Conduction system pacing in everyday clinical practice: EHRA physician survey.

With the increasing interest in conduction system pacing (CSP) over the last few years and the inclusion of this treatment modality in the current guidelines, our aim was to provide a snapshot of current practice across Europe. An online questionnaire was sent to physicians participating in the European Heart Rhythm Association research network as well as to national societies and over social media. Data on previous experience with CSP, current indications, preferred tools, unmet needs, and perceptions for the future are reported and discussed.

The use of remote monitoring of cardiac implantable devices during the COVID-19 pandemic: an EHRA physician survey.

It is unclear to what extent the COVID-19 pandemic has influenced the use of remote monitoring (RM) of cardiac implantable electronic devices (CIEDs). The present physician-based European Heart Rhythm Association (EHRA) survey aimed to assess the influence of the COVID-19 pandemic on RM of CIEDs among EHRA members and how it changed the current practice. The survey comprised 27 questions focusing on RM use before and during the pandemic. Questions focused on the impact of COVID-19 on the frequency of in-office visits, data filtering, reasons for initiating in-person visits, underutilization of RM during COVID-19, and RM reimbursement. A total of 160 participants from 28 countries completed the survey. Compared to the pre-pandemic period, there was a significant increase in the use of RM in patients with pacemakers (PMs) and implantable loop recorders (ILRs) during the COVID-19 pandemic (PM 24.2 vs. 39.9%, P = 0.002; ILRs 61.5 vs. 73.5%, P = 0.028), while there was a trend towards higher utilization of RM for cardiac resynchronization therapy-pacemaker (CRT-P) devices during the pandemic (44.5 vs. 55%, P = 0.063). The use of RM with implantable cardioverter-defibrillators (ICDs) and CRT-defibrillator (CRT-D) did not significantly change during the pandemic (ICD 65.2 vs. 69.6%, P = 0.408; CRT-D 65.2 vs. 68.8%, P = 0.513). The frequency of in-office visits was significantly lower during the pandemic (P < 0.001). Nearly two-thirds of participants (57 out of 87 respondents), established new RM connections for CIEDs implanted before the pandemic with 33.3% (n = 29) delivering RM transmitters to the patient's home address, and the remaining 32.1% (n = 28) activating RM connections during an in-office visit. The results of this survey suggest that the crisis caused by COVID-19 has led to a significant increase in the use of RM of CIEDs.

Current perspectives on wearable rhythm recordings for clinical decision-making: the wEHRAbles 2 survey.

Novel wearable devices for heart rhythm analysis using either photoplethysmography (PPG) or electrocardiogram (ECG) are in daily clinical practice. This survey aimed to assess impact of these technologies on physicians' clinical decision-making and to define, how data from these devices should be presented and integrated into clinical practice. The online survey included 22 questions, focusing on the diagnosis of atrial fibrillation (AF) based on wearable rhythm device recordings, suitable indications for wearable rhythm devices, data presentation and processing, reimbursement, and future perspectives. A total of 539 respondents {median age 38 [interquartile range (IQR) 34-46] years, 29% female} from 51 countries world-wide completed the survey. Whilst most respondents would diagnose AF (83%), fewer would initiate oral anticoagulation therapy based on a single-lead ECG tracing. Significantly fewer still (27%) would make the diagnosis based on PPG-based tracing. Wearable ECG technology is acceptable for the majority of respondents for screening, diagnostics, monitoring, and follow-up of arrhythmia patients, while respondents were more reluctant to use PPG technology for these indications. Most respondents (74%) would advocate systematic screening for AF using wearable rhythm devices, starting at patients' median age of 60 (IQR 50-65) years. Thirty-six percent of respondents stated that there is no reimbursement for diagnostics involving wearable rhythm devices in their countries. Most respondents (56.4%) believe that costs of wearable rhythm devices should be shared between patients and insurances. Wearable single- or multiple-lead ECG technology is accepted for multiple indications in current clinical practice and triggers AF diagnosis and treatment. The unmet needs that call for action are reimbursement plans and integration of wearable rhythm device data into patient's files and hospital information systems.

Diagnostic value of implantable loop recorders in patients with unexplained syncope or palpitations.

BACKGROUND: The implantable loop recorder (ILR) is a small cardiac rhythm-monitoring device. Our aim was to determine ILR diagnostic value in patients with unexplained syncope, presyncope, or palpitations suggesting cardiac arrhythmias. METHODS: This has been a retrospective, observational, single-center study. We included 181 patients in whom ILR was implanted at the Clinical Center of Serbia between January 2006 and July 2019. An event was marked as diagnostic if it led to a diagnosis and ILR was considered diagnostic if it verified or excluded an arrhythmia as the cause of syncope or palpitations. RESULTS: The mean age was 51.8 ± 17.8 years and 94 (51.9%) were male. The mean follow-up period was 20.2 ± 15.8 months. ILR was diagnostic in 98 patients (54.1%). There was no significant difference in diagnostic value of ILR in regard to the baseline patients' characteristics. The mean time to occurrence of the diagnostic event was 11.1 ± 9.6 months. The time to occurrence of a diagnostic event did not differ significantly between patients who underwent basic as compared to extended diagnostics before ILR implantation. CONCLUSIONS: ILR was able to achieve an etiological diagnosis in 54.1% of patients with unexplained syncope, presyncope, or palpitations suggesting cardiac arrhythmias. In a subgroup of patients with recurrent palpitations, ILR was significantly less diagnostic than in patients with syncope or presyncope. ILR should be implanted beforehand in syncope evaluation process.

Isolated negative T waves as independent predictors of short-term and long-term coronary heart disease mortality in men free of manifest heart disease in the Seven Countries Study.

Isolated T-wave findings are generally considered of little importance in clinical electrocardiogram (ECG) interpretation, although a few studies have associated them with excess mortality risk. We used Cox regression models to evaluate coronary heart disease (CHD) mortality risk for isolated inverted T waves in 8713 men in the Seven Countries Study with no manifest cardiac diseases at baseline. The study population was stratified into 3 mutually exclusive groups: (1) isolated inverted T waves in the absence of other codable ECG findings according to the Minnesota Code; (2) other ECG findings with or without negative T waves; and (3) no codable ECG findings, used as the reference group. Mortality follow-up of the entire cohort was performed at 5, 10, 20, 30, and 40 years. The prevalence of isolated negative T waves at baseline was low, 1.6%, in these men from working populations. The hazard ratio (HR) for CHD mortality risk after 5 years in the isolated T-wave inversion group was more than 3 times greater than that in the reference group after adjusting for age, body mass index, cigarette smoking, systolic blood pressure, serum cholesterol and cohort (HR 3.68, 95% confidence interval [1.44-9.37]). Hazard ratio declined gradually with the length of follow-up but was still at 50% excess risk at 40-year follow-up (HR 1.51, 95% confidence interval [1.12-2.05]). T waves in the isolated T-wave inversion group were "flat" or less negative than 1mm (-100 µV) in the majority (86%) of inverted T waves. We conclude that inverted T waves with even a minor degree of negativity as an isolated ECG finding in men with no evidence of heart disease predict an excess short-term and long-term risk of CHD death.

Morphogenetic dispositions for variability in acute kidney injury after cardiac surgery: Pilot study.

Background: The aim of our study was to evaluate the degree of genetic homozygosity in cardiac surgical patients with postoperative acute kidney injury (AKI), compared to the subgroup without postoperative AKI, as well as to evaluate antropomorpho-genetic variability in cardiac surgical patients with regard to the presence and severity degree of AKI. Materials and methods: The prospective cohort study included an analysis of 138 eligible coronary artery disease (CAD) surgical patients that were screened consecutively. The tested group was divided into three subgroups according to RIFLE criteria: Subgroup NoAKI (N = 91), risk (N = 31), and injury (N = 16). All individuals were evaluated for the presence of 19 observable recessive human traits (ORHT) as a marker of chromosomal homozygosity and variability. Results: Comparing subgroups NoAKI and risk, four ORHTs were significantly more frequent in the risk subgroup. Comparing subgroups NoAKI and injury, nine ORHTs were significantly more frequent in the injury subgroup; while comparing the injury subgroup and risk, five ORHTs were significantly more frequent in injury than in the risk subgroup. Results also showed a significant increase in the mean value of ORHTs for the injury subgroup compared to NoAKI subgroup (p = 0.039). Variability decreased proportionally to the increase in the severity of AKI (V NoAKI = 32.81%, V Risk = 30.92%, and V Injury = 28.62%). Conclusion: Our findings pointed to the higher degree of recessive homozygosity and decreased variability in AKI patients vs. NoAKI individuals, thus presumably facilitating the development and severity degree expression of AKI in patients after cardiac surgery.

Role of wearable rhythm recordings in clinical decision making-The wEHRAbles project.

BACKGROUND: Multiple wearable devices for rhythm analysis have been developed using either photoplethysmography (PPG) or handheld ECG. HYPOTHESIS: The aim of this survey was to assess impact of these technologies on physicians' clinical decision-making regarding initiation of diagnostic steps, drug therapy, and invasive strategies. METHODS: The online survey included 10 questions on types of devices, advantages, and disadvantages of wearable devices as well as case scenarios for patients with supraventricular arrhythmias and atrial fibrillation (AF). RESULTS: A total of 417 physicians (median age 37 [IQR 32-43] years) from 42 countries world-wide completed the survey. When presented a tracing of a regular tachycardia by a symptomatic patient, most participants would trigger further diagnostic steps (90% for single-lead ECG vs 83% for PPG, P < .001), while a single-lead ECG would be sufficient to perform an invasive EP study in approximately half of participants (51% vs 22% for PPG, P < .001). When presented with a single-lead ECG tracing suggesting AF, most participants (90%) would trigger further diagnostic steps. A symptomatic AF patient would trigger anticoagulation treatment to a higher extent as an asymptomatic patient (59% vs 21%, P < .001). PPG tracings would only rarely lead to therapeutic steps regardless of symptoms. Most participants would like scientific society recommendations on the use of wearable devices (62%). CONCLUSIONS: Tracings from wearable rhythm devices suggestive of arrhythmias are most likely to trigger further diagnostic steps, and in the case of PPG recordings rarely therapeutic interventions. A majority of participants expect these devices to facilitate diagnostics and arrhythmia screening but fear data overload and expect scientific society recommendations on the use of wearables.

Bidirectional Cardio-Respiratory Interactions in Heart Failure.

We investigated cardio-respiratory coupling in patients with heart failure by quantification of bidirectional interactions between cardiac (RR intervals) and respiratory signals with complementary measures of time series analysis. Heart failure patients were divided into three groups of twenty, age and gender matched, subjects: with sinus rhythm (HF-Sin), with sinus rhythm and ventricular extrasystoles (HF-VES), and with permanent atrial fibrillation (HF-AF). We included patients with indication for implantation of implantable cardioverter defibrillator or cardiac resynchronization therapy device. ECG and respiratory signals were simultaneously acquired during 20 min in supine position at spontaneous breathing frequency in 20 healthy control subjects and in patients before device implantation. We used coherence, Granger causality and cross-sample entropy analysis as complementary measures of bidirectional interactions between RR intervals and respiratory rhythm. In heart failure patients with arrhythmias (HF-VES and HF-AF) there is no coherence between signals (p < 0.01), while in HF-Sin it is reduced (p < 0.05), compared with control subjects. In all heart failure groups causality between signals is diminished, but with significantly stronger causality of RR signal in respiratory signal in HF-VES. Cross-sample entropy analysis revealed the strongest synchrony between respiratory and RR signal in HF-VES group. Beside respiratory sinus arrhythmia there is another type of cardio-respiratory interaction based on the synchrony between cardiac and respiratory rhythm. Both of them are altered in heart failure patients. Respiratory sinus arrhythmia is reduced in HF-Sin patients and vanished in heart failure patients with arrhythmias. Contrary, in HF-Sin and HF-VES groups, synchrony increased, probably as consequence of some dominant neural compensatory mechanisms. The coupling of cardiac and respiratory rhythm in heart failure patients varies depending on the presence of atrial/ventricular arrhythmias and it could be revealed by complementary methods of time series analysis.

Is pacemaker therapy the right key to patients with vasovagal syncope?

Introduction: Vasovagal syncope is the most common type of reflex syncope. Efficacy of cardiac pacing in this indication has not been the subject of many studies and pacemaker therapy in patients with vasovagal syncope is still controversial. Objective: This study aimed to assess the efficacy and safety of pacing therapy in treatment of patients with vasovagal syncope, to determine contribution of new therapeutic models in increasing its success, and to identify risk factors associated with a higher rate of symptoms after pacemaker implantation. Methods: A retrospective study included 30 patients with pacemaker implanted due to vasovagal syncope in the Pacemaker Center, Clinical Center of Serbia, between November 2003 and June 2014. Head-up tilt test was performed to diagnose vasovagal syncope. Patients with cardioinhibitory and mixed type of disease were enrolled in the study. Results: Mean age was 48.1 ± 11.1 years and 18 (60%) patients were men. Mean follow-up period was 5.9 ± 3.0 years. Primarily, implantable loop recorder was implanted in 10 (33.3%) patients. Twenty (66.7%) patients presented cardioinhibitory and 10 (33.3%) mixed type of vasovagal syncope. After pacemaker implantation, 11 (36.7%) patients had syncope. In multiple logistic regression analysis we showed that syncope is statistically more likely to occur after pacemaker implantation in patients with mixed type of vasovagal syncope (p = 0.018). There were two (6.7%) perioperative surgical complications. Conclusion: Pacemaker therapy is a safe treatment for patients with vasovagal syncope, whose efficacy can be improved by strict selection of patients. We showed that symptoms occur statistically more often in patients with mixed type of disease after pacemaker implantation.

The Relationship of Myocardial Collagen Metabolism and Reverse Remodeling after Cardiac Resynchronization Therapy.

BACKGROUND: In the majority of patients with a wide QRS complex and heart failure resistant to optimal medical therapy, cardiac resynchronization therapy (CRT) leads to reverse ventricular remodeling and possibly to changes in cardiac collagen synthesis and degradation. We investigated the relationship of biomarkers of myocardial collagen metabolism and volumetric response to CRT. METHODS: We prospectively studied 46 heart failure patients (mean age 61±9 years, 87% male) who underwent CRT implantation. Plasma concentrations of amino-terminal propeptide type I (PINP), a marker of collagen synthesis, and carboxy-terminal collagen telopeptide (CITP), a marker of collagen degradation, were measured before and 6 months after CRT. Response to CRT was defined as 15% or greater reduction in left ventricular end-systolic volume at 6-month follow-up. RESULTS: Baseline PINP levels showed a negative correlation with both left ventricular end-diastolic volume (r=-0.51; p=0.032), and end-systolic diameter (r=-0.47; p=0.049). After 6 months of device implantation, 28 patients (61%) responded to CRT. No significant differences in the baseline levels of PINP and CITP between responders and nonresponders were observed (p>0.05 for both). During follow-up, responders demonstrated a significant increase in serum PINP level from 31.37±18.40 to 39.2±19.19 µg/L (p=0.049), whereas in non-responders serum PINP levels did not significantly change (from 28.12±21.55 to 34.47± 18.64 µg/L; p=0.125). There were no significant changes in CITP levels in both responders and non-responders (p>0.05). CONCLUSIONS: Left ventricular reverse remodeling induced by CRT is associated with an increased collagen synthesis in the first 6 months of CRT implantation.

Low incidence of complications after cephalic vein cutdown for pacemaker lead implantation in children weighing less than 10 kilograms: A single-center experience with long-term follow-up.

BACKGROUND: Only a few studies on the cephalic vein cutdown technique for pacemaker lead implantation in children weighing ≤10 kg have been reported even though the procedure is widely accepted in adults. OBJECTIVE: The purpose of this study was to prove that cephalic vein cutdown for pacemaker lead implantation is a reliable technique with a low incidence of complications in children weighing ≤10 kg. METHODS: The study included 44 children weighing ≤10 kg with an endocardial pacemaker. Cephalic, subclavian, and axillary vein diameters were measured by ultrasound before implantation. The measured diameters were used to select either an endocardial or epicardial surgical technique. Regular 6-month follow-up visits included pacemaker interrogation and clinical and ultrasound examinations. RESULTS: Two dual-chamber and 42 single-chamber pacemakers were implanted. Mean weight at implantation was 6.24 kg (range 2.25-10.40 kg), and mean age was 11.4 months (range 1 day-47 months). In 40 children (90.1%), the ventricular leads were implanted using the cephalic vein cutdown technique, and implantation was accomplished via the prepared right external jugular vein in 4 of the children (9.9%). The atrial leads were implanted using axillary vein puncture and external jugular vein preparations. Mean follow-up was 8.9 years (range 0-20.9 years). Only 1 pacemaker-related complication was detected (a lead fracture near the connector that was successfully resolved using a lead repair kit). CONCLUSION: The cephalic vein cutdown technique is feasible and reliable in children weighing ≤10 kg, which justifies the application of additional surgical effort in the treatment of these small patients.

[Approach to the Treatment of Atrial Fibrillation in Patients with Cardiovascular Risk Profile: Multicentric International Study].

INTRODUCTION: Atrial fibrillation (AF), the most common arrhythmia that requires treatment, does not come out of the focus of researchers. Monitoring its prevalence and effects of therapy is a good guideline approach to the growing population of patients in which this arrhythmia occurs. OBJECTIVE: The aim of the study was to evaluate the efficacy of treatment of AF and cardiovascular profiles in the observed population. METHODS: In this observational, cross-sectional, multicenter, international study, 584 patients in 30 centers in Serbia and Slovenia, older than 18 years and with AF or in sinus rhythm with a history of AF, were included. The assessment of the efficacy of treatment of AF was performed by analyzing the frequency of adequate therapeutic effect of medication in rhythm or frequency control in patients with AF. RESULTS: The results confirmed that the highest incidence of AF duration is more than seven days, and is accompanied by symptoms. Inadequate frequency regulation was registered at 8.9% of patients. Hypertension was registered in two-thirds of all patients, while other cardiovascular risk factors were registered in about one-third of patients. An echocardiographic finding in the group of patients with AF confirms generally adequate left ventricular function with a slightly enlarged left atrium (4.6±0.8 cm). Increasing age and time from the first episode of AF decreases the probability of maintaining sinus rhythm, while symptomatic AF had a positive impact on the presence of sinus rhythm. Propafenone, sotalol and amiodarone showed a statistically significant connection with a positive therapeutic response, while 3-blockers had a negative impact on the probability of establishing and maintaining sinus rhythm. CONCLUSION: Characteristics of therapeutic approaches, risks, comorbidity of patient populations in Slovenia and Serbia correspond to the fullest extent with the recommendations for good clinical practice, which further stresses the need for extensive measures in these regions.

Epidemiology of typical coronary heart disease versus heart disease of uncertain etiology (atypical) fatalities and their relationships with classic coronary risk factors.

OBJECTIVES: The relationships were explored of some cardiovascular risk factors to typical (TYP) and atypical (ATYP) fatal coronary events (CHD). MATERIAL AND METHODS: Thirteen cohorts of 40-59 year-old men of the Seven Countries Study were followed-up for 40 years (N = 9704 heart disease free subjects). Fatal TYP-CHD were classified when manifested as myocardial infarction, other acute coronary syndromes, angina pectoris and sudden death; and as ATYP-CHD when manifested only as heart failure or arrhythmia in the absence of other clear etiologies. Death rates were computed for single countries separately for TYP and ATYP and for different lengths of follow-up. Cox models included: age, smoking habits, systolic blood pressure (SBP), serum cholesterol (CHOL), forced expiratory volume in ¾ sec (FEV) and diabetes. RESULTS: TYP-CHD was more common in North American and Northern European countries, while ATYP-CHD were more common in Southern and Eastern Europe. Age at death was 5 years greater for ATYP-CHD than for TYP-CHD. Cox models in the pool of 13 cohorts showed that coefficient for age was significantly larger for ATYP-CHD (hazard ratio, HR: 2.36; confidence intervals CI: 2.18 - 2.26) versus TYP-CHD (HR 1.50, CI 1.43-1.58) while coefficients for CHOL was larger and significant for TYP-CHD (HR 1.29, CI 1.22-1.35) but not for ATYP-CHD (HR 0.93, CI 0.85-1.03). SBP, smoking habits, FEV and diabetes all predicted both conditions almost equally. CONCLUSION: The different relationships of CHOL and age with the two types of fatal CHD suggest that the two groups of manifestations may belong to different diseases.