A novel and practical technique to facilitate lead insertion at the His bundle region.

BACKGROUND: His bundle (HB) pacing techniques are challenging and time-consuming. This is primarily due to the limitations in locating the relatively small area of the HB body for pacing. METHODS: Permanent HB pacing was performed in 133 consecutive patients with symptomatic bradycardia. A right atrial septo-gram (RAS) was performed in all patients to locate the HB. Briefly, 8-10 cc of contrast was injected through the Medtronic C315HIS delivery sheath while fluoroscopy cine runs were obtained in the RAO 15-20° projection. The images obtained provided the visualization of an approximately 90° angle composed by the medial aspect of the tricuspid valve annulus (TVA) anteriorly and the superior aspect of the interatrial septum superiorly. The apex of this angle coincides with the tip of the triangle of Koch (TK), where the HB body is usually located. A Medtronic SelectSecure™ MRI SureScan™ Model 3830 lead was then advanced and directed towards this area. The HB was mapped using pace mapping and unipolar recordings from the lead tip. RESULTS: Localization of the apex of the TK/HB body with the RAS was successful in all patients. The overall acute success of inserting the lead at the HB was 95%. CONCLUSION: This study demonstrated that our method of utilizing a RAS to facilitate the localization the HB body proved to be safe and efficient in achieving permanent HB pacing with a success rate higher than previously reported.

A Novel and Practical Method of Performing Atrioventricular Nodal Ablation via a Superior Approach in Patients with Refractory Atrial Fibrillation Undergoing Cardiac Resynchronization Device Implantation.

Atrioventricular node (AVN) ablation is a strategy to manage patients with drug-refractory atrial fibrillation (AF) and heart failure in whom cardiac resynchronization therapy (CRT) device implantation has been prescribed. This study describes a practical method to perform these two procedures using the same surgical site. Twenty-seven patients were indicated for AVN ablation and concurrent CRT device implantation while presenting with AF and rapid ventricular response (RVR) refractory to medical therapy. After placement of the right and left ventricular leads, a third puncture was made in the axillary vein to obtain access to perform the ablation. After hand-injecting contrast media through a RAMP™ (Abbott Laboratories, Chicago, IL, USA) sheath positioned in the right atrial cavity, the anatomical area corresponding to the AVN was identified using fluoroscopy cine runs obtained in the right anterior oblique and left anterior oblique projections. The adequate site for ablation was confirmed by the bipolar recording of a His-bundle deflection at the tip of the ablation catheter. Radiofrequency energy was delivered to achieve complete heart block. Subsequently, device implant was completed. The method was successfully applied in 27 consecutive cases, achieving permanent complete heart block in all patients. The mean radiofrequency time to achieve heart block was 110 seconds ± 43 seconds. The average procedural time including AVN ablation and device implant was 87 minutes ± 21 minutes. The images obtained with the hand-injected contrast media provided adequate information to readily identify the anatomical area corresponding to the AVN with 100% accuracy. This study suggests that ablation of the AVN can be safely and effectively accomplished via a superior approach in patients undergoing a CRT device implant.