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The emergence and attendant mortality of vaccine-induced immune thrombocytopenia and thrombosis (VITT) as a consequence of vaccination against severe acute respiratory syndrome coronavirus 2 have resulted in some patients with VITT being considered as deceased organ donors. Outcomes after kidney transplantation in this context are poorly described. Because the disease seems to be mediated by antiplatelet factor 4 antibodies, there is a theoretical risk of transmission via passenger leukocytes within the allograft.We analyzed the experience of kidney transplantation from donors with VITT in the United Kingdom between January and June 2021. We followed-up all recipients of kidney-only transplants from donors with VITT to detect major postoperative complications or features of disease transmission and assess graft survival and function.There were 16 kidney donors and 30 single kidney transplant recipients in our study period. Of 11 preimplantation biopsies, 4 showed widespread glomerular microthrombi. After a median of 5 mo, patient and graft survival were 97% and 90%, respectively. The median 3-mo estimated glomerular filtration rate was 51 mL/min/1.73 m 2 . Two recipients had detectable antiplatelet factor 4 antibodies but no evidence of clinical disease after transplantation. Major hemorrhagic complications occurred in 3 recipients, all of whom had independent risk factors for bleeding, resulting in the loss of 2 grafts. The involvement of VITT could not be completely excluded in one of these cases.The UK experience to date shows that favorable outcomes are possible after kidney transplantation from donors with VITT but highlights the need for ongoing vigilance for donor-related complications in these patients.

Catalytic depolymerization of lignin to value-added compounds is receiving increasing interest as part of the circular bioeconomy.

Background Kidney transplantation has established itself as the most appropriate mode of renal replacement therapy for the majority with end-stage kidney disease. Although at present this is applicable for children as well as adults, a few decades back kidney transplantation was not considered a first-line option in children. This was due to inferior outcomes following transplantation in this age group compared to that of adults. These poor results were attributed to challenges in paediatric transplantation such as the shortage of suitable donors, technical difficulties in performing a sound vascular anastomosis and the adverse effects of immunosuppressive medication on growth and development. However, current patient and graft-centred outcomes after paediatric transplantation equal or surpass that of adults. The advances in evaluation and management of specific surgical concerns in children who undergo transplantation, such as pre-transplant native nephrectomy, correction of congenital anomalies of the urinary tract, placement of an adult-sized kidney in a small child and minimizing the risk of allograft thrombosis, have contributed immensely for these remarkable outcomes. Conclusions In this review, we aim to discuss surgical factors that can be considered unique for children undergoing kidney transplantation. We believe that an updated knowledge on these issues will be invaluable for transplant clinicians, who are dealing with paediatric kidney transplantation.

Vaccine-induced thrombosis and thrombocytopenia (VITT) may follow immunisation with the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2. Autoantibodies to platelet factor 4 (PF4) may mediate VITT through antibody-dependent platelet activation, though the underlying etiology is uncertain. Anti-PF4 antibodies are also seen in heparin-induced thrombocytopenia, though most cases of VITT do not have prior heparin exposure. More than 20 million people in the United Kingdom (UK) have received the ChAdOx1 nCoV-19 vaccine.

A bifunctional ionic liquid (IL) [DDQM][HSO

Aim Laparoscopic adrenalectomy is considered the optimal approach for most lesions. Various subsets of minimally invasive adrenalectomy are practiced in the UK, including trans-abdominal (TLA), hand-assisted (HLA) and retroperitoneal (RLA) laparoscopic procedures. We aimed to examine the relative operative outcomes between the 3 techniques. Methods We performed a retrospective observational review of contemporaneously maintained databases from two nearby institutions to establish differences in outcomes between minimally invasive adrenalectomy for any size lesion. Statistical analysis was undertaken using R v3.6.0. Results Two hundred and ninety-seven patients underwent laparoscopic adrenalectomy and were included in the analysis (45 RLA, 77 HLA and 175 TLA). There were no significant differences between groups for institution location, wound infection, intra-operative bleeding, blood product requirements, visceral injury, open conversion, re-operation, incisional hernia, laterality of lesion, oncological outcomes and medical complications. Boxplots revealed a wider spread and increased mean operating time for TLA, with less difference in operation time between HLA and RLA groups. This was confirmed by an overall significant finding from Kruskal-Wallis rank sum test (p= Conclusion Minimally invasive adrenalectomy can safely be performed by any of 3 techniques. TLA showed a longer mean operating time. The analysis of outcomes revealed otherwise no significant differences in operative or medical outcomes.

A novel colloidal system comprising choline oleate in deep eutectic solvent (DES: choline chloride–ethylene glycol) is developed and utilized for in situ generation and stabilization of nanosized (1 to 3 nm) N-doped oxygenated, crystalline CDs via dissolution of gelatin. Self-assembly of choline oleate in DES has been characterized using surface tension, DLS and 2D NMR NOESY methods. The stability of colloidal CDs was examined using FTIR and Raman spectroscopy. TEM, HR-TEM, and PXRD techniques have been used to characterize CDs. Optical properties have been investigated using UV, fluorescence and time-resolved photoluminescence (TrPL) spectroscopy. Colloidal CDs possess bright blue to red luminescence and short fluorescence lifetime with exceptionally high quantum yield (ca. 82%), and exhibited excellent biocompatibility as bioimaging agents towards labeling of bacterial cells (both Gram positive and Gram negative), thus indicating a potential benign system for disease detection, drug delivery and light harvesting applications.

Microemulsions (MEs) comprising choline dioctylsulfosuccinate [Cho][AOT], a biobased ionic liquid (IL) surfactant as an emulsifier, (R)-(+)-limonene (RL) as a nonpolar phase, and ethylene glycol (EG)/ethanolammonium formate (EOAF) as an organic solvent/low-viscosity IL polar component were constructed. Spontaneous aggregation of [Cho][AOT] was observed with a negative ΔH form using isothermal titration calorimetry. The aggregates of [Cho][AOT] in RL showed a critical micellar concentration (cmc) of ∼5.49 mM, EG (cmc ∼3.99 mM), and EOAF (cmc ∼1.56 mM), and these are further characterized by various techniques. These novel IL-based MEs have been used as nanoreactors for the sustainable synthesis of uniform nanosized metal-organic frameworks (N-MOFs), such as MIL-53(Al), HKUST-1, UIO-66-NH2, and ZIF-8, with a precise control over size and morphology at room temperature. Characterization of N-MOFs has been performed using scanning electron microscopy, powder X-ray diffraction, and Fourier transform infrared spectroscopy. The synthesized N-MOFs have been used to prepare stable and uniform thin film nanocomposite nanofiltration membranes, suitable for desalination of brackish water with excellent flux (31.8 LMH/bar) and rejection (99.0%) of divalent salts.

Introduction Single antigen bead testing (SAB) for HLA-specific antibody enables efficient organ allocation and aids in the diagnosis of antibody mediated rejection. In this retrospective cohort study, a population of kidney transplant recipients possessing HLA Class I antibodies was used to evaluate the best method for resolving complement interference, the so called “prozone” effect. The aim was to compare the use of EDTA versus a Biotin-Streptavidin Complex as methodological approaches for abating the prozone effect using a fixed 1 in 10 dilution as validation. Methods One hundred and seventeen patients transplanted in our centre between 2009 and 2014 were identified as having class I HLA-specific antibody(−ies) using a Labscreen® Mixed assay. Positive sera underwent class I HLA-specific SAB testing; for comparison a standard SAB with and without EDTA, BSC and dilution (1 in 10) modifications were utilised. Samples were processed on the Luminex platform generating 11,349 bead reactions for analysis. Results We identified sera from 23 patients giving rise to 170 bead reactions showing complement interference. Using linear modelling, we observed slightly higher MFIs on average in both EDTA and BSC modifications when compared to the standard assay, allowing the nominal threshold MFI of 2000 in the standard assay to be adjusted to 2097 and 2033 in the EDTA and BSC assays respectively. We calculated 99% prediction intervals to establish outlier bead reactions for each assay. The 1 in 10 dilution was used as a crosscheck for determining which prozone reactions were overcome by EDTA and BSC. Using ROC curve analysis, EDTA was found to be ~90% sensitive and 100% specific compared to BSC which was ~60% sensitive and 100% specific in ameliorating prozone positive reactions at the thresholds defined by linear models. Discussion Our data indicates that both EDTA and BSC are suitable assays in overcoming CMI. We recommend that all clinical laboratories adopt a validated assay designed specifically to abrogate CMI for all potential renal transplant recipients, as the standard assay is inhibited in nearly 20% of a post-transplant cohort.

This article outlines a sustainable method towards the synthesis of advanced materials such as core/shell Quantum Dots (QDs) and their in situ stabilization using microemulsions (MEs). QDs are versatile materials which show unusual optical properties. We have constructed MEs consisting of an Ionic Liquid (IL) based surfactant i.e. choline dioctylsulfosuccinate, [Cho][AOT] as an emulsifier, toluene as a nonpolar phase and water as a polar phase. The system forms a large single-phase region in the phase diagram without any co-surfactant. Spontaneous formation of micelles has been observed and studied through tensiometry and fluorescence and isothermal titration calorimetry (ITC). The exceptional swelling behaviour of the MEs was studied using Dynamic Light Scattering (DLS) and small angle neutron scattering (SANS). In ME droplets, i.e. Reverse Micelles (RMs), we successfully synthesized spherical core/shell QDs (size ∼3 to ∼6 nm) with precise control over the size and morphology. The QDs have been characterized using Scanning Electron Microscopy (SEM), Transmission Electron Microscopy (TEM) and Powder X-ray Diffraction (PXRD). QDs stabilized in MEs exhibited excellent optical properties and can be suitably used as light harvesting materials for diverse applications.

A 45-year-old man with nonischemic cardiomyopathy and end-stage renal disease had lived uneventfully with a cardiac resynchronization therapy defibrillator (CRT-D) for 5 years. Less than a month before presenting at our institution, he had undergone stenting of his partially occluded subclavian vein, to relieve stenosis of the ipsilateral arteriovenous fistula that was used for his hemodialysis. The CRT-D subsequently discharged. Device interrogation revealed that electrical noise originating from leads damaged by the stent had caused the inappropriate shock and intermittent electrical discharges thereafter. The patient was highly traumatized by these events and insisted upon device removal, which deprived him of a potentially life-saving intervention. He later had a cardiac arrest that resulted in sustained profound hypoxic ischemic encephalopathy with minimal neurologic recovery: his family placed him in a long-term care facility on ventilator support, with a tracheostomy and feeding tube. This situation might have been avoided through collaboration between the interventional radiologist and the electrophysiologist. To our knowledge, this is the first report of a patient with nonischemic cardiomyopathy and end-stage renal disease who presented with inappropriate defibrillator discharge caused by lead damage secondary to stenting across the leads.

Left atrial space occupying lesions pose diagnostic challenge on echocardiography. We report a79-year-old man with history ofpheochromocytoma with left adrenal mass presented with heart failure symptoms after adrenalectomy. Echocardiogram revealed a large echo lucent structure (6.9 x5.9 cm) compressing the posterior wall of the left atrium. Furtherinvestigation with computer tomography and barium swallow confirmed the diagnosis of hiatal hernia. In this report we explain the differential diagnosis and simple steps to assist the diagnosis of left atrial space occupying lesions noninvasively.

The percutaneous transradial approach for coronary angiography and percutaneous coronary intervention is increasing in the United States. Although its vascular safety profile is better than the traditional femoral approach, it is important to learn about potential complications. In this article, we present two cases of vascular complications, namely, pseudoaneurysm and radial artery occlusion, after transradial cardiac catheterization, along with a review of the relevant literature.

Primary cardiac tumors are rare and are usually diagnosed at an advanced stage due to nonspecific symptoms. We report a 46-year-old female who presented to our institution with shortness of breath and was diagnosed with a cardiac spindle-cell tumor. Wide surgical resection is the cornerstone for therapy for cardiac sarcomas. Our patient was considered inoperable due to the extent of the tumor.

Numerous clinical studies have shown that coronary artery calcium scoring provides substantial incremental risk prediction beyond conventional coronary risk factors for coronary heart disease events. About half of all patients with coronary artery disease (CAD) present initially with unexpected myocardial infarction or sudden death. Early identification of this subgroup of patients is vital for institution of intensive, early preventive measures to decrease morbidity and mortality due to CAD.

UNLABELLED Study Type - Therapy (case series). LEVEL OF EVIDENCE 4. What's known on the subject? and What does the study add? The indications and timing of native nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPKD) is controversial, especially for those undergoing renal transplantation. Post-transplant unilateral native nephrectomy appears to be the preferred intervention compared to pre-transplant native nephrectomy. There seems to be substantial additive risk to bilateral over unilateral nephrectomy, especially prior to transplantation. Pre-transplant native nephrectomy should only be carried out when there are clear indications such as massive size preventing allograft placement, severe pain, early satiety, recurrent bleeding and infections, or suspected malignancy. OBJECTIVE To analyse indications, timing and outcomes of native nephrectomy in autosomal dominant polycystic kidney disease (ADPKD) patients listed for kidney transplantation. PATIENTS AND METHODS A retrospective analysis of all ADPKD patients who had a native nephrectomy prior to or following transplantation between January 2003 and December 2009 at a single centre, including those undergoing the sandwich technique (removal of the most severely affected native kidney prior to transplantation, and the other afterwards), was undertaken. RESULTS There were 35 individuals in our cohort (M : F = 16 : 19), with a median age of 51.5 years (range 43-65). Twenty patients were in the pre-transplant nephrectomy group, 12 in the post-transplant group, and three underwent the sandwich technique. Indications for nephrectomy varied but were most commonly pain/discomfort, space for transplantation, ongoing haematuria, recurrent infections, and gastrointestinal pressure symptoms (early satiety). Seven individuals in the pre-transplant group and three in the post-transplant group required critical care admission after nephrectomy. Transient renal graft dysfunction occurred in two post-transplant bilateral nephrectomy patients. Two patients in the bilateral nephrectomy pre-transplant group and one in the bilateral nephrectomy post-transplant group died in the immediate post-operative period. No complications were noted in the sandwich technique group. CONCLUSION Native nephrectomy in ADPKD is a major undertaking associated with significant morbidity especially in the pre-transplant group. Post-transplant unilateral nephrectomy appears to be the safest approach with fewest complications.

Transplantation into an ileal conduit is an established option for patients with end-stage renal failure and a nonfunctioning urinary tract. Urinary fistulae are more common following these complex transplants. Urinary fistula in this scenario can cause substantial morbidity and even result in graft loss. The management options depend on the viability of the transplant ureter, the level of local sepsis and the overall condition of the patient. Urinary diversion with a nephrostomy and ureteric stents has been described in aiding the healing of urinary leaks in renal transplants into a functioning urinary tract. We describe the successful use of negative wound pressure therapy to eradicate the local sepsis and help the healing of a recurrent urinary fistula following kidney transplantation into an ileal conduit. To our knowledge these are the first such cases reported in the literature.

Abundant data have established coronary artery calcium score (CACS) in the algorithm of cardiovascular risk stratification, especially for those at intermediate risk of coronary artery disease (CAD). Absence of CACS is associated with a very low cardiac event rate in asymptomatic individuals and no further imaging is required. Cardiac event rates in symptomatic patients are comparatively higher but still relatively low and have to be interpreted in the context of the population included. Conflicting results from angiography literature with a reported presence of obstructive CAD in up to 39% of mostly symptomatic patients with zero CACS are explained by the higher-risk patients enrolled. CACS is an excellent test for asymptomatic patients in predicting cardiac events and absence of obstructive CAD but has a limited role in symptomatic and higher-risk patients encountered by a cardiovascular specialist, particularly those referred for CT angiography and invasive coronary angiography. This is especially true for relatively young patients (

OBJECTIVE—Corneal confocal microscopy (CCM) is a rapid, noninvasive, clinical examination technique that quantifies small nerve fiber pathology. We have used it to assess the neurological benefits of pancreas transplantation in type 1 diabetic patients. RESEARCH DESIGN AND METHODS—In 20 patients with type 1 diabetes undergoing simultaneous pancreas and kidney transplantation (SPK) and 15 control subjects, corneal sensitivity was evaluated using noncontact corneal esthesiometry, and small nerve fiber morphology was assessed using CCM. RESULTS—Corneal sensitivity (1.54 ± 0.28 vs. 0.77 ± 0.02, P < 0.0001), nerve fiber density (NFD) (13.8 ± 2.1 vs. 42 ± 3.2, P < 0.0001), nerve branch density (NBD) (4.04 ± 1.5 vs. 26.7 ± 2.5, P < 0.0001), and nerve fiber length (NFL) (2.23 ± 0.2 vs. 9.69 ± 0.7, P < 0.0001) were significantly reduced, and nerve fiber tortuosity (NFT) (15.7 ± 1.02 vs. 19.56 ± 1.34, P = 0.04) was increased in diabetic patients before pancreas transplantation. Six months after SPK, 15 patients underwent a second assessment and showed a significant improvement in NFD (18.04 ± 10.48 vs. 9.25 ± 1.87, P = 0.001) and NFL (3.60 ± 0.33 vs. 1.84 ± 0.33, P = 0.002) with no change in NBD (1.38 ± 0.74 vs. 1.38 ± 1.00, P = 1.0), NFT (15.58 ± 1.20 vs. 16.30 ± 1.19, P = 0.67), or corneal sensitivity (1.23 ± 0.39 vs. 1.54 ± 00.42, P = 0.59). CONCLUSIONS—Despite marked nerve fiber damage in type 1 diabetic patients undergoing pancreas transplantation, small fiber repair can be detected within 6 months of pancreas transplantation using CCM. CCM is a novel noninvasive clinical technique to assess the benefits of therapeutic intervention in human diabetic neuropathy.

Patients with prosthetic cardiac valves are at high risk for thromboembolic complications and need life long anticoagulation with warfarin, which can be associated with variable dose requirements and fluctuating level of systemic anticoagulation and may predispose to thromboembolic and or hemorrhagic complications. Prosthetic cardiac valve thrombosis is associated with high morbidity and mortality. A high index of suspicion is essential for prompt diagnosis. Transthoracic echocardiography, and if required transesophageal echocardiography are the main diagnostic imaging modalities. Medically stable patients can be managed with thrombolytic therapy and anticoagulation, while some patients may require surgical thrombectomy or valve replacement. We present a case report of a patient with prosthetic mitral valve and an unusually large left atrial thrombus with both thromboembolic and hemorrhagic complications.

Left ventricular (LV) pseudoaneurysm is a rare complication that is reported in less than 0.1% of all patients with myocardial infarction. It is the result of cardiac rupture contained by the pericardium and is characterized by the absence of myocardial tissue in its wall unlike true aneurysm which involves full thickness of the cardiac wall. The clinical presentation of these patients is nonspecific, making the diagnosis challenging. Transthoracic echocardiogram and cardiac magnetic resonance imaging are the noninvasive modalities whereas coronary arteriography and left ventriculography are invasive modalities used for the diagnosis. As this condition is lethal, prompt diagnosis and timely management is vital.

Bitter Melon (Momordica charantia) is a widely used traditional remedy for hyperglycemia. While the medicinal properties of this plant have been studied extensively using in vitro and animal models, the clinical efficacy and safety in humans is largely unknown. This review discusses the benefits and limitations of bitter melon supplementation in the context of epidemic levels of insulin resistance and pre-diabetes throughout the world.

Pulmonary Hypertension in Patients Undergoing Kidney Transplant - A Single Center Experience Pulmonary hypertension (PH) is a fatal disease with a high mortality rate. It has also been found to increase perioperative complications including persistent post-operative hypoxia, right ventricular failure and coronary ischemia. Reich and colleagues observed that a mean pulmonary artery pressure >30 mm Hg was a significant independent predictor of post-operative mortality in over 2000 patients undergoing cardiopulmonary bypass.

Acute Right Ventricular Failure and Pulmonary Hypertension Secondary to Acute on Chronic Pulmonary Thromboembolic Disease Pulmonary embolism is a potentially correctable cause of Pulmonary Hypertension (PH). The right ventricle is susceptible to failure with acute elevations in afterload. Without intervention, the rate of survival is low and proportional to the degree of PH. Pulmonary thromboendarterectomy is considered in symptomatic patients who have hemodynamic or ventilatory impairment at rest or with exercise.

The role of statins in reducing the risk of coronary artery disease is well established. The use of statins in patients at high risk for cardiovascular disease has reduced the incidence of major clinical events by 25% to 40%. However, despite aggressive statin therapy and the achievement of target low-density lipoprotein cholesterol levels, the residual risk of cardiovascular events remains high. This review investigates emerging therapies to target the residual risk of cardiovascular events with concurrent statin therapy.

Numerous trials have shown that chronic kidney disease increases the risk of cardiovascular disease. Dyslipidemias have been shown to accelerate progression of kidney disease. Statins have assumed a pivotal role in management of hyperlipidemia. However their effect on renal function is still not fully understood. Some clinical trials have shown some renoprotective effect of statins but there is still need for more data to clarify effects of statins on renal function.

Study Type - Therapy (case series).4. What's known on the subject? and What does the study add? The indications and timing of native nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPKD) is controversial, especially for those undergoing renal transplantation. Post-transplant unilateral native nephrectomy appears to be the preferred intervention compared to pre-transplant native nephrectomy. There seems to be substantial additive risk to bilateral over unilateral nephrectomy, especially prior to transplantation. Pre-transplant native nephrectomy should only be carried out when there are clear indications such as massive size preventing allograft placement, severe pain, early satiety, recurrent bleeding and infections, or suspected malignancy.To analyse indications, timing and outcomes of native nephrectomy in autosomal dominant polycystic kidney disease (ADPKD) patients listed for kidney transplantation.A retrospective analysis of all ADPKD patients who had a native nephrectomy prior to or following transplantation between January 2003 and December 2009 at a single centre, including those undergoing the sandwich technique (removal of the most severely affected native kidney prior to transplantation, and the other afterwards), was undertaken.There were 35 individuals in our cohort (M : F = 16 : 19), with a median age of 51.5 years (range 43-65). Twenty patients were in the pre-transplant nephrectomy group, 12 in the post-transplant group, and three underwent the sandwich technique. Indications for nephrectomy varied but were most commonly pain/discomfort, space for transplantation, ongoing haematuria, recurrent infections, and gastrointestinal pressure symptoms (early satiety). Seven individuals in the pre-transplant group and three in the post-transplant group required critical care admission after nephrectomy. Transient renal graft dysfunction occurred in two post-transplant bilateral nephrectomy patients. Two patients in the bilateral nephrectomy pre-transplant group and one in the bilateral nephrectomy post-transplant group died in the immediate post-operative period. No complications were noted in the sandwich technique group.Native nephrectomy in ADPKD is a major undertaking associated with significant morbidity especially in the pre-transplant group. Post-transplant unilateral nephrectomy appears to be the safest approach with fewest complications.

Background. Pancreas transplantation (PT) remains the only treatment that can restore insulin independence among insulin-dependent diabetics. An ageing population in developed countries has led to an increasing number of older patients who may be suitable for PT. Some investigators argue that PT in recipients older than 50 years has an inferior outcome compared with the younger group. Methods. The object of this study was to compare the outcomes of 31 PT in patients aged 50 and above 105 PT in recipients below 50 years performed between June 2001 and December 2007. Results. The incidence of general posttransplant complications were similar in both; 60% in less than 50 vs. 58% in more than or equal to 50, P= 0.539. So, as the incidence of other surgical complication in the more than or equal to 50 group compared with less than 50 (graft thrombosis 13% vs. 11.5%; bleeding 19% vs. 6.7%; abdominal abscess 23% vs. 19%; pancreatic leak 13% vs. 9.6%). There was no significant difference in the incidence of urinary tract infection and early rejection in either group. However, the incidence of respiratory tract infection was significantly higher in more than or equal to 50 (38.7% in ≥50 vs. 9.6% in

Simultaneous pancreas and kidney transplantation (SPK) is the treatment of choice for insulin-dependent diabetics with end-stage renal failure. The shortage of suitable pancreata has led to the use of donors after cardiac death (DCD). Although more than 20,000 pancreas transplants have been performed worldwide, the experience of pancreas transplantation from DCD remains limited. Factors during recovery, storage, and reperfusion may result in injury to the duodenal segment of the pancreas allograft. Here we have reported a case of duodenal necrosis after reperfusion in a patient who underwent SPK from a DCD. The pancreas was salvaged by excising the duodenum and performing a direct pancreas duct to bladder anastomosis. After recovery of function by the transplanted kidney, the patient developed recurrent urinary sepsis. The bladder-drained pancreas was converted to a direct enteric drainage, which resolved the recurrent urinary sepsis.

An 86-year-old white male brought to the emergency room for weakness and lethargy was found to have third degree AV block with a left bundle branch escape rhythm ( Figure 1A ). An Advisa MRI® (Medtronic) dual-chamber pacemaker was implanted. Telemetry tracings revealed asymptomatic episodes of isolated …