The Utility of Rapid Atrial Pacing Immediately Post-TAVR to Predict the Need for Pacemaker Implantation

ObjectivesThe aim of this study was to determine the utility of rapid atrial pacing immediately after transcatheter aortic valve replacement (TAVR) to predict the need for permanent pacemaker implantation (PPI).BackgroundRisk stratification for patients without high-grade atrioventricular block (AVB) after TAVR is imprecise and based on anatomic considerations, electrocardiographic characteristics, and clinical suspicion. A more reliable assessment is necessary to minimize inpatient rhythm monitoring and/or reduce unnecessary PPI.MethodsConsecutive patients undergoing TAVR at 2 centers were included. After valve implantation in patients without pacemakers who did not have complete heart block or atrial fibrillation, the temporary pacemaker was withdrawn from the right ventricle and placed in the right atrium. Rapid atrial pacing was performed from 70 to 120 beats/min, and patients were assessed for the development of Wenckebach AVB. Patients were then followed for clinical outcomes, including PPI.ResultsA total of 284 patients were included. Of these, 130 (45.8%) developed Wenckebach AVB. There was a higher rate of PPI within 30 days of TAVR among the patients who developed Wenckebach AVB (13.1% vs. 1.3%; p < 0.001), with a negative predictive value for PPI in the group without Wenckebach AVB of 98.7%. A greater percentage of patients receiving self-expanding valves required PPI than those receiving a balloon-expandable valves (15.9% vs. 3.7%; p = 0.001), though these rates were still relatively low among patients who did not develop Wenckebach AVB (2.9% and 0.8%).ConclusionsAtrial pacing post-TAVR is easily performed and can help identify patients who may benefit from extended rhythm monitoring. Patients who did not develop pacing-induced Wenckebach AVB demonstrated an extremely low likelihood of PPI.     

Mechanism of Pacemaker Activity in Zebrafish DC2/4 Dopaminergic Neurons

Zebrafish models are used increasingly to study the molecular pathogenesis of Parkinson''s disease (PD), owing to the extensive array of techniques available for their experimental manipulation and analysis. The ascending dopaminergic projection from the posterior tuberculum (TPp; diencephalic populations DC2 and DC4) to the subpallium is considered the zebrafish correlate of the mammalian nigrostriatal projection, but little is known about the neurophysiology of zebrafish DC2/4 neurons. This is an important knowledge gap, because autonomous activity in mammalian substantia nigra (SNc) dopaminergic neurons contributes to their vulnerability in PD models. Using a new transgenic zebrafish line to label living dopaminergic neurons, and a novel brain slice preparation, we conducted whole-cell patch clamp recordings of DC2/4 neurons from adult zebrafish of both sexes. Zebrafish DC2/4 neurons share many physiological properties with mammalian dopaminergic neurons, including the cell-autonomous generation of action potentials. However, in contrast to mammalian dopaminergic neurons, the pacemaker driving intrinsic rhythmic activity in zebrafish DC2/4 neurons does not involve calcium conductances, hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, or sodium leak currents. Instead, voltage clamp recordings and computational models show that interactions between three components – a small, predominantly potassium, leak conductance, voltage-gated sodium channels, and voltage-gated potassium channels – are sufficient for pacemaker activity in zebrafish DC2/4 neurons. These results contribute to understanding the comparative physiology of the dopaminergic system and provide a conceptual basis for interpreting data derived from zebrafish PD models. The findings further suggest new experimental opportunities to address the role of dopaminergic pacemaker activity in the pathogenesis of PD.SIGNIFICANCE STATEMENT Posterior tuberculum (TPp) DC2/4 dopaminergic neurons are considered the zebrafish correlate of mammalian substantia nigra (SNc) neurons, whose degeneration causes the motor signs of Parkinson''s disease (PD). Our study shows that DC2/4 and SNc neurons share a number of electrophysiological properties, including depolarized membrane potential, high input resistance, and continual, cell-autonomous pacemaker activity, that strengthen the basis for the increasing use of zebrafish models to study the molecular pathogenesis of PD. The mechanisms driving pacemaker activity differ between DC2/4 and SNc neurons, providing: (1) experimental opportunities to dissociate the contributions of intrinsic activity and underlying pacemaker currents to pathogenesis; and (2) essential information for the design and interpretation of studies using zebrafish PD models.     

Effects of resynchronization therapy on cardiac function in pacemaker patients "upgraded" to biventricular devices

INTRODUCTION: Cardiac resynchronization therapy (CRT) improves echocardiographic measures of cardiac function and has a variable effect on QRS duration in patients with left bundle branch block (LBBB). How CRT affects these indices in patients with right ventricular (RV) pacing-induced LBBB who are "upgraded" with left ventricular (LV) leads for CRT is unknown. We studied the echocardiographic effects of RV pacing and CRT in patients with prior continuous RV pacing after LV lead placement. METHODS AND RESULTS: Fifteen consecutive patients (age 73 +/- 11 years, LV ejection fraction 24 +/- 6%, QRS duration 190 +/- 27 msec) with New York Heart Association class IIIB-IV symptoms and continuous RV pacing underwent LV lead placement for CRT. Echocardiography and ECG were performed sequentially during RV pacing and CRT. CRT was associated with significantly reduced QRS duration (190 +/- 27 msec vs 165 +/- 18 msec, P = 0.005) and reduced LV electromechanical delay (180 +/- 33 msec vs 161+/- 43 msec). Baseline QRS duration correlated with CRT response. After CRT, patients had significant improvements in indices of systolic function, including LV ejection fraction, myocardial performance index (MPI), and LV ejection time. Abnormal baseline MPI was associated with greater improvement after CRT. LV end-diastolic and systolic volumes were similarly decreased with CRT. Mitral valve deceleration time, an index of diastolic function, was not affected by CRT. CONCLUSION: "Upgrading" RV paced patients with advanced heart failure to CRT improves measures of electrical and LV mechanical synchrony and improves systolic function.     

Do we need pacemakers resistant to magnetic resonance imaging?

AIMS: Manufacturers of pacemakers (PM) and of magnetic resonance imaging (MRI) devices state that MRI scanning of PM wearers is contraindicated. This paper tries to summarise which effects can interfere with PM, what can be hazardous, and how treatment of PM in MRI can be modified to guarantee compatibility. MATERIAL AND METHODS: All PM tested were from deceased patients. Reed contact thresholds and reactions were investigated in low magnetostatic fields and compared with those in strong magnetostatic fields. Influence of gradient fields on PM and heating due to radiofrequency (RF) pulses were estimated. Thirty Legal Medicine Departments were questioned whether deaths of PM patients during MRI are known. RESULTS: Reed contacts are influenced above 0.7 mT. In MRI fields only 28% of the PM in magnet mode remained so in all orientations. Of synchronous PM, 76% remained synchronous in all orientations. Gradient fields can influence sensing but cannot stimulate. Power density and temperature rise produced by RF fall rapidly with distance. Our question revealed six deaths. All suffered from sick-sinus-syndrome and all were not PM dependent. In three cases ventricular fibrillation was proven as the cause of death. DISCUSSION: Asynchronous pacing due to magnetostatic and gradient fields may be problematic in patients with spontaneous rhythm. To avoid them, PM triggered MRI scan restricted to refractory period is proposed. Neither inhibition of PM nor heating of the electrode poses real risks. So far, we have examined eight patients 12 times in MRI triggered mode without problems.     

A New Type of Dual Atrioventricular Nodal Nonreentrant Tachycardia

Dual atrioventricular nodal nonreentrant tachycardia (DAVNNT) is very rarely observed clinically. The first review of this arrhythmia was published in 2011 by Wang, where four types of DAVNNT were described. Our case report presents a phenomenon that has never been published before. We revealed a very specific sequence of double fire phenomenon, 1:1 atrioventricular (AV) conduction and AV block.