EUROPEAN JOURNAL OF ARRHYTHMIA & ELECTROPHYSIOLOGY – VOLUME 7 SUPPLEMENT 1 – 2021

Introduction: Conduction system pacing in the form of His bundle pacing (HBP) can deliver more effective ventricular resynchronization compared to biventricular pacing, which translates to greater acute haemodynamic benefit. Left bundle branch pacing (LBBP) has potential advantages over HBP; capture thresholds are typically lower and it can correct left bundle branch block occurring as a […]

Introduction: Characterising patient-specific atrial fibrillation (AF) phenotype may lead to individualised approaches and improve ablation outcomes. Our novel mapping approach based on signal recurrence plots has not previously been applied to whole chamber, bi-atrial recording of AF. Methods: Simultaneous bi-atrial 30s AF recordings were obtained using non-contact charge density mapping prior to ablation. Mean phase […]

Aims: The association between obstructive sleep apnoea (OSA) and atrial fibrillation (AF) is yet to be fully delineated. Although several observational studies have suggested an independent association between OSA and AF, subsequent randomised controlled trials have failed to demonstrate any benefit of OSA treatment on reducing AF incidence. Complicating the interpretation of the data on […]

Introduction: Left bundle area pacing is a novel conduction system technique that is rapidly expanding. When the left bundle branch (LBB) alone is captured the 12-lead ECG shows an R prime in lead V1 indicative of delayed right ventricular activation. This is usually seen in unipolar pacing. Right septal myocardial capture can be achieved by […]

Introduction: Implantable loop recorders (ILRs) are increasingly used for detection of arrhythmias for prolonged rhythm monitoring. They have become a preferred strategy for investigation and diagnosis of arrhythmia following clinical events such as syncope and stroke. ILR implantation has been shown to have a superior diagnostic yield to conventional, external methods of cardiac monitoring and […]

Introduction: The HeartLogic (HL) index (Boston Scientific) is a novel multisensory approach in the monitoring of heart failure (HF) patients with ResonateTM cardiac defibrillator devices. Without a dedicated HF nurse team onsite at St Bartholomew’s Hospital, and the subsequent COVID-19 pandemic, it has been vital to liaise with patients’ local community care teams to reduce […]

Background: In patients with pre-existing devices, elective generator change is an opportunity to revisit whether a revision of their existing leads or addition of extra leads is required. This is especially the case in individuals who have a high burden of right ventricular pacing (RVP) which can lead to a deterioration in left ventricular systolic […]

Introduction: Cryptogenic stroke accounts for 30–40% of ischaemic strokes, and may be due to undetected atrial fibrillation (AF). Conventionally, 24-hour ECG monitoring is used to detect AF after a cryptogenic stroke; however, the CRYSTAL AF trial concluded that insertable cardiac monitoring (ICM) was superior to conventional-hour ECG monitoring in AF detection with 19.0% and 2.3% […]

Background: Implantable loop recorders (ILRs) are small cardiac rhythm monitoring devices that require a minor invasive procedure to implant. ILR implants are increasing following recommendations for their use in the NICE guidance for secondary stroke prevention. Implants are often performed by nurse and cardiac scientist specialists with variable levels of patient information provided before consent. […]

Introduction: Clinical pharmacists are a new workforce in Primary Care Networks (PCNs) who play a vital role in medication optimisation and high-risk drug monitoring. With the popularity of DOACs growing and increasing treatment options becoming available to patients and clinicians, there is also an increased risk of prescribing errors. Thus, it is important to ensure […]

Introduction: Implantable cardiac monitor (ICM) is a small device implanted to detect and record arrhythmias and symptomatic events. The procedure has a low complication rate, with procedures being performed in an outpatient setting. Due to greater accessibility to ICMs there has been an increasing amount of ICM devices on the market with new innovations in […]

Introduction: Outcomes of ablation for atrial fibrillation (AF) remain suboptimal, and strategies outside pulmonary vein isolation (PVI) vary. The AcQMap 3D imaging and mapping system (Acutus Medical, CA, USA) uses ultrasound to reconstruct the atrial chamber anatomy, whilst an inverse solution uses the non-contact unipolar voltage electrodes to derive charge density propagation maps in order […]

Introduction: A fundamental treatment decision in the management of patients with atrial fibrillation (AF) is whether to adopt a rate or rhythm control strategy. Randomised, controlled trials broadly suggest that mortality is unaffected by this decision. However, there are groups of patients who may benefit from rhythm control for symptom relief, heart failure management or […]

Background: Sleep apnea is highly associated with atrial fibrillation (AF), resulting in increased risk of mortality. However, early identification and intervention of AF is limit among subjects with sleep apnea asoften asymptomatic. Objective: The present study aimed to investigate the occurrence of AF in subjects at high risk for sleep apnea with smart technology. Methods: […]

Introduction: There is an increasing prevalence of atrial fibrillation (AF) and diabetes worldwide, and diabetes is recognised as a risk factor for developing AF. Both diabetes and AF increase stroke risk. Previous AF screening studies have recruited high-risk patient groups but not with diabetes as the lone target group. The aim of this study is […]

Background: Atrial fibrillation (AF) is common and its prevalence continues to increase. It can cause significant morbidity, healthcare economic burden and detriment to quality of life for its sufferers. Success rates for conventional catheter ablation are suboptimal in persistent AF, especially when longstanding. Long-term anti-arrhythmic use is undesirable and often ineffective. Patients with persistent AF […]

Introduction: It is now quite common for patients to be able go home on the same day after their AF ablation. A contributing factor of this is the Proglide Suture-Mediated Closure System which allows quick recovery after large bore venous access (>12F). This study is one of the first to see whether the Proglide device […]

Background: Manufacturers of cardiac implantable electronic devices have incorporated automatic features to improve safety, allow remote monitoring and improve longevity. The Abbott Autocapture algorithm measures capture threshold by verifying impulse capture using an evoked response and adjusts the output. If the device identifies loss of capture (LOC), it delivers a back-up pulse (VPP). However, an […]

Background: Inappropriate implantable cardioverter defibrillator (ICD) therapy can significantly reduce quality of life and is associated with adverse outcomes. Introduction of generic programming strategies, combing high detection rates and long detection times have shown to significantly reduce inappropriate therapy. Each of the 3 large randomised controlled trials that have informed programming strategies included only a […]

Introduction: The subcutaneous implantable cardioverter-defibrillator (S-ICD) has comparable efficacy and avoids many of the complications associated with transvenous ICDs. There is a Class I recommendation for S-ICD implantation in patients at a high risk for infection or are without appropriate venous access and no indication for pacing. Many heart failure (HF) patients fall into these […]

Background: Obesity has been strongly associated with atrial and ventricular arrhythmias. This effect is, in part, mediated by epicardial adipose tissue (EAT), which has previously shown to have a pro-arrhythmic secretome. Therefore, we sought to confirm any paracrine effects of adipose tissue on myocardial conduction and tested the differential effects of human EAT and subcutaneous […]

Introduction: Current methods of identifying scar from the contact electrogram (EGM) are limited. Scar leads to a reduction in myocardial conductivity, which can be represented computationally by the conductivity diffusion tensor. We present a novel deep learning-based method of using EGMs to estimate the conductivity diffusion tensor in simulated myocardial substrate. Methods: We use the […]

Aims: The rate of left ventricular (LV) lead displacement after cardiac resynchronization therapy (CRT) remains high (2–10%) despite recent improvements in lead technology. This post-operative complication often results in an increase in pacing threshold and subsequent loss of ventricular capture, thus negating the benefits of resynchronisation therapy. Under the circumstances where there is loss of […]

Background: Obesity is associated with an increased risk of ventricular arrhythmias and sudden cardiac death. Although the 12-lead electrocardiogram (ECG) may detect repolarisation abnormalities, it lacks the spatial resolution for detailed characterisation of the proarrhythmic substrate associated with obesity. We therefore used electrocardiographic imaging (ECGi) to non-invasively map epicardial potentials to investigate differences in activation […]

Introduction: Patients with structural heart disease (SHD) are susceptible to ventricular tachycardia (VT) and arrhythmic death. Use of anti-arrhythmic drugs is often confounded by unacceptable side effects or suboptimal effectiveness. Catheter ablation (CA) is a viable option in these patients. This study aims to: 1) determine long-term outcome of patients with SHD undergoing CA for […]

Clinically, bipolar electrograms (EGMs) are interpreted based on time and voltage characteristics such as amplitude and fractionation index. However, this discards much of the information within the signal. EGMs can also be analysed in the frequency and time-frequency domain. Omnipolar EGMs are a direction-independent form of bipolar EGMs and can be calculated from unipolar EGMs. […]

Electrograms (EGMs) contain information in the frequency domain (FD) and time-frequency domain (TFD) that is not currently assessed clinically. Greater utilisation of this information could lead to improved understanding of the local electroarchitecture. The Langendorff perfusion system allows EGMs from porcine hearts to be recorded ex-vivo, where cellular components of the pro-arrhythmic substrate ablation targets […]

Introduction: Permanent pacemaker (PPM) implantation is a well-recognised short-term complication after cardiac surgery; however, in some cases, conduction system function may recover, leaving the patient with an unnecessary device and its associated morbidity. Aims: In order to aid in decision-making process for PPM implantation post cardiac surgery, we sought to determine predictors of pacemaker dependency. […]

Introduction: His bundle pacing (HBP) may have a role as an alternative approach to conventional right ventricular pacing in bradycardia and AV node ablation, and for patients with heart failure who require cardiac resynchronisation therapy. There are concerns from the literature with changes in HBP threshold over time. Methods: Patients implanted between 2017 and 2020 […]

Background: With the increasing ageing population, especially in developed countries, the rate of permanent pacemaker (PPM) implantation has increased. The increase in life expectancy associated with the increase in cardiovascular co-morbidities is likely the major contributor to the rising rate of PPM implantation. Over 70% of PPM implantations occur in patients over 65 years of […]

Introduction: Cardiac implantable electronic device (CIED) infection is a major complication resulting in significant morbidity. The Prevention of Arrhythmia Device Infection Trial (PADIT) identified 5 independent risk predictors of device infection: prior procedures, age, depressed renal function, immunocompromise and procedure type, and developed a novel infection risk score ranging from 0 to 15 classifying patients […]

Introduction: Implantable cardiac-defibrillators (ICD) can prevent sudden cardiac death but the risk of recurrent ventricular arrhythmia (VA) and ICD therapies persists. Strategies to minimize such risks include medication optimization, device reprogramming or ventricular tachycardia (VT) catheter ablation (CA). However, the timing and choice of these strategies at ICD follow-up may not be as consistent in […]

Background: Ripple mapping (RM) displays the entire morphology of bipolar electrograms in 3D, facilitating identification of low amplitude pathways often obscured by large far-field signals. We tested the hypothesis that RM improves characterisation of low amplitude signals in three subgroups where such signals are common: atrial tachycardia, the LV conduction system and post infarct LV […]

Introduction: The DiamondTemp ablation (DTA) catheter system delivers high-power, open-irrigated, temperature-controlled radiofrequency (RF) ablation. This study assesses the feasibility of this new technology for VT ablation in patients with ICM. Method: 10 patients (mean age 73.4 years [64–84 years]) with a diagnosis of ICM were recruited over 3 months. 4 patients were classified as high […]

Introduction: Catheter ablation of VT in SHD, endorsed by current guidelines, reduces arrhythmic events and device-delivered therapy. Expert UK consensus recommends services provide a minimum of 20 VT ablations per 1 million population. Limited details exist about local practice in the UK. Nottingham University Hospitals NHS Trust complex VT ablation service commenced in 2016, covering […]

Introduction: Vascular access complications (VAC) are common complications associated with invasive electrophysiology procedures (IEPP) and can lead to significant morbidity and mortality. Reducing the risk of VAC is of considerable interest to Electrophysiologists. We studied the impact of vascular access and vessel closure protocols utilizing ultrasound-guided vascular access (UG) on the incidence of IEPP associated […]

Introduction: Radiofrequency catheter ablation (RFA) is 1st line treatment in symptomatic adult patients with Wolff–Parkinson–White syndrome (WPW). Patients with WPW are often quoted a high success rate for RFA but does this reflect reality? There is a paucity of recent literature, and ongoing service developments in the UK may have affect outcome. Recent significant expansion […]

Introduction: Recurrence of persistent atrial fibrillation (PsAF) has been attributed to conduction gaps, and non-transmural linear lesion sets. Hybrid thorascopic endo-epicardial AF ablation has been shown to reduce AF recurrence when compared to endocardial ablation alone, however with higher complication rates. We propose that the percutaneous pericardial CO2 insufflation technique to access the pericardial space […]

The COVID-19 pandemic has had a major impact on how Arrhythmia services are run throughout the UK. There was a need to quickly establish remote clinics without access to diagnostics such as ECG monitoring. Traditionally patients were seen by Arrhythmia nurses in a face to face setting with 12 lead ECG recording available. We set […]

Background: Implantable loop recorder (ILR) implants are increasingly done in an outpatient setting by different disciplines. A key component of the implant is the closure of the wound with the scar appearance often the only reminder of surgery. Several techniques for wound closure exist; sutures, staples, glue, and wound closure strips (WCS). Our service has […]

Introduction: Worcestershire Acute NHS trust provides a nurse-led outpatient direct current cardioversion (DCCV) service since 2013. We do 300 DCCVs per year. A few clinic patients reported awareness at the time of cardioversion which prompted us to audit the service. We aimed to determine the efficacy of this service and the peri-procedural patient experience. Methods: […]

Background: Techniques for atrial fibrillation (AF) ablation have evolved and reduced patient radiation dose. There are limited contemporary data comparing the dose from AF ablation with other common radiation sources. Purpose: To assess the radiation dose of contemporary AF ablation techniques; cryo-balloon (CB) and radiofrequency ablation (RF). To compare these doses with common sources of […]

Introduction: Cardiac tamponade is a high morbidity complication of transseptal puncture (TSP). We examined the incidence and predictors of TSP-related cardiac tamponade (TRCT) for all patients undergoing left atrial ablation at our centre from 2016-2020. Methods: Patient and procedural variables were extracted retrospectively. Cases of cardiac tamponade were scrutinised to adjudicate TSP culpability. Adjusted multivariate […]

Introduction: Thromboembolic risk appears to be higher in patients with non-paroxysmal atrial fibrillation (AF) and with longer AF episodes. However, guidelines recommend chronic oral anticoagulation (OAC) in patients with AF and additional stroke risk factors without considering AF burden or temporal patterns. Therefore, indefinite OAC may expose patients with short, infrequent AF episodes, to a […]

Background: Interruption of health services during COVID-19 resulting in delays for patients with cardiac implantable electronic devices (CIED) needing face-to-face appointments due to limited home monitoring or a need for essential troubleshooting. Purpose: To provide a drive-through CIED clinic to safely perform cardiac physiologist led checks whilst maintaining social distancing with patients. Methods: An outdoor […]

Introduction: The role of pre-implant and intra-procedural parameters on mortality and hospitalisation for heart failure (HHF) in patients undergoing implantation with cardiac resynchronization therapy pacemaker (CRT-P) or defibrillator (CRT-D) versus CRT upgrade is poorly defined. In the present study we aimed to evaluate mortality predictors and clinical outcomes in patients undergoing CRT-P/D versus CRT upgrade. […]

Introduction: The adverse prognosis in heart failure (HF) correlates with both NT-proBNP and high-sensitivity CRP levels. The latter indicates a greater underlying inflammatory process in more severe heart failure. This inflammatory response is also evidenced by elevated ferritin (acute phase reactant) and reduced haemoglobin (bone marrow suppression) amongst these patients. It is unclear if there […]

Introduction: Protecting individuals from atrial fibrillation (AF)-related stroke through the appropriate initiation of anticoagulation therapy is a national priority. Based on QOF 2019/20, in Cornwall 1,340 (10%) people with AF at risk of stroke were not prescribed anticoagulant therapy. Like many health systems, for the last couple of years our provider acute trust stroke team […]

Introduction: Complex device therapy (CDT) [cardiac resynchronisation therapy pacemaker or defibrillator (CRTP or CRTD) and implantable cardioverter defibrillator (ICD)], is recommended in patients with heart failure (HF) with severe left ventricular systolic dysfunction if they are still symptomatic despite optimisation HF medication. Several patients however, will only tolerate optimal doses of these drugs after CDT, […]

Introduction: Transient global amnesia (TGA) is a clinically important syndrome with a poorly understood aetiology. Patients display sudden and severe anterograde memory impairment associated with differing levels of retrograde amnesia and executive dysfunction. One theory is that TGA occurs as a result of hypoxia and ischaemia affecting susceptible parts of the brain. We report a […]

Background: Royal Papworth Hospital is a tertiary center which manages over 7,000 pacemaker (PPM), implantable defibrillator (ICD) and biventricular (CRT-P and CRT-D) patients each year. Patients are normally seen in face-to-face (F2F) clinics, including outreach and home visits, at least once per year with more complex devices also having remote follow-up (RFU). This typically results […]

Introduction: BHRS guidelines state an objective of device follow up is to monitor the device site for signs of infection. The COVID-19 pandemic changed our centres follow up practice where 2–6-week post implant checks were performed ‘remotely’ as a telephone consultation. To ensure the device site was monitored at this check we developed a process […]

Introduction: Nonagenarians are under-represented in clinical trials of cardiac implantable electronic devices (CIEDs). Complete heart block (CHB) is a time-critical emergency and, particularly in elderly patients, the absence of test results or a comprehensive medical history can challenge operator decision-making, especially when permanent pacing is preferred. In patients over 90 years of age undergoing emergency […]

Introduction: Atrial fibrillation (AF) is the commonest cardiac arrhythmia in clinical practice that is associated with increased risk of stroke, heart failure and cardio-vascular mortality. It is often undiagnosed and undertreated as patients tend to be asymptomatic. Systemic screening at community level for atrial fibrillation with smartphone electrogram had shown to pick up undiagnosed AF, […]

Background: In the response to the COVID-19 pandemic the accepted arbitrary 12 month follow up of pacemaker patients was called into question. With the inability of seeing patients face to face service delivery was altered to ensure that hospital visits were kept to a minimum whilst maintaining patient safety and care. Appointments were deferred as […]

Introduction: Percutaneous left atrial appendage occlusion (LAAO) has been shown to be non-inferior to warfarin in preventing strokes in patients with AF. However, relative contra-indication to anticoagulation or embolic strokes despite therapeutic anticoagulant remain the most common indications. There is also limited data to suggest that maintaining sinus rhythm by AF ablation could reduce the […]

Introduction: Surgical aortic valve replacement (SAVR) improves outcome in patients with severe aortic stenosis (AS). Nevertheless, late mortality remains high (between 15-35% at 3.5 years in some series) following SAVR. Whether this is related to heart failure or brady-/tachyarrhythmia is unknown, and the burden of ventricular arrhythmia after SAVR remains poorly characterised. Objectives: To determine […]

Introduction: Direct Current Cardioversion (DCC) is one of the most effective means of converting atrial fibrillation into sinus rhythm. This is often chosen over medical cardioversion due to its shorter overall procedure duration, high success rate and low risk of proarrhythmias. It is indicated in haemodynamically unstable patients and stable patients who are unlikely to […]

Introduction: Recurrence of persistent atrial fibrillation (PsAF) has been attributed to conduction gaps, and non-transmural linear lesion sets. Hybrid thorascopic endo-epicardial AF ablation has been shown to reduce AF recurrence when compared to endocardial ablation alone, however with higher complication rates. We propose that the percutaneous pericardial CO2 insufflation technique to access the pericardial space […]

Introduction: Implanted loop recorders (ILR) provide long term cardiac monitoring to investigate arrhythmias. ILRs biggest limitation is the low specificity of automated recordings, creating huge volumes of electrograms (EGMs) to be inspected. This burden of work puts strain on services, increases the risk of misdiagnosis, and can lead to inappropriate patient management. To compound this, […]

Introduction: 24-hour Holter monitors are frequently used in order to investigate arrhythmias in settings where limited telemetry resources are available. However, they are time-consuming to analyse, and fail to alert medical personnel to emergent arrhythmias. Their diagnostic yield is uncertain. We investigated the use of inpatient 24-hour Holter monitors at Whipps Cross Hospital to determine […]

Introduction: Historically a CIED was considered an absolute contra-indication to MRI due to perceived risk of device malfunction or tissue damage. More recent MR-conditional devices overcome this and there is also increasing data supporting safety in non-conditional devices. Despite widespread implantation of more expensive MRI conditional systems by cardiac teams, MRI remains an under-utilised modality […]

Introduction: Atrial Fibrillation Association (AFA) recognised there was a prime opportunity to detect AF during COVID-19 vaccination clinics by offering heart rhythm checks. European Society of Cardiology (ESC) recent guidelines recommends single-lead ECG for detection and diagnosis of AF (class one recommendation). AFA-trained volunteers and healthcare professionals established a fluent pathway. Concept: AFA in collaboration […]

Background: According to the 2020 National Institute of Cardiovascular Outcomes Research (NICOR) audit, 32,902 pacemakers were implanted in the United Kingdom. Management of these patients requires effective workflows capable of dealing with the vast amounts of diagnostic data recorded by the device and made available via remote monitoring platforms. The British Heart Rhythm Society (BHRS) […]

Background: Elective Unit replacement or generator change of pacemakers/Intra-cardiac defibrillators (ICD), is a routine procedure performed in the catheter lab, usually as a day case and is associated with a low complication rate. Common complications, mentioned in the consent form include, bleeding, infection and lead displacement. Other complications include pneumothorax, ventricular perforation and tamponade if […]

Introduction: The development of atrioventricular block can be a sign of specific cardiac and medical pathologies including cardiac sarcoidosis, vasculitis and thyroid disease. There are no comprehensive guidelines to help facilitate a standardised workup for the younger patient with AV block, and the timing and relative yield of different investigative parameters. We sought to explore […]

Introduction: Subcutaneous ICD (S-ICD) was designed to avoid complications associated with transvenous ICDs. But not all patients are eligible for S-ICDs and eligibility is identified after screening S-ICD candidates using guidelines by the device manufacturer. The S-ICD is particularly valuable for younger patients such as congenital heart disease (CHD) and hypertrophic cardiomyopathy (HCM) patients requiring […]

Background: Despite the millions of people infected by SARSCoV-2 worldwide, there have only been few reports of cardiac device implantations in such subjects. Purpose: We report a series of patients with SARS-CoV-2 who needed a permanent pacemaker. Methods: Study of a single public hospital population in Northern Italy, entirely converted to a COVID-19-only facility during […]

Background: PPI can improve the quality of research and strengthen health outcomes. It is increasingly a prerequisite for funding support. AF affects 43.6 million individuals globally posing a significant burden to patients and physicians. In view of the recent ESC guidelines for AF, incorporating patient insight in clinical research could optimise management outcomes. Purpose: After […]

Introduction: The COVID-19 pandemic has had a major impact on healthcare services, however the effect has been heterogeneous. We collated cardiac rhythm management (CRM) service provision data from two specialist cardiothoracic centres in the UK without Eds, the Liverpool Heart and Chest Hospital (LHCH) and Royal Papworth Hospital (RPH). We describe the impact of the […]

Objective: To assess the ECG changes and arrhythmias seen in Ebstein’s patients. Design: Retrospective longitudinal cohort. Setting: University Hospital of Wales (UHW). Population/Participants: 74 patients managed at UHW between 1990 and 2020. Results: 53 cases eligible for the study were included. Right bundle branch block was seen in 65.2%, and delta wave in 18.8%. Wolff […]

Introduction: Every year two out of all children up to age eighteen die from heart problems that can be noticed by regular electrocardiography (ECG). Some of these children had been diagnosed with serious heart conditions already but haven’t showed up in routine tests or had continued to exercise with inappropriate workload. In Latvia junior athletes […]

An 11-day old female with no known risk factors for arrhythmias was noted to have ectopic beats postnatally. Subsequent electrocardiogram demonstrated an intermittent regular broad QRS complex rhythm at the same speed as the preceding sinus beats which resembled pre- excitation. Besides a small patent foramen ovale, initial echocardiogram showed normal cardiac morphology and function. […]