Safety and performance of conduction system pacing: Real-world experience from a product surveillance registry.

BACKGROUND: Conduction system pacing (CSP), including His-bundle pacing (HBP) and left bundle branch area pacing (LBBAP), has been used as an alternative for pacemaker indicated patients requiring ventricular pacing. OBJECTIVE: The purpose of this study was to characterize the safety and performance of HBP and LBBAP among patients enrolled in the Medtronic product surveillance registry (PSR). METHODS: This observational analysis included patients who underwent pacemaker implantations for HBP or LBBAP with a Medtronic Model 3830 lead between January 2019 and December 2023 in the Medtronic PSR. The primary outcomes were lead-related complications and pacing capture threshold. Baseline characteristics, R-wave amplitude, impedance, and all-cause mortality were summarized. RESULTS: A total of 2342 patients were included across 77 centers (mean age 74 years; 38.9% female). Of the patients implanted with a 3830 lead for CSP, 64.1% (n = 1502) had LBBAP placement and 35.9% (n = 840) had HBP placement. The most commonly reported indications for CSP were sinus node dysfunction (67.0%) and atrioventricular block (57.2%). LBBAP had lower pacing thresholds, higher R-wave sensing, and higher impedance (all P <.001) through 30 months. At 36 months postimplant, the lead complication rate for LBBAP and HBP was 2.5% and 6.3%, ,respectively with no difference in all-cause mortality. CONCLUSION: In a multicenter cohort of LBBAP and HBP patients treated with the catheter-delivered 3830 lead, lead-related complication rates were low and electrical parameters were stable through 30 months.

Successful use of wearable cardioverter defibrillator in a patient with dextrocardia and persistent left superior vena cava.

Congenital disorders, such as dextrocardia and persistent left superior vena cava, are rare. However, their presence is often associated with other cardiac anomalies, and may lead to lethal ventricular tachyarrhythmias, which result in sudden cardiac death. Treating patients with these disorders can present a challenge to clinicians, as it may cause technical difficulties during interventional procedures, and more often, altered defibrillation techniques in a setting of prehospital sudden cardiac arrest. This report describes the first case of successful defibrillation therapy delivered by the wearable cardioverter defibrillator to a patient with dextrocardia and persistent left superior vena cava during a ventricular tachycardia arrest.

His-Purkinje Conduction System Pacing Optimized Trial of Cardiac Resynchronization Therapy vs Biventricular Pacing: HOT-CRT Clinical Trial.

BACKGROUND: His-Purkinje conduction system pacing (HPCSP) using His bundle pacing (HBP) or left bundle branch pacing (LBBP) has emerged as an alternative to biventricular pacing (BVP) in patients requiring cardiac resynchronization therapy (CRT). OBJECTIVES: The aim of the study was to compare the feasibility and clinical efficacy of HOT-CRT (His-Purkinje conduction system pacing Optimized Trial of Cardiac Resynchronization Therapy) with BVP in patients with heart failure, reduced ejection fraction, and indication for CRT. METHODS: This was a prospective, randomized, controlled trial of HOT-CRT and BVP in patients with LVEF <50% and indications for CRT. If HPCSP resulted in incomplete electrical resynchronization, a coronary sinus (CS) lead was added. The primary outcome was the change in left ventricular ejection fraction (LVEF) at 6 months. The primary safety endpoint was freedom from major complications. RESULTS: A total of 100 patients (female 31%, aged 70 ± 12 years, LVEF 31.5% ± 9.0%) were randomized. HOT-CRT was successful in 48 of 50 (96%) and BVP-CRT in 41 of 50 (82%) patients (P = 0.03). QRS duration significantly decreased from 164 ± 26 ms to 137 ± 20 ms with HOT-CRT and 166 ± 28 ms to 141 ± 19 ms with BVP. Fluoroscopy results (18.8 ± 12.4 min vs 23.8 ± 12.4 min, P = 0.05) and procedure duration (119 ± 42 min vs 114 ± 36 min, P = 0.5) were similar. The primary outcome of change in LVEF at 6 months was greater in HOT-CRT than in BVP (12.4% ± 7.3% vs 8.0% ± 10.1%, P = 0.02). The primary safety endpoint was similar (98% vs 94%, P = 0.62). Echocardiographic response of improvement in LVEF >5% occurred in 80% vs 61% (P = 0.06). Complications occurred in 3 (6%) in HOT-CRT vs 10 (20%) in BVP (P = 0.03). CONCLUSIONS: HPCSP-guided CRT resulted in greater change in LVEF compared with BVP. Randomized clinical trials with long-term follow-up are necessary. (His-Purkinje Conduction System Pacing Optimized Trial of Cardiac Resynchronization Therapy [HOT-CRT]; NCT04561778).

Coronary Venous Visualization During Deep Septal Lead Placement: An Unexpected Finding.

Left bundle branch area pacing has emerged as a safe and feasible alternative to conventional pacing. Acute septal injury, septal perforation, and arteriovenous fistula are potential risks of deep septal implants. Contrast drainage through the lesser cardiac veins and subsequent filling of major epicardial vessels may be benign observations noted during forceful hand injection. (Level of Difficulty: Advanced.).

Conduction system pacing versus conventional pacing in patients undergoing atrioventricular node ablation: Nonrandomized, on-treatment comparison.

Background: Atrioventricular node ablation (AVNA) with right ventricular or biventricular pacing (conventional pacing; CP) is an effective therapy for patients with refractory atrial fibrillation (AF). Conduction system pacing (CSP) using His bundle pacing or left bundle branch area pacing preserves ventricular synchrony. Objective: The aim of our study is to compare the clinical outcomes between CP and CSP in patients undergoing AVNA. Methods: Patients undergoing AVNA at Geisinger Health System between January 2015 and October 2020 were included in this retrospective observational study. CP or CSP was performed at the operators' discretion. Procedural, pacing parameters, and echocardiographic data were assessed. Primary outcome was the combined endpoint of time to death or heart failure hospitalization (HFH) and was analyzed using Cox proportional hazards. Secondary outcomes were individual outcomes of time to death and HFH. Results: AVNA was performed in 223 patients (CSP, 110; CP, 113). Age was 75 ± 10 years, male 52%, hypertension 67%, diabetes 25%, coronary disease 40%, and left ventricular ejection fraction (LVEF) 43% ± 15%. QRS duration increased from 103 ± 30 ms to 124 ± 20 ms (P < .01) in CSP and 119 ± 32 ms to 162 ± 24 ms in CP (P < .001). During a mean follow-up of 27 ± 19 months, LVEF significantly increased from 46.5% ± 14.2% to 51.9% ± 11.2% (P = .02) in CSP and 36.4% ± 16.1% to 39.5% ± 16% (P = .04) in CP. The primary combined endpoint of time to death or HFH was significantly reduced in CSP compared to CP (48% vs 62%; hazard ratio 0.61, 95% confidence interval 0.42-0.89, P < .01). There was no reduction in the individual secondary outcomes of time to death and HFH in the CSP group compared to CP. Conclusion: CSP is a safe and effective option for pacing in patients with AF undergoing AVNA in high-volume centers.

Clinical outcomes of conduction system pacing compared to biventricular pacing in patients requiring cardiac resynchronization therapy.

BACKGROUND: Cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) is well-established therapy in patients with reduced left ventricular ejection fraction (LVEF) and bundle branch block or indication for pacing. Conduction system pacing (CSP) using His-bundle pacing (HBP) or left bundle branch area pacing (LBBAP) has been shown to be a safe and more physiological alternative to BVP. OBJECTIVE: The purpose of this study was to compare the clinical outcomes between CSP and BVP among patients undergoing CRT. METHODS: This observational study included consecutive patients with LVEF ≤35% and class I or II indications for CRT who underwent successful BVP or CSP at 2 major health care systems. The primary outcome was the composite endpoint of time to death or heart failure hospitalization (HFH). Secondary outcomes included subgroup analysis in left bundle branch block as well as individual endpoints of death and HFH. RESULTS: A total of 477 patients (32% female) met inclusion criteria (BVP 219; CSP 258 [HBP 87, LBBAP 171]). Mean age was 72 ± 12 years, and mean LVEF was 26% ± 6%. Comorbidities included hypertension 70%, diabetes mellitus 45%, and coronary artery disease 52%. Paced QRS duration in CSP was significantly narrower than BVP (133 ± 21 ms vs 153 ± 24 ms; P <.001). LVEF improved in both groups during mean follow-up of 27 ± 12 months and was greater after CSP compared to BVP (39.7% ± 13% vs 33.1% ± 12%; P <.001). Primary outcome of death or HFH was significantly lower with CSP vs BVP (28.3% vs 38.4%; hazard ratio 1.52; 95% confidence interval 1.082-2.087; P = .013). CONCLUSION: CSP improved clinical outcomes compared to BVP in this large cohort of patients with indications for CRT.

Clinical outcomes of left bundle branch area pacing compared to right ventricular pacing: Results from the Geisinger-Rush Conduction System Pacing Registry.

BACKGROUND: Left bundle branch area pacing (LBBAP) has been shown to be a feasible option for patients requiring ventricular pacing. OBJECTIVE: The purpose of this study was to compare clinical outcomes between LBBAP and RVP among patients undergoing pacemaker implantation METHODS: This observational registry included patients who underwent pacemaker implantations with LBBAP or RVP for bradycardia indications between April 2018 and October 2020. The primary composite outcome included all-cause mortality, heart failure hospitalization (HFH), or upgrade to biventricular pacing. Secondary outcomes included the composite endpoint among patients with a prespecified burden of ventricular pacing and individual outcomes. RESULTS: A total of 703 patients met inclusion criteria (321 LBBAP and 382 RVP). QRS duration during LBBAP was similar to baseline (121 ± 23 ms vs 117 ± 30 ms; P = .302) and was narrower compared to RVP (121 ± 23 ms vs 156 ± 27 ms; P <.001). The primary composite outcome was significantly lower with LBBAP (10.0%) compared to RVP (23.3%) (hazard ratio [HR] 0.46; 95%T confidence interval [CI] 0.306-0.695; P <.001). Among patients with ventricular pacing burden >20%, LBBAP was associated with significant reduction in the primary outcome compared to RVP (8.4% vs 26.1%; HR 0.32; 95% CI 0.187-0.540; P <.001). LBBAP was also associated with significant reduction in mortality (7.8% vs 15%; HR 0.59; P = .03) and HFH (3.7% vs 10.5%; HR 0.38; P = .004). CONCLUSION: LBBAP resulted in improved clinical outcomes compared to RVP. Higher burden of ventricular pacing (>20%) was the primary driver of these outcome differences.

Percutaneous Closure of Persistent Atrial Septal Defects After Pulmonary Vein Isolation.

Pulmonary vein isolation (PVI) with radiofrequency or cryoballoon ablation to treat atrial fibrillation requires trans-septal puncture. This creates a small iatrogenic atrial septal defect (iASD). In most patients, the defect spontaneously closes after 3-6 months. However, persistent iASDs can cause hemodynamic changes and adverse consequences from inter-atrial shunting. Persistent post PVI iASDs that are clinically significant can be closed percutaneously. This diagnosis should be considered in patients with worsening dyspnea or fatigue after PVI. We present a case of post PVI iASDs causing immediate or late onset hemodynamic changes and clinical symptoms, which improved after ASD closure. We provide a review of previously reported cases and literature on post PVI ASD prevalence, risk factors and outcomes after ASD closure.

On-treatment comparison between corrective His bundle pacing and biventricular pacing for cardiac resynchronization: A secondary analysis of the His-SYNC Pilot Trial.

BACKGROUND: The His-SYNC pilot trial was the first randomized comparison between His bundle pacing in lieu of a left ventricular lead for cardiac resynchronization therapy (His-CRT) and biventricular pacing (BiV-CRT), but was limited by high rates of crossover. OBJECTIVE: To evaluate the results of the His-SYNC pilot trial utilizing treatment-received (TR) and per-protocol (PP) analyses. METHODS: The His-SYNC pilot was a multicenter, prospective, single-blinded, randomized, controlled trial comparing His-CRT vs BiV-CRT in patients meeting standard indications for CRT (eg, NYHA II-IV patients with QRS >120 ms). Crossovers were required based on prespecified criteria. The primary endpoints analyzed included improvement in QRS duration, left ventricular ejection fraction (LVEF), and freedom from cardiovascular (CV) hospitalization and mortality. RESULTS: Among 41 patients enrolled (aged 64 ± 13 years, 38% female, LVEF 28%, QRS 168 ± 18 ms), 21 were randomized to His-CRT and 20 to BiV-CRT. Crossover occurred in 48% of His-CRT and 26% of BiV-CRT. The most common reason for crossover from His-CRT was inability to correct QRS owing to nonspecific intraventricular conduction delay (n = 5). Patients treated with His-CRT demonstrated greater QRS narrowing compared to BiV (125 ± 22 ms vs 164 ± 25 ms [TR], P < .001;124 ± 19 ms vs 162 ± 24 ms [PP], P < .001). A trend toward higher echocardiographic response was also observed (80 vs 57% [TR], P = .14; 91% vs 54% [PP], P = .078). No significant differences in CV hospitalization or mortality were observed. CONCLUSIONS: Patients receiving His-CRT on-treatment demonstrated superior electrical resynchronization and a trend toward higher echocardiographic response than BiV-CRT. Larger prospective studies may be justifiable with refinements in patient selection and implantation techniques to minimize crossovers.

Clinical Outcomes of His Bundle Pacing Compared to Right Ventricular Pacing.

BACKGROUND: Right ventricular pacing (RVP) is associated with heart failure and increased mortality. His bundle pacing (HBP) is a physiological alternative to RVP. OBJECTIVES: This study sought to evaluate clinical outcomes of HBP compared to RVP. METHODS: All patients requiring initial pacemaker implantation between October 1, 2013, and December 31, 2016, were included in the study. Permanent HBP was attempted in consecutive patients at 1 hospital and RVP at a sister hospital. Implant characteristics, all-cause mortality, heart failure hospitalization (HFH), and upgrades to biventricular pacing (BiVP) were tracked. Primary outcome was the combined endpoint of death, HFH, or upgrade to BiVP. Secondary endpoints were mortality and HFH. RESULTS: HBP was successful in 304 of 332 consecutive patients (92%), whereas 433 patients underwent RVP. The primary endpoint of death, HFH, or upgrade to BiVP was significantly reduced in the HBP group (83 of 332 patients [25%]) compared to RVP (137 of 433 patients [32%]; hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.534 to 0.944; p = 0.02). This difference was observed primarily in patients with ventricular pacing >20% (25% in HBP vs. 36% in RVP; HR: 0.65; 95% CI: 0.456 to 0.927; p = 0.02). The incidence of HFH was significantly reduced in HBP (12.4% vs. 17.6%; HR: 0.63; 95% CI: 0.430 to 0.931; p = 0.02). There was a trend toward reduced mortality in HBP (17.2% vs. 21.4%, respectively; p = 0.06). CONCLUSIONS: Permanent HBP was feasible and safe in a large real-world population requiring permanent pacemakers. His bundle pacing was associated with reduction in the combined endpoint of death, HFH, or upgrade to BiVP compared to RVP in patients requiring permanent pacemakers.

Permanent His-bundle pacing: Long-term lead performance and clinical outcomes.

BACKGROUND: Right ventricular pacing (RVP) is associated with heart failure and increased mortality. His-bundle pacing (HBP) is a physiological alternative to RVP. OBJECTIVE: The purpose of this study was to report long-term performance and compare the clinical outcomes of permanent HBP vs RVP. METHODS: All patients requiring pacemaker implantation underwent an attempt at permanent HBP in 2011 at one hospital and RVP at the sister hospital. Patients were followed from implantation, 2 weeks, 2 months, and yearly for 5 years. Left ventricular ejection fraction (LVEF), pacing thresholds, lead revision, and generator change were tracked. Primary outcome was the combined endpoint of death or heart failure hospitalization (HFH) at 5 years. RESULTS: HBP was attempted in 94 consecutive patients and was successful in 75 (80%); 98 patients underwent RVP. LVEF remained unchanged in the HBP group (55% ± 8% vs 57% ± 6%; P = .13), whereas significant decline was noted in the RVP group (57% ± 7% vs 52% ± 11%; P = .002). Incidence of pacing-induced cardiomyopathy was significantly lower in HBP compared to RVP patients (2% vs 22%; P = .04). At 5 years, death or HFH was significantly lower in HBP compared to RVP patients with >40% ventricular pacing (32% vs 53%; hazard ratio 1.9; P = .04). At 5 years, the need for lead revisions (6.7% vs 3%) and for generator change (9% vs 1%) were higher in the HBP group. CONCLUSION: In patients undergoing pacemaker implantation, permanent HBP was associated with reduction in death or HFH during long-term follow-up compared to RVP. HBP was associated with higher rates of lead revisions and generator change.

Permanent His-bundle pacing is feasible, safe, and superior to right ventricular pacing in routine clinical practice.

BACKGROUND: Right ventricular pacing (RVP) has been associated with heart failure and increased mortality. His-bundle pacing (HBP) is more physiological but requires a mapping catheter or a backup right ventricular lead and is technically challenging. OBJECTIVE: We sought to assess the feasibility, safety, and clinical outcomes of permanent HBP in an unselected population as compared to RVP. METHODS: All patients requiring pacemaker implantation routinely underwent attempt at permanent HBP using the Select Secure (model 3830) pacing lead in the year 2011 delivered through a fixed-shaped catheter (C315 HIS) at one hospital and RVP at the second hospital. Patients were followed from implantation, 2 weeks, 2 months, 1 year, and 2 years. Fluoroscopy time (FT), pacing threshold (PTh), complications, heart failure hospitalization, and mortality were compared. RESULTS: HBP was attempted in 94 consecutive patients, while 98 patients underwent RVP. HBP was successful in 75 patients (80%). FT was similar (12.7 ± 8 minutes vs 10 ± 14 minutes; median 9.1 vs 6.4 minutes; P = .14) and PTh was higher in the HBP group than in the RVP group (1.35 ± 0.9 V vs 0.6 ± 0.5 V at 0.5 ms; P < .001) and remained stable over a 2-year follow-up period. In patients with >40% ventricular pacing (>60% of patients), heart failure hospitalization was significantly reduced in the HBP group than in the RVP group (2% vs 15%; P = .02). There was no difference in mortality between the 2 groups (13% in the HBP group vs 18% in the RVP group; P = .45). CONCLUSION: Permanent HBP without a mapping catheter or a backup right ventricular lead was successfully achieved in 80% of patients. PTh was higher and FT was comparable to those of the RVP group. Clinical outcomes were better in the HBP group than in the RVP group.

Assessment of exit block following pulmonary vein isolation: far-field capture masquerading as entrance without exit block.

BACKGROUND: Complete electrical isolation of pulmonary veins (PVs) remains the cornerstone of ablation therapy for atrial fibrillation. Entrance block without exit block has been reported to occur in 40% of the patients. Far-field capture (FFC) can occur during pacing from the superior PVs to assess exit block, and this may appear as persistent conduction from PV to left atrium (LA). OBJECTIVE: To facilitate accurate assessment of exit block. METHODS: Twenty consecutive patients with symptomatic atrial fibrillation referred for ablation were included in the study. Once PV isolation (entrance block) was confirmed, pacing from all the bipoles on the Lasso catheter was used to assess exit block by using a pacing stimulus of 10 mA at 2 ms. Evidence for PV capture without conduction to LA was necessary to prove exit block. If conduction to LA was noticed, pacing output was decreased until there was PV capture without conduction to LA or no PV capture was noted to assess for far-field capture in both the upper PVs. RESULTS: All 20 patients underwent successful isolation (entrance block) of all 76 (4 left common PV) veins: mean age 58 ± 9 years; paroxysmal atrial fibrillation 40%; hypertension 70%, diabetes mellitus 30%, coronary artery disease 15%; left ventricular ejection fraction 55% ± 10%; LA size 42 ± 11 mm. Despite entrance block, exit block was absent in only 16% of the PVs, suggesting persistent PV to LA conduction. FFC of LA appendage was noted in 38% of the left superior PVs. FFC of the superior vena cava was noted in 30% of the right superior PVs. The mean pacing threshold for FFC was 7 ± 4 mA. Decreasing pacing output until only PV capture (loss of FFC) is noted was essential to confirm true exit block. CONCLUSIONS: FFC of LA appendage or superior vena cava can masquerade as persistent PV to LA conduction. A careful assessment for PV capture at decreasing pacing output is essential to exclude FFC.

Adenosine facilitates dormant conduction across cavotricuspid isthmus following catheter ablation.

BACKGROUND: Recurrence of trans-isthmus conduction following catheter ablation of common right atrial flutter (AFL) has been reported to be as high as 15%-31% at 3 months with invasive follow-up. Intravenous adenosine has previously been shown to facilitate acute, transient reconnection of pulmonary veins following catheter ablation of atrial fibrillation. OBJECTIVE: To determine whether intravenous adenosine can facilitate dormant trans-isthmus conduction after achieving bidirectional conduction block (BDB) with catheter ablation. METHODS: Thirty-two patients underwent radiofrequency catheter ablation of cavotricuspid isthmus (CTI) for common right AFL at 2 institutions. Once persistent BDB was achieved for 30 minutes and during isoproterenol infusion, 18 mg of intravenous adenosine was injected during coronary sinus pacing. Evidence for transient reconduction across the isthmus was observed. Additional ablation lesions were performed, and adenosine infusion was repeated to reassess for dormant conduction. RESULTS: Thirty-two (men 81%, hypertension 72%, coronary artery disease 15%, congestive heart failure 25%, diabetes mellitus 30%, left atrial size 42 ± 11 mm, left ventricular ejection fraction 51% ± 10%) patients underwent ablation of CTI. BDB was achieved in 30 of the 32 patients. Following adenosine infusion, transient reconduction was observed in 7 of the 30 patients (23%) for 10-45 seconds. Following additional ablation lesions, persistent BDB could be achieved in all 7 patients without evidence for reconduction with repeat adenosine infusion. During a mean follow-up of 19 ± 12 months, only 1 of 30 patients (3%) had clinical recurrence of AFL. None of the patients with transient reconduction after adenosine developed symptomatic recurrence of AFL. CONCLUSIONS: Adenosine infusion can facilitate dormant conduction across CTI following catheter ablation. Persistent BDB can be achieved with additional ablation. Adenosine challenge with additional ablation may improve long-term clinical outcome.

A novel approach to differentiating orthodromic reciprocating tachycardia from atrioventricular nodal reentrant tachycardia.

BACKGROUND: Various diagnostic maneuvers have been proposed to help differentiate orthodromic reciprocating tachycardia (ORT) from atrioventricular nodal reentrant tachycardia (AVNRT) prior to ablation. However, not all criteria are applicable in every situation as each has limitations. OBJECTIVE: The purpose of this study was to determine whether the behavior of tachycardia during onset of right ventricular (RV) pacing would help differentiate ORT from AVNRT. METHODS: We retrospectively reviewed 72 cases (42 typical AVNRT, 7 atypical AVNRT, 15 left free-wall pathways, 6 septal pathways, 2 right free-wall pathways). We assessed the number of beats required to accelerate the tachycardia cycle length (TCL) to the paced cycle length (PCL) once a fully RV paced complex was achieved during supraventricular tachycardia. RESULTS: In the AVNRT group, delta cycle length (DCL = PCL-TCL) was 29 +/- 16 ms compared to 29 +/- 10 ms in ORT group (P = NS). In the AVNRT group, the average number of fully RV paced beats required to reset the tachycardia was 3.7 +/- 1.1 compared to 1 +/- 0 in the ORT group (P <.0001). Using a cutoff >1 beat yielded both positive and negative predictive values of 100% for diagnosing AVNRT versus ORT. During entrainment attempts, AVNRT terminated 51% of the time and ORT terminated 65% of the time but still allowed application of the new criterion. CONCLUSION: Assessing timing and type of response of supraventricular tachycardia to RV pacing can help differentiate ORT from AVNRT with high certainty and prevent the need for other pacing maneuvers and measurements.

Cardiac tamponade as complication of active-fixation atrial lead perforations: proposed mechanism and management algorithm.

BACKGROUND: Cardiac tamponade is a rare complication after implantation of dual chamber pacemaker or defibrillator systems. Its pathophysiology and optimal management are not currently well established. METHODS: Three cases of cardiac tamponade following successful implantation of transvenous dual chamber pacemakers with active-fixation atrial leads were identified. RESULTS: All three patients with post-implant cardiac tamponade were suspected to have the same etiology of bleeding into the pericardial space. This was due to protrusion of the helix of the active-fixation atrial pacing lead through the atrial wall with subsequent abrasion of visceral pericardial layer and bleeding from the atrium through the perforation. In two patients, the perforation sites were visualized and repaired during open thoracotomy in the operating room. The third patient underwent lead repositioning under fluoroscopic guidance in the electrophysiology laboratory. CONCLUSION: Based on the reviewed cases, we describe the pathophysiology of, and recommend a safe conservative algorithm for, the management of cardiac tamponade after successful transvenous lead implantation. Percutaneous pericardiocentesis with placement of the pericardial drain followed by lead repositioning under fluoroscopic guidance with surgical backup appears to be safe and effective.