Initial experience of left bundle branch pacing using the Abbott Agilis HisPro Catheter with stylet-driven leads.

AIMS: Conduction system pacing has gained steady interest over recent years. While the majority of tools and delivery techniques were developed for His bundle pacing (HBP), the feasibility and reproducibility of using these similar tools for left bundle branch pacing (LBBP) has yet to be determined. We describe our technique for performing LBBP using the Abbott Agilis HisPro™ Steerable Catheter. METHODS AND RESULTS: A series of 22 patients with a mean age of 71.7 years (16 males, 72.7%), underwent LBBP procedure with this catheter between May and October 2021. Nineteen patients (86%) had successful LBBP lead implantation. There were no major complications or mortality. CONCLUSION: The Agilis HisPro™ catheter along with the stylet driven Tendril STS Model 2088TC lead is a safe and feasible delivery system for LBBP.

Epicardial ablation utilizing remote magnetic navigation in a patient with Brugada syndrome and inferior early repolarization.

We report a case of epicardial ablation in a combined Brugada and inferior early repolarization syndrome patient with recurrent defibrillator therapy for spontaneous ventricular fibrillation. Electroanatomic mapping and ablation were achieved with remote magnetic navigation. Highly fractionated electrograms were seen epicardially in the anterior right ventricular outflow tract (RVOT) and at the anterior-inferior right ventricle. Ablation of the RVOT region resulted in resolution Brugada pattern electrocardiogram. The inferior early repolarization persisted despite ablation of the inferior right ventricular epicardium. Our patient remained event free at 12-months follow-up.

Remote magnetic catheter navigation versus conventional ablation in atrial fibrillation ablation: Fluoroscopy reduction.

BACKGROUND: Percutaneous transcatheter radiofrequency ablation of atrial fibrillation with remote controlled magnetic navigation (RMN) has been shown to reduce radiation exposure to patients and physicians compared with conventional manual (MAN) ablation techniques. METHODS: Catheter ablation for atrial fibrillation was performed utilizing RMN in 214 consecutive patients and MAN ablation techniques in 229 patients. We compared the fluoroscopy and procedural times between RMN and MAN catheter ablation of atrial fibrillation. Secondary objectives included comparing acute procedural success and short-term complication rates between both ablation strategies. RESULTS: Fluoroscopy time was significantly shorter in the RMN group than the MAN group (53.5±30.1 vs 68.1±27.6 min, respectively; p<0.01); however, the total procedural time was longer in the RMN group (280.2±74.4 min vs 213.1±64.75, respectively; p>0.001). Further subgroup analysis of the most recent 50 ablations each from the RMN and MAN groups, to attenuate the RMN learning curve effect, showed an even greater difference in fluoroscopy time (RMN vs MAN: 53.5±30.1 vs 68.1±27.6 min), though a consistently longer procedure time with RMN (249.5±65.5 vs 186.3±65.6 min, respectively). The acute procedural success rate was comparable between the groups (98.6% vs 95.6%, respectively; p=0.07). The rates of acute complications were similar in both groups (2.3% vs 4.8%, respectively; p=0.16). CONCLUSIONS: In radiofrequency ablation of atrial fibrillation, RMN appears to significantly reduce fluoroscopy time compared with conventional MAN ablation, though at a cost of increased total procedural time, with comparable acute success rates and safety profile. A reduction in procedure and fluoroscopy times is possible with gaining experience.

Wenckebach pattern in right bundle branch block - benign or not?

A Mobitz type I block (Wenckebach phenomenon) with narrow QRS complex is almost always due to a lesion in the AV node. In a type I block with wide QRS complex (>0.12sec), the block can be in the His-Purkinje system in 60-70% of the cases. Even though the progressive PR prolongation with every conducted beat suggests Wenckebach phenomenon, one needs to pay attention to the accompanying QRS complex. In the setting of persistent right bundle branch block, axis change of subsequent conducted beat before an unconducted p suggests alternating fascicular block, giving clue to unreliable infra-Hisian conduction; and in the setting of symptoms, a pacemaker should be implanted. Infra-Hisian Wenckebach block is rare with only sparse literature reports. The present case report adds to these, suggesting that wide QRS with Wenckebach block on surface ECG may indicate infra-Hisian conduction abnormalities.

Remote monitoring of patients with cardiac implantable electronic devices: a Southeast Asian, single-centre pilot study.

INTRODUCTION: Remote monitoring of cardiac implantable electronic devices (CIED) has been shown to improve patient safety and reduce in-office visits. We report our experience with remote monitoring via the Medtronic CareLink(®) network. METHODS: Patients were followed up for six months with scheduled monthly remote monitoring transmissions in addition to routine in-office checks. The efficacy of remote monitoring was evaluated by recording compliance to transmissions, number of device alerts requiring intervention and time from transmission to review. Questionnaires were administered to evaluate the experiences of patients, physicians and medical technicians. RESULTS: A total of 57 patients were enrolled; 16 (28.1%) had permanent pacemakers, 34 (59.6%) had implantable cardioverter defibrillators and 7 (12.3%) had cardiac resynchronisation therapy defibrillators. Overall, of 334 remote transmissions scheduled, 73.7% were on time, 14.5% were overdue and 11.8% were missed. 84.6% of wireless transmissions were on time, compared to 53.8% of non-wireless transmissions. Among all transmissions, 4.4% contained alerts for which physicians were informed and only 1.8% required intervention. 98.6% of remote transmissions were reviewed by the second working day. 73.2% of patients preferred remote monitoring. Physicians agreed that remote transmissions provided information equivalent to in-office checks 97.1% of the time. 77.8% of medical technicians felt that remote monitoring would help the hospital improve patient management. No adverse events were reported. CONCLUSION: Remote monitoring of CIED is safe and feasible. It has possible benefits to patient safety through earlier detection of arrhythmias or device malfunction, permitting earlier intervention. Wireless remote monitoring, in particular, may improve compliance to device monitoring. Patients may prefer remote monitoring due to possible improvements in quality of life.

Coronary sinus ostial atresia and persistent left-sided superior vena cava: clinical significance and strategies for cardiac resynchronization therapy.

A 48-year-old male patient underwent cardiac resynchronization therapy defibrillator implantation, and he was found to have atresia of the coronary sinus ostium with venous drainage occurring via a persistent left-sided superior vena cava, which was connected to the right-sided superior vena cava by the innominate vein. This is a rare benign cardiac anomaly that can pose problems when the coronary sinus needs to be cannulated. To identify the course of the coronary sinus, a coronary angiogram can be performed with attention directed to the venous phase of the angiogram. Although the technical difficulty of coronary sinus cannulation increases, various catheters, wires, and delivery systems can be utilized and this anomaly does not usually prevent successful left ventricular lead placement in cardiac resynchronization therapy via a left-sided superior vena cava approach. There however needs to be consideration regarding caliber of the left-sided superior vena cava being sufficiently large to avoid compromise of venous drainage after lead insertion.

Pacemaker failure due to loss of fluid seal in a patient with a 5/6mm pacemaker header port and a 5mm unipolar lead.

INTRODUCTION: Before IS-1 (3.2 mm) standardization of pacemaker leads and connectors, 5/6 mm connector ports accomodated 5mm or 6mm diameter lead connector pins. CASE REPORT: A patient with sick sinus syndrome underwent implantation of a 5mm unipolar atrial lead, mated to a 5/6mm connector port Medtronic Spectrax Sx 5985 pacemaker. Pulse generator reached ERI in 2006, with change out to a Medtronic Sigma SSR306 (5/6mm connector port) and preservation of the 5mm lead. She was admitted in 2010 for atrial lead non capture from blood leak and corrosion of the header-connector pin apparatus. DISCUSSION: 5/6mm pacemaker header ports have a 5mm flexible sealing ring at the port entrance to seal 5mm or 6mm lead connector pins. The inner barrel diameter of the connector port is 6mm and insertion of a 5mm lead results in a 0.5mm tolerance circumferentially. Should the seal be compromised, blood can corrode the apparatus. To minimize this, we can employ (a) a cinching tie to further seal the silicone ring (b) universal adaptor sleeves (c) splice kits (d) lead adaptor kits. Aging leads, adaptor kits or sleeves themselves can result in lead failure. It may be safer to re-implant the entire system. CONCLUSIONS: A 5/6mm configuration pacemaker header connector port allows for significant tolerances when a 5 mm lead is used. Consideration must be made to prevent leaks.