The majority of embolic strokes in patients with nonvalvular atrial fibrillation are caused by thrombi in the left atrial appendage. It is projected that strokes related to atrial fibrillation will markedly increase in the future unless effective mitigation strategies are implemented. Systemic anticoagulation has been known to be highly effective in reducing stroke risk in patients with atrial fibrillation. However, bleeding complications and nonadherence are barriers to effective anticoagulation therapy. Surgical and percutaneous left atrial appendage occlusion devices are nonpharmacologic strategies to mitigate the challenges of drug therapy. We present a contemporary review of left atrial appendage occlusion for stroke prevention in nonvalvular atrial fibrillation. A thorough review of the history of surgical and percutaneous left atrial appendage occlusion devices, recent trials, and US Food and Drug Administration milestones of current left atrial appendage occlusion devices are discussed.

Background - Left Bundle Branch Pacing (LBBP) has recently emerged as a promising alternative modality for conduction system pacing. However, limited real-world data exists on the advantages and complications associated with LBBP. We analyzed the Rush conduction system pacing registry on LBBP to assess the success rates and complications associated with LBBP. Methods - All patients with an indication for pacing (PPM) or cardiac resynchronization therapy (CRT) that underwent LBBP for various reasons from 06/2018 to 04/2020 were included in the analysis. Results - A total of 57 of 59 patients underwent successful LBBP (success rate 97%). The average follow-up duration was 6.2 ± 5 months. The implanted devices included 38 dual-chamber pacemakers, 17 CRT defibrillators, and 2 CRT pacing systems. The most common reason for performing LBBP was a high His Bundle Pacing threshold (n = 23) at implant. The mean LBBP capture threshold at implant was 0.62 ± 0.21 V @ 0.4 ms which remained stable during follow up at 0.65 ± 0.68 V @ 0.4ms. In 21 patients with cardiomyopathy, there was a significant improvement in LVEF from 30 ± 11% to 42 ± 15%. A total of 7 lead-related complications (12.3%) were noted in the follow-up period. Three patients (5.3%) required lead revision during the follow-up period. Interventricular septal (IVS) perforation occurred (as late sequela) after 2 weeks in one patient. Conclusions - LBBP can be achieved with a high success rate and low capture thresholds. Left ventricular dysfunction improved significantly during follow-up. Lead-related complications were relatively common occurring in 12.3% of initially successful implants. Lead revision was required in 3 (5%) of patients.

Background: Conventional right ventricular pacing (RVP) has been associated with an increased incidence of atrial fibrillation (AF). We sought to compare the occurrence of new‐onset AF and assessed AF disease progression during long‐term follow‐up between His bundle pacing (HBP) and RVP. Methods and Results: We included patients undergoing initial dual‐chamber pacemaker implants at Rush University Medical Center between January 1, 2016, and June 30, 2019. A total of 360 patients were evaluated, and 225 patients (HBP, n=105; RVP, n=120) were included in the study. Among the 148 patients (HBP, n=72; RVP, n=76) with no history of AF, HBP demonstrated a lower risk of new‐onset AF (adjusted hazard ratio [HR], 0.53; 95% CI, 0.28–0.99; P =0.046) compared with traditional RVP. This benefit was observed with His or RVP burden exceeding 20% (HR, 0.29; 95% CI, 0.13–0.64; P =0.002), ≥40% (HR, 0.31; P =0.007), ≥60% (HR, 0.35; P =0.015), and ≥80% (HR, 0.40; P =0.038). There was no difference with His or RV pacing burden <20% (HR, 0.613; 95% CI, 0.213–1.864; P =0.404). In patients with a prior history of AF, there was no difference in AF progression ( P =0.715); however, in a subgroup of patients with a pacing burden ≥40%, HBP demonstrated a trend toward a lower risk of AF progression (HR, 0.19; 95% CI, 0.03–1.16; P =0.072). Conclusions: HBP demonstrated a lower risk of new‐onset AF compared with RVP, which was primarily observed at a higher pacing burden.