Left Posterior Fascicular Pacing.

Left bundle branch pacing (LBBP) is emerging as an alternative to His bundle pacing that overcomes the latter's limitations. Several studies have reported on the safety, efficacy, and electrophysiological properties of LBBP, while postoperative success rates range from 80.5% to 94%. The left posterior fascicle is composed of broad bands of fibers coursing inferiorly and posteriorly toward the papillary muscle, while the anterior fascicle is a thin, tendon-like structure. We report a case of a 70-year-old man in whom left posterior fascicular pacing was done after LBBP failed. We were able to demonstrate all the features of left posterior fascicular capture, including fascicular potential and a left anterior hemiblock pattern, using surface 12-lead electrocardiography. Left posterior fascicular pacing could be an alternative technique when attempts to deploy LBBP fail.

Feasibility, safety and outcomes of left bundle branch pacing in octogenarians.

OBJECTIVES: Left bundle branch pacing (LBBP) provides physiological pacing at low and stable threshold. The safety and efficacy of LBBP in elderly population is unknown. Our study was designed to assess the safety, efficacy and electrophysiological parameters of LBBP in octogenarian (≥80 years) population. RESULTS: LBBP was successful in 10 out of 11 patients. Mean age 82.1 ± 2.5 yrs. Follow up duration 7.7 months(range4-10). Indication for pacing included atrioventricular (AV) block 5 patients, Left bundle branch block (LBBB) with low ejection fraction (EF) 4 patients, sinus node dysfunction in 1. QRS duration reduced from 145.9 ± 27.7ms to 107.1 ± 9.5ms (p value0.00001) LV ejection fraction increased from 47.6% to 58.4% after LBBP (p value0.017). Pacing threshold was 0.58 ± 0.22 V and sensed R wave 17.35 ± 6.5 mV and it remained stable during follow up. LBBB with low EF patients also showed similar reduction in QRS duration along with improvement in LVEF. CONCLUSION: LBBP is a safe and effective strategy (91% acute success) of physiological pacing in elderly patients. LBBP also provided effective resynchronization therapy in our small group of elderly patients. The pacing parameters remained stable over a period of 10 months follow up.

Mid-term feasibility, safety and outcomes of left bundle branch pacing-single center experience.

BACKGROUND: His bundle pacing (HBP) has evolved as the most physiological form of pacing but associated with limitations. Recently, left bundle branch pacing (LBBP) is emerging as an effective alternative strategy for HBP. OBJECTIVES: Our study was designed to assess the feasibility, efficacy, electrophysiological parameters, and mid-term outcomes of LBBP in Indian population. METHODS: All patients requiring permanent pacemaker implantation for symptomatic bradycardia and heart failure were prospectively enrolled. Echocardiography, QRS duration, pacing parameters, left bundle (LB) potentials, paced QRS duration, and peak left ventricular activation time (pLVAT) were recorded. RESULTS: LBBP was successful in 93 out of 99 patients (94% acute success). Mean age was 62.6 ± 13 years, male 59%, diabetes 69%, and coronary artery disease 65%. Follow-up duration was 4.8 months (range1-12 months). Indication for pacing included atrioventricular (AV) block 43%, cardiac resynchronization therapy 44%, and AV node ablation 4%. LB potential was noted in 37 patients (40%). QRS duration reduced from 144.38 ± 34.6 at baseline to 110.8 ± 12.4 ms after LBBP (p < 0.0001). Pacing threshold was 0.59 ± 0.22 V and sensed R wave 14.14 ± 7.19 mV, and it remained stable during follow-up. Lead depth in the septum was 9.62 mm. LV ejection fraction increased from 44.96 to 53.3% after LBBP (p < 0.0001). One died due to respiratory tract infection on follow up. CONCLUSION: LBBP is a safe and effective strategy (94% acute success) of physiological pacing. The pacing parameters remained stable over a period of 12 months follow-up. LBBP can effectively overcome the limitations of HBP.

Psychological Insulin Resistance in Patients with Type 2 Diabetes.

AIMS/HYPOTHESIS: To identify risk factors associated with psychological insulin resistance (PIR) in Indian type 2 diabetes (T2DM) population. METHODS: Patients with T2DM, aged 18 years, undergoing treatment with oral hypoglycaemic agents and providing written informed consent were considered eligible for the study. Patient's data was collected by face-to-face interaction using 5 validated diabetes questionnaires--Diabetes Attitude Scale, Diabetes Knowledge Test, Diabetes Self-Efficacy Scale, Interpersonal Processes of Care Survey-29, and Barriers to Insulin Treatment scale. Demographic variables, categories of patients based on their annual family income, education, glycosylated haemoglobin (HbA1c), occupation and type of healthcare setup were correlated with overall scores of validated questionnaires. Statistical analyses were performed using Pearson correlation coefficients, analysis of variance, two-group t-test and hierarchical multiple regression. RESULTS: One hundred ninty-eight patients with T2DM were enrolled where 63% were males, 52% had HbA1c <7% (<53 mmol/mol), 32% were in service, 35% had the annual family income between Rs 100,000-500,000, 50% were graduates and 81% were enrolled from private healthcare set ups. Significant high opposition to use insulin was observed in females, patients based at home, patients with insufficient education, and patients visiting government set-ups compared to males, service-class patients, graduates, and patients approaching private set-ups, respectively. CONCLUSIONS: In India, major factors contributing to PIR were fear of injection or fear of pain during injection, fear of hypoglycemia, social stigma and lack of education. Effective interpersonal interactions with healthcare providers could help to counteract PIR, especially in patients who are not sufficiently literate highlighting the need of skilled healthcare staffs in Indian public hospitals.

Correlation of capillary and venous blood glucometry with laboratory determination.

BACKGROUND: During resuscitation in the Singapore Armed Forces, blood glucose samples are often obtained for analysis using the capillary glucometer. A drop of venous blood from the intravenous cannula is sometimes used to ascertain the patient's blood glucose level. Venous samples may be sent to a commercial laboratory, but this does not allow immediate results. OBJECTIVE: To establish the correlation between the glucose levels of the capillary fingerprick sample analyzed by the glucometer (Cap), the venous sample analyzed by the glucometer (Ven), and the venous sample tested by the commercial laboratory (Lab). METHODS: This multicenter, prospective study enrolled subjects from Selarang, Clementi, and Maju Camp Medical Centers in the Singapore Armed Forces from November 2002 to January 2003. All subjects provided at least two samples; because provision of the capillary blood glucose sample was voluntary, only some gave consent for capillary fingerprick and provided three samples. There were no exclusion criteria. Bland-Altman plots were then constructed to compare the capillary and venous-on-capillary values with the laboratory results. RESULTS: A total of 270 subjects were recruited. One hundred seventy subjects (63.0%) gave consent for capillary glucose measurement and, thus, had three readings for comparison. There was a mean difference of 0.97 mmol/L (17.46 mg/dL) between the Ven and Lab results. There was an insignificant mean difference of 0.01 mmol/L (0.18 mg/dL) between the Cap and Lab results. CONCLUSION: Capillary whole-blood glucose values best approximated venous plasma glucose values from the laboratory. Measuring the venous whole-blood glucose using the glucometer resulted in an overestimation of the venous plasma glucose compared with the laboratory result by about 0.97 mmol/L (17.46 mg/dL). This may result in the withholding of intravenous glucose for patients who are actually hypoglycemic.