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Objective Lead migration after spinal cord stimulator (SCS) implant is a commonly reported complication and the most common reason for revision surgery in cases of loss of efficacy. The primary aims of this study are to describe the incidence and degree of lead migration in the subacute postoperative period after SCS implant and to report potential risk factors for lead migration. Materials and methods We performed a retrospective chart review of all patients at a single academic center who received an SCS implant from January 1, 2020, to December 31, 2020. Information on patient (age, sex, weight, and height) and operative factors (device manufacturer, epidural access level and method, and implantable pulse generator location) were extracted from medical records. Intraoperative imaging was compared to subacute follow-up imaging obtained less than 20 days postimplant to measure lead migration distance. Regression models were fitted to determine associations between lead migration distance and potential clinical risk factors. Results A total of 91 cases (182 leads) were included in the study. Within 20 days of implantation, 88.5% of leads had migrated (86.3% caudal and 2.2% cephalad). Mean migration distance for leads with caudal migration only was 12.34 ± 12.19 mm based on antero-posterior radiographs and 16.95 ± 15.68 mm on lateral radiographs. There was an association of greater caudal lead migration as patient body mass index increased (β-coefficient 0.07 [95% confidence interval 0.01-0.13], p = 0.031). Within the entire cohort, one patient (1.1%) required lead revision for loss of efficacy. Conclusions In the subacute postoperative period after SCS implant, the majority of SCS leads migrated caudally with an average of two lead contacts. Knowledge of this expected migration and risk factors can better inform implanting physicians intraoperatively when deciding final lead placement location. The finding of high likelihood of caudal lead migration in the subacute postoperative period brings the need for a well-designed prospective study to the forefront of our field. This will allow implanting providers to make well-informed decisions for intraoperative lead placement.

BACKGROUND: Deep brain stimulation (DBS) of the subthalamic nucleus (SNT) is a treatment modality for Parkinson's Disease (PD). Either single central trajectory tract or multiple selected trajectory tracts based on microelectrode recordings (MER) are used for the placement of the final stimulating electrodes. This study aims to explore how many times trajectory tracts, other than the central tract are used for final lead placement. METHODS: Retrospective analysis of a randomly selected convenience sample of 24 subjects from patients who had DBS by a single neurosurgeon. After MRI and CT assessment, planning using a stereotactic frame for variable trajectory placement of temporary electrodes and MER that was the basis for site and tract selection for the final electrode placements used for DBS. RESULTS: Twenty four patients had 47 DBS electrodes placed: 1 unilateral and 23 bilateral. The central tract was used in 45 (95.75%) of these cases. The central trajectory tract accounted for 30 (63.83%), the anterior trajectory tract for 7 (14.89%), the medial tract for 5 (10.64%), the posterior for 4 (8.51%) and the lateral for 1 (2.13%) of final lead placements. CONCLUSION: The results of this study based on the predicted best stimulating sites following MER show that alternates to the central trajectory tract are required in 37% of site placements. A comparative study exploring clinical benefit is required to assess if variable electrode trajectory placement based on accurate physiological measurements is superior to single central trajectory placement.

Complex coronary vein morphology impedes the insertion of the left ventricular (LV) lead and reduces the effectiveness of cardiac resynchronization therapy (CRT). A 77-year-old woman underwent dual-chamber pacemaker implantation via the left subclavian approach for a complete atrioventricular block 17 years previously. She was hospitalized due to decompensated heart failure, and her cardiac rhythm completely depended on ventricular pacing at that time. Transthoracic echocardiography showed thinning of the ventricular septum in the basal region and pacing-induced dyssynchrony. She was clinically diagnosed with cardiac sarcoidosis with severe LV systolic dysfunction. She was referred for an upgrade to CRT. Given that prior contrast venography showed occlusion of the left subclavian vein, an additional LV lead was inserted through the right subclavian vein. Coronary venography showed a lateral vein that branched from the great cardiac vein with an acute angle and had multiple tortuosities in the peripheral branches. Since the LV lead placement was unsuccessful with the conventional method, we attempted the lead placement using the balloon occlusion technique (BOT). Lead delivery into the anatomical optimal lateral vein was successful by using BOT, and LV pacing from the most delayed basal region was achieved in combination with the active fixation LV lead.

Introduction: For those cardiac resynchronization therapy (CRT) candidates who experience left-ventricular (LV) lead placement failure or underwent concomitant cardiac surgeries, surgical placement of epicardial LV lead guided by electroanatomic mapping may be a promising alternative. Methods: Electroanatomic mapping was used to guide positioning of the LV lead through a surgical approach. The LV lead was placed at the region with the latest local LV activation and normal voltage, away from the scar. Results: From April 2010 to September 2018, 10 consecutive patients (3 female) underwent surgical epicardial LV lead implantation. Among them, 3 had other surgical indications simultaneously (including 1 CRT non-responder), and 7 had failed transvenous LV lead placement. After CRT, the QRS duration was shortened from 149.3 ± 20.4 ms to 125.1 ± 15.2 ms (p = 0.01). At 6 months, the LV ejection fraction was significantly improved and remained stable in the follow-up (FU) period thereafter (baseline vs. 6 months, 31.0 ± 8.3% vs. 42.2 ± 13.4%, p = 0.006). Other parameters, including the threshold and impedance of the LV lead, were also stable at a mean FU of 755 ± 406 days, and the NYHA functional classification decreased from 2.9 ± 0.7 to 1.8 ± 0.8 (p = 0.002). Conclusions: Placement of an epicardial LV lead guided by electroanatomic mapping could be used as an adjunctive strategy in patients who were unable or refractory to conventional CRT therapy. This approach could also be applied in patients who had other surgical indications at the same time.

Aims To evaluate the benefit of speckle tracking radial strain imaging (STRSI)-guided left ventricular (LV) lead (LVL) positioning in cardiac resynchronization therapy (CRT) in patients (pts) with ischaemic cardiomyopathy with CRT indication. Methods and results We conducted a prospective randomized controlled trial. Patients were enrolled in nine centres with 2:1 randomization into two groups (guided vs. control). Patients underwent STRSI to identify the optimal LV position from six LV segments at midventricular level. Implantation via STRSI was attempted for recommended segment in the guided group only. Follow-up included echocardiography (6 months) and clinical evaluation (6 and 12 months). The primary endpoint was comparison % reduction in LV end-systolic volume at 6 months with baseline. Secondary endpoints included hospitalizations for heart failure and death, and improvement in additional echocardiographic measurements and quality of life score. A total of 172 patients (115 guided vs. 57 control) were enrolled. In the guided group, 60% of the implanted LV leads were adjudicated to be successfully located at the recommended segment, whereas in the control group 44% reached the best STRSI determined segment. There was no difference between the groups in any of the primary or secondary endpoints at 6 and 12 months. Conclusion Our findings suggest that echo-guided implantation of an LV lead using STRSI does not improve the clinical or echocardiographic response compared with conventional implantation.

INTRODUCTION The Fontan procedure, used to palliate univentricular physiology, eliminates direct venous access to the ventricle and complicates implantable cardioverter-defibrillator (ICD) placement. METHODS AND RESULTS We describe two patients with Fontan palliation who underwent a novel transvenous approach to ICD placement. The approach uses a transvenous bipolar lead placed in a coronary sinus branch for ventricular sensing, and a defibrillation lead placed in the right atrium for atrial sensing and ventricular defibrillation. CONCLUSION Transvenous ICD implantation is possible in some patients with an atriopulmonary Fontan. This approach avoids a redo sternotomy for epicardial leads and excludes the need for lead placement in the systemic circulation.

Background The effect of right ventricular (RV) leads on tricuspid valve has been already raised concerns, especially in terms of prognostic implication. For such assessment, three-dimensional transthoracic echocardiography (3D-TTE) has been used previously but there was no data on the use of post-procedural fluoroscopy in the literature. Methods We prospectively enrolled 59 patients who underwent clinically indicated placement of pacemaker or implantable cardioverter defibrillator (ICD). Vena contracta (VC) and tricuspid regurgitation (TR) severity were measured using two-dimensional transthoracic echocardiography (2D-TTE) at baseline. Follow up 3D-TTE was performed 6 months after device implantation to assess TR severity and RV lead location. Results Lead placement position in TV was defined in 51 cases.TR VC was increased after the lead placement, compared to the baseline study (VC: 3.86 ± 2.32 vs 3.18 ± 2.39; p = 0.005), with one grade worsening in TR in 25.4% of cases. The mean changes in VC levels were 1.14 ± 0.67 mm. Among all investigated parameters, VC changes were predicted based on lead placement position only in 3D-TTE (p Conclusion The RV Lead location examined by 3D-TTE seems to be a valuable parameter to predict the changes in the severity of the tricuspid regurgitation. Fluoroscopy findings did not improve the predictive performance, at least in short term follow up.

Better characterisation of the electromechanical substrate (part I) may promote more appropriate patient selection for cardiac resynchronization therapy (CRT) implantation. By developing an and-to-end automated and explainable deep learning-based approach, we were able to identify a patient cluster with the predicted combination of non-response and poor outcome after CRT (chapter 2). This approach allows for objective risk-stratification that outperforms contemporary electrocardiogram characteristics and QRSAREA, and thereby reliable excludes the presence of a CRT-amendable substrate. Chapter 3 illustrates how incorporating the mechanical substrate may extend the accuracy of such prediction models, which in turn is illustrated in the form of a combined assessment of the electrical substrate and mechanical dysfunction in chapter 4. Here, a simple four-variable model was shown to be associated with a sustained volumetric response, which indicates stable disease remission. Optimizing left ventricular (LV) lead position (part II) may improve outcome after CRT, whereas poor placement may preclude response despite an underlying amendable substrate or favourable patient characteristics. Hence, chapter 5 discusses the importance of optimizing LV-lead placement. It is shown how the optimal pacing site is highly variable, patient-specific, difficult to predict during implantation, and especially critical in the presence of atypical LV activation or myocardial scar. In these patients, image-guidance, rather than electrical-guidance, is likely the most important approach for achieving the optimal transvenous lead position. Hence, chapter 6 demonstrates that real-time navigation of the LV-lead is feasible in a multicentre setting. Not only were leads adequately positioned in 76% of patients, echocardiographic response was achieved in 86% of patients. Chapter 7 then discusses the protocol of the multicentre randomised controlled ‘Advanced Image Supported Lead Placement in Cardiac Resynchronization Therapy’ (ADVISE) trial, which will further investigate the clinical efficacy of this approach. Lastly, part III explores the potential diagnostic (chapter 8), prognostic (chapter 9), and therapeutic (chapter 10) implications of exercise in heart failure. In chapter 8, the feasibility of strain-based discoordination-imaging during stress echocardiography was demonstrated. Stress echocardiography could unmask dynamic changes in mechanical dyscoordination. Although feasible, many challenges remain to overcome. Chapter 9 demonstrates that submaximal oxygen uptake (VO2) kinetics are associated with volumetric response to CRT. While at least equally effective as measuring VO2 Peak, submaximal VO2 kinetics may provide a more relevant characterisation of exercise tolerance, which is also more reliable and patient-friendly. Finally, in chapter 10, we illustrate how differences in cardiac output and VO2 kinetics during submaximal exercise distinguish the severity of functional impairment in chronic heart failure, rather than differences in resting echocardiography. Moreover, we demonstrate that both high-intensity interval training and CRT improve submaximal exercise tolerance. By contrast, only CRT induces cardiac reverse remodelling, whereas only an exercise training program improved exercising haemodynamics. Hence, combining both therapies may further improve functional recovery through differential effects.

Better characterisation of the electromechanical substrate (part I) may promote more appropriate patient selection for cardiac resynchronization therapy (CRT) implantation. By developing an and-to-end automated and explainable deep learning-based approach, we were able to identify a patient cluster with the predicted combination of non-response and poor outcome after CRT (chapter 2). This approach allows for objective risk-stratification that outperforms contemporary electrocardiogram characteristics and QRSAREA, and thereby reliable excludes the presence of a CRT-amendable substrate. Chapter 3 illustrates how incorporating the mechanical substrate may extend the accuracy of such prediction models, which in turn is illustrated in the form of a combined assessment of the electrical substrate and mechanical dysfunction in chapter 4. Here, a simple four-variable model was shown to be associated with a sustained volumetric response, which indicates stable disease remission. Optimizing left ventricular (LV) lead position (part II) may improve outcome after CRT, whereas poor placement may preclude response despite an underlying amendable substrate or favourable patient characteristics. Hence, chapter 5 discusses the importance of optimizing LV-lead placement. It is shown how the optimal pacing site is highly variable, patient-specific, difficult to predict during implantation, and especially critical in the presence of atypical LV activation or myocardial scar. In these patients, image-guidance, rather than electrical-guidance, is likely the most important approach for achieving the optimal transvenous lead position. Hence, chapter 6 demonstrates that real-time navigation of the LV-lead is feasible in a multicentre setting. Not only were leads adequately positioned in 76% of patients, echocardiographic response was achieved in 86% of patients. Chapter 7 then discusses the protocol of the multicentre randomised controlled ‘Advanced Image Supported Lead Placement in Cardiac Resynchronization Therapy’ (ADVISE) trial, which will further investigate the clinical efficacy of this approach. Lastly, part III explores the potential diagnostic (chapter 8), prognostic (chapter 9), and therapeutic (chapter 10) implications of exercise in heart failure. In chapter 8, the feasibility of strain-based discoordination-imaging during stress echocardiography was demonstrated. Stress echocardiography could unmask dynamic changes in mechanical dyscoordination. Although feasible, many challenges remain to overcome. Chapter 9 demonstrates that submaximal oxygen uptake (VO2) kinetics are associated with volumetric response to CRT. While at least equally effective as measuring VO2 Peak, submaximal VO2 kinetics may provide a more relevant characterisation of exercise tolerance, which is also more reliable and patient-friendly. Finally, in chapter 10, we illustrate how differences in cardiac output and VO2 kinetics during submaximal exercise distinguish the severity of functional impairment in chronic heart failure, rather than differences in resting echocardiography. Moreover, we demonstrate that both high-intensity interval training and CRT improve submaximal exercise tolerance. By contrast, only CRT induces cardiac reverse remodelling, whereas only an exercise training program improved exercising haemodynamics. Hence, combining both therapies may further improve functional recovery through differential effects.

INTRODUCTION His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) have emerged as attractive alternatives to traditional biventricular pacing to achieve cardiac resynchronization therapy. Early reported results have been inconsistent, particularly amongst patients in whom initial placement with traditional approaches has been unsuccessful or those with complex anatomy or congenital abnormalities. In this report, we describe the use of three-dimensional electroanatomic mapping (EAM) in five selected cases. METHODS Five patients from multiple clinical sites underwent EAM-guided HBP or LBBAP by highly trained electrophysiologists with significant experience with conduction system pacing. Each patient in this series underwent EAM-guided conduction system pacing due to complex anatomy and/or prior failed lead implantation. RESULTS EAM-guided lead implantation was successful in all five cases. Capture thresholds were relatively low and patients continued to have evidence of successful lead implantation with minimum 1-month follow-up. The fluoroscopy time varied, likely owing to the variable complexity of the cases. CONCLUSIONS The use of EAM, in combination with traditional intracardiac electrograms with or without fluoroscopy, allows more targeted and precise placement of leads for HBP and LBBAP pacing. Further investigation is needed to determine this strategy's long-term performance and to optimize patient selection.

Introduction Spinal cord stimulation (SCS) is a commonly utilized therapy for the treatment of neuropathic pain conditions. The Neurostimulation Appropriateness Consensus Committee (NACC) has recommended that the placement of percutaneous SCS leads be performed in an awake patient capable of providing feedback. It is not currently known how commonly this recommendation is adhered to by physicians in clinical practice. This article presents the findings of a survey designed to answer this important question. Methods We conducted a survey of the active membership of the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the Spine Intervention Society (SIS) regarding practice patterns with SCS therapy. We analyzed the percent of respondents who indicated that they use deep sedation and general anesthesia during SCS placement as well as any reported complications. Results Many practitioners frequently utilize deep sedation as well as general anesthesia when performing SCS implants. Our findings demonstrate that 77% of physicians reported that they utilize deep sedation for permanent SCS implants at times, and 45% of physicians reported the use of general anesthesia for 10 kHz implants. Additionally, 94% of physicians reported that they have never had a complication related to the use of general anesthesia for a spinal cord stimulator placement. Conclusions This survey provides initial data on SCS practices among a large cohort of clinicians who utilize SCS. SCS lead placement under deep sedation and general anesthesia appears to be common practice for many physicians who perform implants. This survey should stimulate further research on this topic, given that the current safety guidelines and the rate of physicians reporting the use of deep sedation and general anesthesia for spinal cord stimulator placement remain at odds.

Item does not contain fulltext INTRODUCTION: Dorsal root ganglion stimulation (DRG-S), has demonstrated superiority in the treatment of complex regional pain syndrome and causalgia. Lead migration and fracture impact DRG-S therapeutic stability. Lead anchoring reduces DRG-S lead migration without increasing lead fracture. Lead fracture may be related to lead entrapment in the superficial fascial plane. A novel medialized approach for lead placement and anchoring is presented to address these issues. METHODS: We suggest an alternative technique for implanting percutaneous DRG-S leads at the T10-L5 levels. RESULTS: A novel medialized ipsilateral technique for lead placement and anchoring for single, bilateral, and adjacent segment placement is presented. The Tuohy needle puncture site is medial to the pedicle and adjacent to the spinous process, two vertebral levels caudad to the target foramen. Trajectory is maintained in the sagittal plane, to access the caudad interlaminar space near the midline. This technique allows for ipsilateral or contralateral lead placement. After epidural access, the introducer sheath is rotated toward the targeted foramen and advanced. The guidewire followed by the lead is passed, and once lead position is confirmed, tension "S" loops are created, followed by anchoring to the deep fascia. CONCLUSION: We describe a new paramedian technique for DRG-S lead placement. We propose it will decrease DRG-S complication rates through anchoring to reduce migration and by avoiding the fascial planes thought to be responsible for fracture. Long-term outcomes applying our proposed techniques are required for determining the true impact, however, early anecdotal results suggest that these new techniques are favorable.

We describe a simple technique of securing surgically implanted leads for spinal cord (SCS), dorsal root ganglion (DRG) and occipital nerve stimulation (ONS), for both primary surgical implantation and correcting lead migration. This technique could also be adapted for securing percutaneously implanted leads. Thirty-nine patients underwent neurosurgical implantation of SCS, DRG, and ONS devices utilizing titanium mini-plates to obtain secure anchorage of leads to adjacent laminae close to their exit point from the epidural space, thereby minimizing the risk of further lead migration or electrode displacement. There were no cases of primary or recurrent lead migration in any patient undergoing lead placement using mini-plate anchorage. The technique appears to offer a reliable means of preventing post-operative lead migration in a variety of spinal and extra-cranial neuromodulation implants.

OBJECTIVE Electrophysiologic mapping (EM) has been instrumental in advancing neuroscience and ensuring accurate lead placement for deep brain stimulation. However, EM is associated with increased operative time, expense, and potential risk. Intraoperative imaging to verify lead placement provides an opportunity to reassess the clinical role of EM. We investigated whether EM 1) provides new information that corrects suboptimal preoperative target selection by the physician or 2) simply corrects intraoperative stereotactic error, which can instead be quickly corrected with intraoperative imaging. METHODS Deep brain stimulation lead location errors were evaluated by measuring whether repositioning leads based on EM directed the final lead placement 1) away from or 2) toward the original target. We retrospectively identified 50 patients with 61 leads that required repositioning directed by EM. The stereotactic coordinates of each lead were determined with intraoperative computed tomography. RESULTS In 45 of 61 leads (74%), the electrophysiologically directed repositioning moved the lead toward the initial target. The mean radial errors between the preoperative plan and targeted contact coordinates before and after repositioning were 2.2 and 1.5 mm, respectively (P < 0.001). Microelectrode recording was more likely than test stimulation to direct leads toward the initial target (88% vs. 63%; P = 0.03). The nucleus targeted was associated with the likelihood of moving toward the initial target. CONCLUSIONS Electrophysiologic mapping corrected primarily for errors in lead placement rather than providing new information regarding errors in target selection. Thus, intraoperative imaging and improvements in stereotactic techniques may reduce or even eliminate dependence on EM.

Sacral neuromodulation remains an effective therapy for multiple conditions and both the technology and implant techniques have evolved over more than two decades. Understanding of the ideal conditions for testing and administration of the therapy continue to progress as well, though considerable controversy still exists. This review seeks to clarify the current knowledge and opinion surrounding types of neuromodulation testing, what constitutes an optimized lead and best practices for maximizing therapeutic success. There are distinct advantages and disadvantages to each method of sacral neuromodulation testing that should be individualized to each patient. While motor response during lead implantation may be more reliable and even necessary, an approach which balances both motor and sensory data may be advantageous. Optimized lead placement, though not conclusively proven to offer definite advantages, remains a laudable goal for most implantations. Sacral neuromodulation remains an important therapy for patients with pelvic voiding and elimination dysfunction. Important considerations including office-based or staged testing, motor or sensory prioritization, and the importance of lead optimization remain debatable. However, there remain important lessons that can influence the likelihood of successful therapy. Although there is still work to be done, we are continuing to strive for improvement in patient outcomes as a result of optimized lead placement in sacral neuromodulation.

Objective Stereoelectroencephalography (sEEG), despite its established usefulness, has not been thoroughly evaluated for its adverse events profile. In this study, hemorrhage rates were evaluated both per patient and per lead placed not only in the immediate postoperative period, but also over the course of admission and after explantation when available. Methods This is a single-center retrospective study of pediatric and adult patients undergoing sEEG lead placement at a large urban hospital. All available postoperative imaging was reviewed for the presence of hemorrhage, including any imaging occurring throughout admission as well as within 1 month of lead explantation. Age and number of leads placed per procedure were compared using an unpaired t test assuming unequal variance. Results A total of 1855 leads were placed in 147 cases. The mean age was 30.4 ±15.0 and the male/female ratio was 47:53. 9 leads (0.49%) in 9 cases (6.12%) were involved with postimplantation hemorrhage occurring on postoperative day 0.44 on average. Postexplantation imaging was available for 45 cases. Seven leads (1.40%) in 7 cases (15.56%) were involved with postexplantation hemorrhage occurring on average on postoperative day 1.42. There was a significant difference in mean age between patients with postexplantation hemorrhage versus control (45.0 vs. 32.2; P = 0.0277). No cases of hemorrhage required surgical intervention and no patients had permanent neurologic deficit. Conclusions Hemorrhage after sEEG lead implantation and explantation may be more common than previously reported. Consistent postexplantation imaging may be of clinical benefit in detecting hemorrhage that precludes patients from immediate discharge, particularly in older patients.

Persistent left superior vena cava (PLSVC) is the most common variant of abnormal venous return to the heart. While usually asymptomatic, it is known to complicate transvenous cardiac procedures, such as implantation of cardiac electronic devices and ablations. PLSVC can present with or without the concomitant absence of right superior vena cava (RSVC). Depending on the operator's preference, implantation of permanent cardiac pacemakers (PPMs) may be performed from the left or right side. As most often the PLSVC is only identified at the time of intervention, it follows that the variant with the absence of RSVC can be diagnosed in practice only when implanting from the right side. For this reason, the true prevalence of this variant is largely unknown because most published cases of cardiac device implantations in patients with PLSVC have been performed from the left side. We present a short 3-case series of PPM implantations in a tertiary center from the right side in patients with PLSVC and absent RSVC. We found that the use of a standard curve for ventricular lead septal placement and a wide C-curve for right atrial lead placement in these patients was a feasible technique with good outcomes.

Cardiac resynchronization therapy (CRT) greatly reduces morbidity and mortality in patients with dyssynchronous heart failure. However, despite tremendous efforts, response has been variable and can be further improved. Although optimizing left ventricular lead placement (LVLP) is arguably the cornerstone of CRT, the procedure of LVLP using the transvenous approach has remained largely unchanged for more than 2 decades. Improvements have been developed using scar location and electrical and/or mechanical mapping, and interest in conduction system pacing as an alternative to biventricular pacing has emerged recently. Conduction system pacing is promising but may not be suitable for all patients with dyssynchronous heart failure. This review underscores the importance of a patient-tailored approach and discusses the potential applications of both conduction system pacing and targeted biventricular CRT.

Background The purpose of this study is to evaluate cardiac functions using transthoracic echocardiography, change in lead parameters and electrocardiogram (ECG) morphology in patients undergoing permanent pacemaker implantation over a follow-up period of 6 months. Methods This is a prospective study in patients undergoing permanent pacemaker implantation in a tertiary care hospital. Patients undergoing permanent pacemaker implantation were enrolled for up to one year and Echocardiographic parameters (by 2 blind operators) and ECG parameters were recorded at admission (within 24 h), before discharge (within 7 days of pacemaker implantation), after 1 month (± 7 days) and after 6 months (± 7 days) of follow-up. Results A total of 96 patients (60.4% males and 39.6% female, mean age 66.65 years) were implanted with permanent pacemaker. The mean QRS duration was 133.18 ms and increased significantly to 146.03 ms by 6 months despite septal lead placement in majority (92%) of patients. The mean baseline ejection fraction of 51.47 decreased significantly to 47.83 by 6 months. Diastolic parameters like left atrial volume index, early to late diastolic transmitral flow velocity (E/A) and early diastolic mitral annular tissue velocity (E/e′) showed a significant increase (> 5%) from baseline by the end of first week. By the end of first month, systolic dysfunction of RV sets in with significant (> 5%) change from baseline in parameters like Right ventricle myocardial performance index, transannular plane systolic excursion and right ventricle systolic excursion velocity (RVS′). Conclusion We have observed that pacemaker recipients with baseline reduced left ventricle (LV) systolic functions perform significantly worse compared to those with baseline normal cardiac functions and had a higher rate of deterioration of LV function. RV dysfunction is the first abnormality that occurs, by 1 week followed by LV dysfunction which starts by 1 month and the diastolic dysfunctions precede the systolic dysfunction. QRS duration also showed a gradual increase despite septal lead placement in majority (92%) and lead parameters showed no significant change over 6 months.

Although the conventional methods for endo-cardial pacemaker lead implantation via subclavian or cephalic or axillary vein routes is common, but sometimes due to anatomical variations it is not feasible to access these veins Emergence of newer techniques are useful for lead implantation. This case report focuses on a hybrid approach of combined mini-thoracotomy for endocardial pacemaker lead implantation. This fluoroscopy guided minimal thoracotomy approach with endocardial MRI compatible lead placement had the benefits of simple procedural, minimal hospital stay, low early complication rates and economically viable to the patient.

This case series demonstrates 2 innovative approaches to successful coronary sinus lead placement in the setting of coronary sinus ostial atresia. Use of venous phase coronary angiography, a computed tomography scan with venous phase, or a left-sided upper extremity venogram may help reveal a variant anatomy and guide tool selection. (Level of Difficulty: Advanced.), Central Illustration