Tailoring cardiac resynchronisation therapy to non-left bundle branch block: Successful cardiac resynchronisation for right bundle branch block with left posterior fascicular block without implantation of a left ventricular lead.

Despite advances, cardiac resynchronisation therapy (CRT) remains fundamentally orientated to the dyssynchrony of left bundle branch block (LBBB), in which septo-lateral electrical and mechanical delays predominate. For non-LBBB patients response rates to conventional CRT are lower and mortality and rehospitalisation rates are not reduced. Despite this, alternative approaches which tailor CRT to the differing dyssynchrony patterns of non-LBBB have yet to be developed. In the specific non-LBBB subgroup of right bundle branch block (RBBB) with left posterior fascicular block (LPFB), ventricular conduction via the left anterior fascicle results in a unique early lateral, and late septal depolarisation, or lateral to septal left ventricular (LV) delay, an electrical sequence which is followed mechanically. This latero-septal delay is somewhat the reverse of LBBB and was overcome by fusing right ventricular (RV) septal pacing with intrinsic conduction via the left anterior fascicle, achieving successful resynchronisation without implantation of a left ventricular lead. A stable fusion pattern was achieved via the 'Negative AV Hysteresis with Search' algorithm (Abbott, St Paul, Minnesota). Improvement in all standard CRT response indices was achieved at 3 months: QRS duration was reduced from 153 to 106 ms, ejection fraction increased from 14 to 32%, and LV end-systolic and end-diastolic diameters reduced by 19% and 12.5% respectively. NYHA class improved from III-IV to class II. Cardiac resynchronisation for RBBB with LPFB can be successfully achieved with a standard pacemaker or defibrillator without left ventricular lead implantation by fusing RV septal-only pacing with intrinsic conduction.

TEMPORARY REMOVAL: ECG quiz answers.

This article has temporarily being removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Nasopharyngeal oxygen (NPO) as a safe and comfortable alternative to face mask oxygen therapy.

Nasopharyngeal oxygen (NPO) therapy is an emerging alternative to conventional face mask oxygen administration. It warrants consideration for treating hypoxaemia when face mask therapy is impractical or when patient intolerance or non-compliance regularly interrupt treatment. The effectiveness of the NPO route has been validated in post anaesthetic care and paediatric intensive care units (PICUs), but use in the adult ICU remains minimal. Recent research in the adult ICU setting has shown the nasopharyngeal route to be as effective as face mask oxygen administration in alleviating mild to moderate hypoxaemia, and is significantly more comfortable for patients. Therefore, NPO, administered via a fine catheter advanced into the nasopharynx, should be considered when face masks (FMs) or nasal prongs (NPs) are impractical or poorly tolerated and, because of its effectiveness and improved comfort, in patients for whom traditional non-invasive oxygen therapy is indicated. Implications for resource utilisation and costs also exist.

Pacemaker mediated tachycardia as a complication of the autointrinsic conduction search function.

The autointrinsic conduction search (AICS) option, featured on some DDD pacemakers, performs periodic assessments of atrioventricular (AV) conduction capability during a single beat AV delay extension. Demonstration of ventricular conduction during the prolonged AV delay, permits ongoing AV delay extension if the patient's intrinsic conduction is preferred to ventricular pacing. A case is presented where the wide separation of atrial and ventricular pacing during the conduction search permitted retrograde ventriculoatrial conduction, precipitating pacemaker mediated tachycardia (PMT) on seven occasions in one patient. Two onset patterns are reported, both attributable to the AICS option. Recommendations for prevention strategies are made.