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Objective In MADIT-CRT, patients with non-LBBB (right bundle branch block or nonspecific ventricular conduction delay) and a prolonged PR-interval derived significant clinical benefit from cardiac resynchronization therapy with defibrillator (CRT-D) compared to an implantable cardioverter defibrillator (ICD)-only. We aimed to study the long-term outcome of non-LBBB patients by baseline PR-interval with CRT-D versus ICD-only. Methods Non-LBBB patients ( n  = 534) were dichotomized based on baseline PR-interval: normal PR (PR < 230 ms), and markedly prolonged PR (PR ≥ 230 ms). The primary end point was heart failure (HF) or death. Secondary end points were HF only and all-cause death. Results In patients with a prolonged PR-interval, CRT-D treatment related to a 67 % significant reduction in the risk of HF/death (HR = 0.33, 95 % CI 0.16–0.69, p  = 0.003), 69 % decrease in HF (HR = 0.31, 95 % CI 0.14–0.68, p  = 0.003), and 76 % reduction in the risk of death (HR = 0.24, 95 % CI 0.07–0.80, p  = 0.020) compared to ICD-only (median follow-up 5.8 years). In normal PR-interval patients, CRT-D therapy was associated with a trend towards increased risk of HF/death (HR = 1.49, 95 % CI 0.98–2.25, p  = 0.061), and significantly increased mortality (HR = 2.27, 95 % CI 1.16–4.44, p  = 0.014). Significant statistical interaction with the PR-interval was demonstrated for all end points. Results were consistent for QRS 130–150 ms and QRS > 150 ms. Conclusion In MADIT-CRT, non-LBBB patients with a prolonged PR-interval derive sustained long-term clinical benefit with reductions in heart failure or death from CRT-D implantation, compared to an ICD-only. Our findings support implantation of CRT-D in non-LBBB patients with prolonged PR-interval irrespective of baseline QRS duration.

ObjectiveMany patients undergoing transcatheter aortic valve implantation (TAVI) have a pre-existing, permanent pacemaker (PPM) or receive one as a consequence of the procedure. We hypothesised that chronic pacing may have adverse effects on TAVI outcomes.Methods and resultsFour groups of patients undergoing TAVI in the Placement of Aortic Transcatheter Valves (PARTNER) trial and registries were compared: prior PPM (n=586), new PPM (n=173), no PPM (n=1612), and left bundle branch block (LBBB)/no PPM (n=160). At 1 year, prior PPM, new PPM and LBBB/no PPM had higher all-cause mortality than no PPM (27.4%, 26.3%, 27.7% and 20.0%, p<0.05), and prior PPM or new PPM had higher rehospitalisation or mortality/rehospitalisation (p<0.04). By Cox regression analysis, new PPM (HR 1.38, 1.00 to 1.89, p=0.05) and prior PPM (HR 1.31, 1.08 to 1.60, p=0.006) were independently associated with 1-year mortality. Surviving prior PPM, new PPM and LBBB/no PPM patients had lower LVEF at 1 year relative to no PPM (50.5%, 55.4%, 48.9% and 57.6%, p<0.01). Prior PPM had worsened recovery of LVEF after TAVI (Δ=10.0 prior vs 19.7% no PPM for baseline LVEF <35%, p<0.0001; Δ=4.1 prior vs 7.4% no PPM for baseline LVEF 35–50%, p=0.006). Paced ECGs displayed a high prevalence of RV pacing (>88%).ConclusionsIn the PARTNER trial, prior PPM, along with new PPM and chronic LBBB patients, had worsened clinical and echocardiographic outcomes relative to no PPM patients, and the presence of a PPM was independently associated with 1-year mortality. Ventricular dyssynchrony due to chronic RV pacing may be mechanistically responsible for these findings.Trial registration number(ClinicalTrials.gov NCT00530894).

•Conduction system pacing, also termed physiologic pacing, is a novel alternative to biventricular resynchronization that may improve left ventricular remodeling while minimizing costs.•PhysioSync-HF is an investigator-led, randomized, multicenter clinical trial comparing conduction system pacing and biventricular resynchronization on heart failure-related outcomes in 179 patients with heart failure with reduced ejection fraction and left bundle branch block.•Half of trial participants are women, and most are non-White, ensuring patient representativeness and generalizability. Cardiac resynchronization therapy reduces heart failure hospitalizations and mortality in patients with heart failure with reduced ejection fraction (HFrEF) and left bundle branch block (LBBB). Conduction system pacing, which directly activates the His-Purkinje system, has emerged as a safe alternative to traditional biventricular resynchronization that may offer clinical benefits at lower costs. The PhysioSync-HF trial is an investigator-led, randomized, multicenter clinical trial designed to assess whether conduction system pacing is noninferior to biventricular resynchronization on heart failure-related outcomes in patients with HFrEF and LBBB. The study population consists of 179 adults with symptomatic heart failure (New York Heart Association [NYHA] class II-III), left ventricular ejection fraction (LVEF) ≤35%, and LBBB (QRS ≥130 ms). Patients were randomized 1:1 to receive conduction system pacing or biventricular resynchronization and followed for 12 months postprocedure. The primary endpoint is a hierarchy of all-cause death, any hospitalization for heart failure, any urgent visit for heart failure, and change in LVEF from baseline. The key secondary endpoint is the mean total direct medical cost per patient. Additional endpoints include assessments of health-related quality of life, functional capacity, and safety. Enrollment began in November 2022 and concluded in December 2023. PhysioSync-HF will determine whether conduction system pacing is noninferior to biventricular resynchronization on heart failure-related outcomes in patients with HFrEF with LBBB. NCT05572736. *In selected sites. 6MWT indicates 6-minute walk test; CPET, cardiopulmonary exercise test; ECG, electrocardiogram; EQ-5D, EuroQol Group 5-Dimensions questionnaire; HF, heart failure; KCCQ, Kansas City Cardiomyopathy Questionnaire; LVEF, left ventricular ejection fraction. [Display omitted]

Continuous automatic optimisation of cardiac resynchronisation therapy (CRT), stimulating only the left ventricle to fuse with intrinsic right bundle conduction (synchronised left ventricular stimulation), might offer better outcomes than conventional CRT in patients with heart failure, left bundle branch block, and normal atrioventricular conduction. This study aimed to compare clinical outcomes of adaptive CRT versus conventional CRT in patients with heart failure with intact atrioventricular conduction and left bundle branch block. This global, prospective, randomised controlled trial was done in 227 hospitals in 27 countries across Asia, Australia, Europe, and North America. Eligible patients were aged 18 years or older with class 2–4 heart failure, an ejection fraction of 35% or less, left bundle branch block with QRS duration of 140 ms or more (male patients) or 130 ms or more (female patients), and a baseline PR interval 200 ms or less. Patients were randomly assigned (1:1) via block permutation to adaptive CRT (an algorithm providing synchronised left ventricular stimulation) or conventional biventricular CRT using a device programmer. All patients received device programming but were masked until procedures were completed. Site staff were not masked to group assignment. The primary outcome was a composite of all-cause death or intervention for heart failure decompensation and was assessed in the intention-to-treat population. Safety events were collected and reported in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT02205359, and is closed to accrual. Between Aug 5, 2014, and Jan 31, 2019, of 3797 patients enrolled, 3617 (95·3%) were randomly assigned (1810 to adaptive CRT and 1807 to conventional CRT). The futility boundary was crossed at the third interim analysis on June 23, 2022, when the decision was made to stop the trial early. 1568 (43·4%) of 3617 patients were female and 2049 (56·6%) were male. Median follow-up was 59·0 months (IQR 45–72). A primary outcome event occurred in 430 of 1810 patients (Kaplan-Meier occurrence rate 23·5% [95% CI 21·3–25·5] at 60 months) in the adaptive CRT group and in 470 of 1807 patients (25·7% [23·5–27·8] at 60 months) in the conventional CRT group (hazard ratio 0·89, 95% CI 0·78–1·01; p=0·077). System-related adverse events were reported in 452 (25·0%) of 1810 patients in the adaptive CRT group and 440 (24·3%) of 1807 patients in the conventional CRT group. Compared with conventional CRT, adaptive CRT did not significantly reduce the incidence of all-cause death or intervention for heart failure decompensation in the included population of patients with heart failure, left bundle branch block, and intact AV conduction. Death and heart failure decompensation rates were low with both CRT therapies, suggesting a greater response to CRT occurred in this population than in patients in previous trials. Medtronic.

In patients with reduced ejection fraction, mild heart failure, and prolonged QRS duration, CRT with a defibrillator improved survival, as compared with defibrillator therapy alone. The survival benefit was limited to patients with left bundle-branch block. The Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) showed the safety and effectiveness of cardiac-resynchronization therapy (CRT) with a defibrillator (CRT-D) in patients with asymptomatic or mildly symptomatic heart failure, a reduced ejection fraction, and a prolonged QRS duration. 1 The study showed that treatment with CRT-D was associated with a 34% relative reduction in the risk of nonfatal heart-failure events or death from any cause, as compared with implantable cardioverter–defibrillator (ICD) therapy alone over a median follow-up period of 2.4 years. The benefit of CRT-D in the trial was primarily driven by a significant relative reduction of . . .

Background Left bundle branch area pacing (LBBaP) is a new physiological pacing strategy that produces comparable clinical effects to His bundle pacing (HBP). Objective The purpose of this study was to investigate the immediate clinical outcomes of LBBaP vs RVP. Methods and Results From April 2018 to September 2018, we included 44 patients under continuous pacemaker implantation. Patients were randomly divided into the LBBaP group and conventional RVP group. Compared to the RVP group, the LBBaP group displayed significantly increased operative (90.10 ± 19.68 minutes vs 61.57 ± 6.62 minutes, P < .001) and X‐ray exposure times (15.55 ± 5.62 minutes vs 4.67 ± 2.06 minutes, P < .001). The lead threshold of the LBBaP group was increased (0.68 ± 0.20 mV vs 0.51 ± 0.0 mV, P = .001), while the R‐wave amplitude and ventricular impedance did not significantly differ between the two groups. The conventional RVP procedure significantly widened the QRS complex (93.62 ± 8.28 ms vs 135.19 ± 12.21 ms, P = .001), whereas the LBBaP had no effect on QRS complex (130.13 ± 43.30 ms vs 112.63 ± 12.14 ms, P = .904). Furthermore, the LBBaP procedure significantly narrowed the QRS complex in patients with left bundle branch block (LBBB) (168.43 ± 38.870 ms vs 119.86 ± 6.69 ms, P = .019). Conclusion LBBaP is a new physiological, safe and effective pacing procedure with a high overall success rate. Compared to conventional RVP, LBBaP can correct LBBB, thereby improving cardiac electrical dyssynchrony.

Branch structure is the fundamental component of an individual tree crown and has an important effect on tree growth and wood quality. A number of studies have focused on the primary branch attributes, but only a few research has been conducted on secondary branch size distribution and models. To analyze the secondary branch structure, we selected 54 Korean pine sample trees from Northeast China and measured a total of 24,053 secondary branches on 717 primary branches. The length and diameter for all the secondary branches and the current-year shoot of the secondary branch distribution were quantified. The allometric relationship between the length and diameter for the primary and secondary branches of the same age and the scaling factor variation within the tree crown were quantified. The nonlinear mixed-effects secondary branch diameter and length model were finally developed. The results indicated that the secondary branches showed an increase in length and diameter, then a decline as they reached deeper into the base of the primary branch. Secondary branch structure varies slightly among trees of varying ages and sizes. The Roeecp function was selected as the basic model to explore the relationship between different variables and the length and diameter of the secondary branches. Absolute distance from the tree tip to the primary branch base and the diameter of the primary branch significantly impacted the branch model, while the individual tree variables and competitive variables had minimal influence on the model. Ultimately, we developed two-level nonlinear mixed-effects models incorporating branch variables for secondary branch length and diameter.

Background Coronary Artery Spasm (CAS) often presents in the epicardial coronary arteries. The anterior septal branch is distributed within the myocardium, and occurrences of spasms are rare. Currently, there is no available literature on this topic, and the onset of symptoms remains elusive, potentially leading to misdiagnosis. Case presentation We present a case of acute myocardial infarction (AMI) caused by spasm in the anterior septal branch, accompanied by transient right bundle branch block (RBBB). The administration of nitroglycerin via intracoronary injection resulted in the alleviation of spasm in the anterior septal branch and the disappearance of RBBB. After the administration of anti-coronary spasm medications, the patient exhibited favorable recovery outcomes. No episodes of myocardial ischemia were observed during the six-month follow-up. Conclusions The presence of new RBBB in patients may warrant consideration of anterior septal coronary artery spasm, which necessitates urgent coronary angiography to clarify the underlying cause and facilitate the prompt initiation of anti-spasm treatment.

The aim of this qualitative study is to analyse the role of in-branch efforts of banks on migrating customers from branch banking to digital banking in India. In-depth semi-structured interviews were conducted with bank executives representing senior management from public and private sector banks in India. Qualitative content analysis technique was used to analyse the data. Varieties of responses received during interviews were clubbed into four main themes based on data reduction, display, and conclusion-drawing processes. In-branch communication with customers, digital transformation of the branch, customer-centric initiatives, and redefined role of branch staff hold the potential to bridge the customers’ migration to digital banking. The paper suggests that the key identified factor in improving digital banking acceptance in India is the requirement of integrated cultural and organisational changes at the bank’s level to gain the customers’ confidence and trust in digital banking.