His-bundle Pacing as a Bailout Therapy for a Patient with Subclavian Stenosis and No Suitable Coronary Sinus Branch: A Double Whammy.

We present an interesting case of an 88-year-old man who was referred to our arrhythmia service for an upgrade of his dual-chamber pacemaker to a biventricular pacemaker for right ventricular pacing-induced cardiomyopathy. The patient was found to have stenosis of the left subclavian vein. Here, we describe the approach used to perform venoplasty in this patient. After venoplasty of the left subclavian vein, the patient did not have suitable coronary venous anatomy for deployment of the coronary sinus lead. Subsequently, a His lead was implanted. We achieved significant narrowing of the QRS with good thresholds and other lead parameters. Through this case report, we seek to present our approach of venoplasty in patients with occluded venous access for either an upgrade or a de novo implant.

Transient Inferior Lead ST Elevation During Radiofrequency Ablation of Atrial Fibrillation.

Radiofrequency ablation (RFA) is a commonly performed procedure for symptomatic atrial fibrillation (AF). Herein, we describe a case of transient ST elevation during the isolation of right-sided pulmonary veins. The patient was hemodynamically stable and due to the transient nature of ST-elevation, the procedure was completed successfully. Subsequently, the cardiac catheterization was performed which did not reveal any significant obstructive coronary lesion or a thrombus. In this report, we attempt to explain possible mechanisms for ST-elevation during RFA of AF.

Persistent Left Superior Vena Cava and Absent Right Superior Vena Cava with Left Subclavian Vein Stenosis: Technical Challenges with Pacemaker Implantation.

We present a challenging case of a 75-year-old female with a history of paroxysmal atrial fibrillation (PAF) and symptomatic sick sinus syndrome (SSS) who presented for a dual chamber pacemaker implantation and was found to have persistent left superior vena cava and absent right superior vena cava with stenosis of the left subclavian vein. In this report, we discuss the implant technique in this group of patients.

Blue-green neutrophilic inclusion bodies in the critically ill patient.

Previously termed "Green Crystals of Death," bright blue-green inclusion bodies within neutrophils are a rare clinical finding. They have been reported as a predictive sign of mortality in critically ill patients and often accompany acute liver failure, lactic acidosis with multisystem organ failure, or septic shock due to Escherichia coli.