His bundle pacing (HBP) offers physiologic pacing by placing the pacing lead directly to the His bundle. We present a case in which a HBP lead, implanted at the fragile membranous septum, resulted in a persistent restrictive peri-membranous ventricular septal defect (VSD). This complication of HBP has not been reported before but brings new insights in the discussion regarding the optimal position of a pacing lead in the ventricular septum. The fragility of the membranous septum and low rate of spontaneous closure of membranous VSD, might favor lead placement in the muscular septum when aiming for physiologic pacing.

Introduction: Silent cerebral events (SCEs) are related to the potential thromboembolic risk in atrial fibrillation (AF) ablation. Peri-procedural uninterrupted oral anticoagulation (OAC) reportedly reduced the risk of SCEs, but the incidence still remains. Methods and Results: AF patients undergoing catheter ablation were eligible. All patients took non-vitamin K antagonist oral anticoagulants (NOACs, n=248) or vitamin K antagonist (VKA, n=37) for peri-procedural OAC (>4 weeks) without interruption during the procedure. Brain magnetic resonance imaging was performed within 2 days after the procedure to detect SCEs. Clinical characteristics and procedure-related parameters were compared between patients with and without SCEs. SCEs were detected in 66 patients (23.1%, SCE[+]) but were not detected in 219 patients (SCE[-]). Average age was higher in SCE[+] than in SCE[-] (66±10 years vs. 62±12 years, p<0.05). Persistent AF prevalence, CHADS2/CHA2DS2-VASc scores, serum NT-ProBNP levels, left-atrial dimension (LAD), and spontaneous echo contrast prevalence in transesophageal echocardiography significantly increased in SCE[+] vs. SCE[-]. SCE[+] had lower baseline activated clotting time (ACT) before heparin injection and longer time to reach optimal ACT (>300 sec) than SCE [-] (146±27 sec vs. 156±29 sec and 44±30 sec vs. 35±25 sec, p<0.05, respectively). In multivariate analysis, LAD, baseline ACT, and time to reach the optimal ACT were predictors for SCEs. The average values of the ACT parameters were significantly different among NOACs/VKA. Conclusion: LAD and intra-procedural ACT kinetics significantly affect SCEs during AF ablation. Different anticoagulants have different impacts on ACT during the procedure, which should be considered when estimating the risk of SCEs.

A global coronavirus (COVID-19) pandemic occurred at the start of 2020 and is already responsible for more than 74,000 deaths worldwide, just over 100 years after the influenza pandemic of 1918. At the center of the crisis is the highly infectious and deadly SARS-CoV-2, which has altered everything from individual daily lives to the global economy and our collective consciousness. Aside from the pulmonary manifestations of disease, there are likely to be several electrophysiologic (EP) sequelae of COVID-19 infection and its treatment, due to consequences of myocarditis and the use of QT-prolonging drugs. Most crucially, the surge in COVID-19 positive patients that have already overwhelmed the New York City hospital system requires conservation of hospital resources including personal protective equipment (PPE), reassignment of personnel, and reorganization of institutions, including the EP laboratory. In this proposal, we detail the specific protocol changes that our EP department has adopted during the COVID-19 pandemic, including performance of only urgent/emergent procedures, afterhours/7-day per week laboratory operation, single attending-only cases to preserve PPE, appropriate use of PPE, telemedicine and video chat follow-up appointments, and daily conferences to collectively manage the clinical and ethical dilemmas to come. We discuss also discuss how we perform EP procedures on presumed COVID positive and COVID tested positive patients in order to highlight issues that others in the EP community may soon face in their own institution as the virus continues to spread nationally and internationally.