Kella, D

ABSTRACT Background In patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF), atrioventricular node ablation (AVNA) and permanent pacing are often pursued when rhythm control is not pursued. Biventricular pacing (BiVP) has demonstrated benefits over right ventricular pacing, while conduction system pacing (CSP) has emerged as an alternative. However, evidence directly comparing CSP with BiVP in this high‐risk population remains inconsistent. Objective To compare CSP versus BiVP in patients with AF and HFrEF undergoing AVNA, focusing on cardiac function, clinical outcomes, and procedural metrics. Methods Following PRISMA guidelines, we searched PubMed, Scopus, and Web of Science through February 2026 for studies comparing CSP and BiVP in adults with AF and HFrEF undergoing AVNA. Outcomes included all‐cause mortality, heart failure hospitalization (HFH), changes in left ventricular ejection fraction (LVEF), QRS duration, New York Heart Association (NYHA) class, pacing threshold, procedure duration, and fluoroscopy duration. A random‐effects model was used to pool mean differences (MDs) or risk ratios (RRs) with 95% confidence intervals (CIs). Results Six studies (one randomized crossover trial and five observational studies; N = 766 patients: CSP = 356, BiVP = 410) were included. All‐cause mortality was significantly reduced in favor of CSP (RR 0.64 [CI: 0.44 to 0.94], p = 0.02, I 2 = 0%). There was also a trend towards lower HFH, but it marginally missed statistical significance (RR 0.77 [CI: 0.58 to 1.03], p = 0.08; I 2 = 0%). Additionally, CSP decreased NYHA class (MD ‐0.64 [CI: −1.18 to −0.10], p = 0.02; I 2 = 85%) and significantly reduced QRS duration (MD −33.56 ms [CI: −52.36 to −14.76], p = 0.0005; I 2 = 97%). LVEF improvement did not significantly differ between groups (MD 4.51% [95% CI: −1.50 to 10.52], p = 0.14; I 2 = 98%). Procedure duration and fluoroscopy times did not show statistically significant difference between the two groups (MD −11.54 min [CI: −50.05 to 26.97], p = 0.56, I 2 = 96%), and (MD −5.75 min [CI: −13.13 to 1.63], p = 0.13, I 2 = 88%), respectively. Overall pacing thresholds did not significantly differ between CSP and BiVP; however, modality‐specific subgroup analysis showed comparable thresholds between HBP and BiVP, whereas LBBP was associated with significantly lower pacing thresholds than BiVP. Conclusions Among patients with AF and HFrEF undergoing AVNA, CSP may offer symptomatic and electrocardiographic advantages over BiVP, with a possible signal toward improved major clinical outcomes that requires confirmation in larger randomized studies.

Abstract Background Cardiovascular implantable electronic device (CIED)-associated infective endocarditis with large vegetations carries substantial morbidity and a high risk of embolization during transvenous lead extraction (TLE). Purpose To evaluate procedural outcomes, microbiological clearance, and embolic risk in patients undergoing percutaneous aspiration of vegetations in the setting of CIED-associated infective endocarditis prior to TLE. Methods Between January 2023 and October 2025, patients with confirmed CIED-associated infective endocarditis and echocardiographic evidence of vegetations on transvenous leads or cardiac valves were included. Mechanical aspiration was performed at the operator’s discretion for vegetation size > 20 mm, multiple vegetations, prior or potential embolization risk, or ongoing sepsis. All patients underwent percutaneous aspiration using the AngioVac or Penumbra system, followed by TLE either during the same session or in a staged procedure. Baseline clinical characteristics, microbiologic data, procedural details, and outcomes were reviewed. Results Our cohort comprised five patients (60% male) with a median age of 56.8 years (IQR 49.4–66.1). Median lead dwell time was 6.1 years (IQR 3.9–14.8). Median vegetation size was 12.5 mm (IQR 8–17). Two patients had prior septic pulmonary emboli. Microbiology identified Staphylococcus aureus in 2, Streptococcus spp. in 2, and Salmonella spp. in 1. The tricuspid valve and lead were involved in 4 patients, the mitral valve in 2, and the aortic valve in 1. The AngioVac system was used in 4 cases and Penumbra in 1. Successful aspiration (≥70% reduction in vegetation size of the targeted valve) was achieved in all cases. Two patients underwent staged extraction and three underwent concomitant TLE with complete removal of the transvenous system. A total of 8 leads were extracted (median 1, IQR 1–2.5); 4 patients had ICD leads, 2 with dual coil. No clinically significant embolic events occurred during the procedures. Among two patients with persistent infection, blood cultures cleared within 24 hours in one and 96 hours in the other. There were no major procedural complications or in-hospital or 30-day mortality. One patient with multivalvular involvement (aortic, mitral, tricuspid) subsequently underwent valve replacement surgery after blood cultures became sterile post-aspiration and TLE. Conclusion Percutaneous mechanical aspiration of vegetations prior to TLE was feasible and safe, resulting in effective microbiological clearance without periprocedural embolic events or major complications. This approach provides a viable alternative to surgical extraction in selected high-risk patients with large vegetations and device-related infective endocarditis and helps control sepsis.TEE images of the TV vegetationMacroscopic image of the vegetation