACKGROUND: In patients with atrial fibrillation (AF), the incidence of regular, slow ATs amendable by ATP is unknown. METHODS: Forty patients with previously documented AT (70% with AF) received a new pacemaker with atrial electrogram (AEG) storage and atrial ATP capabilities for standard pacing indications. The AEGs acquired during the first month (study phase 1) were classified into high (type I), intermediate (type II) and low (type III) degrees of organization. Atrial ATP was then activated, and treated AT episodes were retrieved three and six months after implantation (study phase 2). RESULTS: Of 824 AEGs retrieved before ATP activation (study phase 1), 351 (43%) were classified as type 1, 47% as type II and 10% as type III. Episodes of AT starting as type I (35%) and type II or III (65%) maintained their type over 1 min in 73%. All patients with an exclusive history of AF also showed type I AEGs. In 361 subsequently treated AT episodes (study phase 2), ATP was successful in 62% of type I and 34% of type II episodes, but not in type III (p < 0.0001). CONCLUSIONS: The majority of patients with a history of AF show not only disorganized but also highly organized AT episodes, which can be successfully terminated by ATP.