Electrophysiological study in chagasics with syncope and conduction disorder

BACKGROUND: Investigation of syncope involves the use of electrophysiological study, particularly in patients with cardiac conduction disorder. There is conflicting evidence about the role of electrophysiological study in patients with Chagas disease. OBJECTIVE: The objective of this study was to evaluate the lectrophysiological study findings in patients with Chagas disease and bundle Branch block and/or divisional block presenting with syncope. METHODS: This is a retrospective study of patients with Chagas disease and cardiac conduction disorder who underwent electrophysiological study from 2017 to 2021 for the investigation of syncope in a tertiary hospital in São Paulo, Brazil. Those with non-interpretable ECG, known coronary artery disease, and/or other cardiomyopathies were excluded. HV interval and electrophysiological study-induced malignant ventricular arrhythmias data were analyzed. RESULTS: A total of 45 patients (60.2±11.29 years, 57.8% males) were included. The mean HV interval was 58.37 ms±10.68; 22.2% of the studied population presented an HV interval of ≥70 ms; and malignant ventricular arrhythmias were induced in 57.8% patients. The use of beta-blockers and amiodarone (p=0.002 and 0.036, respectively), NYHA functional class≥II (p=0.013), wide QRS (p=0.047), increased HV interval (p=0.02), Rassi score >6.5 (p=0.003), and reduced left ventricular ejection fraction (p=0.031) were associated with increased risk of inducible malignant ventricular arrhythmias. CONCLUSION: More than half of the patients with Chagas disease, syncope, and cardiac conduction disorder have inducible malignant ventricular arrhythmias. Prolonged HV interval was observed in only 20% of population. Wide QRS, prolonged HV, reduced ejection fraction, and higher Rassi score were associated with increased risk of malignant ventricular arrhythmias.

False Tendons in the Left Ventricle: Implications for Successful Ablation of Left Posterior Fascicular Tachycardias.

BACKGROUND: The anatomical substrate for left posterior fascicular ventricular tachycardia (LPF-VT) is still unclear. OBJECTIVES: The purpose of this study is to describe the endocavitary substrate of the re-entrant loop of LPF-VT. METHODS: A total of 26 consecutive patients with LPF-VT underwent an electrophysiology study and radiofrequency ablation. RESULTS: Intracardiac echocardiography imaging observed a 100% prevalence of false tendons (FTs) at the left posterior septal region in all patients, and 3 different types of FTs could be classified according to their location. In 22 patients, a P1 potential could be recorded via the multielectrode catheter from a FT. In 4 patients without a recorded P1 during LPF-VT, the earliest P2 potentials were recorded from a FT in 3 patients, and from a muscular connection between 2 posteromedial papillary muscles in 1 patient. Catheter ablation focused on the FTs with P1 or earliest P2 (in patients without P1) was successful in all 26 patients. After 19 ± 8.5 months of follow-up, no patients had recurrence of LPF-VT. CONCLUSIONS: FTs provide an electroanatomical substrate for LPF-VT and a "culprit FT" may be identified as the critical structure bridging the macro-re-entrant loop. Targeting the "culprit FT" is a novel anatomical ablation strategy that results in long-term arrhythmia-free survival.

A Simulation Study of the Effects of His Bundle Pacing in Left Bundle Branch Block.

His bundle pacing (HBP) has emerged as a feasible alternative to right (RVP) and biventricular pacing (BVP) for Cardiac Resynchronization Therapy (CRT). This study sought to assess, in ex-vivo experimental models, the optimal setup for HBP in terms of electrode placement and pacing protocol to achieve superior electrical synchrony in the case of complete His-Purkinje block and left bundle branch block (LBBB). We developed a 3D model of His bundle and bundle branches, embedded in a patient-specific biventricular heart model reconstructed from CT images. A monodomain reaction-diffusion model was adopted to describe the propagation of cardiac action potential, and a custom procedure was developed to compute pseudo-ECGs. Experimental measurements of tip electrode potential waveforms have been performed on ex-vivo swine myocardium to determine the appropriate boundary condition for delivering the electrical stimulus in the numerical model. An extended parametric analysis, investigating the effect of the electrode orientation and helix length, pacing protocol, and atrioventricular delay, allowed us to determine the optimal setup for HBP therapy. Both selective (S-HBP) and non-selective (NS-HBP) His bundle pacing were tested, as the variable anatomical location of the His bundle can result in the activation of the surrounding myocardium. Our study indicates a perpendicular placement of the electrode as the most advantageous for restoring the physiological function of the His-Purkinje system. We found that higher-energy protocols can compensate for the effects of an angled placement though concurring to potential tip fibrosis. Promisingly, we also revealed that an increased electrode helix length can provide optimal resynchronization even with low-energy pacing protocols. Our results provide informative guidance for implant procedure and therapy optimization, which will hopefully have clinical implications further improving the procedural success rates and patients' quality of life, due to reduced incidence of lead revision and onset of complications.

Characteristics of intracardiac electrogram of the interventricular septum in the left bundle branch pacing.

BACKGROUND: Left bundle branch pacing (LBBP) has become a hot topic in the field of physiological pacing. However, only a few studies have described the characteristics of the intrinsic intracardiac electrogram (EGM) while placing the left bundle branch (LBB) lead. CASE PRESENTATION: Herein, we reported a case with atrial premature contractions to the ventricle during the LBBP procedure. Paced and intrinsic (supraventricular) EGMs were recorded and analyzed. CONCLUSIONS: The myocardium of the interventricular septum could be divided into four regions based on electrophysiology: the right septal area, the left septal area, the endocardium of the left ventricular septum, and the LBB area. This might guide the electrophysiological localization of the LBB lead in the septum.

Recording an isoelectric interval as an endpoint of left bundle branch pacing with continuous paced intracardiac electrogram monitoring.

BACKGROUND: The present study aimed to evaluate the feasibility and safety of the novel left bundle branch pacing (LBBP) procedure that uses isoelectric interval as an endpoint for lead implantation. METHODS: A total of 41 patients with indications for pacing were enrolled. All patients underwent a novel LBBP procedure guided by recording an isoelectric interval as an endpoint for lead implantation. The procedural details and electrophysiological characteristics were then analyzed. RESULTS: A total of 38/41 (92.7%) cases were confirmed of left bundle branch (LBB) capture. An isoelectric interval was observed in 36/41 cases (87.8%). A total of 36/41 (87.8%) cases with LBB potential were observed. The mean unipolar LBBP threshold at the implant was 0.5 ± 0.2 V. The mean sensed amplitude of the R wave and the pacing impedance at the implant were 12.9 ± 5.0 mV and 723.5 ± 117.1 Ω. During the final threshold testing, a transition from non-selective to selective LBBP (S-LBBP) was demonstrated in 26 patients. A transition from non-selective LBBP (NS-LBBP) to left ventricular septal myocardial capture was observed in 12 patients. CONCLUSION: Using an isoelectric interval as an endpoint to guide the LBBP was feasible in a high proportion of captured LBB cases.

Simple electrophysiological predictor of QRS change induced by cardiac resynchronization therapy: A novel marker of complete left bundle branch block.

BACKGROUND: QRS complex shortening by cardiac resynchronization therapy (CRT) has been associated with improved outcomes. OBJECTIVE: We hypothesized that the absence of QRS duration (QRSd) prolongation by right ventricular mid-septal pacing (RVP) may indicate complete left bundle branch block (cLBBB). METHODS: We prospectively collected 12-lead surface electrocardiograms (ECGs) and intracardiac electrograms during CRT implant procedures. Digital recordings were edited and manually measured. The outcome measure was a change in QRSd induced by CRT (delta CRT). Several outcome predictors were investigated: native QRSd, cLBBB (by using Strauss criteria), interval between the onset of the QRS complex and the local left ventricular electrogram (Q-LV), and a newly proposed index defined by the difference between RVP and native QRSd (delta RVP). RESULTS: One hundred thirty-three consecutive patients were included in the study. Delta RVP was 27 ± 25 ms, and delta CRT was -14 ± 28 ms. Delta CRT correlated with native QRSd (r = -0.65), with the presence of ECG-based cLBBB (r = -0.40), with Q-LV (r = -0.68), and with delta RVP (r = 0.72) (P < .00001 for all correlations). In multivariable analysis, delta CRT was most strongly associated with delta RVP (P < .00001), followed by native QRSd and Q-LV, while ECG-based cLBBB became a nonsignificant factor. CONCLUSION: Baseline QRSd, delta RVP, and LV electrical lead position (Q-LV) represent strong independent predictors of ECG response to CRT. The absence of QRSd prolongation by RVP may serve as an alternative and more specific marker of cLBBB. Delta RVP correlates strongly with the CRT effect on QRSd and outperforms the predictive value of ECG-based cLBBB.

Electrophysiological Study-Guided Permanent Pacemaker Implantation in Patients With Conduction Disturbances Following Transcatheter Aortic Valve Implantation.

Conduction disturbances remain common following transcatheter aortic valve implantation (TAVI). Aside from high-degree atrioventricular block (HAVB), their optimal management remains elusive. Invasive electrophysiological studies (EPS) may help stratify patients at low or high risk of HAVB allowing for an early discharge or permanent pacemaker (PPM) implantation among patients with conduction disturbances. We evaluated the safety and diagnostic performances of an EPS-guided PPM implantation strategy among TAVI recipients with conduction disturbances not representing absolute indications for PPM. All patients who underwent TAVI at a single expert center from June 2017 to July 2020 who underwent an EPS during the index hospitalization were included in the present study. False negative outcomes were defined as patients discharged without PPM implantation who required PPM for HAVB within 6 months of the initial EPS. False positive outcomes were defined as patients discharged with a PPM with a ventricular pacing percentage <1% at follow-up. A total of 78 patients were included (median age 83.5, 39% female), among whom 35 patients (45%) received a PPM following EPS. The sensitivity, specificity, positive and negative predictive values of the EPS-guided PPM implantation strategy were 100%, 89.6%, 81.5%, and 100%, respectively. Six patients suffered a mechanical HAVB during EPS and received a PPM. These 6 patients showed PPM dependency at follow-up. In conclusion, an EPS-guided PPM implantation strategy for managing post-TAVI conduction disturbances appears effective to identify patients who can be safely discharged without PPM implantation.

Integration of activation maps of epicardial veins in computational cardiac electrophysiology.

In this work we address the issue of validating the monodomain equation used in combination with the Bueno-Orovio ionic model for the prediction of the activation times in cardiac electro-physiology of the left ventricle. To this aim, we consider four patients who suffered from Left Bundle Branch Block (LBBB). We use activation maps performed at the septum as input data for the model and maps at the epicardial veins for the validation. In particular, a first set (half) of the latter are used to estimate the conductivities of the patient and a second set (the remaining half) to compute the errors of the numerical simulations. We find an excellent agreement between measures and numerical results. Our validated computational tool could be used to accurately predict activation times at the epicardial veins with a short mapping, i.e. by using only a part (the most proximal) of the standard acquisition points, thus reducing the invasive procedure and exposure to radiation.

Refractory Ventricular Tachycardia in a Patient With a Left Ventricular Assist Device Successfully Treated With Stellate Ganglion Phototherapy.

Neuraxial modulation therapies, such as stellate ganglion block, thoracic epidural anaesthesia, and cardiac sympathetic denervation, are effective for ventricular arrhythmias. However, these treatments can increase the risk of bleeding and infection. In this case report, stellate ganglion phototherapy was safely and effectively performed for refractory ventricular tachycardias in a patient with a history of left ventricular assist device implantation. Stellate ganglion phototherapy may have the potential to treat refractory ventricular arrhythmias as an additive therapy or bridge therapy.

QTc interval evaluation in patients with right bundle branch block or bifascicular blocks.

BACKGROUND: The right bundle branch block (RBBB) and the bifascicular blocks affect QRS duration in the right precordial leads, which are usually used for QT interval determination. Up to now, there is no clear recommendation how to determine QT interval in patients with RBBB or bifascicular block. HYPOTHESIS: The hypothesis of the present study was to evaluate the feasibility of a simple formula for RBBB and bifascicular block correction, thereby making it easier to determine the QTc interval. METHODS: In patients with intrinsic QRS duration <120 ms, artificial RBBB with either left posterior (LPFB) or left anterior fascicular block (LAFB), created by left ventricular pacing maneuvers, were corrected using the Bogossian formula (QTm) and afterward were heart rate corrected (QTmc). Heart rate correction was performed using different heart rate formulas in comparison to each other. The QTmc intervals were compared in each patient with the QTc interval during intrinsic rhythm. RESULTS: A total of scheduled 71 patients were included in this prospective multicenter observational comparative study. Compared to intrinsic QTc interval, the mean ΔQTmc interval by combination of the Bogossian and the Hodge formulas was -3 ± 24 ms in RBBB + LPFB (P = .44) and -6 ± 25 ms in RBBB + LAFB (P = .15). The Bogossian formula showed a significant deviation from the actual QTc interval with both the Bazett and the Fridericia formulas. CONCLUSION: In combination with the Hodge formula, the Boggosian formula delivered the best results in comparing the true QTc interval in narrow QRS with the QTmc interval in the presence of a bifascicular block.

New-onset intrinsic and paced QRS morphology of right bundle branch block pattern after atrioventricular nodal ablation: Longitudinal dissociation or anatomical bifurcation?

We performed left bundle pacing combined with atrioventricular nodal (AVN) ablation in a patient with persistent atrial fibrillation and refractory symptomatic heart failure. The major findings were new-onset intrinsic and paced QRS morphology of right bundle branch block (RBBB) pattern after AVN ablation which was performed at a more atrial site compared with the pacing site and the paced RBBB pattern could not be corrected regardless of the pacing output. Longitudinal dissociation cannot explain this observation, while anatomical separation could. We also confirm this was proximal left bundle pacing rather than His bundle pacing.

Electrophysiology Testing to Stratify Patients With Left Bundle Branch Block After Transcatheter Aortic Valve Implantation.

Background Left bundle branch block (LBBB) is common after transcatheter aortic valve implantation (TAVI) and is an indicator of subsequent high-grade atrioventricular block (HAVB). No standardized protocol is available to identify LBBB patients at risk for HAVB. The aim of the current study was to evaluate the safety and efficacy of an electrophysiology study tailored strategy in patients with LBBB after TAVI. Methods and Results We prospectively analyzed consecutive patients with LBBB after TAVI. An electrophysiology study was performed to measure the HV-interval the day following TAVI. In patients with normal His-ventricular (HV)-interval ≤55 ms, a loop recorder was implanted (ILR-group), whereas pacemaker implantation was performed in patients with prolonged HV-interval >55 ms (PM-group). The primary end point was occurrence of HAVB during a follow-up of 12 months. Secondary end points were symptoms, hospitalizations, adverse events because of device implantation or electrophysiology study, and death. Of 373 patients screened after TAVI, 56 patients (82±6 years, 41% male) with LBBB were included. HAVB occurred in 4 of 41 patients (10%) in the ILR-group and in 8 of 15 patients (53%) in the PM-group (P<0.001). We did not identify other predictors for HAVB than the HV interval. The negative predictive value for the cut-off of HV 55 ms to detect HAVB was 90%. No HAVB-related syncope occurred in the 2 groups. Conclusions An electrophysiology study tailored strategy to LBBB after TAVI with a cut-off of HV >55 ms is a feasible and safe approach to stratify patients with regard to developing HAVB during a follow-up of 12 months.

Reentrant para-Hisian ventricular tachycardia eliminated from the noncoronary cusp: Importance of regional anatomy for vantage-point ablation.

We present a rare case of reentrant ventricular tachycardia proven by entrainment maneuvers that was successfully ablated from the noncoronary cusp. The case highlights regional anatomy, pacing maneuvers with multi-modality images from fluoroscopy, intracardiac echo, and electroanatomical mapping.