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Background: A lack of standard Bachmann bundle (BB) capture criteria has affected the clinical impact of Bachmann bundle area pacing (BBAP) in patients with interatrial block (IAB)., Objective: The purpose of this study was to evaluate the feasibility and safety of electrogram-guided Bachmann bundle pacing (BBP) using sheath assisted, stylet-driven atrial lead implantation., Methods: Patients with baseline IAB undergoing dual-chamber pacemaker or implantable cardioverter-defibrillator implantation were enrolled in a single-center prospective study. BBAP was attempted in all patients using a Selectra 3D S-40 delivery sheath and Solia S-60 pacing lead. BB capture was confirmed using a combination of fluoroscopy, P-wave morphology, and electrophysiological criteria. These included recording of a high-frequency BB potential and transition between nonselective and selective BB capture during threshold testing. Procedure-related complications, lead parameters, and P-wave morphology were assessed at implantation and follow-up., Results: Permanent BBAP was successful in 32 of the 36 enrolled patients (88.9%). Baseline P-wave duration was 148.5 ± 16.1 ms. Among patients who underwent successful BBP, final paced P-wave duration was 117.8 ± 19.6ms. Correction of partial or complete IAB occurred in 22 patients (91.7%) and 6 patients (75.0%), respectively. BB potentials were recorded in 83.3% of all study patients. Transition from NS to S BB capture could be demonstrated during threshold testing in 22 patients (87.5%). The only major complications were 2 BBAP lead dislodgments within 24 hours and a rise in pacing impedance at 3 weeks in 1 patient., Conclusion: BBAP is feasible in a high percentage of patients and is associated with stable capture thresholds during follow-up., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Etiopathogenesis of cardiac sarcoidosis is poorly understood. The objective of this study is to examine a possible role of previous dental procedures on the development of cardiac sarcoidosis (CS)., Methods: Clinical details of 73 patients with CS from the Granulomatous Myocarditis Registry were extracted. Data regarding clinical presentation, comorbidities, baseline electrocardiogram, echocardiogram, and 18 fluorodeoxyglucose(FDG) PET-CT was extracted from the registry database. A comprehensive history of dental procedures for all patients was recorded. The two control groups comprised of 79 patients with idiopathic ventricular tachycardia and/or complete heart block (with similar clinical presentation) and 145 healthy age and sex matched patients, respectively., Results: Dental evaluation revealed that patients with CS had undergone a previous prosthetic dental implant(PI) (OR 12.4, 95% CI 4.0-38.1, p<0.001) or root canal treatment (RCT) (OR 2.43, 95% CI 1.12-5.26, p=0.025) more often than the healthy controls. The patients with CS and previous dental procedures had higher 18 FDG uptake in the LV myocardium (SUV max 8.6±3.3vs.5.5 ±1.8 (mean±SD), p<0.001) and mediastinal lymph nodes (9.3±4.6vs.5.4±1.7 (mean±SD), p<0.001) as compared to patients who did not undergo a dental procedure. The subset of CS patients with a previous PI or RCT had higher uptake levels in the myocardium (max SUV 9.4±3.1vs.6.7±2.0, p=0.011, number of abnormal LV Segments 10.3±3.1vs.6.5±2.8(mean±SD), p=0.008) and mediastinal lymph nodes(max SUV 10.5±4.8vs. 7.2±1.8,p=0.002) compared to those who underwent crowning or extraction. In addition, CS was diagnosed after a shorter latency period (47.3±21.0vs.81.6±25.3 months (mean±SD), p<0.001) following PI and RCT compared to other dental procedures., Conclusions: We observed a significant association between PI and RCT and the occurrence of CS. This group of patients also appear to have a more severe form of the disease., Competing Interests: CS: cardiac Sarcoidosis; 18FDG-PET CT: 18Fluorodeoxy glucose positron emission tomography; ASNC: American Society of Nuclear Cardiology; SUV: standardized uptake value (SUV); OR: odds ratio (OR); UI: Uptake Index; PI: prosthetic dental implants; RCT: root canal treatment; VT: ventricular tachycardiaThe authors sincerely thank Dr. Robert Baughman MD, University of Cincinati and Dr. Indersingh Anand MD, University of Minnesota Medical School for their suggestions to improve the study design and critical revision of the manuscript.Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article., (Copyright: © 2021 SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES.)

A 48-year-old man who was previously a responder to cardiac resynchronization therapy (CRT) presented with worsening of heart failure and reduction in the percentage biventricular (BiV) pacing. Device interrogation revealed T-wave oversensing that was eliminated by optimizing the interventricular (VV) delay. Compared to simultaneous BiV pacing, both sequential left ventricle-right ventricle (LV-RV) and univentricular LV pacing shortened the QTc, T peak-end intervals and reduced the T wave amplitude. Modification of VV delays can result in changes in wavefront of activation and thereby affect ventricular repolarization patterns., Competing Interests: Declaration of competing interest None declared., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: The occurrence of stroke in patients with cardiac sarcoidosis (CS) is an under-recognized entity. The objective of this study is to evaluate the clinical presentation, risk factors, etiology, temporal relationship and management of stroke in patients with CS., Methods: The data of 111 patients with CS from the Granulomatous Myocarditis Registry was analyzed. Clinical data regarding the clinical presentation, risk factors for vascular disease, electrocardiogram, echocardiogram and 18 Fluorodeoxyglucose (FDG) PET-CT were extracted from the registry database., Results: Among the 111 patients with CS, 8 patients (7.2%) had a history of ischemic stroke. Six of the eight patients with ischemic stroke were young (<50 years) without conventional risk factors for vascular disease. In five patients, stroke occurred prior to the diagnosis of CS. In all except one patient the ischemic stroke occurred in the anterior cerebral circulation. LV dysfunction was noted in all patients at the time of stroke, with the presence of an LV apical clot in four of the eight patients. Atrial fibrillation was documented in 2 patients. Two patients received thrombolysis and mechanical thrombectomy, while the others were treated with standard antiplatelets and statins. There was a significant improvement in the LV Ejection fraction (33.6 ± 15.2 to 49.1 ± 13.8%, p = 0.043) following immunosuppression. Two patients developed refractory HF and respiratory sepsis, respectively, and succumbed following prolonged ICU admissions., Conclusions: Ischemic stroke in patients with CS can be attributed to a cardioembolic phenomenon. A high index of clinical suspicion is needed for early diagnosis and management of these patients., Competing Interests: Declaration of competing interest All authors have none to declare, (Copyright © 2020. Published by Elsevier B.V.)

Background: Patients with outflow tract ventricular tachycardia (OTVT) with normal echocardiogram are labeled as idiopathic VT (IVT). However, a subset of these patients is subsequently diagnosed with underlying cardiac sarcoidosis (CS)., Objective: Whether electrocardiogram (ECG) abnormalities in sinus rhythm (SR) can differentiate underlying CS from IVT., Methods: We retrospectively analyzed the SR-ECGs of 42 patients with OTVT/premature ventricular complexes (PVC) and normal echocardiography. All underwent advanced imaging with cardiac magnetic resonance (CMR)/ 18 FDG PET-CT for screening of CS. Twenty-two patients had significant abnormalities in cardiac imaging and subsequently had biopsy-proven CS (Cases). Twenty patients had normal imaging and were categorized as IVT (Controls). SR-ECGs of all patients were analyzed by 2 independent, blinded observers., Results: Baseline characteristics were comparable. Among the ECG features analyzed - fascicular (FB) or bundle branch block (BBB) was seen in 9/22 Cases vs. 1/20 controls (p = 0.01). Among patients without FB or BBB, fragmented QRS (fQRS) was present in 9/13 cases but in none of the controls (p < 0.001). Low voltage QRS was more often seen among cases as compared to controls (10/22 vs. 3/20 p = 0.03). A stepwise algorithm based on these 3 sets of ECG findings helped to diagnose CS among patients presenting with OTVT/PVC with sensitivity of 91%, specificity of 75%, a PPV of 80%, and a NPV of 88%., Conclusions: In patients presenting with OTVT/PVC: FB/BBB, fQRS, and low QRS voltage on the baseline ECG were more often observed among patients with underlying CS as compared to true IVT. These findings may help to distinguish underlying CS among Cases presenting with OTVT/PVC., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Indian Heart Rhythm Society. Production and hosting by Elsevier B.V. All rights reserved.)

Background and Objectives: Cardiovascular implantable electronic devices (CIED) are frequently implanted in patients on anti-thrombotic agents. Pocket hematomas are more likely to occur in these patients. The use of a sterile surgical drain in the pulse generator pocket site could prevent hematomas, but fear of infection precludes its use. The objective of the present study is to study the safety and efficacy of surgical drain in patients on antithrombotics undergoing CIED implantations., Methods: This is a single-centre, retrospective study involving patients undergoing CIED implantations on antithrombotics (antiplatelets and anticoagulants) from August 2013 to July 2016. Patients with high risk of thromboembolism were continued on oral antithrombotics or were bridged with heparin after stopping oral antithrombotics. A sterile close wound suction drain was placed in device pockets following CIED implantations. Post procedure, pressure dressing was applied and removed after 12 h once the drain volume was less than 10 ml in 24 h., Results: Sixty seven patients required surgical drain implantation. Major indications for antithrombotic use were presence of intracoronary stent, atrial fibrillation and mechanical valve replacements. The mean post-procedural hospital stay was 3 ± 0.9 days and mean overall drain was 16.6 ± 8.2 ml. At a mean follow up of 17.6 ± 8.2 months, one patient (1.4%) had pocket hematoma. There were no infections., Conclusion: The use of a surgical drain in CIED implantation significantly reduces the risk of hematoma formation without increasing the risk of infection. Antithrombotic drugs can be safely continued at the time of implantation of cardiac devices., (Copyright © 2017. Published by Elsevier B.V.)

Background: Brugada syndrome (BrS) is known to cause malignant ventricular arrhythmia (VA) and sudden cardiac death (SCD). Patients with implantable cardioverter defibrillator (ICD) may experience recurrent shocks from ICD. Recent reports indicate that radiofrequency ablation (RFA) in BrS is feasible, and effective. Catheter ablation of premature ventricular complexes (PVCs) triggering VA and substrate modification of right ventricular outflow tract (RVOT) has been described., Methods and Results: Five patients (4 males, age-23 to 32 years) with BrS and electrical storm (ES) despite being on isoprenaline infusion and cilostazol (phosphodiestrase-3 inhibitor) underwent 3 dimensional electroanatomic mapping and RFA. Ventricular fibrillation was easily inducible in two patients. Voltage map of right ventricle was created in sinus rhythm in all patients. Substrate modification of RVOT was performed endocardially in one patient, both endocardial and epicardial in three and only epicardially in one patient. Brugada pattern gradually resolved over one week in all patients post procedure. These patients completed follow up of median 40 months (1.5-70). One patient had inappropriate shock due to atrial fibrillation, one had an episode of VF and appropriate shock 24 months after the RFA. The remaining four patients had no device therapy or VA in device log on follow up., Conclusion: Abnormal myocardial substrate is observed in RVOT among patients with BrS. Substrate modification in these patients may abolish Brugada pattern on the ECG and prevents spontaneous VAs on long term follow up., (Copyright © 2017. Published by Elsevier B.V.)

Introduction: Treating ventricular tachycardia (VT) in patients with cardiac sarcoidosis (CS) is challenging as patients present in different phase of the disease (inflammatory, scar, or sometimes both). A  customized approach to treatment is required for better outcomes. We describe our experience in the management of VT in CS based on the phase of the disease., Methods and Results: Patients were considered to have myocardial inflammation if there was an increased myocardial 18 fluorodeoxy glucose (FDG) uptake in PET-CT scan of the chest (n = 14). These patients were treated with antiarrhythmic drugs (AADs) and immunosuppression. Patients with scar related VT (without active inflammation) were managed with AADs and underwent radiofrequency ablation (RFA) if unresponsive to drug therapy (n = 4). Patients previously treated for CS who presented with VT and evidence of reactivation (abnormal FDG uptake) after a quiescent period of 6 months were treated with intensified immunosuppression alongside AADs (n = 3/14). Patients with myocardial inflammation responded well to immunosuppression. Patients with drug resistant VT in the scar phase responded well to RFA. Four patients in the inflammatory group had recurrence of VT during follow-up of whom 3 were found to have disease reactivation. Intensified immunosuppression suppressed VT in all 3 patients. In 1 patient, VT recurrence was found to be scar related and required RFA for control., Conclusion: Tailoring therapy for VT in CS according to the phase of disease results in good clinical outcome and avoids unnecessary immunosuppression., (© 2017 Wiley Periodicals, Inc.)

Objective: Alcohol septal ablation (ASA) is a therapeutic alternative to surgical myectomy in patients with hypertrophic obstructive cardiomyopathy (HOCM). However, the anatomical variability of the septal branch, risk of complete heart block, and late onset ventricular arrhythmias are limitations to its therapeutic usage. There is recent interest in the use of radiofrequency catheter ablation (RFCA) as a therapeutic option in HOCM. We aimed to assess the safety and efficacy of RFCA in the treatment of symptomatic HOCM., Methods: Seven patients with symptomatic HOCM (mean age 43.7±15.6 years, five males), and significant left ventricular outflow tract (LVOT) gradient despite optimal drug therapy, underwent ablation of the hypertrophied interventricular septum. These patients had unfavorable anatomy for ASA. Ablation was performed under 3D electro-anatomical system guidance using an open irrigated tip catheter. The region of maximal LV septal bulge as seen on intracardiac echocardiography was targeted. Patients were followed up at 1, 6, and 12 months post-procedure., Results: The mean baseline LVOT gradient by Doppler echocardiography was 81±14.8mm of Hg which reduced to 48.5±22.6 (p=0.0004), 49.8±19.3 (p=0.0004), and 42.8±26.1mm of Hg (p=0.05) at 1, 6, and 12 months respectively. Symptoms improved at least by one NYHA class in all but one patient. One patient developed transient pulmonary edema post-RFA. There were no other complications., Conclusion: RFCA of the hypertrophied septum causes sustained reduction in the LVOT gradient and symptomatic improvement among patients with HOCM. Electroanatomical mapping helps to perform the procedure safely., (Copyright © 2016 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Background: Electrical storm (ES) due to drug refractory ventricular tachycardia (VT) occurring within first few weeks of acute myocardial infarction (MI) has poor prognosis. Catheter ablation has been proposed for treating VT occurring late after MI, but there is limited data on catheter ablation in VT within first few weeks of MI., Methods and Results: Five patients (4 males, mean age 54.2±12.11 years) between June 2008 to July 2012, referred for VT presenting as ES refractory to antiarrhythmic drugs in the early post infarction period (six weeks following MI) despite revascularization. Three patients had anterior wall MI and two inferior wall MI with left ventricular ejection fraction ranging from 26 to 35%.All underwent catheter ablation within 48 hours of being in VT except one who presented late. Clinical VT was induced in all five patients. Total number of VTs induced were 11 (2.2±1.09 per patient). Two patients needed epicardial ablation via pericardial puncture. Though acute success was 100%, one patient had recurrence of clinical VT the next day of procedure.One patient succumbed to sepsis with multiple organ failure. The remaining four patients are doing well without further clinical recurrence of VT over a period of 3.7 years of follow-up., Conclusion: Catheter ablation can be a useful adjunctive therapy for patients with recurrent VT in the early post infarction period. This procedure appears to be safe with acceptable success rate.