Introduction Conduction system pacing (CSP) has emerged as an ideal physiologic pacing strategy for patients with permanent pacing indications. We sought to evaluate the safety and feasibility of CSP in a consecutive series of unselected patients with congenital heart disease (CHD). Methods Consecutive patients with CHD in which CSP was attempted were included. Safety and feasibility, implant tools and electrical parameters at implant and at follow‐up were evaluated. Results A total of 20 patients were included (10 with a previous device). A total of 10 patients had complex forms of CHD, 9 moderate defects and 1 a simple defect. CSP was achieved in 75% of cases (10 His bundle pacing, 5 left bundle branch pacing) with left ventricular septal pacing in the remaining 5 patients. Procedure times and fluoroscopy times were prolongued (126 ± 82 min and 27 ± 30 min, respectively). Ventricular lead implant times widely varied ranging from 4 to 115 min, (mean 31 ± 28 min) and the use of multiple delivery sheaths was frequent (50%). The QRS width was reduced from 145 ± 36 ms at baseline to 116 ± 18 ms with CSP. Implant electrical parameters included: CSP pacing threshold 0.95 ± 0.65 V; R wave amplitude 9.2 ± 8.8 mV and pacing impedance 632 ± 183 Ohms, and remained stable at a median follow‐up of 478 days (interquartile range: 225–567). Systemic ventricle systolic function and NYHA class (1.50 ± 0.51 vs. 1.10 ± 0.31; p = .008) significantly improved at follow‐up. Lead revision was required in one patient at Day 4. Conclusions Permanent CSP is safe and feasible in patients with CHD although implant technique is complex.
Introduction: Stand-alone substrate ablation has become a standard ventricular tachycardia (VT) ablation strategy. We sought to evaluate the influence of baseline VT inducibility and activation mapping on ablation outcomes in patients with structural heart disease (SHD) undergoing VT ablation.Methods: Single center, observational and retrospective study including consecutive patients with SHD and documented VT undergoing ablation. Baseline VT induction was attempted before ablation in all patients and VT activation mapping performed when possible. Ablation was guided by activation mapping for mappable VTs plus substrate ablation for all patients. Ablation outcomes and complications were evaluated.Results: One hundred and sixty patients were included and were classified in three groups according to baseline VT inducibility:group 1 (non inducible, n = 18), group 2 (1 VT morphology induced, n = 53), and group 3 (>1 VT morphology induced, n = 89).VT activation mapping was possible in 35%. After a median follow-up of 38.5 months, baseline inducibility of greater than 1 VT morphology was associated with a significant incidence of VT recurrence (42% for group 3 vs. 15.1% for group 2% and 5.6% for group 1, Log-rank p < .0001) and activation mapping with a lower rate of VT recurrence (24% vs. 36.3%, Log-rank p = .035). Baseline inducibility of greater than 1 VT morphology (hazards ratio [HR]: 12.05, 95% confidence interval [CI]:1.60-90.79, p = .016) was an independent predictor of VT recurrence while left ventricular ejection fraction less than 30% (HR: 1.93, 95% CI: 1.13-3.25, p = .014) and advanced heart failure (HR: 4.69, 95% CI: 2.75-8.01, p < .0001) were predictors of mortality or heart transplantation. Complications occurred in 11.2% (5.6% hemodynamic decompensation). Conclusion:Baseline VT inducibility and activation mapping may add significant prognostic information during VT ablation procedures.
Introduction: Conduction system pacing (CSP) has emerged as an ideal physiologic pacing strategy for patients with permanent pacing indications. We sought to evaluate the safety and feasibility of CSP in a consecutive series of unselected patients with congenital heart disease (CHD). Methods: Consecutive patients with CHD in which CSP was attempted were included. Safety and feasibility, implant tools and electrical parameters at implant and at follow-up were evaluated. Results: A total of 20 patients were included (10 with a previous device). Ten patients had complex forms of CHD, 9 moderate defects and 1 a simple defect. His bundle pacing (HBP) or left bundle branch area pacing (LBBAP) were achieved in all patients (10 HBP, 5 LBBP and 5 left ventricular septal pacing). Procedure times and fluoroscopy times were prolongued (126±82 min and 27±30 min, respectively). CSP lead implant times widely varied ranging from 4 to 115 minutes, (mean 31±28 min) and the use of multiple delivery sheaths was frequent (50%). The QRS width was reduced from 144±32 ms at baseline to 116±16 ms with CSP. Implant electrical parameters included: CSP pacing threshold 0.85±0.61V; R wave amplitude 9.8±9.2mV and pacing impedance 735±253 Ohms, and remained stable at a median follow-up of 478 days (IQR 225-567). Systemic ventricle systolic function and NYHA class (1.50±0.51 vs 1.10±0.31; p=0.008) significantly improved at follow-up. Lead revision was required in one patient at day-4. Conclusions: Permanent CSP is safe and feasible in patients with CHD although implant technique is complex.
Funding Acknowledgements Type of funding sources: None. Background Lumen-less leads (LLL) and stylet driven leads (SDL) are currently used for left bundle branch area pacing (LBBAP). We sought to evaluate the acute performance of SDL during LBBAP in comparison with LLL. Methods This is an observational retrospective study including consecutive patients undergoing LBBAP at our institution.Acute lead performance was evaluated including implant success rate,electrical parameters,ECG characteristics and lead related complications (intraprocedure LBBAP lead dislodgment after having being penetrated into the septum in an stable position needing lead repositioning, septal perforation, coronary venous fistula, development of complete AV block not previously present and LBBAP lead damage during implant).Conduction system capture criteria were assessed before patient discharge during asynchronous ventricular pacing. Ventricular lead position within the septum was evaluated using paced QRS axis, fluoroscopic orthogonal views and post-procedure TTE, and classified as basal,mid or apical septum. Results 451 consecutive LBBAP implants were included, 333 using LLL and 118 using SDL. LBBAP acute success was significantly higher with LLL (91.6% for LLL vs 79.7% for SDL,p=0.001).Among patients with successful LBBAP,LBB capture criteria were achieved in 53.2% for LLL vs 36.4% for SDL,while left ventricular septal pacing (LVSP) was achieved in 39% vs 44.1%,respectively (p<0.0001). A basal lead position was more frequently obtained with LLL (19.8% for LLL vs 13.3% for SDL),while SDL were more frequently located at mid to apical septal positions (86.7% for SDL vs 80.1% for LLL, p=0.003).Paced ECG axis was inferior in 43.9% of LLL vs 28.9% of SDL and superior in 24.5% vs 42.1%, respectively,p=0.001.Intraprocedure lead dislodgment occurred in 9.3% of SDL vs 2.1% of LLL,p=0.001.In 5 cases of SDL (4.2%),lead damage occurred during lead implant needing lead replacement due to helix entrapment or malfunction with no such cases registered among LLL patients.Acute LBBAP lead-related complications were significantly higher for SDL vs LLL (29.1% vs 12.6%, respectively, p<0.0001,table 1),none of them needing additional interventions.Among patients with LBBAP criteria at the end of the procedure,34 (7.5%) experienced loss of r prime wave in V1 with paced QRS widening before hospital discharge,more frequently in patients with SDL (17.8% vs. 9.4%, respectively,p<0.0001) indicative of lead microdislodgment. Conclusions In our experience,acute lead performance is different between LLL and SDL.LBBAP implant success rate is significantly higher with LLL with higher percentage of patients with LBB capture criteria in comparison with SDL.SDL are associated with a more mid to apical and inferior lead position in the septum.A significantly higher rate of lead related complications during the implant procedure as well as higher rates of acute microdislodgment after implantation were also seen in SDL,none of them needing acute re-intervention.
Funding Acknowledgements Type of funding sources: None. Background Left bundle branch area pacing (LBBAP) includes both left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP). The implant procedure characteristics of these two pacing modalities have not been yet fully described. We sought to compare 2 different LBBAP implant strategies: the first one accepting LVSP as a procedure endpoint and the second one aiming at achieving LBBP in every patient. Methods Consecutive patients undergoing LBBAP at our centre from January 2020 to October 2022 were included. After our initial LBBAP learning curve, LVSP was accepted as a procedure endpoint in the first 217 patients. Thereafter, LBBP was attempted in every patient with a maximum of 5 lead deployment attempts or > 30 minutes for lead implant even if LVSP had been previously achieved. Definition of LBBP or LVSP was established according to currently accepted criteria. Procedure characteristics including total procedure time, LBBAP lead implant time, radiation exposure parameters, electrical parameters and acute complications were evaluated. Results A total of 422 consecutive patients were included in the analysis (217 patients with LVSP as acceptable endpoint, and 205 patients with LBBP as final endpoint). Baseline characteristics of the patients are described in table 1. In the LVSP group, the final capture pattern was LVSP in 57.6% and LBBP in 29% whereas in the LBBP group the final capture pattern was LVSP in 19.5% and LBBP in 71.2%. Failure of LBBAP occurred in 13.4% of LVSP group and 9.3% of LBBP group. LBBAP lead position in the septum was basal in 12,5% of LVSP group vs. 23,9% of LBBP group and medium in 81.7% and 72%, respectively (Table 2). A discrete LB potential was identified in 21.2% of LVSP group patients and in 45.8% of LBBP patients, p<0.0001. The LBBP strategy was associated with significantly longer LBBAP lead implant time (19±11min vs. 17±10 min, p=0.05), higher number of lead deployment attempts (3.4±1.8 vs 2.9±1.9, p=0.004), higher number of lead turns (22.4±4.3 vs. 18.3±4,1, p<0,0001) and higher fluoroscopy time (13.2±9.5 min vs. 10.6±9.3 min, p=0.003). Incidence of septal perforation was comparable between the 2 groups (10.6% for LVSP group and 7.8% for LBBP group, p=0.4) but development of complete AV block during implant tended to be more frequent in LBBP group (3.9% vs. 1.4%, p=0.13). The final paced QRS width, measured from the pacing spike, was comparable between the 2 groups: 161±18 ms for LVSP group and 158±19 ms for LBBP group, p=0.2. Conclusions LBBP can be achieved in more than 70% of unselected patients with significantly prolonged procedure time, higher number of lead deployment attempts and higher radiation exposure. When LVSP is accepted as an outcome, LBBP can be achieved in up to 29% of cases. The final paced QRS duration is comparable between the two implant strategies. Any potential clinical benefit of LBBP over LVSP in the long-term remains to be proven.
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