Background: Left bundle branch area pacing (LBBAP) and endocardial resynchronization (Endo-CRT) are alternatives to biventricular pacing for cardiac resynchronization therapy (CRT). Objective: To compare the outcomes of LBBAP vs. Endo-CRT using conventional pacing leads. Methods: Patients with heart failure (HF) undergoing CRT with LBBAP or Endo-CRT were included. The primary efficacy outcome was a composite of HF-related hospitalization and all-cause mortality. The primary safety outcome was any procedure-related complication. Secondary outcomes included procedural characteristics, electrocardiographic, and echocardiographic parameters. Results: A total of 223 patients (LBBAP n=197, Endo-CRT n=26; mean age 69±10.3 years, 32.3% female) were included. Patients in the LBBAP group had lower NYHA class, shorter preprocedural QRS durations (161 [142-183] vs. 180 [170-203] msec, p<0.001), and a lower preprocedural spironolactone use (57.4% vs. 84.6%, p=0.009) than patients in the Endo-CRT group. Fluoroscopy time was significantly shorter in patients undergoing LBBAP (11.4 [7.2-20] vs. 23 [14.2-34.5] min; p<0.001). There was no significant difference in the primary efficacy outcome between both groups (Cox proportional HR 1.21, 95% CI 0.635-2.31; p=0.56). During follow-up, patients undergoing LBBAP had a lower incidence of stroke than patients in the Endo-CRT group (0% vs. 11.5%, p=0.001). Postprocedural LVEF (35% [25-45] vs. 40% [20-55]; p=0.307) and change in LVEF (7% [0-20] vs. 11% [2-18]; p=0.384) between the LBBAP and the Endo-CRT groups, respectively. Conclusion: LBBAP and Endo-CRT using conventional leads are associated with similar clinical outcomes, as well as improvements in LVEF. Endo-CRT is associated with longer fluoroscopy times and a higher risk of stroke.

Background: Intracardiac echocardiography (ICE) is increasingly used during left atrial appendage occlusion (LAAO) as an alternative to transesophageal echocardiography (TEE) Aim: To evaluate the impact of ICE vs. TEE guidance during LAAO on procedural characteristics and acute outcomes, as well the presence of peri-device leaks and residual septal defects during follow-up. Methods: All studies comparing ICE-guided vs. TEE-guided LAAO were identified. The primary outcomes were procedural efficacy and occurrence of procedure-related complications. Secondary outcomes included lab efficiency (defined as a reduction in in-room time), procedural time, fluoroscopy time, and presence of peri-device leaks and residual interatrial septal defects (IASD) during follow-up. Results: Twelve studies (n=5637) were included. There were no differences in procedural success group (98.3% vs. 97.8%; OR 0.73, 95% CI 0.42-1.27, p=0.27; I2=0%) or adverse events (4.5% vs. 4.4%; OR 0.81 95% CI 0.56-1.16, p=0.25; I2=0%) between the ICE-guided and TEE-guided groups. ICE guidance reduced in in-room time (mean-weighted 28.6-minute reduction in in-room time) without differences in procedural time or fluoroscopy time. There were no differences in peri-device leak (OR 0.93, 95% CI 0.68-1.27, p=0.64); however, an increased prevalence of residual IASD was observed with ICE-guided vs. TEE-guided LAAO (46.3% vs. 34.2%; OR 2.23, 95% CI 1.05-4.75, p=0.04). Conclusion: ICE guidance is associated with similar procedural efficacy and safety, but could result in improved lab efficiency (as established by a significant reduction in in-room time). No differences in the rate of periprocedural leaks were found. A higher prevalence of residual interatrial septal defects was observed with ICE guidance.

Introduction: Capsulectomy is recommended in patients with cardiac implantable electronic device (CIED) infection after transvenous lead extraction (TLE) but is time-consuming and requires extensive tissue debridement. In this study, we describe the outcomes of chlorhexidine gluconate (CHG) scrubbing in lieu of capsulectomy for the treatment of CIED infections. Methods: This retrospective observational study included patients who underwent TLE for CIED-related infections. In the capsulectomy group, complete capsulectomy was performed after hardware removal. In the CHG group, thorough scrubbing of the generator pocket with 20 cc of 2% CHG followed by irrigation with approximately 500 cc of sterile normal saline (SNS) was performed. The primary outcomes included reinfection and hematoma formation in the generator pocket. Secondary outcomes included any adverse reaction to chlorhexidine, the need for reintervention, infection-related mortality, and total procedural time. Results: A total of 102 patients (mean age 67.2±13 years, 32.4% female) underwent CIED extraction with either total capsulectomy (n=54) or CHG (n=48) scrubbing. Hematoma formation was significantly higher in the capsulectomy group vs. the CHG group (13% vs. 0%, p=0.014), with no significant differences in the reinfection rate. Capsulectomy was associated with longer procedural time (133.7±78.5vs. 89.9±51.8 minutes, p=0.002). No adverse reactions to CHG were found. Four patients (4.3%) died from worsening sepsis: 3 in the capsulectomy group and 1 in the CHG group (p=0.346). Conclusions: In patients with CIED infections, the use of CHG without capsulectomy resulted in a lower risk of hematoma formation and shorter procedural times without an increased risk of reinfection or adverse events associated with CHG use.

Since the advent of catheter ablation (CA) for atrial fibrillation (AF) in 1998, our understanding of the pathophysiology, as well as our capacity to target triggers and effectively achieve freedom from AF, has come a long way. However, as the average age of the population and the prevalence of chronic diseases increases, the progression of AF from paroxysmal (PAF) into persistent (PersAF) and long-standing persistent AF (LSPAF) is on the rise. Given the complex mechanisms involved and the presence of multiple trigger sites leading to recurrences, managing non-PAF is a challenge for electrophysiologists around the globe. Multiple ablation techniques have been investigated, some of which have shown promising results, but a standardized technique is yet to be elucidated. In this review, we outline the evidence behind contemporary ablation techniques in the treatment of AF.

Introduction: Increasing evidence has suggested improved outcomes in atrial fibrillation (AF) patients with heart failure (HF) undergoing catheter ablation (CA) as compared to medical therapy. We sought to investigate the benefit of CA on outcomes of patients with AF and HF as compared to medical therapy. Methods and Results: A systematic review of PubMed, Embase, and Cochrane Central Register of Clinical Trials was performed for clinical studies evaluating the benefit of CA for patients with AF and HF. Primary endpoint was all-cause mortality. Secondary endpoints included atrial-arrhythmia recurrence and improvement in left ventricular ejection fraction (LVEF). Eight randomized controlled trials were included with a total of 2121 patients (mean age: 65 ± 5 years; 72% male). Mean follow-up duration was 32.9 ± 14.5 months. All-cause mortality in patients who underwent CA was significantly lower than in the medical treatment group (8.8% vs. 13.5%, RR 0.65, 95% CI 0.51-0.83, P=0.0005). A 35% relative risk reduction and 4.7% absolute risk reduction in all-cause mortality was observed with CA. Rates of atrial-arrhythmia recurrence were significantly lower in the CA group (39.9% vs 69.6%, RR 0.55, 95% CI 0.40-0.76, P=0.0003). Improvement in LVEF was significantly higher in patients undergoing CA (+9.4 ±7.6%) as compared to conventional treatment (+3.3±8%) (Mean difference 6.2, 95% CI 3.6-8.8, P<0.00001). Conclusion: CA for AF in patients with HF decreases all-cause mortality, improves atrial-arrhythmia recurrence rate and LVEF when compared to medical management. CA should be considered the treatment of choice to improve survival in this select group of patients.

Background: Transvenous lead extraction (TLE) is standard of care for the management of patients with cardiac implantable electronic device infection or lead related complications. Currently, objective data on TLE in Latin America is lacking. Objective: To describe the current practice standards in Latin American centers performing TLE. Methods: An online survey was sent through the mailing list of the Latin American Heart Rhythm Association (LAHRS). Online reminders were sent through the mailing list; duplicate answers were discarded. The survey was available for one month, after which no more answers were accepted. Results: A total of 48 answers were received, from 44 different institutions (39.6% from Colombia, 27,1% from Brazil), with most respondents (83%) being electrophysiologists. Twenty-nine institutions (66%) performed less than 10 lead extractions/year, with 7 (15%) institutions not performing lead extraction. Although most institutions in which lead extraction is performed reported using several tools, mechanical rotating sheaths were cited as the main tool (73%), 13.5% reported the use of mechanical extraction sheaths and only 13.5% reporting the use of laser sheaths. Management of infected leads was performed according to current guidelines. Conclusion: This survey is the first attempt to provide information on TLE procedures in Latin America and could provide useful information for future prospective registries. According to our results, the number of centers performing high volume lead extraction in Latin America is smaller than that reported in other continents, with most interventions performed using mechanical tools. Future prospective registries assessing acute and long-term success are needed.