Abstract Introduction Transvenous lead implantation for pacemaker implantation is commonly performed by the cephalic vein cutdown (CVC), subclavian (SVP), or axillary vein puncture (AVP)(1). However, the CVC or AVP should be considered as first choice, according to the last guidelines, due to high rate of lead complications and pneumothorax of SVP. Objective To compare efficacy and safety of AVP compared with CVC for CIED implantation by a meta-analysis. Methods We systematically searched Medline, Embase and Cochrane electronic databases up to September 5th, 2022, for studies that evaluated the efficacy and safety of AVP and CVC reporting at least one clinical outcome of interest. The primary outcome was acute procedural success. The secondary outcomes were pneumothorax, lead failure, pocket hematoma/bleeding, device infection, total procedure time, venous access time and fluoroscopy time. The effect size was estimated using a random-effect model as Risk Ratio (RR) and relative 95% Confidence Interval (CI). Results A total of 8 studies were included enrolling 1926 patients with 3532 leads and average age of 72.3±14.8 years. AVP compared to CVC showed a significant increase in the procedural success (95.7% vs 76.1%; RR: 1.24; 95% CI: 1.09-1.40; p=0.001), (Figure 1). Total procedural time (Mean Difference [MD]: -8.25 min; 95%CI: -10.23- -6.27; p<0.0001) and Venous access time (MD: -6.24 min; 95%CI: -7.01- -5.47; p<0.0001) were significantly shorter with AVP compared with CVC. No differences were found between AVP and CVC for pneumothorax (RR: 0.72; 95% CI: 0.13 - 4.0; p=0.71), lead failure (RR: 0.58; 95% CI: 0.23-1.48; p=0.26), pocket hematoma/bleeding (RR: 0.58; 95% CI: 0.15- 2.23; p=0.43), device infection (RR: 0.95; 95% CI: 0.14- 6.60; p=0.96) and fluoroscopy time (MD: -0.24 min; 95%CI: -0.75- 0.28; p=0.36). Conclusion Our meta-analysis proved that AVP improves procedural success and reduces total procedural time and venous access time compared to CVC. Figure 1 – Forest plots comparing Acute Procedural Success between Axillary Vein Puncture Versus Cephalic Vein Cutdown.
The implantable cardioverter defibrillator (ICD) has been demonstrated to successfully prevent sudden cardiac death (SCD) in children and young adults. A wide range of device-related complications/malfunctions have been described, which depend on the intrinsic design of the defibrillation system (transvenous-implantable cardioverter defibrillator [TV-ICD] vs. subcutaneous-implantable cardioverter defibrillator [S-ICD]).To compare the device-related complications and inappropriate shocks with TV-ICD versus S-ICD.Electronic databases were queried for studies focusing on the prevention of SCD in children and young adults with TV-ICD or S-ICD. The effect size was estimated using a random-effect model as odds ratio (OR) and relative 95% confidence interval (CI). The primary endpoint was a composite of any device-related complications and inappropriate shocks. We identified a total of five studies including 236 patients (Group S-ICD: 76 patients; Group TV-ICD: 160 patients) with a mean follow-up time of 54.2 ± 24.9 months. S-ICD implantation contributed to a significant reduction in the risk of the primary endpoint of any device-related complications and inappropriate shocks (OR: 0.18; 95% CI: 0.05-0.73; p = .02). S-ICD was also associated with a significantly lower incidence of inappropriate shocks (OR: 0.28; 95% CI: 0.11-0.74; p = .01) and lead-related complications (OR: 0.18; 95% CI: 0.05-0.66; p = .01). A trend toward a higher risk of pocket complications (OR: 5.91; 95% CI: 0.98-35.63; p = .05) was recorded in patients with S-ICD.Children and young adults undergoing S-ICD implantation may have a lower risk of a composite of device-related complications and inappropriate shocks, compared to TV-ICD patients.
Abstract Background Conduction system pacing (CSP) and atrioventricular junction ablation (AVJA) improve outcomes in patients with symptomatic, refractory atrial fibrillation (AF). Superior approach (SA) from the pocket via axillary or subclavian vein has been proposed as an alternative to the conventional femoral venous access (FA) to perform AVJA. Objective To assess the feasibility and safety of SA for AVJA performed simultaneously with CSP, and to compare this approach with FA. Methods A prospective, observational study, enrolling consecutive patients with symptomatic, refractory AF undergoing simultaneous CSP and AVJA. Results A total of 107 patients were enrolled: in 50, AVJA was primarily attempted with SA, in 69 from FA. AVJA with SA was successful in 38 patients (76.0%), while in 12 patients, a subsequent FA was required. AVJA from FA was successful in 68 patients (98.5%), while in one patient, a left‐sided approach via femoral artery was required. Compared with FA, SA was associated with a significantly longer duration of ablation (238.0 ± 218.2 vs. 161.9 ± 181.9 s; p = .035), a significantly shorter procedure time (28.1 ± 19.8 vs. 19.8 ± 16.8 min; p = .018), an earlier ambulation (2.7 ± 3.2 vs. 19.8 ± 0.1 h; p < .001), and an earlier discharge from procedure completion (24.0 ± 2.7 vs. 27.1 ± 5.1 h; p < .001). After a median follow‐up of 12 months, the rate of complications was similar in the two groups (2.0% in SA, 4.3% in FA; p = .483). Conclusion Simultaneous CSP and AVJA with SA is feasible, with a safety profile similar to FA. Compared to FA, this approach reduces the procedure times and allows earlier ambulation and discharge.
Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left ventricular function recovery (LV-REC) or left ventricular adverse remodelling (LV-REM) after acute myocardial infarction (AMI) play an important role for identifying patients at risk of heart failure. Purpose In this study we aim to evaluate the usefulness of non-invasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LV-REC or LV-REM after AMI. Methods Fifty patients with AMI (mean age, 63,8 ±13,4 years), treated by primary percutaneous coronary intervention (PCI), were prospectively enrolled. They underwent a baseline transthoracic Doppler echocardiography (TTE) within 48 hours after PCI and a second TTE after a median of 31 days during the follow-up. MW was derived from the strain-pressure loops, integrating in its calculation the non-invasive arterial pressure, according to standard speckle tracking echocardiography recommendations. LV-REC was defined as an absolute improvement of left ventricular ejection fraction (LVEF) ≥ 5% from LVEF at baseline, whereas LV-REM was defined as an increase of ≥ 20% of the LV end diastolic volume (LVEDV) at 1 month follow up. Results We overall found a significant improvement from baseline to one-month follow-up for values of LVEF (49,8 ± 9,5 % vs 52,8 ± 9,3 %, p = 0.001), Global Longitudinal Strain (GLS) (-13,4 ± 3,9 % vs -18,7 ± 5,4 %, p = 0.016), Global Work Index (GWI) (1368,6 ±435,2 vs 1788 ±493 mmHg/%, p = 0.0001), Global Work Efficiency (GWE) (89,96 ± 9,3 % vs 91,3 ± 6,4 %, p = 0.001), Global Constructive Work (GCW) (1619,16 ± 497,9 mmHg/% vs 2008,6 ± 535,3 mmHg/%, p = 0.0001), Global Wasted Work (GWW) (188,8 ± 19,8 mmHg/% vs 149,2 ± 16,5 mmHg/%). However, LV-REC at 1 month of follow-up was observed only in 36 % of the population enrolled, whereas LV-REM was described in 18% of cases. Using ROC curve analysis, we identified a cut off value of 202 mmHg/% for baseline GWW (Sensitivity 75%, Specificity 62%, AUC 0.6667, CI 95%: 0,51618 - 0,81715, p =0.0001) to identify patients with LV-REM at 1 month. With regards to conventional echo parameters, patients with LV-REC showed lower baseline Wall Motion Score Index (WMSI) than those without LV-REC (1,73 vs 1,38, p = 0.007). Conclusions Among standard and advanced TTE parameters, only baseline GWW is able to predict early LV-REM at 1 month after primary PCI. Therefore, it could be used during baseline evaluation of AMI patients for a more accurate stratification of those at higher risk of heart failure. However, further larger scale studies are needed to validate these findings. Abstract table 1 Abstract table 2
Abstract Background The diagnostic value of the β-angle in the diagnosis of patients with Brugada Syndrome (BrS) is still unclear. Objective to evaluate the diagnostic accuracy of the β-angle and establish its best cut-off value. Methods We searched databases for studies evaluating sensitivity and specificity of the β-angle in patients with suspected BrS undergoing Sodium Channel Blocker Provocation Test (SCBPT). The pooled sensitivity and specificity were calculated, and the Summary Receiver Operating Characteristic curve was constructed. The effect size was estimated using a random-effect model as Odds Ratio. Results we included 4 studies enrolling 1471 patients (Positive SCBPT: 382 patients; Negative SCBPT: 1089 patients). Patients with positive SCBPT had a higher mean β-angle value than those with negative SCBPT (39.25° vs 22.52°; p<0.0001). The best diagnostic accuracy was observed at the IV Intercostal space (Ic) (AUC: 0.82; 95% CI: 0.78-0.85) compared to IIIic (AUC:0.77; 95% CI: 0.74–0.81) and IIic (AUC: 0.68; 95% CI: 0.64–0.72), Figure 1. The risk of positive SCBPT was significantly increased in patients with a β-angle≥58° than those with a β-angle≥23° (OR:16.33 vs 3.39; p=0.0004). Conclusion A β-angle ≥58° represents the best diagnostic predictor for patients with suspected BrS.
Cardiogenic Shock (CS) complicating acute myocardial infarction (AMI) poses a significant mortality risk, suggesting the opportunity to implement effective mechanical circulatory support strategies. The comparative efficacy of Intra-Aortic Balloon Pump (IABP) and Impella in managing CS-AMI remains a subject of investigation.
Abstract Background Pulsed field ablation (PFA) is an innovative technology recently adopted for the treatment of atrial fibrillation (AF). Preclinical and clinical studies have reported a remarkable safety profile, as a result of its tissue specific effect targeting cardiomyocytes and sparing adjacent tissues. The FarapulseTM system was the first PFA device to receive regulatory approval. Objective We performed a meta-analysis to compare the efficacy and safety of PFA with the FarapulseTM system versus currently available 2nd generation Cryoballoon technologies (CRYO). Methods We systematically searched electronic databases for studies focusing on AF ablation employing the FarapulseTM PFA or 2nd generation CRYO technologies. The primary endpoints were acute procedural success assessed on a vein and patient basis. Safety endpoints included overall periprocedural complications and major periprocedural complications. We also compared procedural, fluoroscopy times, and freedom from atrial tachyarrhythmias (ATs) at follow-up (secondary endpoints). Results Fifteen and 69 studies were included for PFA and CRYO, respectively. PFA demonstrated greater acute procedural success on a vein basis (99.9% vs 99%;p<0.001), as well as per patient (99.5% vs 98.4%;p<0.001). PFA yielded lower overall periprocedural complications (3.0% vs 5.7%;p<0.001) and shorter fluoroscopy time (14.0 min vs 18.9 min;p=0.02) compared to CRYO (Figure 1). No differences were found for major periprocedural complications (1.2% vs 1.0%;p=0.37), procedural time (84.4 min vs 106.2 min;p=0.07) (Figure1) and freedom from ATs at 1 year (81.8% vs 80.3%; Log-rank p =0.98) (Figure 2). Conclusions PFA contributed to higher acute procedural success, and safety compared to CRYO. No statistically significant differences in AT recurrence at 1-year follow-up were observed.Figure 1Figure 2
Abstract Introduction Cardiac resynchronization therapy (CRT) reduces heart failure (HF) hospitalization and all‐cause mortality in HF patients with left bundle branch block (LBBB). Biventricular pacing (BVP) is the gold standard for achieving CRT, but about 30%–40% of patients do not respond to BVP‐CRT. Recent studies showed that left bundle branch pacing (LBBP) provided remarkable results in CRT. Therefore, we conducted a meta‐analysis aiming to compare LBBP‐CRT versus BVP‐CRT in HF patients. Methods We systematically searched the electronic databases for studies published from inception to December 29, 2022 and focusing on LBBP‐CRT versus BVP‐CRT in HF patients. The primary endpoint was HF hospitalization. The effect size was estimated using a random‐effect model as Risk Ratio (RR) and mean difference (MD). Results Ten studies enrolling 1063 patients met the inclusion criteria. Compared to BVP‐CRT, LBBP‐CRT led to significant reduction in HF hospitalization [7.9% vs.14.5%; RR: 0.60 (95%CI: 0.39–0.93); p = .02], QRSd [MD: 30.26 ms (95%CI: 26.68–33.84); p < .00001] and pacing threshold [MD: −0.60 (95%CI: −0.71 to −0.48); p < .00001] at follow up. Furthermore, LBBP‐CRT improved LVEF [MD: 5.78% (95%CI: 4.78–6.77); p < .00001], the rate of responder [88.5% vs.72.5%; RR: 1.19 (95%CI: 1.07–1.32); p = .002] and super‐responder [60.8% vs. 36.5%; RR: 1.56 (95%CI: 1.27–1.91); p < .0001] patients and the NYHA class [MD: −0.42 (95%CI: −0.71 to −0.14); p < .00001] compared to BVP‐CRT. Conclusion In HF patients, LBBP‐CRT was superior to BVP‐CRT in reducing HF hospitalization. Further significant benefits occurred within the LBBP‐CRT group in terms of QRSd, LVEF, pacing thresholds, NYHA class and the rate of responder and super‐responder patients.
