Conduction system pacing in difficult cardiac anatomies: Systematic approach with the 3D electroanatomic mapping guide.

Introduction: Restoring physiological cardiac electrical activity in patients with conduction disease can be crucial for the survival and quality of life. Conduction system pacing (CSP) is a valuable option, although it is limited by technical challenges in difficult anatomies. 3D electroanatomical mapping (3D-EAM) can support CSP ensuring high electro-anatomical precision and low fluoroscopy.

His Bundle Pacing: My Experience, Tricks, and Tips.

His Bundle Pacing (HBP) is a form of physiologic pacing achieved through implantation of a pacing electrode into the His bundle. HBP began 20 years ago without any dedicated tools. As specific tools became available HBP quickly spread and proved to be a viable alternative to traditional right ventricle pacing.

Prognostic Impact of New-Onset Atrial Fibrillation After Single or Double Stent Left Main Bifurcation PCI.

Objective: Incidence and prognostic value of new-onset atrial fibrillation after single versus double stent strategy in bifurcation left main disease has not been yet investigated.

Methods: We retrospectively analyzed the procedural and medical data of patients referred to our center for complex left main bifurcation disease, treated using crossover provisional stenting, T or T-and-Protrusion, Culotte, and Nano-inverted-T techniques between January 1, 2008, and May 1, 2018. Multivariate Cox-regression analysis was used to assess the role of different stent strategies, adjusted for confounders, on the risk of new-onset atrial fibrillation during the follow-up period.

Occurrence of persistent atrial fibrillation during pacing for sinus node disease: The influence of His bundle pacing versus managed ventricular pacing.

Introduction: In patients with sinus node disease (SND), the dual-chamber pacemaker (PM) is programmed in DDDR mode with an algorithm to avoid unnecessary right ventricular (RV) pacing. This pacing mode may prolong PR interval with consequently atrioventricular (AV) asynchrony which is associated with a higher risk of atrial fibrillation (AF). We evaluate whether preserving AV synchrony by setting a fixed AV delay during physiological RV pacing, that is, His bundle pacing (HBP), could reduce the risk of AF occurrence in comparison with a standard pacing mode with an algorithm to avoid unnecessary RV pacing (DDD-VPA).

Implantation technique of His bundle pacing.

His bundle pacing (HBP) preserves physiological ventricular synchrony, with clinical benefits particularly evident when a high percentage of ventricular pacing is required. First experiences with standard leads and manually shaped stylets produced the impression that HBP is highly complex and time-consuming. However, with dedicated leads and sheaths, reliable HBP can be achieved in routine clinical practice.

Electrogram-only guided approach to His bundle pacing with minimal fluoroscopy: A single-center experience.

Introduction: His bundle pacing (HBP) is the most physiological pacing. The standard technique based on fluoroscopic approach might be challenging and fluoro consuming. Targeting the His guided exclusively by the electrical signals could enable a precise lead implant, thus reducing fluoroscopy time (FT) and X-ray dose, desirable both for patients and operators.

The QR-max index, a novel electrocardiographic index for the determination of left ventricular conduction delay and selection of cardiac resynchronization in patients with non-left bundle branch block.

Non-left bundle branch block (non-LBBB) remains an uncertain indication for cardiac resynchronization therapy (CRT). Non-LBBB includes right bundle branch block (RBBB) and non-specific LV conduction delay (NSCD), two different electrocardiogram (ECG) patterns which are not generally considered to be associated with LV conduction delay as judged by the invasive assessment of the Q-LV interval. We evaluated whether a novel ECG interval (QR-max index) correlated with the degree of LV conduction delay regardless of the type of non-LBBB ECG pattern, and could, therefore, predict CRT response.

Long term performance and safety of His bundle pacing: A multicenter experience.

Introduction: Several single-center short-term studies have demonstrated the feasibility, safety, and positive clinical outcomes of permanent His bundle pacing (HBP). We performed a retrospective study to evaluate long-term technical and safety performances of HBP in a large population of pacemaker patients from two different centers.

Methods And Results: The analysis includes 844 patients (345 female, mean age = 75 ± 9 years) who underwent successful permanent HBP for pacemaker indications from 2004 to 2016.

Long-Term Clinical Outcomes of Isolated Ostial Left Anterior Descending Disease Treatment: Ostial Stenting Versus Left Main Cross-Over Stenting.

Background: The optimal strategy for treating ostial left anterior descending coronary artery (LAD) disease remains matter of speculation. We evaluated the impact on long-term outcomes of ostial LAD disease treated by means of ostial stenting (the floating-stent) or left main (LM)-to-LAD cross-over stenting.

Methods: Clinical and instrumental records of 74 consecutive patients with isolated ostial LAD disease, enrolled between the 1st January 2012 and the 1st January 2017 were reviewed.

Hemodynamic comparison of different multisites and multipoint pacing strategies in cardiac resynchronization therapies.

Purpose: In order to increase the responder rate to CRT, stimulation of the left ventricular (LV) from multiple sites has been suggested as a promising alternative to standard biventricular pacing (BIV). The aim of the study was to compare, in a group of candidates for CRT, the effects of different pacing configurations-BIV, triple ventricular (TRIV) by means of two LV leads, multipoint (MPP), and multipoint plus a second LV lead (MPP + TRIV) pacing-on both hemodynamics and QRS duration.

Methods: Fifteen patients (13 male) with permanent AF (mean age 76 ± 7 years; left ventricular ejection fraction 33 ± 7%; 7 with ischemic cardiomyopathy; mean QRS duration 178 ± 25 ms) were selected as candidates for CRT.

Patients with right bundle branch block and concomitant delayed left ventricular activation respond to cardiac resynchronization therapy.

Aims: Right bundle branch block (RBBB) typically presents with only delayed right ventricular activation. However, some patients with RBBB develop concomitant delayed left ventricular (LV) activation. Such patients may show a specific electrocardiographic (ECG) pattern resembling RBBB in the precordial leads in association with an insignificant S-wave in lateral limb leads (atypical RBBB).

Basic Properties And Clinical Applications Of The Intracardiac.

The electric signals detected by intracardiac electrodes provide information on the occurrence and timing of myocardial depolarization, but are not generally helpful to characterize the nature and origin of the sensed event. A novel recording technique referred to as intracardiac ECG (iECG) has overcome this limitation. The iECG is a multipolar signal, which combines the input from both atrial and ventricular electrodes of a dual-chamber pacing system in order to assess the global electric activity of the heart.

Optimization of left ventricular pacing site plus multipoint pacing improves remodeling and clinical response to cardiac resynchronization therapy at 1 year.

Background: Approximately one-third of the patients with heart failure (HF) treated with cardiac resynchronization therapy (CRT) fail to respond. Positioning the left ventricular (LV) pacing lead in the area of the latest electrical delay may improve the response to CRT. Multipoint pacing (MPP) of the LV has been shown to improve the acute hemodynamic response.

ECG parameters predict left ventricular conduction delay in patients with left ventricular dysfunction.

Background: Estimating left ventricular electrical delay (Q-LV) from a 12-lead ECG may be important in evaluating cardiac resynchronization therapy (CRT).

Objective: The purpose of this study was to assess the impact of Q-LV interval on ECG configuration.

Methods: One hundred ninety-two consecutive patients undergoing CRT implantation were divided electrocardiographically into 3 groups: left bundle branch block (LBBB), right bundle branch block (RBBB), and nonspecific intraventricular conduction delay (IVCD).

The risk of atrial fibrillation during right ventricular pacing.

Aims: Right ventricular pacing adversely affects left atrial (LA) structure and function that may trigger atrial fibrillation (AF). This study compares the occurrence of persistent/permanent AF during long-term Hisian area (HA), right ventricular septal (RVS), and right ventricular apex (RVA) pacing in patients with complete/advanced atrioventricular block (AVB).

Methods And Results: We collected retrospective data from 477 consecutive patients who underwent pacemaker implantation for complete/advanced AVB.

Multipoint pacing by a left ventricular quadripolar lead improves the acute hemodynamic response to CRT compared with conventional biventricular pacing at any site.

Background: Response to cardiac resynchronization therapy (CRT) remains challenging. Pacing from multiple sites of the left ventricle (LV) has shown promising results.

Objective: The purpose of this study was to systematically compare the acute hemodynamic effects of multipoint pacing (MPP) by means of a quadripolar lead with conventional biventricular (BiV) pacing.

Determination of the longest intrapatient left ventricular electrical delay may predict acute hemodynamic improvement in patients after cardiac resynchronization therapy.

Background: One of the reasons for patient nonresponse to cardiac resynchronization therapy is a suboptimal left ventricular (LV) pacing site. LV electric delay (Q-LV interval) has been indicated as a prognostic parameter of cardiac resynchronization therapy response. This study evaluates the LV delay for the optimization of the LV pacing site.

Hisian area and right ventricular apical pacing differently affect left atrial function: an intra-patients evaluation.

Aims: Right ventricular apex (RVA) pacing has adverse effects on left atrial (LA) function and may contribute to atrial arrhythmias. The effects of Hisian area (HA) pacing on LA function are still lacking. The objective of this study is to assess the left ventricular (LV) electromechanical activation/relaxation, systolic (S), diastolic (D) phases, and their effects on LA function during pacing from HA and RVA.

How can we identify the optimal pacing site in the right ventricular septum? A simplified method applicable during the standard implanting procedure.

Aims: A short paced (p) QRS duration (d) can be a marker for selecting the most appropriate RV pacing site. Although this could be achieved by continual 12-Lead ECG monitoring, such a technique is not applicable during pacemaker (PM) implantation. The purpose of this study was to validate a method for identifying the optimal site for RV septum pacing using simple markers derived from few real-time ECG leads and fluoroscopy (F).

A new integrated approach to improve left ventricular electromechanical activation during right ventricular septal pacing.

Aims: The deleterious effects of apical right ventricular pacing has fostered the utilization of alternative pacing sites. Although right ventricular septal (RVS) sites are commonly used, the results have been controversial because of poor standardization of lead position by fluoroscopy. This study investigated the utility of a new RVS pacing technique based on the combination of fluoroscopy (F), and electrophysiological mapping (F + EP).

Failure of transvenous ICD to terminate ventricular fibrillation in a patient with left ventricular noncompaction and polycystic kidneys.

Implantable cardioverter defibrillator (ICD) testing in patients with left ventricular noncompaction (LVNC) at the time of implantation and potential difficulties with ventricular fibrillation (VF) induction/termination in LVNC patients are often not stated in the literature. This report describes the failure of transvenous implantation of an ICD in a 40-year-old patient with LVNC and polycystic kidneys. A high defibrillation threshold (DFT) prevented termination of ICD-induced VF.

Variability of left ventricular electromechanical activation during right ventricular pacing: implications for the selection of the optimal pacing site.

Background: The right ventricular septum (RVS) and Hisian area (HA) are considered more "physiological" pacing sites than right ventricular apex (RVA). Studies comparing RVS to RVA sites have produced controversial results. There are no data about variability of electromechanical activation obtained by an approach using fluoroscopy and electrophysiological markers.

Left ventricular dyssynchrony resulting from right ventricular apical pacing: relevance of baseline assessment.

Objectives: Evaluation of left ventricular (LV) dyssynchrony in patients undergoing short-term right ventricular apical (RVA) pacing and correlation with baseline echocardiographic and clinical characteristics.

Background: RVA pacing causes abnormal ventricular depolarization that may lead to mechanical LV dyssynchrony. The relationships between pacing-induced LV dyssynchrony and baseline echocardiographic and clinical variables have not been fully clarified.