Atrial Fibrillation to Atrio-Ventricular Nodal Reentrant Tachycardia: Shocking!Short Title- Shock inducing AVNRTAnindya Ghosh, MD1 │Deep Chandh Raja, MD, DM2 │ Chenni S. Sriram, MD31Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure Academy, The Madras Medical Mission, Chennai, Tamil Nadu, India2Department of Cardiac Electrophysiology and Pacing, Kauvery Hospital, Chennai, India3Division of Cardiology, Sub-section of Electrophysiology, Children’s Hospital of Michigan and Detroit Medical Center, Detroit, MI, USA

A document by Anindya Ghosh. Click on the document to view its contents.

A document by Anindya Ghosh. Click on the document to view its contents.

BACKGROUND Conduction system pacing (CSP) in recent years is being considered as the ideal pacing strategy. Lumen less leads (LLLs) have been the predominantly used technology since its inception until recently. We herein share the largest single-center experience of Stylet-driven leads (SDLs) using deflectable mapping catheter, a recent technology for conduction system pacing at both HB and LB areas, and their medium-term outcomes. MATERIALS AND METHODS Patients with standard pacing indications were enrolled between June 2021 and November 2022. The aim of this study was to evaluate safety and feasibility of CSP using SDL guided by deflectable mapping delivery catheter by analyzing implant tools, parameters during implant and follow- up. RESULTS A total of 37 patients (mean age 67.16 + 9.89 years, 53.3% males, 31 pacemakers, 4 His-CRT-Ps and 2 dual chamber Defibrillators, Mean follow up duration 210.7 + 25.1 days) were enrolled. HBP was the default strategy. Procedural success was seen in 17/37 (45.9%) patients. Incidence of lead dislodgement was 17.6%. LBBaP was tried in the rest (20/37). A septal curve was manually made in 3 patients. Procedural success was seen in all patients (3/3) in whom septal curve was added and in 12/17 (70.5%) patients without it. Compared to HBP, procedural parameters didn’t differ significantly for LBBaP. Sensing and Pacing parameters remained stable on follow up. CONCLUSION Use of SDL is adequate for both HB and LB areas. Preeshaping the deflectable mapping catheter can help in achieving better results and also lower the overall procedure time.

Preventive algorithm ending up being the ‘Cause’!Anindya Ghosh, MD1 │ Deep Chandh Raja, MD21Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure Academy, The Madras Medical Mission, Chennai, Tamil Nadu, India2Department of Cardiac Electrophysiology and Pacing, Kauvery Hospital, Chennai, India

An asymptomatic 48-year-old gentleman presented for routine interrogation of his Medtronic dual chamber transvenous pacemaker. The device was implanted 4 years ago for post-operative intermittent high grade atrio-ventricular block following mechanical aortic valve replacement. As per our protocol, we performed a 12-lead electrocardiogram with and without magnet application. The unusual response elicited after application of magnet is mechanistically explained.

A 65 year-old with history of prior ablations for regular narrow QRS short- RP tachycardia presented with recurrence of palpitations. An electrophysiological study showed long VA tachycardia with concentric atrial activation with a left ventricular origin extrastimulus delivered during His refractoriness, advancing the next ‘A’. A HRVPB can only reset an ORT if it ‘pulls in’ the local V at the ventricular insertion of an accessory pathway. As showcased in this case, erudite analysis of the pattern of perturbation of local ventricular electrograms is of paramount significance when interpreting responses to this maneuver. This concept when fortified with a heightened index of clinical suspicion for mitral annular block, anatomical knowledge of the pattern of LA-CS muscular connections, and pathway orientation, led to accurate electrophysiological diagnosis and management.

Introduction Atrio-ventricular (AV) conduction abnormalities and subsequent permanent pacemaker (PPM) implantation frequently complicate Transcatheter Aortic Valve Replacement(TAVR). Current guidelines are still unclear in certain clinical scenarios. Methods and Results A 78 year-old with pre-existing Left Bundle Branch Block and 1 st degree AV block underwent TAVR complicated by transient complete heart block with no further prolongation of preexisting conduction. Electrophysiology study (otherwise not indicated based on guidelines), 3 days post-procedure revealed evidence of significant infra Hisian disease requiring PPM. Conclusion No specific guidelines are available at this stage and thus our report highlights need for further research into this patient subset.

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