Expert opinion of the Heart Rhythm Association of the Polish Cardiac Society and the Polish Neurological Society on evidence-driven implementation of implantable loop recorders in Poland.

Implantable loop recorders (ILR) are considered increasingly helpful in diagnosing cardio-neurological conditions, especially if arrhythmic events are of high clinical importance but are unlikely to be captured by standard methods of electrocardiogram recording due to the low frequency of events and short duration of a single event. The compelling evidence from randomized trials and observational studies strongly supports ILR utilization in patients after cryptogenic stroke or transient ischemic attack and in patients with recurrent transient loss of consciousness of unknown origin. These two groups of patients are expected to gain the most from initiating ILR-driven clinically effective management strategies. Stroke or transient ischemic attack survivors with detected subclinical atrial fibrillation can be switched from antiplatelets to anticoagulants, whilst patients with recurrent syncope may avoid severe injuries and/or substantial impairment of their quality of life. This joint opinion of the Heart Rhythm Association of the Polish Cardiac Society and experts from the Polish Neurological Society summarizes the up-to-date rationale for using ILR in everyday clinical practice and describes the road map for implementing this technology in Poland. Special emphasis is placed on the most recent guidelines issued by both cardiological and neurological scientific societies.

Clinical and Laboratory Predictors of Long-Term Outcomes after Catheter Ablation for a Ventricular Electrical Storm.

Background: Ventricular electrical storm (VES) is characterized by the occurrence of multiple episodes of sustained ventricular arrhythmias (VA) over a short period of time. Radiofrequency ablation (RFA) has been reported as an effective treatment in patients with ventricular tachycardia (VT). Objective: The aim of the present study was to indicate the short-term and long-term predictors of recurrent VA after RFA was performed due to VES. Methods: A retrospective, single-centre study included patients, who had undergone RFA due to VT between 2012 and 2021. In terms of the short-term (at the end of RFA) effectiveness of RFA, the following scenarios were distinguished: complete success: inability to induce any VT; partial success: absence of clinical VT; failure: inducible clinical VT. In terms of the long-term (12 months) effectiveness of RFA, the following scenarios were distinguished: effective ablation: no recurrence of any VT; partially successful ablation: VT recurrence; ineffective ablation: VES recurrence. Results: The study included 62 patients. Complete short-term RFA success was obtained in 77.4% of patients. The estimated cumulative VT-free survival and VES-free survival were, respectively, 28% and 33% at the 12-month follow-up. Ischemic cardiomyopathy and complete short-term RFA success were predictors of long-term RFA efficacy. Neutrophil to lymphocyte ratio (NLR) and GFR <60 mL/min/1.73 m2 were associated with VES recurrence. NLR ≥2.95 predicted VT and/or VES recurrence with a sensitivity of 66.7% and specificity of 72.2%. Conclusion: Ischemic cardiomyopathy and short-term complete success of RFA were predictors of no VES recurrence during the 12-month follow-up, while NLR and GFR <60 ml/min/1.73 m2 were associated with VES relapse.

Comparison of Preoperative ECG Screening and Device-Based Vector Analysis in Patients Receiving a Subcutaneous Implantable Cardioverter-Defibrillator.

Background and Objectives: Subcutaneous implantable cardioverter-defibrillators (S-ICDs) provide protection against sudden cardiac death from outside the cardiovascular system. ECG screening is a prerequisite for implantation, but the reproducibility of its results post-operatively in the device is only partial. We aimed to compare the results of ECG screening with device-based sensing vector analysis. Materials and Methods: We screened the hospital records of all S-ICD recipients in our clinic. All of them had pre-operative ECG screening performed (primary, secondary, and alternate vectors). The results were compared with device-based vector analysis to determine the relation of the pre- and post-operative vector availability. Results: Complete ECG screening and device-based vector analysis were obtained for 103 patients. At least two acceptable vectors were found in 97.1% of the patients pre-operatively and in 96.1% post-operatively. When comparing vectors in terms of agreement (OK or FAIL) pre- and post-operatively, in 89.3% of the patients, the result for the primary vector was the same in both situations; for the secondary, it was in 84.5%, and for the alternate, it was in 74.8% of patients, respectively. In 55.3% of patients, all three vectors were labeled the same (OK or FAIL); in 37.9%, two vectors had the same result, and in 6.8%, only one vector had the same result pre- and post-operatively. The number of available vectors was the same pre- and post-operatively in 62.1% of patients, while in 15.5%, it was lower, and in 22.3% of patients, it was higher than observed during screening. Conclusions: Routine clinical pre-operative screening allowed for a good selection of candidates for S-ICD implantation. All patients had at least one vector available post-operatively. The final number of vectors available in the device-based analysis in most patients was at least the same (or higher) than during screening. The repeatability of the positive result for a single vector was high.

How likely is the sense-B-noise to affect patients with subcutaneous implantable cardioverter-defibrillators and can we solve that problem in every case?

BACKGROUND: Sense-B-noise is a newly reported possible cause of inappropriate shocks in patients with subcutaneous implantable cardioverter-defibrillators (S-ICDs). The nature of that noise is unknown, it is not related to mechanical failure of the S-ICD system. Reprogramming to the secondary sensing vector is suggested by the producer as a possible solution. METHODS: We analyzed the medical records of S-ICD recipients from two university clinical centers (Gdansk and Szczecin, Poland). Our aim was to determine the rate of sense-B-noise, and whether the secondary sensing vector would be available for reprogramming if such a problem occurred in our patients. RESULTS: The sense-B-noise issue affected three patients in our cohort (3%), which corresponds to the incidence of 0.012 events per patient-year of follow-up. The primary vector was permanently used in 47 patients (52%), secondary in 28 (31%), and alternate in 16 (17%), respectively. Therefore, the total number of patients potentially vulnerable to sense-B noise (with the primary or alternate vector programmed permanently) was 63 (69%). Among those 63 patients, 51 individuals (81%) had also the secondary vector available for permanent use. CONCLUSION: The sense-B-noise affected 3% of patients in our cohort, with an incidence of 0.012 per patient-year of follow-up. Most patients potentially vulnerable to sense-B noise could be reprogrammed to the secondary sensing vector, if necessary. Further investigation of the sense-B-noise issue is needed.

Case report: Transected Hickman catheter and its thrombotic occlusion in a patient with idiopathic pulmonary arterial hypertension-can a catheter replacement be avoided?

A 25-year-old female with idiopathic pulmonary arterial hypertension (PAH), who had a Hickman catheter implanted for continuous intravenous epoprostenol infusion, was admitted to the clinic after inadvertently cutting the catheter with nail scissors during a routine dressing change. Approximately 7 cm of the external segment of the Hickman catheter remained intact, with the distal end knotted by paramedics. A decision was made to repair the damaged Hickman catheter. However, it was discovered that its lumen was completely occluded by thrombosis. Therefore, catheter patency was mechanically restored using a 0.035-inch stiff guidewire in a sterile operating theatre setting, under fluoroscopy guidance. Successful aspiration and catheter flushing were achieved. Continuity of the Hickman catheter was then restored using a repair kit (Bard Access Systems) as per the manufacturer's instructions, with no visible leakage thereafter. Epoprostenol infusion through the Hickman catheter was resumed 24 h later, and the patient was discharged in good general condition two days afterward.

Application of Novel Technologies in Cardiac Electrotherapy to Prevent Complications.

(1) Background: Cardiac electrotherapy is developing quickly, which implies that it will face a higher number of complications, with cardiac device-related infective endocarditis (CDRIE) being the most frequent, but not the only one. (2) Methods: This is a retrospective case study followed by a literature review, which presents a patient with a rare but dangerous complication of electrotherapy, which could have been prevented if modern technology had been used. (3) Results: A 34-year-old female was admitted with suspicion of CDRIE based on an unclear echocardiographic presentation. However, with no signs of infection, that diagnosis was not confirmed, though an endocardial implantable cardioverter-defibrillator (ICD) lead was found folded into the pulmonary trunk. The final treatment included transvenous lead extraction (TLE) and subcutaneous ICD (S-ICD) implantation. (4) Conclusions: With the increasing number of implantations of cardiac electronic devices and their consequences, a high index of suspicion among clinicians is required. The entity of the clinical picture must be thoroughly considered, and various diagnostic tools should be applied. Lead dislocation into the pulmonary trunk is an extremely rare complication. Our findings align with the available literature data, where asymptomatic cases are usually effectively treated with TLE. Modern technologies, such as S-ICD, can effectively prevent lead-related problems and are indicated in young patients necessitating long-term ICD therapy.

Implantable Cardioverter-Defibrillators in Poland Compared with other European Countries from the Patient's Perspective: Insights from the EHRA Patient Survey.

BACKGROUND: The aim of this study was to compare differences between Polish ICD recipients and ICD recipients from other European countries in terms of quality of life, information provision before ICD implantation, and end-of-life issues. METHODS: This is a sub-analysis of the "Living with an ICD" patient survey (25-item questionnaire) organized by the European Heart Rhythm Association between 12 April 2021 and 5 July 2021 in ten European countries. RESULTS: There were 410 (22.7%) patients from Poland and 1399 (77.3%) from other European countries. A total of 51.0% of Polish patients reported improvement in their quality of life compared with 44.3% in other countries (p = 0.041). Remote monitoring was three times more often utilized in other countries than in Poland (66.8% vs. 21.0%, p < 0.001). While 78.1% of Poles felt well informed before ICD implantation compared with 69.6% of subjects from other countries (p = 0.001), they were less familiar with the ICD deactivation process than others (38.9% vs. 52.5%, p < 0.001). CONCLUSIONS: Despite the less frequent use of remote monitoring and gaps in end-of-life issues, Polish ICD recipients reported more favorable quality of life and a higher level of information received before device placement than patients in other European countries.

Subcutaneous implantable cardioverter-defibrillator therapy in Poland: Results of the Polish S-ICD Registry.

BACKGROUND: The use of subcutaneous implantable cardioverter-defibrillators (S-ICD) has been growing in Poland since 2014. The Polish Registry of S-ICD Implantations was run by the Heart Rhythm Section of the Polish Cardiac Society between May 2020 and September 2022 to monitor the implementation of that therapy in Poland. AIMS: To investigate and present the state-of-the-art of S-ICD implantation in Poland. METHODS: Implanting centers reported clinical data of patients undergoing S-ICD implantations and replacements, including age, sex, height, weight, underlying disease, history of pacemaker and defibrillator implantations, indications for S-ICD, electrocardiographical parameters, procedural techniques, and complications. RESULTS: Four hundred and forty patients undergoing S-ICD implantation (411) or replacement (29) were reported by 16 centers. Most patients were in New York Heart Association class II (218 patients, 53%) or I (150 patients, 36.5%). Left ventricular ejection fraction was 10%-80%, median (IQR) was 33% (25%-55%). Primary prevention indications were present in 273 patients (66.4%). Non-ischemic cardiomyopathy was reported in 194 patients (47.2%). The main reason for the choice of S-ICD were: young age (309, 75.2%), risk of infectious complications (46, 11.2%), prior infective endocarditis (36, 8.8%), hemodialysis (23, 5.6%), and immunosuppressive therapy (7, 1.7%). Electrocardiographic screening was performed in 90% of patients. The rate of adverse events was low (1.7%). No surgical complications were observed.

Flecainide in clinical practice.

Flecainide, similar to encainide and propafenone, is IC class antiarrhythmic, inhibiting Nav1.5 sodium channels in heart muscle cells and modulates cardiac conduction. Despite its over 40-year presence in clinical practice, strong evidence and well-known safety profile, flecainide distribution in Europe has not always been equal. In Poland, the drug has been available in pharmacies only since October this year, and previously it had to be imported on request. Flecainide can be used successfully in both the acute and chronic treatment of cardiac arrhythmias. The main indication for flecainide is the treatment of paroxysmal supraventricular tachycardias, including atrial fibrillation, atrioventricular nodal re-entrant tachycardia, atrioventricular re-entrant tachycardia and ventricular arrhythmias in patients without structural heart disease. Beyond that, it may be used in some supraventricular tachycardia in children and for sustained fetal tachycardia. Many studies indicate its efficacy comparable to or better than previously used drugs such as propafenone and amiodarone, depending on the indication. This review aims to highlight the most important clinical uses of flecainide in the light of the latest scientific evidence and to provide an overview of the practical aspects of treatment, including indications, off-label use, contraindications, areas of use, monitoring of treatment and most common complications, taking into account special populations: children and pregnant women.

The SIDECAR project: S-IcD registry in European paediatriC and young Adult patients with congenital heaRt defects.

AIMS: Subcutaneous-implantable cardiac defibrillators (S-ICDs) are used increasingly to prevent sudden cardiac death in young patients. This study was set up to gain insight in the indications for S-ICD, possible complications, and their predictors and follow-up results. METHODS AND RESULTS: A multicentre, observational, retrospective, non-randomized, standard-of-care registry on S-ICD outcome in young patients with congenital heart diseases (CHDs), inherited arrhythmias (IAs), idiopathic ventricular fibrillation (IVF), and cardiomyopathies (CMPs). Anthropometry was registered as well as implantation technique, mid-term device-related complications, and incidence of appropriate/inappropriate shocks (IASs). Data are reported as median (interquartile range) or mean ± standard deviation. Eighty-one patients (47% CMPs, 20% CHD, 21% IVF, and 12% IA), aged 15 (14-17) years, with body mass index (BMI) 21.8 ± 3.8 kg/m2, underwent S-ICD implantation (primary prevention in 59%). This was performed with two-incision technique in 81% and with a subcutaneous pocket in 59%. Shock and conditional zones were programmed at 250 (200-250) and 210 (180-240) b.p.m., respectively. No intraoperative complications occurred. Follow up was 19 (6-35) months: no defibrillation failure occurred, 17% of patients received appropriate shocks, 13% of patients received IAS (supraventricular tachycardias 40%, T-wave oversensing 40%, and non-cardiac oversensing 20%). Reprogramming, proper drug therapy, and surgical revision avoided further IAS. Complications requiring surgical revision occurred in 9% of patients, with higher risks in patients with three-incision procedures [hazard ratio (HR) 4.3, 95% confidence interval (95% CI) 0.5-34, P = 0.038] and BMI < 20 (HR 5.1, 95% CI 1-24, P = 0.031). CONCLUSION: This multicentre European paediatric registry showed good S-ICD efficacy and safety in young patients. Newer implantation techniques and BMI > 20 showed better outcome.

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.

Eligibility of patients with temporary paced rhythm for a subcutaneous implantable cardioverter-defibrillator.

BACKGROUND: A concomitant use of a pacemaker and a subcutaneous implantable cardioverter-de-fibrillator (S-ICD) may be required in some patients. AIMS: Our study aimed to evaluate the influence of permanent cardiac pacing on the morphology of the QRS complex in the context of S-ICD screening. METHODS: One hundred patients with cardiac electronic implantable devices (CIEDs) were included in whom S-ICD screening could be performed both during intrinsic and paced rhythm. RESULTS: The positive result of screening during spontaneous rhythm for at least one vector (in both supine and standing positions) was obtained in 80% and for 2 vectors in 59% of patients. Positive screening during paced rhythm for at least one vector was recorded in 36% of patients (78% right ventricular and 22% biventricular pacing) and for 2 vectors in 15% of patients (93% right ventricular and 7% biventricular pacing). At least one vector acceptable during both types of rhythm and in both positions was recorded in 23% of patients and at least 2 vectors in 8% of patients. CONCLUSIONS: The use of S-ICD in patients with paced ventricular rhythm is associated with a serious risk of inappropriate sensing due to different QRS morphology during intrinsic and paced rhythm, and it is particularly high in patients in whom periods of spontaneous rhythm interchange with periods of ventricular pacing. That risk has been hardly acknowledged in available reports, but according to our data, it is significant, and therefore it should be considered during S-ICD screening.

Real-Life Inter-Rater Variability of the PRAETORIAN Score Values.

(1) Background: The PRAETORIAN score is a tool developed for postoperative evaluation of the position of subcutaneous implantable cardioverter-defibrillator systems. The aim of our study was to evaluate the real-life inter-rater variability of the PRAETORIAN score, based on chest radiographs of S-ICD patients reviewed by independent clinical raters. (2) Methods: Postoperative chest X-rays of patients that underwent S-ICD implantation were evaluated by five clinical raters who gave values of the PRAETORIAN score. Ratings were then compared in a fully crossed manner to determine the inter-rater variability of the attributed scores. (3) Results: In total, 87 patients were included in the study. In the case of the most important final risk category of the PRAETORIAN score, the mean Light's kappa was 0.804, the Fleiss' kappa was 0.249, and the intraclass correlation was 0.38. The final risk category was identically determined by all five raters in 75.86% of patients, by four raters in 14.94%, and by three raters in 9.20% of patients. (4) Conclusions: The overall inter-rater variability of the PRAETORIAN score in a group of electrophysiologists experienced in S-ICD implantation, yet previously naive to the PRAETORIAN score, and self-trained in its utilization, was only modest in our study. Appropriate use of the score might require training of clinical raters.

Right Ventricular Endocardial Mapping and a Potential Arrhythmogenic Substrate in Cardiac Amyloidosis-Role of ICD.

Patients with cardiac amyloidosis (CA) have an increased risk of sudden cardiac death. (SCD). However, the role of an implantable cardioverter-defibrillator in the primary prevention of SCD in this group of patients is still controversial. We present a case with CA with recurrent syncope and non-sustained ventricular tachycardia. In order to further stratify the risk of SCD, an electrophysiological study with endocardial electroanatomic voltage mapping was performed prior to the ICD placement.