Background/Objectives: Pacemaker-induced cardiomyopathy (PICM) develops in up to 30% of patients with chronic right ventricular pacing. While biventricular (BIV) upgrade is the conventional strategy, conduction system pacing (CSP) offers a physiologic alternative recently endorsed by the 2025 ESC/EHRA Consensus Statement. However, comparative evidence in PICM is limited. Therefore, we aimed to compare outcomes of PICM patients undergoing CSP versus BIV upgrade. Methods: This retrospective analysis included consecutive PICM patients who were upgraded to CSP or BIV between 2022 and 2024 at a single, experienced center. Follow-up averaged >19 months. Clinical outcomes, lead performance, echocardiographic parameters, complications, and quality of life (QoL) were evaluated. Results: Sixty-three patients were included (CSP: 26; BIV: 37). Mean age and sex distribution were similar; both groups had wide paced QRS complexes and a high ventricular pacing burden. Baseline left ventricular ejection fraction (LVEF) was lower in BIV patients (29 ± 7% vs. 35 ± 6%, p = 0.01). Procedure duration was comparable, but fluoroscopy was shorter with CSP. QRS duration narrowed significantly in both groups (CSP: 163 ± 28→132 ± 12 ms; BIV: 171 ± 23→140 ± 18 ms; both p < 0.05). During follow-up, LVEF improved (CSP: 41 ± 8%; p = 0.008; BIV: 39 ± 8%, p = 0.0001), as did NYHA class, with no significant intergroup differences. The rates of heart failure hospitalization, all-cause mortality, and QoL were similar. Notably, 34.6% of CSP patients retained their existing generator, suggesting procedural and economic benefits. Conclusions: CSP is a feasible and potentially cost-efficient alternative to BIV upgrade in PICM, with comparable improvements in ventricular function, symptoms, and clinical outcomes. Larger prospective trials are warranted.

Background: Left atrial appendage closure (LAAC) is an established alternative to oral anticoagulation for stroke prevention in patients with nonvalvular atrial fibrillation who are at high risk of thromboembolic events or bleeding complications. Methods: In this single-center retrospective study, we analyzed 70 consecutive patients who underwent successful LAAC with the Watchman™ device between 2012 and 2024. Acute procedural outcomes, long-term thromboembolic and bleeding events, transfusion requirements and mortality were evaluated. Mean follow-up duration was 1210 days. Results: Procedural success was achieved in 98.6% of cases with a low periprocedural complication rate. Ischemic stroke/transient ischemic attack occurred in 2.8% of patients; no hemorrhagic strokes or stroke-related deaths were observed. LAAC resulted in a significant reduction in both the number (144 vs. 56 events; 2.36 vs. 1.55 events per patient, p < 0.05) and severity of bleeding events. Nonetheless, 42.9% of patients required bleeding-related hospitalization after implantation, predominantly within the first 6 months during dual antiplatelet therapy. Overall mortality was 40% with a 12% yearly mortality rate; heart failure and infections were leading causes of death. Pre- and postprocedural transfusion requirements were independently associated with a six-fold increase in mortality risk (HR = 5.97). Conventional risk scores (CHA₂DS₂-VASc, HAS-BLED) failed to predict transfusion needs; atrial enlargement, right ventricular dysfunction, smoking and alcohol consumption were associated with higher risk. Conclusions: LAAC is a safe and effective alternative to long-term anticoagulation, significantly reducing bleeding burden without increasing thromboembolic mortality. Persistent postprocedural bleeding remains a major determinant of long-term prognosis, underscoring the need for individualized, multidisciplinary post-implant management.