Roderick Tung

Background and Aims Pericardiocentesis is usually completed under fluoroscopy. The electroanatomic mapping (EAM) system allows visualizing puncture needle tip (NT) while displaying the electrogram recorded from NT, making it possible to obtain epicardial access (EA) independent of fluoroscopy. This study was designed to establish and validate a technique by which EA is obtained under guidance of 3-dimensional (3D) EAM combined with NT electrogram. Methods 3D shell of the heart was generated and the NT was made trackable in the EAM system. Unipolar NT electrogram was continuously monitored. Penetration into pericardial sac was determined by an increase in NT potential amplitude and an injury current. A long guidewire of which the tip was also visible in the EAM system was advanced to confirm EA. Results EA was successfully obtained without complication in 13 pigs and 22 patients. In the animals, NT potential amplitude was 3.2± 1.0 mV when it was located in mediastinum, 5.2±1.6 mV when in contact with fibrous pericardium and 9.8±2.8 mV after penetrating into pericardial sac (all p≤0.001). In human subjects, it measured 1.54±0.40 mV, 3.61±1.08 mV and 7.15±2.88 mV respectively (all p<0.001). Fluoroscopy time decreased in every 4-5 cases (64±15, 23±17 and 0 second for animals 1-4, 5-8, 9-13 respectively, p=0.01; 44±23, 31±18; 4±7 seconds for patients 1-7, 8-14, 15-22 respectively, p<0.001). In 5 pigs and 7 patients, EA was obtained without X-ray exposure. Conclusions By tracking NT in the 3D EAM system and continuously monitoring the NT electrogram, it is feasible and safe to obtain EA with minimum or no fluoroscopic guidance.

Background There has been recent growing interest in the use of conduction system pacing (CSP) for both bradycardia and heart failure indications. There remains a paucity of data, however, regarding complications related to the intraventricular septum associated with CSP implant and the management of these events. Case summary We present a case of a patient with non-ischemic dilated cardiomyopathy presenting for cardiac resynchronization therapy in whom left bundle branch area pacing was complicated with interventricular septal perforation and managed intra-procedurally with repositioning of the lead to provide His bundle pacing (HBP) for QRS correction of underlying left bundle branch block. Post-procedure echocardiography did not show persistent ventricular septal defect. Left ventricular ejection fraction improved from 13% four months before implant to 30% at 32 months post-implant. Corrective HBP pacing thresholds showed a rise at 3-year follow-up. Discussion Interventricular septal perforation during CSP is a possible complication during lead fixation. Pre-operative septal assessment with imaging can be helpful to provide important septal anatomical features. Septal perforation can be managed appropriately with lead repositioning intra-procedurally and close follow-up.