Clinical profile and outcomes of semi-permanent pacing in a tertiary care institute in southern India.

BACKGROUND: Semi-permanent pacing (SPP) includes the placement of a permanent lead through the internal jugular vein and connection to a pulse generator on the skin outside the venous access site. AIM: To evaluate the clinical profile and outcomes of semi-permanent pacing in a tertiary care institute in Southern India. METHODS: This is a retrospective observational study. All patients admitted and requiring management with semi-permanent pacing from January 2017 to June 2020 were included. RESULTS: From January 2017 to June 2020, 20 patients underwent semi-permanent pacing (SPP) with a median age of 54 (21-74) years. Males comprised a majority of the patients (55%). Hypertension was noted in 50% of patients and 30% were diabetic. The right internal jugular vein was the most common access in 95% of patients. The most common indication for semi-permanent pacing was pocket site infection in 30% of patients. There were no procedural complications. The median duration on SPP was 7 (5-14) days and the median duration of hospital stay was 13 (8-21) days. Permanent pacemaker implantation was done in 55% of patients. Mortality in our study group was 15% with 10% dying due to cardiogenic shock (post resuscitated cardiac arrest) and 5% dying due to non-cardiac cause (Epidural hematoma). CONCLUSION: In our study, semi-permanent pacing was noted to be a safe procedure and was more commonly indicated in emergent conditions with complete heart block secondary to underlying reversible causes and in the management of pocket site infection.

A Team-Based Approach Toward Risk Factors of Atrial Fibrillation.

Atrial fibrillation (AF), being the most common arrhythmia, the service of primary care physicians and internists in preventing, identifying, and treating AF is of paramount importance. There are nonmodifiable, modifiable, and reversible risk factors for AF. The modifiable risk factors include hypertension, obesity, coronary artery disease, heart failure, diabetes mellitus etc. These risk factors should be screened and adequately treated to prevent occurrence of AF at the primary care level itself. This will reduce recurrence rates of AF and will treat underlying conditions predisposing to AF.

Cardiac resynchronization with His-CRT-D in a patient with severe heart failure and Scimitar syndrome.

Cardiac resynchronization therapy with His-bundle pacing is evolving rapidly as a viable cardiac device strategy for the treatment of severe chronic heart failure. The success of this technique in patients with congenital heart disease is facilitated by advanced integrated imaging modalities. We report a case of cardiac resynchronization therapy with His-bundle pacing with defibrillator for the management of a patient with heart failure with severely reduced ejection fraction, left bundle branch block, and congenital heart disease characterized by Scimitar syndrome with cardiac dextroposition. We highlight the contribution of integrated imaging modalities to guide accurate lead positioning.

Interesting response to ventricular overdrive pacing during regular narrow QRS tachycardia. What is the mechanism?

33 year old gentleman has undergone an electrophysiology study for recurrent paroxysmal palpitation. During one of the episodes of palpitation a regular narrow QRS tachycardia was documented which has terminated with intravenous adenosine. Baseline electrocardiogram did not show any pre-excitation. Atrial-His (AH) and His-Ventricular (HV) intervals were normal at baseline. There was no evidence of dual atrioventricular (AV) nodal physiology. Earliest atrial electrogram during ventricular pacing was recorded at coronary sinus (CS) 9,10 dipoles placed at CS OS region. Narrow QRS tachycardia with cycle length (TCL) of 400 ms and earliest retrograde atrial activation at CS 9,10 dipoles was induced with programmed ventricular stimulation. Ventricular overdrive (VOD) pacing was performed at 30 ms shorter than TCL during the tachycardia (Fig: 1). What is the mechanism of tachycardia?

Classical response of antidromic atriofascicular tachycardia to premature atrial extrastimulus delivered during septal refractoriness.

A 23-year-old gentleman presented with a history of palpitations. The 12-lead electrocardiogram showed no manifest ventricular pre-excitation. Echocardiogram was within normal limits. A retrograde study showed concentric activation of the atrium with decremental conduction. Atrial pacing from right atrial free wall showed progressive pre-excitation. No anterograde nodal duality was documented.

An unusual cause of heart failure in a young man.

A 21year old gentleman was admitted with shortness of breath and heart failure. He was noted to have incessant supraventricular tachycardia which was refractory to pharmacological and electrical cardioversion. Electrophysiology study revealed focal atrial tachycardia from an unusual location which was successfully ablated.

RBBB tachycardia with north-west axis. What is the mechanism?

RBBB tachycardia with NW axis is considered to be VT unless proved otherwise. However underlying conduction system disease can produce electrocardiographic patterns suggestive of bundle branch block with extreme left axis which can cause difficulty in differentiating VT from SVT as in this case.