Mindfulness-based emotional regulation for patients with implantable cardioverter-defibrillators: A randomized pilot study of efficacy, applicability, and safety.

BACKGROUND: The efficacy of mindfulness-based interventions to reduce anxiety or improve quality of life (QoL) in patients with cardiac pathologies is well established. However, there is scarce information on the efficacy, applicability, and safety of these interventions in adult patients with an implantable cardioverter-defibrillator (ICD). In this study, we examined their efficacy on QoL, psychological and biomedical variables, as well as the applicability and safety of a mindfulness-based intervention in patients with an ICD. METHODS: Ninety-six patients with an ICD were randomized into two intervention groups and a control group. The interventions involved training in mindfulness-based emotional regulation, either face-to- -face or using the "REM Volver a casa" mobile phone application (app). RESULTS: The sample presented medium-high QoL baseline scores (mean: 68), low anxiety (6.84) and depression (3.89), average mindfulness disposition (128), and cardiological parameters similar to other ICD populations. After the intervention, no significant differences were found in the variables studied between the intervention and control groups. Retention was average (59%), and there were no adverse effects due to the intervention. CONCLUSIONS: After training in mindfulness-based emotional regulation (face-to-face or via app), no significant differences were found in the QoL or psychological or biomedical variables in patients with an ICD. The intervention proved to be safe, with 59% retention.

Tumescent local anesthesia versus general anesthesia for subcutaneous implantable cardioverter-defibrillator implantation: A cost-effectiveness analysis.

BACKGROUND: General anesthesia (GA) is the standard anesthetic approach for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation. Nonetheless, GA is expensive and can be associated with adverse events. Tumescent local anesthesia (TLA) has been shown to reduce in-room and procedural times and to decrease post-procedural pain, all of which could result in a reduction in procedure-related costs. OBJECTIVE: The purpose of this study is to compare the cost-effectiveness of GA and TLA in patients undergoing S-ICD implantation. METHODS: The present study is a prospective, nonrandomized, controlled study of patients who underwent S-ICD implantation between 2019 and 2022. Patients were allocated to either the TLA or the GA group. We performed a cost analysis for each intervention. As an effectiveness measure, the 0-10 point Numeric Pain Rating Scale at 1, 12, and 24 hours post-implantation was analyzed and compared between the groups. A score of 0 was considered no pain; 1-5, mild pain; 6-7, moderate pain; and 8-10, severe pain. Cost-effectiveness was calculated using incremental cost-effectiveness ratios. RESULTS: Seventy patients underwent successful S-ICD implantation. The total cost of the electrophysiology laboratory was higher in the GA group than in the TLA group (median ± interquartile range US$55,824 ± US$29,411 vs US$37,222 ± US$24,293; P < .001), with a net saving of $20,821 when compared with GA for each S-ICD implantation. There was a significant decrease in post-procedural pain scores in the TLA group when compared with the GA group (repeated measures analysis of variance, P = .009; median ± interquartile range 0 ± 3 vs 0 ± 5 at 1 hour, P = .058; 3 ± 4 vs 6 ± 8 at 12 hours, P = .030; 0 ± 4 vs 2 ± 6 at 24 hours, P = .040). CONCLUSION: TLA is a more cost-effective alternative to GA for S-ICD implantation, with both direct and indirect cost reductions. Importantly, these reduced costs are associated with reduced postprocedural pain.

A survey study of the use of a subcutaneous implantable cardioverter-defibrillator in various clinical scenarios by expert electrophysiologists in Poland.

BACKGROUND: A subcutaneous implantable cardioverter-defibrillator (S-ICD) has become a recognized alternative to a traditional transvenous implantable cardioverter-defibrillator (T-ICD). Despite the growing evidence of non-inferiority of S-ICD, there are no clear clinical guidelines for selection of either of the two available systems. The aim of the study was to analyze the decisions made in predefined typical clinical scenarios by Polish cardiologists experienced in the use of both S-ICDs and T-ICDs. METHODS: A group of 30 experts of cardiac electrotherapy experienced in the use of S-ICDs was recruited and invited to participate in a web-based anonymous survey. The survey questions regarded the proposed therapy in various but typical clinical scenarios. RESULTS: From the invited 30 experts representing 18 clinical centers, 25 completed the survey. 72% of them declared that the number of S-ICDs implanted at their center during the preceding 12 months exceeded 10, and 40% - that it was over 20. Rates of responders preferring S-ICD or T-ICD in various clinical scenarios are reported and discussed in detail. CONCLUSIONS: Significant divergence of opinion exists among Polish experts regarding the use of a subcutaneous cardioverter-defibrillator. It is especially pronounced on the issue of the use of the system in middle-age patients, in case of complications of the hitherto ICD therapy, or the need of upgrading the existing cardiac implantable electronic device.

Successful use of stellate ganglion phototherapy in refractory ventricular tachycardia in a patient with cardiac sarcoidosis.

Ventricular arrhythmias are a life-threatening factor in cardiac sarcoidosis (CS), posing a significant therapeutic challenge. Stellate ganglion phototherapy (SGP), a non-invasive procedure for modification of the sympathetic nervous system, is an effective treatment for refractory ventricular tachycardia (RVT). However, there are limited data on the efficacy of SGP for RVT in patients with CS. In our case report, we found that SGP was effective for treating RVT in a patient with CS.We present the case of a man in his 60s with multiple cardioversions of implantable cardioverter defibrillator for ventricular tachycardia. The patient was administered prednisolone for the management of CS, which subsequently led to an increase in anti-tachycardia pacing for ventricular tachycardias. We introduced SGP to suppress RVT and anti-tachycardia pacing decreased from 371 to 25 events. Thus, SGP could be a feasible option for the management of RVT in patients with CS.

Impact of early ventricular tachycardia ablation in patients with an implantable cardioverter-defibrillator: An updated systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: There is limited information on whether early catheter ablation (CA) for ventricular tachycardia (VT) is associated with better outcomes compared with alternative strategies in patients with implantable cardioverter-defibrillator (ICD). OBJECTIVE: The purpose of this article was to assess the efficacy of early VT CA in patients with ICD. METHODS: EMBASE, PubMed, and Cochrane were searched from inception to April 2022. Randomized controlled trials comparing the efficacy of early VT CA with control groups, both in patients with ICD, were included in the analysis. Data on effect estimates in individual studies were extracted and combined via random effects meta-analysis using the DerSimonian and Laird method, a generic inverse variance strategy. RESULTS: Nine randomized controlled trials with 1106 patients (n = 1018, 92.1% with ischemic cardiomyopathy and n = 88, 7.9% with nonischemic cardiomyopathy) were evaluated. VT CA was associated with reduced VT recurrences (odds ratio [OR] 0.64; P = .007), appropriate ICD shocks (OR 0.53; P = .002), ICD therapies (OR 0.54; P = .002), and cardiovascular hospitalization (OR 0.67; P = .004). However, no significant differences were observed in terms of mortality rate, heart failure hospitalization, and quality of life between the early VT CA and control groups. CONCLUSION: Early CA was beneficial in reducing VT burden and ICD therapies. However, it did not affect mortality rate and quality of life. Since most patients in the included studies presented with ischemic cardiomyopathy, further studies on nonischemic cardiomyopathy should be conducted to validate if early CA has similar outcomes.

The cost of CIED infectious complications treatment in Poland from the perspective of Polish hospitals.

INTRODUCTION: Cardiac implantable electronic devices (CIED) are a recognized form of therapy in cardiology. Apart from the benefits, the use of CIEDs is also associated with the risk of complications, and the most important ones influencing treatment results and prognosis are infectious complications. AIM: This study aimed to calculate the cost of treatment of CIED-related infections, including transvenous lead extraction and device reimplantation, from the perspective of a Polish hospital. METHODS: A retrospective analysis of hospitalization costs of patients referred to transvenous lead extraction (TLE) for CIED infection was performed. The study covers cases from three Polish reference centers specializing in the comprehensive treatment of cardiac electrotherapy complications. RESULTS: It was shown that the average cost of treating a CIED infection is 34 000 PLN (8010 EUR) and is the highest in the cardiac resynchronization therapy with defibrillator function (CRT-D) group, where it amounts to almost 50 000 PLN (11 440 EUR). Thus, treatment of CIED infections is associated with an average loss of 3000 PLN for the healthcare provider and the length of hospitalization has a major influence on final outcomes. CONCLUSIONS: The hospital cost of treatment of CIED-related infections was high and related mainly to the type of device and length of hospitalization. Despite the low utilization of costly extraction tools, the hospitalization was still likely to be unprofitable.

Long-Term Outpatient Care and Rehospitalizations in Patients after Cardiac Electrotherapy Device Implantation.

Background and Objectives: Cardiovascular implantable electronic device (CIED) treatment is widely used in modern cardiology. Indications for this type of treatment are increasing. However, a significant proportion of CIED implantation patients require subsequent hospitalization for cardiovascular reasons. Older age and the associated complex clinical picture necessitate multidisciplinary outpatient specialist care for these patients. The aim of this study was to analyze the reasons for subsequent hospitalizations in the cardiology department and the impact of outpatient specialty care on these hospitalizations. To the best of our knowledge, there are no such studies in the available literature. Materials and Methods: This study was conducted on a population of patients treated with CIED. Reasons for subsequent hospitalizations were divided into clinically and statistically valid groups according to the main diagnosis. Using an electronic database, causes of hospitalization were determined based on this diagnosis. Using data on consultations at outpatient specialty clinics, a logistic regression model was created for the probability of subsequent hospitalization for cardiovascular causes according to the specialty of the clinic. Results: The 9-year follow-up included a population of 2071 patients treated with CIED. During the follow-up period, 508 patients (approximately 24.5%) required subsequent hospitalization for cardiovascular reasons. The most common leading causes were heart failure, atrial fibrillation, and coronary artery disease. The need for consultation at outpatient specialty clinics increased the likelihood of hospitalization. Moreover, the need to consult patients in nephrology outpatient, pulmonary disease outpatient, and orthopedic outpatient clinics was the most significant. Conclusions: The use of electronic implantable cardiovascular devices is a very important part of therapy in modern cardiology. The methods for their use are constantly being improved. However, they represent only one stage of cardiac treatment. After CIED procedures, patients require further care in both inpatient and outpatient specialty care settings. In this paper, we outline the reasons for subsequent hospitalizations and the importance of outpatient specialty care in this context. Effective organization of care after CIED procedures may be important in reducing the most expensive component of this care, that is, inpatient treatment.

Adverse device-device interaction between pacemaker and subcutaneous implantable cardiac defibrillator.

A 26-year-old patient with prior surgery for Ebstein's anomaly and a pacemaker (placed for post-surgical heart block and poor underlying rhythm) underwent SICD was placement. During defibrillation testing, device-device interaction led to undersensing of ventricular fibrillation with failure to shock. Increasing the pacemaker sensitivity resolved the problem but post shock pacing was unable to capture the heart after both shocks. The patient underwent removal of both the pacemaker and the SICD and placement of a transvenous ICD. Complex device-device interactions can occur in patients who are pacemaker dependent and undergo placement of a SICD.

Effective Use of Keishibukuryogan in Subcutaneous Hematoma after Implantable Cardiac Device Surgery in Two Cases.

Keishibukuryogan is a Kampo medicine that induces vasodilation and improves the blood flow velocity in subcutaneous blood vessels. We herein report two cases in which keishibukuryogan completely diminished subcutaneous hematoma after cardiac resynchronization therapy pacemaker implantation and defibrillator battery replacement within a month. Keishibukuryogan can be a good option for treating or preventing subcutaneous hematoma after surgical procedures for devices.

[Clinical pathway for electrical storm treatment in a healthcare network modeling. A proposal from ANMCO Tuscany]. / Percorso clinico-assistenziale in rete per il trattamento del paziente con "storm" aritmico. La proposta dell'ANMCO Toscana.

Electrical storm (ES) is defined as three or more episodes of sustained ventricular tachycardia (VT) or fibrillation (VF) within 24 h, or an incessant VT/VF lasting more than 12 h. It usually occurs in implantable cardioverter-defibrillator (ICD) recipients, and three or more device interventions are typically used for the diagnosis. ES incidence is particularly high in case of ICD implanted in secondary prevention (10-30%), with recurrences occurring in up to 80% of patients. A comprehensive evaluation of triggers, predictive factors of high-risk patients and an appropriate management of the acute/subacute and chronic phases are pivotal to reduce mortality and recurrences. Medical therapy with antiarrhythmic and anesthetic drugs, with appropriate device reprogramming and neuroaxial modulation if needed, are used to cool down the ES, which should ultimately be treated with ablation therapy or, less often, with an alternative treatment, such as denervation or stereotactic radiosurgery. An optimization of the clinical pathway in a network modeling is crucial to achieve the best treatment, eventually addressing patients to centers with VT ablation programs, and identifying the most challenging procedures and the most critical patients that should be treated only in high-volume tertiary centers. In this paper, we present a proposal of healthcare network modeling for ES treatment in a regional setting.

2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Position Statement on the Management of Ventricular Tachycardia and Fibrillation in Patients With Structural Heart Disease.

This Canadian Cardiovascular Society position statement is focused on the management of sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) that occurs in patients with structural heart disease (SHD), including previous myocardial infarction, dilated cardiomyopathy, and other forms of nonischemic cardiomyopathy. This patient population is rapidly increasing because of advances in care and improved overall survival of patients with all forms of SHD. In this position statement, the acute and long-term management of VT/VF are outlined, and the many unique aspects of care in this population are emphasized. The initial evaluation, acute therapy, indications for chronic suppressive therapy, choices of chronic suppressive therapy, implantable cardioverter-defibrillator programming, alternative therapies, and psychosocial care are reviewed and recommendations for optimal care are provided. The target audience for this statement includes all health professionals involved in the continuum of care of patients with SHD and VT/VF.

Safety and compatibility of smart device heart rhythm monitoring in patients with cardiovascular implantable electronic devices.

INTRODUCTION: Emerging medical technology has allowed for monitoring of heart rhythm abnormalities using smartphone compatible devices. The safety and utility of such devices have not been established in patients with cardiac implantable electronic devices (CIEDs). We sought to assess the safety and compatibility of the Food and Drug Administration-approved AliveCor Kardia device in patients with CIEDs. METHODS AND RESULTS: We prospectively recruited patients with CIED for a Kardia recording during their routine device interrogation. A recording was obtained in paced and nonpaced states. Adverse clinical events were noted at the time of recording. Electrograms (EGMs) from the cardiac device were obtained at the time of recording to assess for any electromagnetic interference (EMI) introduced by Kardia. Recordings were analyzed for quality and given a score of 3 (interpretable rhythm, no noise), 2 (interpretable rhythm, significant noise) or 1 (uninterpretable). A total of 251 patients were recruited (59% with a pacemaker and 41% with ICD). There were no adverse clinical events noted at the time of recording and no changes to CIED settings. Review of all EGMs revealed no EMI introduced by Kardia. Recordings were correctly interpreted in 90% of paced recordings (183 had a score of 3, 43 of 2, and 25 of 1) and 94.7% of nonpaced recordings (147 of 3, 15 of 2, and 9 of 1). CONCLUSION: The AliveCor Kardia device has an excellent safety profile when used in conjunction with most CIEDs. The quality of recordings was preserved in this population. The device, therefore, can be considered for heart rhythm monitoring in patients with CIEDs.

Detection of high-frequency artifact as a function of pulse generator algorithms and outer-insulation material.

BACKGROUND: A high rate of malfunction, predominantly intermittent high-frequency artifacts (HFAs), has been recently reported in Abbott Medical Tendril pacing leads. OBJECTIVE: To investigate the factors associated with the occurrence of HFAs on Tendril leads using a commonly used comparator lead for a control. METHODS: We reviewed institutional data for Medtronic CapSureFix 5076 and Abbott Medical Tendril pace-sense leads retrospectively. Recordings deemed to be due to electromagnetic interference and far-field oversensing were not included in the classification of HFAs. RESULTS: A total of 7673 leads were analyzed: 1628 Optim-insulated Tendril leads, 825 non-Optim Tendril leads, and 5220 CapSureFix 5076. HFAs were seen in 212 leads and were more frequently observed in Tendril compared to CapSureFix leads during a mean follow-up of 4.1 ± 3.6 years. Lower age at implant, defibrillator systems, atrial position, and connection to an Abbott Medical generator were associated with increased HFA. In multivariable analysis, only connection to Abbott Medical generators (odds ratio 7.686, P < .001) and age (odds ratio 0.988 per year, P = .016) were independently associated with HFAs on pace-sense leads. In an Abbott-generator-only analysis, Optim-insulated Tendril leads were more likely to display HFAs than non-Optim Tendril leads but not Medtronic CapSureFix 5076 leads. CONCLUSION: Abbott Medical pulse generators independently predict HFA in Tendril and CapSureFix 5076 leads, likely the result of displaying short or low-amplitude noise episodes that other devices do not record. When restricted to Abbott generators only, Optim-insulated Tendril leads show an increased incidence of HFAs when compared to non-Optim Tendril leads but not CapSureFix 5076 leads.

Pol-CDRIE registry - 1-year observational data on patients hospitalized due to cardiac device-related infective endocarditis in Polish referential cardiology centres.

BACKGROUND: The rate of cardiac device-related infective endocarditis (CDRIE) is increasing worldwide, but no detailed data are available for Poland. AIMS: We aimed to evaluate clinical, diagnostic, and therapeutic data of patients hospitalized due to CDRIE in 22 Polish referential cardiology centers from May 1, 2016 to May 1, 2017. METHODS: Participating cardiology departments were asked to fill in a questionnaire that included data on the number of hospitalized patients, number and types of implanted cardiac electrotherapy devices, and number of infective endocarditis cases. We also collected clinical data and data regarding the management of patients with CDRIE. RESULTS: Overall, 99 621 hospitalizations were reported. Infective endocarditis unrelated to cardiac device was the cause of 596 admissions (0.6%), and CDRIE, of 195 (0.2%). Pacemaker was implanted in 91 patients with CDRIE (47%); cardioverter­defibrillator, in 51 (26%); cardiac resynchronization therapy­defibrillator, in 48 (25%); and cardiac resynchronization therapy­pacemaker, in 5 (2.5%). The most common symptoms were malaise (62%), fever/chills (61%), cough (21%), chest pain (19.5%), and inflammation of the device pocket (5.6%). Cultures were positive in 77.5% of patients. The cardiac device was removed in 91% of patients. The percutaneous approach was most common for cardiac device removal. All patients received antibiotic therapy, and 3 patients underwent a heart valve procedure. Transesophageal echocardiography was performed in 80% of patients. The most common complication was heart failure (25% of patients). CONCLUSIONS: The clinical profile, pathogen types, and management strategies in Polish patients with CDRIE are consistent with similar data from other European countries. Transesophageal echocardiography was performed less frequently than recommended. The removal rate in the Polish population is consistent with the general rates observed for interventional treatment in patients with CDRIE.

Prognostic importance of serum troponin concentration in patients with an implanted cardioverter­defibrillator admitted to the emergency department due to electric shock.

BACKGROUND: High-energy implantable cardioverter-defibrillator (ICD) therapy may increase serum troponin (cTnI) concentration.   Aims: We aimed to assess an impact of cTnI concentration after ICD high-energy therapy on mortality. METHODS: A total of 150 patients aged 64.2 +/- 12.8 years admitted to the Emergency Departments (EDs) due to at least one electrical shock during the last 24 hours with measured serum cTnI concentration at admission were included. Age, gender, comorbidities, shocks' numbers, therapy appropriateness, serum creatinine concentration, and left ventricular ejection fraction were noted for the retrospective analysis. Survival was obtained using the personal identification numbers (PESEL), on November 2018 until death or a period of three years had elapsed (1057 days). RESULTS: cTnI concentration was increased in 92 (61.3%) patients. The mortality rate was related to age - HR: 1.04, 95% CI: 1.01-1.08, p = 0.026; increased cTnI concentration - HR: 2.88, 95% CI: 1.30-6.37, p = 0.009; diabetes - HR: 2.19, 95% CI: 1.09-4.39, p = 0.027; ischemic heart disease - HR: 2.96, 95% CI: 1.11-7.87, p = 0.030, serum creatinine concentration - HR: 2.17, 95% CI: 1.18-4.00, p = 0.013; LVEF (HR 0.95, 95% CI: 0.91-0.99, p = 0.009), and previous or current CABG or PCI (HR: 0.38, 95% CI: 0.15-0.96, p = 0.040 and HR: 0.29, 95% CI: 0.13-0.65, p = 0.003, respectively). CONCLUSIONS: Increased mortality rate in patients with ICD shocks is multifactorial. Increased cTnI concentration at ED admission, but not the number of ICD shocks, is an independent marker of higher long-term mortality.

Occult bacteraemia in cardiac implantable electronic device patients: a review of diagnostic workflow and mandatory therapy.

: Cardiac implantable electronic device (CIED) implantation has greatly increased, with an associated exponential increase in CIED infections (CDIs). Cardiac device related infective endocarditis (CDRIE) has high morbidity and mortality: approximately 10-21%. Therefore, a prompt diagnosis and radical treatment of CDRIE are needed; transvenous lead extraction (TLE) is the mainstay for the complete healing, even if associated with wide logistic problems, high therapeutic costs and high mortality risk for patients. Some criticisms about the value of Duke criteria and their limitations for the diagnosis of CDRIE are known. The significance of classic laboratory data, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), considered in the Duke score, are reviewed and critically discussed in this article, with regard to the specific field of the diagnosis of CDI. The need for new techniques for achieving the diagnostic reliability has been well perceived by physicians, and additional techniques have been introduced in the new European Society of Cardiology (ESC) and British Heart Rhythm Society (BHRS) guidelines on infective endocarditis. These suggested techniques, such as 18-Fluorodeoxyglucose PET/computed tomography (FDG-PET/CT), white blood cell PET (WBC PET) and lung multislice CT (MSCT), are also discussed in the study. This short review is intended as an extensive summary of the diagnostic workflow in cases of CDI and will be useful for readers who want to know more about this issue.

Cardiac implantable electronic devices in adults with tetralogy of Fallot.

BACKGROUND: Tachyarrhythmias and bradyarrhythmias affect 20%-50% of adult patients with tetralogy of Fallot (TOF) and some of these patients will require cardiac implantable electronic devices (CIED) such as pacemaker and/or internal cardioverter defibrillator. METHODS: The Mayo Adult Congenital Heart Disease database was queried for patients with repaired TOF and history of CIED implantation, 1990-2017. The study objectives were: (1) determine the occurrence of device-related complications defined as lead failure, lead recall, device infection and lead thrombus; and (2) determine the occurrence and risk factors for defibrillator shock. RESULTS: There were 99 patients (age 46±14 years and 66 (66%) men) with CIED, and the CIEDs were 41 (41%) pacemakers and 73 (73%) defibrillators. Indication for defibrillator implantation was for primary prevention in 28 (38%) and secondary prevention in 45 (62%). Device-related complications occurred in 20 (20%) patients (lead failure 17, lead recall 4, device infection 12 and thrombus 3). Twenty-five per cent of all device infections occurred within 30 days from the time of device generator change. Annualised rates of appropriate and inappropriate shocks were 5.7% and 6.2%, respectively. The use of class III antiarrhythmic drug was protective against defibrillator shock. CONCLUSION: The current study provides useful outcome data to aid patient counselling and clinical decision-making. Further studies are required to explore ways to decrease the risk of postprocedural infection after device generator change, and to determine which patients will benefit from empirical antiarrhythmic therapy as a strategy to decrease incidence of inappropriate defibrillator shock.

Infections of cardiac implantable electronic devices: Epidemiology, classification, treatment, and prognosis.

The increasing number of implantation procedures of implantable cardiac electronic devices (ICEDs) leads to a substantial growth of a cohort of patients in whom complications of such a therapy occur. Infective complications are among the most severe ones, as they are often associated with poor prognosis. Depending on the criteria applied, the incidence of cardiac device infection (CDI) is estimated at 0.5-2.2%. Many risk factors of CDIs have been identified, among which the most important are numerous previous cardiac electrotherapy procedures and their complexity, and the lack of perioperative antibiotic prophylaxis. Appropriate diagnosis of a suspected CDI is of utmost importance, as well as the correct classification of the infection, which leads to adequate treatment. Management of a CDI should include complete removal of the implanted device. Additionally, empirical and then targeted antibiotic therapy should be instituted. The prognosis of CDI may, nonetheless, be unfavorable. Despite appropriate treatment, the total mortality rate of such complication is estimated to be as high as 35%.

Cardiac implantable electronic device and vascular access: Strategies to overcome problems.

For arrhythmia treatment or sudden cardiac death prevention in hemodialysis patients, there is a frequent need for placement of a cardiac implantable electronic device (pacemaker, implantable cardioverter defibrillator, or cardiac resynchronization device). Leads from a cardiac implantable electronic device can cause central vein stenosis and carry the risk of tricuspid regurgitation or contribute to infective endocarditis. In patients with end-stage kidney disease requiring vascular access and cardiac implantable electronic device, the best strategy is to create an arteriovenous fistula on the contralateral upper limb for a cardiac implantable electronic device and avoidance of central vein catheter. Fortunately, cardiac electrotherapy is moving toward miniaturization and less transvenous wires. Whenever feasible, one should avoid transvenous leads and choose alternative options such as subcutaneous implantable cardioverter defibrillator, epicardial leads, and leadless pacemaker. Based on recent reports on the leadless pacemaker/implantable cardioverter defibrillator effectiveness, in patients with rapid progression of chronic kidney disease (high risk of renal failure) or glomerular filtration rate <20 mL/min/1.73 m2, this option should be considered by the implanting cardiologist for future access protection.