Liu, Xiaoke

ABSTRACT Background Optimal management of direct oral anticoagulants (DOAC) prior to implantation of cardiac implantable electronic devices (CIED) remains controversial. Objective To determine whether a strategy of minimal interruption of DOAC before cardiac CIED implantation is associated with improved clinical outcomes compared to uninterrupted DOAC use. Methods The electronic clinical records of 310 patients who were on DOAC and underwent CIED implantation were evaluated. The patients were separated into 2 groups: patients in Group 1 had minimal DOAC interruption (DOAC held < 24 h before procedure), while patients in Group 2 continued DOAC before procedure. Resumption of DOAC in both groups was on the same day of the procedure or the next morning at the operator's discretion. Clinically significant pocket hematoma and thromboembolic events were compared. Results Among the 310 patients, 71 (22.9%) of them had DOAC held < 24 h before procedure, while DOAC was continued without interruption in 239 (77.1%) in the periprocedural period. Clinically significant pocket hematomas were found in 1 patient (1.4%) in the DOAC interrupted group and 24 (10.0%) in the DOAC continuous group ( p = 0.046). Low thromboembolic events were observed in both groups: 0 in the minimally interrupted group and 1 (0.4%) in the un‐interrupted group ( p > 0.05). Conclusion The bleeding risk in our cohort of patients who underwent CIED implantation with the uninterrupted DOAC approach is higher than previously reported in the literature. A minimally interrupted approach appears to mitigate this risk without significantly increasing the risk of thromboembolism.

ABSTRACT Background Optimal management in patients presenting with persistent atrial fibrillation, cardiomyopathy, and atrial as well as ventricular dyssynchrony with left bundle branch block is unclear. Results and Methods A 67‐year‐old female patient presented with persistent atrial fibrillation, cardiomyopathy with a newly reduced ejection fraction (EF), increased P wave duration on electrocardiogram (ECG) and left bundle branch block. After shared decision making, the patient elected to proceed with Bachman bundle/left bundle branch area pacing plus atrioventricular (AV) node ablation. At 6‐month follow‐up post procedure, a repeat echocardiogram showed normalized atrial size and EF (65%). Device interrogation demonstrated no recurrent atrial fibrillation with the patient off antiarrhythmic and heart failure medical therapy. Conclusions Integrated atrial and ventricular synchronization through Bachmann bundle and left bundle branch area pacing may help break the cycle of dyssynchrony, remodeling, and arrhythmia. In combination with AV node ablation, it may be considered as an alternative treatment option in certain cases after shared decision making.

Abstract Background Optimal management of checkpoint inhibitor-induced complete heart block is unknown. Previous reports showed relatively high incidence of pacing failure due to the co-existing myocarditis. Case summary A 71-year-old male with a prior history of stage IV metastatic squamous cell lung cancer presents was admitted for dyspnoea and hypotension 10 days after checkpoint inhibitor treatment using pembrolizumab. He was found to have myocarditis, third-degree AV block, severe left ventricular systolic dysfunction with EF 35%, and required pressure support. A dual chamber pacemaker using left bundle branch area pacing (LBBAP) was urgently placed that immediately improved his haemodynamics. Both the cathode and anode were able to capture the ventricle at different pacing outputs. The patient was taken off all intravenous pressors and successfully transferred to a larger centre for further management of the myocarditis with no further arrhythmia or hypotension. Discussion In conclusion, because of the unique ability to capture a large amount of myocardium from both the tip and ring electrodes as well as the ability to deliver cardiac resynchronization therapy, LBBAP may be the preferred pacing strategy in patients who develop complete heart block due to checkpoint inhibitor-induced myocarditis.

Abstract Objectives Heart failure (HF) impacts millions of patients worldwide, yet the variability in treatment responses remains a major challenge for healthcare professionals. The current treatment strategies, largely derived from population based evidence, often fail to consider the unique characteristics of individual patients, resulting in suboptimal outcomes. This study aims to develop computational models that are patient-specific in predicting treatment outcomes, by utilizing a large Electronic Health Records (EHR) database. The goal is to improve drug response predictions by identifying specific HF patient subgroups that are likely to benefit from existing HF medications. Materials and Methods A novel, graph-based model capable of predicting treatment responses, combining Graph Neural Network and Transformer was developed. This method differs from conventional approaches by transforming a patient's EHR data into a graph structure. By defining patient subgroups based on this representation via K-Means Clustering, we were able to enhance the performance of drug response predictions. Results Leveraging EHR data from 11 627 Mayo Clinic HF patients, our model significantly outperformed traditional models in predicting drug response using NT-proBNP as a HF biomarker across five medication categories (best RMSE of 0.0043). Four distinct patient subgroups were identified with differential characteristics and outcomes, demonstrating superior predictive capabilities over existing HF subtypes (best mean RMSE of 0.0032). Discussion These results highlight the power of graph-based modeling of EHR in improving HF treatment strategies. The stratification of patients sheds light on particular patient segments that could benefit more significantly from tailored response predictions. Conclusions Longitudinal EHR data have the potential to enhance personalized prognostic predictions through the application of graph-based AI techniques.

AbstractBackgroundLeft bundle branch block (LBBB) induced cardiomyopathy is an increasingly recognized disease entity. However, no clinical testing has been shown to be able to predict such an occurrence.Case reportA 70‐year‐old male with a prior history of LBBB with preserved ejection fraction (EF) and no other known cardiovascular conditions presented with presyncope, high‐grade AV block, and heart failure with reduced EF (36%). His coronary angiogram was negative for any obstructive disease. No other known etiologies for cardiomyopathy were identified. Artificial intelligence‐enabled ECGs performed 6 years prior to clinical presentation consistently predicted a high probability (up to 91%) of low EF. The patient successfully underwent left bundle branch area (LBBA) pacing with correction of the underlying LBBB. Subsequent AI ECGs showed a large drop in the probability of low EF immediately after LBBA pacing to 47% and then to 3% 2 months post procedure. His heart failure symptoms markedly improved and EF normalized to 54% at the same time.ConclusionsArtificial intelligence‐enabled ECGS may help identify patients who are at risk of developing LBBB‐induced cardiomyopathy and predict the response to LBBA pacing.

Background: Left bundle branch area pacing (LBBAP) has rapidly emerged as a promising modality of physiologic pacing and has demonstrated excellent lead stability. In this retrospective study, we evaluate whether this pacing modality can allow concomitant atrioventricular node (AVN) ablation and same-day dismissal. Methods: Twenty-four consecutive patients (female 63%, male 37%) with an average age of 78 ± 5 years were admitted for pacemaker (75%)/defibrillator (25%) implantations and concomitant AVN ablation. Device implantation with LBBAP was performed first, followed by concomitant AVN ablation through left axillary vein access to allow for quicker post-procedure ambulation. The patients were discharged on the same day after satisfactory post-ambulation device checks. Results: LBBAP was successful in 22 patients (92% in total, 20 patients had an LBBP and two patients had a likely LBBP), followed by AVN ablation from left axillary vein access (21/24, 88%). All patients had successful post-op chest x-rays, post-ambulation device checks, and were discharged on the same day. After a mean follow up of three months, no major complications occurred, such as LBBA lead dislodgement requiring a lead revision. The LBBA lead pacing parameters immediately after implantation vs. three-month follow up were a capture threshold of 0.8 ± 0.3 V@0.4 ms vs. 0.6 ± 0.3 V@0.4 ms, sensing 9.9 ± 3.9 mV vs. 10.4 ± 4.1 mV, and impedance of 710 ± 216 ohm vs. 544 ± 110 ohm. The QRS duration before and after AVN ablation was 117 ± 32 ms vs. 123 ± 14 ms. Mean LVEF before and three months after the implantation was 44 ± 14% vs. 46 ± 12%. Conclusion: LBBA pacing not only offers physiologic pacing, but also allows for a concomitant AVN ablation approach from the left axillary vein and safe same-day hospital dismissal.

Abstract Background Physiologic pacing through left bundle branch area pacing (LBBAP) has recently been shown to be a very promising alternative for cardiac resynchronization therapy (CRT) and to avoid pacing induced cardiomyopathy. However, it is not clear whether the position of LABBP lead may affect the clinical outcomes. Case Report We here report a case of likely LBBAP induced worsening heart failure and cardiomyopathy reversed by re‐positioning of the pacing lead towards a more annular position. A 70‐year‐old male with a previous history of non‐ischemic dilated cardiomyopathy (ejection fraction 40%) who developed intermittent complete heart block and required permanent ventricular pacing. LBBAP was performed with the lead positioned to a position relatively far away from the tricuspid annulus (3.7 cm), due to difficulty in fixating the lead deep into the septum at a more annular position. One month post procedure, the patient's heart failure symptoms worsened, and his EF decreased to 31% despite good heart failure management. He underwent CRT upgrade with successful revision of the originally implanted LBBAP lead to a more annular position, using a deflectable delivery sheath. This resulted in further narrowing of the paced QRS duration from 135 to 106 ms. Two months post procedure, his heart failure symptoms improved by one functional class, and EF improved to 41% by echocardiogram. Conclusions LBBAP may be harmful when the lead is placed too far away from the annulus and may cause paced induced cardiomyopathy.

AbstractBackgroundConventional cardiac resynchronization therapy (CRT) involves implantation of a coronary sinus pacing lead through a delivery sheath, which typically requires a large venous access through a safe sheath of 9 French or greater in size. In patients who have very limited access due to scar tissue from previous implants or critical venous stenosis/closure, such large caliber access may not be available.Methods and ResultsWe report a case of CRT procedure in an 84‐year‐old male with a previous history of ischemic dilated cardiomyopathy (ejection fraction 40%) who was dependent on right ventricular pacing with worsening heart failure symptoms. The patient was incidentally discovered to have chronic total closure (CTO) of the left subclavian vein during the procedure. Although the CTO was crossed by a wire and dilated, the venous access was limited to a 7 French sheath which rendered conventional CRT through coronary sinus lead implant impossible. However, using the left bundle branch area pacing (LBBAP) technique which requires a smaller venous access, we were able to successfully achieve CRT. Postprocedure, the patient's paced QRS duration narrowed from 198 to 130 ms. His heart failure symptoms improved, and ejection fraction increased to 45% one‐month after the procedure.ConclusionsIn patients with vascular access limited to a small caliber sheath not suitable for conventional CRT, LBBAP may help achieve procedural success and improve clinical outcome.

Background: A patient with ischemic cardiomyopathy and left bundle branch block (LBBB) who did not respond to standard bi-ventricular pacing underwent attempted left bundle area (LBA) pacing to achieve better cardiac resynchronization (CRT). Methods: LBA pacing failed to correct the LBBB or narrow the QRS. However, simultaneous pacing through the coronary sinus (CS) and LBA pacing leads resulted in marked shortening of the QRS Results: The patient’s EF improved from 30% to 45% two months post procedure and heart failure symptoms improved by one functional class. Conclusions: Simultaneous LBA and CS pacing may improve clinical outcomes compared to either alone.