Tracheal tube introducer-associated airway trauma: a systematic review.

BACKGROUND: Tracheal tube introducers are recommended in airway management guidelines and are used increasingly as videolaryngoscopy becomes more widespread. This systematic review aimed to summarise the published literature concerning tracheal tube introducer-associated airway trauma. METHODS: PubMed, EMBASE and CINAHL databases were searched using pre-determined criteria. Two authors independently assessed search results and performed data extraction and risk of bias assessments. RESULTS: We included 16 randomised controlled trials and five observational studies involving 10,797 patients. There was heterogeneity in patient characteristics, airway manipulation, and airway trauma definition and measurement. One study investigated hyperangulated videolaryngoscopy. The standard stylet was the most commonly reported introducer, followed by bougie and stylets with additional features such as video or lighted tip. Airway trauma resulted in low harm and most frequently involved injuries to the upper airway, followed by laryngeal and tracheobronchial injuries. Eighteen studies were comparative and reported a reduction in airway trauma incidence when an introducer was used, with the exception of the standard stylet. Median (IQR [range]) pooled incidence of airway trauma associated with standard stylets was 13.1% (4.2-31.4 [0.5-79.2])% and with bougies was 5.4% (0.4-49.9 [0.0-68.0])%. The risk of bias of included studies was variable and many randomised trials were found to be at high risk due to non-robust measurement of the outcome. CONCLUSIONS: Stylets might be associated with an increased risk of airway trauma compared with other devices or when no stylet was used, though the quality of evidence is modest. However, other introducers appear to be safe and reduce the risk of airway trauma.

Structured Routine Use of Styletubation for Oro-Tracheal Intubation in Obese Patients Undergoing Bariatric Surgeries-A Case Series Report.

The aim of this case series report is to provide a new topical view of styletubation (video intubating stylet technique) in obese patients undergoing bariatric surgeries. In contrast to various conventional direct laryngoscopes (DLs), videolaryngoscopes (VLs) have been applied in such obese populations with potentially difficult airway complications. The safety and effectiveness of VLs have been repeatedly studied, and the superiority of VLs has then been observed in and advocated for routine use. In this article, among our vast use experiences with styletubation (more than 54,998 patients since 2016) for first-line routine tracheal intubation, we present the unique experience to apply the styletubation technique in obese patients undergoing bariatric surgery. Consistent with the experiences applied in other patient populations, we found the styletubation technique itself to be swift (the time to intubate from 5 s to 24 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction). The learning curve is steep, but competency can be enhanced if technical pitfalls can be avoided. We, therefore, propose that the styletubation technique can be feasibly and routinely applied as a first-line airway modality in obese patients undergoing bariatric surgery.

Clinical impact and predictors of periprocedural myocardial injury among patients undergoing left bundle branch area pacing.

BACKGROUND: The clinical impact of Periprocedural myocardial injury (PMI) in patients undergoing permanent pacemaker implantation with Left Bundle Branch Area Pacing (LBBAP) is unknown. METHODS: 130 patients undergoing LBBAP from January 2020 to June 2021 and completing 12 months follow up were enrolled to assess the impact of PMI on composite clinical outcome (CCO) defined as any of the following: all-cause death, hospitalization for heart failure (HHF), hospitalization for acute coronary syndrome (ACS) and ventricular arrhythmias (VAs). High sensitivity Troponin T (HsTnT) was measured up to 24-h after intervention to identify the peak HsTnT values. PMI was defined as increased peak HsTnT values at least > 99th percentile of the upper reference limit (URL: 15 pg/ml) in patients with normal baseline values. RESULTS: PMI occurred in 72 of 130 patients (55%). ROC analysis yielded a post-procedural peak HsTnT cutoff of fourfold the URL for predicting the CCO (AUC: 0.692; p = 0.023; sensitivity 73% and specificity 71%). Of the enrolled patients, 20% (n = 26) had peak HsTnT > fourfold the URL. Patients with peak HsTnT > fourfold the URL exhibited a higher incidence of the CCO than patients with peak HsTnT ≤ fourfold the URL (31% vs. 10%; p = 0.005), driven by more frequent hospitalizations for ACS (15% vs. 3%; p = 0.010). Multiple (> 2) lead repositions attempts, the use of septography and stylet-driven leads were independent predictors of higher risk of PMI with peak HsTnT > fourfold the URL. CONCLUSIONS: PMI seems common among patients undergoing LBBAP and may be associated with an increased risk of clinical outcomes in case of more pronounced (peak HsTnT > fourfold the URL) myocardial damage occurring during the procedure.

Left bundle branch area pacing using a stylet-driven, retractable-helix lead: Short-term results from a prospective multicenter IDE trial (the BIO-CONDUCT study).

BACKGROUND: Left bundle branch area pacing (LBBAP) has swiftly emerged as a safe and effective alternative to right ventricular pacing. Limited data exist on the use of retractable-helix, stylet-driven leads for LBBAP. OBJECTIVE: The objective of this study was to prospectively evaluate the performance and safety of a stylet-driven pacing lead in a rigorously controlled multicenter trial to support US market application. METHODS: A multicenter, prospective, nonrandomized trial enrolled patients with standard pacing indications. Implant procedure and lead data, including threshold, sensing, impedance, and capture type, were collected through 3 months. Primary end points were freedom from LBBAP lead-related serious complications through 3 months and LBBAP implant success according to prespecified criteria. A blinded clinical events committee adjudicated all potential end point complications. RESULTS: A total of 186 patients were included from 14 US sites. LBBAP implants were successful in 95.7% (178 of 186; 95% confidence interval 91.7%-98.1%; P < .0001 for comparison to the performance goal of 88%). Through the 3-month follow-up visit, 3 patients (1.7%) experienced a serious LBBAP complication (all lead dislodgments), resulting in a LBBAP lead-related complication-free rate of 98.3%. A total of 13 patients (7.8%) experienced any system- or procedure-related complication. The mean threshold was 0.89 V at 0.4 ms, the sensing value was 10.8 mV, and impedance was 608 Ω. CONCLUSION: The short-term results from this prospective trial demonstrate both high implant success and freedom from LBBAP lead-related complications using this stylet-driven retractable helix lead. This trial supports the safety, use, and effectiveness of stylet-driven leads for performing contemporary physiologic pacing.

A stylet use may be beneficial for elective and rescue intubation of prematurely born infants < 30 weeks.

BACKGROUND: Recent studies have reported that using a stylet does not provide any advantages during intubation within a diverse infant population. Our research focuses on the issue, specifically in premature infants who undergo elective or rescue intubation (EI or RI) in the delivery room (DR). METHODS: We conducted a single-center retrospective observational study comparing the number of intubation attempts, the duration of intubation procedure until successful, and the rate of associated desaturations exceeding 20%. We derived outcomes from video recordings and performed statistical analyses. RESULTS: We have analyzed 104 intubation attempts in 70 infants with a mean gestational age and birth weight of 25±1.9 weeks and 736±221 grams, respectively; 39 of these attempts involved stylet use, and 65 did not. 75% of infants requiring intubation were less than 26 weeks of gestational age. The use of a stylet increased the rate of successful initial attempts [OR (95% CI) 4.3 (1.3-14.8), P=0.019], reduced the duration of the intubation procedure [median (IQR) seconds: 43 (30-72) vs 140 (62-296), P<0.001], and decreased the occurrences of desaturation exceeding 20% (13% vs 50%, P=0.003). CONCLUSION: The benefits of using a stylet during rescue and elective intubations of premature infants in the delivery room outweigh the potential harms. Its use may be advantageous in settings where proactive approaches are implemented for periviable infants.

Dynamic Workflow Proposal for Continuous Frameless Electromagnetic Neuronavigation in Rigid Neuroendoscopy.

BACKGROUND: Ventriculoscopic neuronavigation has been described in several articles. However, there are different ventriculoscopes and navigation systems. Due to these different combinations, it is difficult to find detailed neuronavigation protocols. We describe, step-by-step, a simple method to navigate both the trajectory until reaching the ventricular system, as well as the intraventricular work. METHODS: We use a rigid ventriculoscope (LOTTA, KarlStorz) with an electromagnetic stylet (S8-StealthSystem, Medtronic). The protocol is based on a modified or 3-dimensionally printed trocar for navigating the extraventricular step and on a modified pediatric nasogastric tube for the intraventricular navigation. RESULTS: This protocol can be set up in less than 10 minutes. The extraventricular part is navigated by introducing the electromagnetic stylet inside the modified or 3-dimensionally printed trocar. Intraventricular navigation is done by combining a modified pediatric nasogastric tube with the electromagnetic stylet inside the endoscope's working channel. The most critical point is to obtain a blunt-bloodless ventriculostomy while achieving perfect alignment of all targeted structures via pure straight trajectories. CONCLUSIONS: This protocol is easy-to-set-up, avoids head rigid-fixation and bulky optical-based attachments to the ventriculoscope, and allows continuous navigation of both parts of the surgery. Since we have implemented this protocol, we have noticed a significant enhancement in both simple and complex ventriculoscopic procedures because the surgery is dramatically simplified.

Dynamic versus standard bougies for tracheal intubation with direct or indirect laryngoscopy in simulated or real scenarios: a systematic review and meta-analysis.

INTRODUCTION: This systematic review and meta-analysis aimed to compare the efficacy of dynamic versus standard bougies to achieve tracheal intubation. METHODS: We searched MEDLINE, Embase, CENTRAL, Web of Science, Scopus and Google Scholar on 10 October 2023. We included clinical trials comparing both devices. The primary outcome was the first-attempt intubation success rate. The secondary outcome was the time required for tracheal intubation. RESULTS: Eighteen studies were included. Dynamic bougies do not increase first-attempt success rate (RR 1.11; p = 0.06) or shorten tracheal intubation time (MD -0.30 sec; p = 0.84) in clinical trials in humans. In difficult airways, first-attempt success intubation rate was greater for dynamic bougies (RR 1.17; p = 0.002); Additionally, they reduced the time required for intubation (MD -4.80 sec; p = 0.001). First-attempt intubation success rate was higher (RR 1.15; p = 0.01) and time to achieve intubation was shorter when using Macintosh blades combined with dynamic bougies (MD -5.38 sec; p < 0.00001). Heterogeneity was high. CONCLUSION: Dynamic bougies do not increase the overall first-pass success rate or shorten tracheal intubation time. However, dynamic bougies seem to improve first-attempt tracheal intubation rate in patients with difficult airways and in those intubated with a Macintosh blade. Further research is needed for definitive conclusions. REGISTRATION OF PROSPERO: CRD42023472122.

Lead performance of stylet-driven leads in left bundle branch area pacing: Results from a large single-center cohort and insights from in vitro bench testing.

BACKGROUND: Left bundle branch area pacing (LBBAP) requires deep septal lead deployment for left-sided conduction stimulation. Advancing leads toward deep septal positions might add mechanical stress on these leads. Concerns about lead performance and reliability remain an unanswered question. OBJECTIVE: The purpose of this study was to analyze lead performance and integrity of stylet-driven pacing leads (SDLs) for LBBAP. METHODS: This study assessed lead fracture rates of SDL in a large single-center cohort of adult LBBAP patients. Fluoroscopic analysis of lead bending angulations at the septal insertion point and in vitro bench testing of lead preconditioning were performed to simulate clinical use conditions. Lead performance was compared between LBBAP and conventional right ventricular apical pacing (RVp) sites. RESULTS: The study included 325 LBBAP patients (66% male; age 71±15 years). During median follow-up of 18 months, 2 patients (0.6%) experienced conductor fracture between tip housing and ring electrode, whereas no such fractures occurred with RVp patients (n = 149; P = .22). X-ray analysis revealed that high lead bending angulations occurred in 1.3% of the patients. Accelerated bench testing of excessive preconditioned leads showcased a higher probability of early conductor fracture compared to standard preconditioned leads. CONCLUSION: The incidence of early conductor failure in LBBAP seems higher than with conventional RVp sites. The most vulnerable lead part seems to be the interelectrode space between the tip housing and ring electrode. Excessive angulation and preconditioning might contribute to early fatigue fracture.

Extraction of stylet-driven pacing lead for left bundle branch area pacing.

We present a case where a stylet-driven pacing lead was successfully extracted from the left bundle branch area pacing, 10 months after implantation. The procedure was performed without any complications, using a standard stylet and employing gentle counterclockwise rotations of the lead body.

Randomized controlled trial to evaluate the rate of successful neonatal endotracheal intubation performed with a stylet versus without a stylet.

INTRODUCTION: Neonates in intensive care units often require endotracheal intubation and mechanical ventilation. During this intubation procedure, a stylet is frequently used along with an endotracheal tube. Despite the widespread use of a stylet, it is still not known whether its use increases the intubation success rate. This study examined the association between stylet use and the intubation success rate in surgical neonates. METHODOLOGY: This single-center study was conducted between December 2021 and December 2022 in the Neonatal surgical intensive care unit of a tertiary care center in Northern India. Infants were randomized to have the endotracheal intubation procedure performed using either an endotracheal tube alone or with a stylet. The primary outcome of the study was to assess the successful first-attempt neonatal endotracheal intubation rate with and without using a stylet. Apart from the rate of successful intubation, the duration of the intubation and complications during the intubation procedures as measured by bradycardia, desaturation episodes, and local trauma were also recorded. Both groups were thus compared on above mentioned outcomes. RESULTS: The total number of neonates enrolled were 200, and the overall success rate (81% in the stylet group vs. 73% in the non-stylet group) was not statistically significant. Intubation time was however less, when stylet was used (16.2 ± 4.3 vs. 17.5 ± 5.0 s, p = .046). When the endotracheal tube size was 3 or less, the success rate was substantially higher in the stylet group (80%) than the non-stylet group (63%), p = .03. No statistical difference was recorded for bleeding and local trauma, though the esophageal intubation rate was higher when intubation was attempted without the stylet. CONCLUSION: Endotracheal intubation using a stylet did not significantly improve the success rate of the procedure, however, intubation time significantly varied between groups and in different conditions. The rigidity and curvature provided by the stylet may facilitate the process of intubation when smaller caliber endotracheal tubes are used.

Video-stylet vs. channeled hyperangulated videolaryngoscope: Efficacy in simulated Ludwig's angina randomized cadaver trial.

INTRODUCTION: Ludwig's angina (LA) is a life-threatening infection that can affect the floor of the mouth and neck, potentially causing serious airway obstruction. In such cases, rescue airway management and oxygenation can be challenging due to swelling of the mouth floor, trismus, and limited mouth opening. The aim of this study was to assess the efficacy of the Trachway video-stylet (VS) and Pentax AWS hyperangulated videolaryngoscope with channel (HAVL-C) compared to the standard geometric video-laryngoscope (SGVL, Macintosh 3, Trachway) in simulating Ludwig's angina with cadavers. METHODS: Three fresh frozen cadavers were prepared with varying degrees of difficulty to simulate the airway conditions of patients with LA, including mouth floor swelling, restricted mouth opening, and trismus. Fifty-five second-year resident physicians from various specialties participated in the study and received training in airway management using SGVL, VS, and HAVL-C devices. Participants were randomly assigned to intubate simulated LA with cadavers using the three devices in a random order, and intubation times and success rates were recorded. Participants also rated the difficulty of intubation using a visual analogue scale (VAS) score. The primary outcome assessed the first-pass intubation success or failure, while the secondary outcomes measured the intubation time and subjective difficulty using a visual analogue scale with different laryngoscopes. RESULTS: The success rates for intubation within 90 s were 40% for SGVL, 82% for VS, and 76% for HAVL-C. VS and HAVL-C had significantly higher success rates than SGVL, with hazard ratios of 3.4 and 2.7, and 95% confidence intervals (CI) of 2.0-5.7 and 1.6-4.6, p < 0.001, respectively. The odds ratios of successful intubation for VS and HAVL-C were 8.1 and 6.3, respectively, with a 95% CI of 3.7-17.8 and 2.4-16.7, p < 0.001, compared to SGVL. The VAS score was significantly correlated with intubation success rate and time. CONCLUSIONS: In cases of LA, the use of VS and HAVL-C is preferable over SGVL. These findings suggest that using VS and HAVL-C can improve intubation success rates and reduce intubation time in patients with LA.

Comparison of the success rate of tracheal intubation between stylet and bougie with a hyperangulated videolaryngoscope: a randomised controlled trial.

Hyperangulated videolaryngoscopes are known to increase the success rate of tracheal intubation in the setting of difficult airway management when used with a stylet or bougie. However, there is controversy over which adjunct is more useful. This randomised study aimed to compare first attempt tracheal intubation success rate between a stylet and bougie when using a hyperangulated videolaryngoscope. We recruited patients aged > 20 years who were scheduled for elective surgery under general anaesthesia and required tracheal intubation. We only included patients with factors predicting difficult tracheal intubation based on pre-anaesthesia airway evaluation. Tracheal intubation was attempted using a Glidescope® with either a stylet or bougie as an adjunct according to group assignment. Primary outcome was the success rate of the first tracheal intubation attempt, and secondary outcomes were success of second and third attempts; tracheal intubation time; and occurrence of sore throat, dysphagia or hoarseness. A total of 166 patients were included. The success rate of the first tracheal intubation attempt was significantly higher in patients allocated to the bougie group compared with those allocated to the stylet group (81/83 (98%) vs. 73/83 (88%), respectively; p = 0.032). The number of patients who needed two attempts was significantly lower in those allocated to the bougie group compared with those allocated to the stylet group (1/83 (1%) vs. 9/83 (11%), respectively; p = 0.018). Each group had one patient (1%) where tracheal intubation was achieved after a third attempt. There was no significant difference in the occurrence of sore throat, dysphagia and hoarseness between the two groups. When difficult tracheal intubation is anticipated and a hyperangulated videolaryngoscope is used, the success rate of the first attempt is higher when a bougie is used compared with a stylet.

The Key to a Successful PBC in Treatment of Trigeminal Neuralgia.

As a minimally invasive treatment of trigeminal neuralgia, percutaneous balloon compression (PBC) has become increasingly popular worldwide. Because it is simple and straightforward, it does not need a complicated apparatus only a fluoroscope plus an operator's experience. Therefore, the surgical technique seems to be essential and worth further addressing. The paper stresses that the target of PBC should be the semilunar ganglion (the soma of neurons) rather than the rootlets (axons) because the latter is renewable. To obtain a sufficient pressure against the ganglion, Meckel's cave should be covered utterly by an inflating balloon, which fluoroscopically appears in a pear shape. To attain a proper balloon position, it is suggested to make a tunnel with a blunt stylet in a proper penetrative angle before inserting a soft catheter. Too large a pear is unnecessary, hence injecting should be stopped when growth becomes apparently slow. To avoid an unacceptable postoperative paresthesia, a prolonged compression is not encouraged.

Probing behavior of the leafhopper analyzed through DC electropenetrography and microscopy.

Yamatotettix flavovittatus Matsumara is a new leafhopper species vector of sugarcane white leaf (SCWL) phytoplasma that causes sugarcane chlorosis symptoms. The effects of probing behavior of Y. flavovittatus on sugarcane and its implication for SCWL phytoplasma transmission are yet to be studied. In this research, we used DC electropenetrography (EPG) to define waveforms produced by adult and fifth-instar nymphal Y. flavovittatus on sugarcane and correlated them with salivary sheath termini (likely stylet tip locations) via light and scanning electron microscopy. The following six waveforms and associated activities are described: (NP) non-probing, (Yf1) stylet probing into epidermal cells, (Yf2) stylet probing through mesophyll/parenchyma, (Yf3) stylet contact with phloem and likely watery salivation, (Yf4) active ingestion of sap from phloem, probably sieve elements, and (Yf5) unknown stylet activity in multiple cell types. Study findings reveal that the Y. flavovittatus vector ingests sieve tube element more frequently and for longer durations than any other cell type, supporting that Y. flavovittatus is primarily a phloem feeder. Adult Y. flavovittatus show a longer total probing duration and produces a high density of puncture holes on sugarcane leaves. Moreover, probing behaviors revealed that adults typically ingest phloem sap more frequently and for longer durations than fifth-instar nymphs, enhancing sap ingestion. Furthermore, we propose that adults are more likely to acquire (during Yf4) and inoculate (during Yf3) higher amounts of phytoplasma than fifth-instar nymphs. This information on the penetration behavior of leafhopper Y. flavovittatus serves as a basis for advanced studies on the transmission mechanism of SCWL phytoplasma.

Caveats related to conduction system pacing utilizing a proprietary deflectable mapping catheter with a stylet-driven lead.

BACKGROUND: Hitherto, lumen less leads (LLLs) were routinely utilized for conduction system pacing (CSP). We report the largest experience using stylet-driven leads (SDLs) with a deflectable mapping catheter for CSP. METHODS: Patients were prospectively and sequentially enrolled for CSP with SDL between June, 2021 and November, 2022 to (i) a novel deflectable mapping catheter (AgilisHisProTM, Abbott) (Group A) or (ii) a fixed curve sheath (Selectra3D, Biotronik) (Group B) in a 1:1 non-randomized fashion. The primary aim was to evaluate safety, feasibility, and efficacy of the CSP using SDL and deflectable mapping catheter (Group A) while reporting procedural success and intermediate-term follow-up. RESULTS: Seventy-nine patients (59.4%M, mean age 67.2+/-10.6 years) were allocated to either (i) Group A (n = 40) or (ii) Group B (n = 39). In Group A (n = 40, 50% M, mean age 67.2+/-9.5 years, follow-up 210.7 + 25.1days), His bundle pacing (HBP) was the default strategy with left bundle branch area pacing (LBBaP) for bailout. Procedural success with HBP was feasible in 17/40 (42.5%) patients with remaining 23/40 (57.5%) needing LBBaP bailout. After initial learning curve, a manual septal curve was introduced to successfully aid LBBaP in 6/23 (26.1%) cases. Procedural and follow-up parameters did not differ significantly in HBP vs. LBBaP. Head-to-head comparison was not performed between the groups owing to different default protocols (HBP-Group A, Discretionary-Group B). CONCLUSIONS: Use of SDL with single-curve deflectable mapping catheter was safe, feasible and yielded moderate procedural success with HBP and frequently needed a LBBaP bailout strategy. In approximately one-fourth of the latter, an out-of-plane manual septal curve was needed to optimize LBBaP.

Comparison of the left ventricular dyssynchrony between stylet-driven and lumen-less lead technique in left bundle branch area pacing using myocardial perfusion scintigraphy.

Background: Left bundle branch area pacing (LBBAP) has emerged as a novel physiological pacing method to reduce left ventricular (LV) dyssynchrony due to ventricular pacing. Only lumen-less pacing leads (LLLs) with fixed helixes could achieve LBBAP previously, but recently, LBBAP has been performed using stylet-driven leads (SDLs). This study aimed to evaluate the LV dyssynchrony between SDLs and LLLs techniques in LBBAP. Methods: We retrospectively evaluated patients who underwent LBBAP with either SDLs or LLLs. We compared both groups' electrocardiogram (ECG) findings and LV dyssynchrony parameters derived from myocardial perfusion scintigraphy. LV dyssynchrony parameters consisted of phase analysis and regional wall motion analysis. We evaluated bandwidth, phase standard deviation (PSD), and entropy in the phase analysis. The time to the end-systolic frame (TES) was calculated in regional wall motion analysis using single-photon emission computed tomography (SPECT). We also evaluated the maximum differences between segmental TES (MDTES), the standard deviation of TES (SDTES), and the difference in the TES between the lateral wall and septum (DTES-LS). Results: In total, 97 patients were enrolled. The success rate of LBBAP did not differ between the groups [SDLs: 47/48 patients (98%) vs. LLLs: 47/51 patients (92%), P=0.36]. The paced QRS duration and the stimulus to the peak LV activation time (stim-LVAT) also did not differ between SDL and LLL groups (122±10 vs. 119±12 ms, P=0.206; 69±12 vs. 66±13 ms, P=0.31, respectively). There were no differences in bandwidth, PSD, and entropy between SDL and LLL groups (73°±37° vs. 86°±47°, P=0.18; 19°±8.5° vs. 21°±9.7°, P=0.19; 0.57±0.08 vs. 0.59±0.08, P=0.17, respectively). The regional wall motion analysis parameters MDTES, SDTES, and DTES-LS also did not differ between SDL and LLL groups (19%±10% vs. 20%±10%, P=0.885; 5.0%±2.5% vs. 5.0%±2.5%, P=0.995; 5.0%±3.7% vs. 4.8%±4.2%, P=0.78, respectively). Conclusions: LBBAP using SDLs was comparable to LV electrical and mechanical synchrony with LLLs.

Procedural outcome and follow-up of stylet-driven leads compared with lumenless leads for left bundle branch area pacing.

AIMS: Left bundle branch area pacing (LBBAP) is most often delivered using lumenless leads (LLLs), but may also be performed using stylet-driven leads (SDLs). There are limited reports on the comparison of these tools, mainly limited to reports describing initial operator experience or without detailed procedural data. Our aim was to perform an in-depth comparison of SDLs and LLLs for LBBAP at implantation and follow-up in a larger cohort of patients with experience that extends beyond that of the initial learning curve. METHODS AND RESULTS: A total of 306 consecutive patients (age 77 ± 11 years, 183 males) undergoing LBBAP implantation at a single centre were prospectively included. The population was split into two groups of 153 patients based on the initial use of an SDL (from 4 manufacturers) or an LLL. After having discounted the initial learning curve of 50 patients, there was no difference in the success rate between the initial use of lead type (96.0% with SDL vs. 94.3% with LLL, P = 0.56). There were no significant differences in success between lead models. Electrocardiogram and electrical parameters were comparable between the groups. Post-operative macro-dislodgement occurred in 4.3% of patients (essentially within the first day following implantation) and presumed micro-dislodgement with loss of conduction system capture or rise in threshold (occurring mostly during the first month) was observed in 4.7% of patients, without differences between groups. CONCLUSION: Left bundle branch area pacing may be safely and effectively performed using either LLLs or SDLs, which provides implanters with alternatives for delivering this therapy.

Styletubation in Bariatric Surgery: A Case Report.

Direct laryngoscopes and videolaryngoscopes are the dominant endotracheal intubation tools. The styletubation technique (using a video-assisted intubating stylet) has shown its advantages in terms of short intubation time, high success rate, less required stimulation, and operator satisfaction. The learning curve can be steep but is easily overcome if technical pitfalls are avoided. Conditions that make styletubation challenging include secretions/blood, short/stiff neck, restricted mouth opening and cervical spine mobility, anatomical abnormalities over head and neck regions, obesity, etc. In this clinical report, we present the effectiveness and efficiency of the routine use of the styletubation for tracheal intubation in a super-super-obese patient (BMI 103 kg/m2) undergoing bariatric surgery with laparoscopic sleeve gastrectomy.