I'd like to announce the next speaker, which is Roman Gebauer from Leipzig and Germany, and he will give an overview about CRT and adolescent congenital heart defects, predicting the future. Good afternoon, ladies and gentlemen. Thank you very much for being here and have the opportunity to speak today. Thank you very much. I have nothing to disclose. Okay CRT and congenital heart disease is predicting the future, so I would like to spend the next few minutes with these three topics. What is up to date in the adult CRT world, because adult CRT world is the source of inspiration for us and the source of new technologies for us, and we can use them afterwards. So how do we apply CRT in congenital heart disease patients today, and what are the possible strategies for the future? So let me start with some history of evolution of cardiac pacing. The first period was the primary and just to capture the myocardium. The second one we were happy with the DDD pacing, and the devices became smaller and smarter, and the leads thinner and softer, and there was a lot of technical improvement. The third period was a period of desynchrony. So we tried to reduce the unnecessary ventricular pacing, the CRT was born. We try to use another ways how to pace the ventricle with the requirement of the Hispanic Parking System and the pacing from the LV endocardium. The next period is the period of reduction of the heart. So these are the leadless pacemakers, and the last one is elimination of the heart work completely with the battery-less pacemakers, and if you want, biological pacemakers. So let's start with the cardiac CRT. We know nowadays that this therapy is in the structural heart disease well established, and for the patients with the heart failure and LBB morphology right indicated. We know also about the harmful, potential harm in patients with a non-LBB morphology, and despite the selection, we still have 25 to 30% of non-responders to this therapy. So the CRT in congenital heart diseases is based on the same principles as in the normal heart. So the CRT corrects an electrical activation delay within the failing systemic ventricle, and we had at the beginning a lot of patients with the RV pacing induced cardiomyopathy, left ventricle cardiomyopathy. We don't know, so we don't have the patients more because of trying to choose the right pacing for the right pacing site for the stimulation with less disinheriting potential. So we use usually apex of the systemic ventricle from epicardium. We can use a biventricular multi-site pacing if you want in the single ventricle patient. We can use also or perform CRT by using single-leach pacing by pacing from the site of the latest activation infusion with a spontaneous conduction as I show you here in a single ventricle patient with an early and late activation contralaterally and just to pace the late activated segment in the fusion with the spontaneous activation to get a normal conduction. This is a case of this patient is not adult, is a child, has a hypoplastic left heart after TCPC, eight years old with a dysfunction of the systemic ventricle. What you can see here is the thin early activated segment and the thick late activated segment if you pace simultaneously from the late activated site. This is the result pacing infusion with a spontaneous contraction of a spontaneous activation after six months of CRT and these are the pacing system. The patient has two epicardial leads just for case of worsening of spontaneous AV conduction. We put the lead also in the epics of the systemic right ventricle. So the next case, the same situation or the same principles but another situation, another substrate CRT in sub-pulmonary ventricle and in Tetralogy of Fallot patient 32 years old corrected with a conduit RVPA and it's indication to secondary preventive ICD implantation. What we did was a implantation of a biventricular system with a lead on the antralateral wall of the right ventricle and you can see it with the arrow and to pace simultaneously with a spontaneous activation and diffusion and this is the result. This is his QRS with pacing and this is the initial QRS without stimulation. And the result of this is the reverse remodeling of the right ventricle and the better function of the right ventricle. So what about his pacing? So permanent his pacing was described in 2000 already as we know it's effective in the patient with nodal but also with this infranodal and bundle branch blocks and this is one of our patients, one of our first patients, one year old ECG adult patient with a nodal AV block without structurally hard disease at this time. What you can see here in this segment of the ECG is a non-selective pacing with high energy. If you reduce the energy you will get a selective his bundle pacing with a nice QRS, narrow QRS activation. So the implantation technique you are probably familiar with. I think you need a specifically designed sheet for this and the electrode. You need to be patient. It takes a longer time than the usual implantation but it's a very promising procedure. A few of the published data as you can see here the success rate of his pacing is increasing with the learning curve and with the time and we know from this retrospective data that the patient are doing better with this stimulation. There are two randomized study ongoing so we have to wait this data but I'm very optimistic. There's just one case I found and congenital heart diseases and his bundle pacing case of adult patient with L-CCTGA AV block and stenotic coronary osteum and to outers this is the ECG from this case report. We're able just to get a non-selective his bundle pacing but it's also probably hopefully better than the pacing from the morphologic left ventricle in this case. So how easy his can be reach and permanently paced it's a difficult question with no clear answers. So I think there's probably two edges of the spectrum. It could be simple in the usual biventricular physiology with the systemic left ventricle and there are of course cases with a mission impossible with the univentricular hearts to look at his potential. So what about LV endocardial pacing? This is a meta-analysis published last year of more than 20 studies using endocardial LV pacing for CRT and structured normal heart. So you can see here procedure success more than 95% clinical response in more than 80% of the patients. The majority of the studies use transatrial approach to put the lead. The big issue are thromboembolic complications. But it's probably some of the possibilities how to pace the patient with a univentricular heart. This is a nice review published this year just to showing the different possibilities how to get the endocardial lead in a patient after surgical palliation of univentricular heart. And again to address stress to need for appropriate anticoagulation in these patients. So leadless pacemakers, you know that there are two companies but there's no possibility for CRT. So I go further through. And this is another case, another situation which is potentially from benefit in our patients could be it's a multi-component system by CRT. The CRT system provides wireless pacing by transmitting the ultrasound energy from the transducer implanted subcutaneously to the lead which is implanted in the LV endocardium transvenously without need for anticoagulation. Initial data published two years ago with a positive clinical outcome for the patient. A little bit more complications but it's an early phase of this tool. What you have to do is a co-implant device on the right side. Because this device triggers the left part of this system. So there's also ongoing study multicenter prospective randomized on this tool. So probably we can use it in the selected patients. So the fifth period, elimination of the hardware. So bacterial pacemaker, it sounds as science fiction. It's no more completely science fiction because the human and animal body has many sources of abundant energy in the form of mechanical or chemical or thermal energy which can be used for overcoming the limitation of the battery in pacemakers and ICDs with the time. So there are already many animal models using kinetic energy from the movement from the heart during systole and diastole and another using the excursion of diaphragm during x-end inspiration. So biological pacemakers, we hear about it the last 15 years but anyway it's still too long to the clinical day and let me to go to summary. In my eyes as a His bundle pacing, very promising method in some patients with congenital heart diseases. My vision would be a wireless LV endocardial or direct His pacing powered by human body itself or as eventuality thoracoscopic implantable epicardial wireless pacing covered by remote monitoring system in few years and the way to biopacemakers is still too long. Thank you very much. Thanks Roman for all these ideas and good talk. Any questions from the audience? So Roman do you think that we will have epicardial leadless pacing? Epicardial leadless pacing, yes. I hope. I hope we will have it. One of these. That would be a good option. What's your opinion about His bundle pacing? I am very excited. We do it, our department do it more than one and a half year nowadays and I see the increasing experience with this so we started with 10 minutes scaloscopy so it's a huge improvement and if you are patient you will get this in 90% of the patients there is no data about congenital heart disease patients so that's what we should start with to look at our patient if there is a potential for this I think it's a good option. Thank you very much.

cardiac resynchronization therapy

congenital heart defects

cardiac pacing

structural heart disease

His bundle pacing