Publications by authors named "Parikshit S Sharma"

83 Publications

A Clinical Challenge Overcome by His Bundle Pacing.

JACC Case Rep 2020 Feb 19;2(2):240-244. Epub 2020 Feb 19.

Division of Cardiology, Rush University Medical Center, Chicago, Illinois.

We highlight a diagnostic challenge in a patient with dyspnea on exertion due to radiation therapy-induced severe first-degree atrioventricular block and how permanent His bundle pacing was helpful in overcoming these symptoms. ().
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http://dx.doi.org/10.1016/j.jaccas.2019.11.077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8298658PMC
February 2020

Feasibility and Outcomes of Upgrading to Left Bundle Branch Pacing in Patients With Pacing-Induced Cardiomyopathy and Infranodal Atrioventricular Block.

Front Cardiovasc Med 2021 14;8:674452. Epub 2021 Jun 14.

Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.

His bundle pacing (HBP) can reverse left ventricular (LV) remodeling in patients with right ventricular (RV) pacing-induced cardimyopathy (PICM) but may be unable to correct infranodal atrioventricular block (AVB). Left bundle branch pacing (LBBP) results in rapid LV activation and may be able to reliably pace beyond the site of AVB. Our study was conducted to assess the feasibility, safety, and outcomes of permanent LBBP in infranodal AVB and PICM patients. Patients with infranodal AVB and PICM who underwent LBBP for cardiac resynchronization therapy (CRT) were included. Clinical evaluation and echocardiographic and electrocardiographic assessments were recorded at baseline and follow-up. Permanent LBBP upgrade was successful in 19 of 20 patients with a median follow-up duration of 12 months. QRS duration (QRSd) increased from 139.3 ± 28.0 ms at baseline to 176.2 ± 21.4 ms ( < 0.001) with right ventricular pacing (RVP) and was shortened to 120.9 ± 15.2 ms after LBBP ( < 0.001). The mean LBBP threshold was 0.7 ± 0.3 V at 0.4 ms at implant and remained stable during follow-up. The left ventricular ejection fraction (LVEF) increased from 36.3% ± 6.5% to 51.9% ± 13.0% ( < 0.001) with left ventricular end-systolic volume (LVESV) reduced from 180.1 ± 43.5 to 136.8 ± 36.7 ml ( < 0.001) during last follow-up. LBBP paced beyond the site of block, which results in a low pacing threshold with a high success rate in infranodal AVB patients. LBBP improved LV function with stable parameters over the 12 months, making it a reasonable alternative to cardiac resynchronization pacing via a coronary sinus lead in infranodal AVB and PICM patients.
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http://dx.doi.org/10.3389/fcvm.2021.674452DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236829PMC
June 2021

Use of infrared thermography to delineate temperature gradients and critical isotherms during catheter ablation with normal and half normal saline: Implications for safety and efficacy.

J Cardiovasc Electrophysiol 2021 Jun 1. Epub 2021 Jun 1.

Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA.

Background: Radiofrequency (RF) ablation with half-normal saline (HNS) has shown promise as a bail-out strategy following failed ventricular tachycardia ablation using standard approaches.

Objective: To use a novel infrared thermal imaging (ITI) model to evaluate biophysical and lesion characteristics during RF ablation using normal saline (NS) and HNS irrigation.

Methods: Left ventricular strips of myocardium were excised from fresh porcine hearts. RF ablation was performed using an open-irrigated ablation catheter (Thermocool ST/SF) with NS (n = 75) and HNS (n = 75) irrigation using different power settings (40/50 W), RF durations (30/60 s), contact force of 10-15 g, and flow rate of 15 ml/min. RF lesions were recorded using an infrared thermal camera and border zone, lethal, 100° isotherms were matched with necrotic borders after 2% triphenyltetrazolium chloride staining. Lesion dimensions and isotherms (mm ) were measured.

Results: In total, 150 lesions were delivered. HNS lesions were deeper (6.4 ± 1.1 vs. 5.7 ±0.8 mm; p = .03), and larger in volume (633 ± 153 vs. 468 ± 107 mm ; p = .007) than NS lesions. Steam pops (SPs) occurred during 19/75 lesions (25%) in the NS group and 32/75 lesions (43%) in the HNS group (p = .34). Lethal (57.8 ± 6.5 vs. 36.0 ± 3.9 mm ; p = .001) and 100°C isotherm areas (16.9 ± 6.9 vs. 3.8 ± 4.2 mm ; p = .003) areas were larger and were reached earlier in the HNS group.

Conclusions: RFA using HNS created larger lesions than NS irrigation but led to more frequent SPs. The presence of earlier lethal isotherms and temperature rises above 100°C on ITI suggest a potentially narrower therapeutic-safety window with HNS.
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http://dx.doi.org/10.1111/jce.15121DOI Listing
June 2021

Conduction System Pacing for Cardiac Resynchronisation.

Arrhythm Electrophysiol Rev 2021 Apr;10(1):51-58

Geisinger Heart Institute, Wilkes-Barre, PA, US.

Conduction system pacing (CSP) is a technique of pacing that involves implantation of permanent pacing leads along different sites of the cardiac conduction system and includes His bundle pacing and left bundle branch pacing. There is an emerging role for CSP to achieve cardiac resynchronisation in patients with heart failure with reduced ejection fraction and inter-ventricular dyssynchrony. In this article, the authors review these strategies for resynchronisation and the available data on the use of CSP in overcoming dyssynchrony.
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http://dx.doi.org/10.15420/aer.2020.45DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076975PMC
April 2021

Evaluation of the Criteria to Distinguish Left Bundle Branch Pacing From Left Ventricular Septal Pacing.

JACC Clin Electrophysiol 2021 Apr 22. Epub 2021 Apr 22.

Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; The Key Lab of Cardiovascular Disease, Science and Technology of Wenzhou, Wenzhou, China. Electronic address:

Objectives: This study sought to assess the predictive value of the proposed electrocardiogram and intracardiac electrogram characteristics for confirmation of left bundle branch (LBB) capture.

Background: Previously proposed criteria to distinguish left bundle branch pacing (LBBP) and left ventricular septum (LVS) pacing (LVSP) have not been fully validated.

Methods: A His bundle pacing lead, an LBBP lead, and a multielectrode catheter at the LVS were placed. Direct LBB capture was defined as demonstration of retrograde His potential on the His bundle pacing lead and/or anterograde left conduction system potentials on the multielectrode catheter during LBBP. The routinely used parameters-His, LBB potential, time from stimulus to left ventricular activation (Stim-LVAT), and paced QRS morphology during LVSP and LBBP at various depths and outputs were analyzed.

Results: Thirty patients (21 non-left bundle branch block [LBBB], 9 LBBB) who demonstrated direct LBB capture using the defined criteria were included. The proportion of paced right bundle branch block was 100% during LBB capture in all patients compared to 23.4% in non-LBBB and 44.4% in LBBB during LVSP. LBB potential was recorded in all patients during intrinsic rhythm (non-LBBB group) or His corrective pacing in LBBB. Paced QRS duration was longer during selective LBBP compared to nonselective LBBP or LVSP only. All patients with characteristics of selective LBBP or abrupt decrease in Stim-LVAT of ≥10 ms demonstrated LBB capture.

Conclusions: Direct LBB capture can be confirmed by recording retrograde His potential and anterograde left conduction system potentials. Abrupt decrease in Stim-LVAT of ≥10 ms and demonstration of selective LBBP could be used as simple criteria to confirm LBB capture.
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http://dx.doi.org/10.1016/j.jacep.2021.02.018DOI Listing
April 2021

Clinical Applications of Laser Technology: Laser Balloon Ablation in the Management of Atrial Fibrillation.

Micromachines (Basel) 2021 Feb 12;12(2). Epub 2021 Feb 12.

Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA.

Catheter-based ablation techniques have a well-established role in atrial fibrillation (AF) management. The prevalence and impact of AF is increasing globally, thus mandating an emphasis on improving ablation techniques through innovation. One key area of ongoing evolution in this field is the use of laser energy to perform pulmonary vein isolation during AF catheter ablation. While laser use is not as widespread as other ablation techniques, such as radiofrequency ablation and cryoballoon ablation, advancements in product design and procedural protocols have demonstrated laser balloon ablation to be equally safe and effective compared to these other modalities. Additionally, strategies to improve procedural efficiency and decrease radiation exposure through low fluoroscopy protocols make this technology an increasingly promising and exciting option.
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http://dx.doi.org/10.3390/mi12020188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7917803PMC
February 2021

Left Bundle Branch Area Pacing for Cardiac Resynchronization Therapy: Results From the International LBBAP Collaborative Study Group.

JACC Clin Electrophysiol 2021 02 28;7(2):135-147. Epub 2020 Oct 28.

First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland.

Objectives: The aim of this study was to assess the feasibility and outcomes of left bundle branch area pacing (LBBAP) in patients eligible for cardiac resynchronization therapy (CRT) in an international, multicenter, collaborative study.

Background: CRT using biventricular pacing is effective in patients with heart failure and left bundle branch block (LBBB). LBBAP has been reported as an alternative option for CRT.

Methods: LBBAP was attempted in patients with left ventricular ejection fraction (LVEF) <50% and indications for CRT or pacing. Procedural outcomes, left bundle branch capture, New York Heart Association functional class, heart failure hospitalization, echocardiographic data, and lead complications were recorded. Clinical (no heart failure hospitalization and improvement in New York Heart Association functional class) and echocardiographic responses (≥5% improvement in LVEF) were assessed.

Results: LBBAP was attempted in 325 patients, and CRT was successfully achieved in 277 (85%) (mean age 71 ± 12 years, 35% women, ischemic cardiomyopathy in 44%). QRS configuration at baseline was LBBB in 39% and non-LBBB in 46%. Procedure and fluoroscopy duration were 105 ± 54 and 19 ± 15 min, respectively. LBBAP threshold and R-wave amplitudes were 0.6 ± 0.3 V at 0.5 ms and 10.6 ± 6 mV at implantation and remained stable during mean follow-up of 6 ± 5 months. LBBAP resulted in significant QRS narrowing from 152 ± 32 to 137 ± 22 ms (p < 0.01). LVEF improved from 33 ± 10% to 44 ± 11% (p < 0.01). Clinical and echocardiographic responses were observed in 72% and 73% of patients, respectively. Baseline LBBB (odds ratio: 3.96; 95% confidence interval: 1.64 to 9.26; p < 0.01) and left ventricular end-diastolic diameter (odds ratio: 0.62; 95% confidence interval: 0.49 to 0.79; p < 0.01) were independent predictors of echocardiographic response.

Conclusions: LBBAP is feasible and safe and provides an alternative option for CRT. LBBAP provides remarkably low and stable pacing thresholds and was associated with improved clinical and echocardiographic outcomes.
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http://dx.doi.org/10.1016/j.jacep.2020.08.015DOI Listing
February 2021

High-power short duration vs. conventional radiofrequency ablation of atrial fibrillation: a systematic review and meta-analysis.

Europace 2021 May;23(5):710-721

Section of Electrophysiology, Division of Cardiology, Department of Medicine, Rush University Medical Center, 1717 W Congress Pkwy Suite 317 Kellogg, Chicago, IL 60612, USA.

Aims: We sought to compare the effectiveness and safety of high-power short-duration (HPSD) radiofrequency ablation (RFA) with conventional RFA in patients with atrial fibrillation (AF).

Methods And Results: MEDLINE, Cochrane, and ClinicalTrials.gov databases were searched until 15 May 2020 for relevant studies comparing HPSD vs. conventional RFA in patients undergoing initial catheter ablation for AF. A total of 15 studies involving 3718 adult patients were included in our meta-analysis (2357 in HPSD RFA and 1361 in conventional RFA). Freedom from atrial arrhythmia was higher in HPSD RFA when compared with conventional RFA [odds ratio (OR) 1.44, 95% confidence interval (CI) 1.10-1.90; P = 0.009]. Acute PV reconnection was lower (OR 0.56, P = 0.005) and first-pass isolation was higher (OR 3.58, P < 0.001) with HPSD RFA. There was no difference in total complications between the two groups (P = 0.19). Total procedure duration [mean difference (MD) -37.35 min, P < 0.001], fluoroscopy duration (MD -5.23 min, P = 0.001), and RF ablation time (MD -16.26 min, P < 0.001) were all significantly lower in HPSD RFA. High-power short-duration RFA also demonstrated higher freedom from atrial arrhythmia in the subgroup analysis of patients with paroxysmal AF (OR 1.80, 95% CI 1.29-2.50; P < 0.001), studies with ≥50 W protocol in the HPSD RFA group (OR 1.53, 95% CI 1.08-2.18; P = 0.02] and studies with contact force sensing catheter use (OR 1.65, 95% CI 1.21-2.25; P = 0.002).

Conclusion: High-power short-duration RFA was associated with better procedural effectiveness when compared with conventional RFA with comparable safety and shorter procedural duration.
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http://dx.doi.org/10.1093/europace/euaa327DOI Listing
May 2021

Novel left ventricular cardiac synchronization: left ventricular septal pacing or left bundle branch pacing?

Europace 2020 12;22(Suppl_2):ii10-ii18

Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou 325000, PR China.

It is well recognized that a high burden of right ventricular pacing results in deleterious clinical outcomes over the long term. His bundle pacing can achieve optimal ventricular synchronization; however, relatively high pacing thresholds, low R-wave amplitudes, and the long-term performance have been concerns. Recently, left ventricular (LV) septal endocardium pacing (LVSP) has demonstrated improved acute haemodynamics. Another novel technique of intraseptal left bundle branch pacing (LBBP) via transvenous approach has been adopted rapidly and has demonstrated its feasibility and effectiveness. This article reviews the clinical application and differences between LVSP and LBBP. Compared with LVSP, LBBP has strict criteria for left conduction system capture and lead location. In addition to LV septal capture it also stimulates the proximal left bundle branch, resulting in rapid and physiological LV activation. With a uniformity and standardization of the implant procedure and definitions, it may be possible to achieve widespread application of this form of physiological pacing.
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http://dx.doi.org/10.1093/europace/euaa297DOI Listing
December 2020

Long-term results of His bundle pacing and atrioventricular node ablation: is this the future?

Europace 2020 12;22(Suppl_2):ii1-ii2

Division of Cardiology, Rush University Medical Center, 1717 W Congress Pkwy, Suite 300, Kellogg, Chicago, IL 60612, USA.

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http://dx.doi.org/10.1093/europace/euaa260DOI Listing
December 2020

Pros and Cons of Left Bundle Branch Pacing: A Single-Center Experience.

Circ Arrhythm Electrophysiol 2020 12 16;13(12):e008874. Epub 2020 Nov 16.

Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL.

Background: Left bundle branch pacing (LBBP) has recently emerged as a promising alternative modality for conduction system pacing. However, limited real-world data exists on the advantages and complications associated with LBBP. We analyzed the Rush conduction system pacing registry on LBBP to assess the success rates and complications associated with LBBP.

Methods: All patients with an indication for permanent pacemaker or cardiac resynchronization therapy that underwent LBBP for various reasons from June 2018 to April 2020 were included in the analysis.

Results: A total of 57 of 59 patients underwent successful LBBP (success rate 97%). The average follow-up duration was 6.2±5 months. The implanted devices included 38 dual-chamber pacemakers, 17 cardiac resynchronization therapy defibrillators, and 2 cardiac resynchronization therapy pacing systems. The most common reason for performing LBBP was a high His-Bundle pacing threshold (n=23) at implant. The mean LBBP capture threshold at implant was 0.62±0.21 V at 0.4 ms which remained stable during follow-up at 0.65±0.68 V at 0.4ms. In 21 patients with cardiomyopathy, there was a significant improvement in left ventricle ejection fraction from 30±11% to 42±15%. A total of 7 lead-related complications (12.3%) were noted in the follow-up period. Three patients (5.3%) required lead revision during the follow-up period. Interventricular septal perforation occurred (as late sequela) after 2 weeks in one patient.

Conclusions: LBBP can be achieved with a high success rate and low capture thresholds. Left ventricular dysfunction improved significantly during follow-up. Lead-related complications were relatively common occurring in 12.3% of initially successful implants. Lead revision was required in 3 (5%) of patients.
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http://dx.doi.org/10.1161/CIRCEP.120.008874DOI Listing
December 2020

Development of New-Onset or Progressive Atrial Fibrillation in Patients With Permanent HIS Bundle Pacing Versus Right Ventricular Pacing: Results From the RUSH HBP Registry.

J Am Heart Assoc 2020 11 11;9(22):e018478. Epub 2020 Nov 11.

Division of Cardiology Department of Medicine Rush University Medical Center Chicago IL.

Background Conventional right ventricular pacing (RVP) has been associated with an increased incidence of atrial fibrillation (AF). We sought to compare the occurrence of new-onset AF and assessed AF disease progression during long-term follow-up between His bundle pacing (HBP) and RVP. Methods and Results We included patients undergoing initial dual-chamber pacemaker implants at Rush University Medical Center between January 1, 2016, and June 30, 2019. A total of 360 patients were evaluated, and 225 patients (HBP, n=105; RVP, n=120) were included in the study. Among the 148 patients (HBP, n=72; RVP, n=76) with no history of AF, HBP demonstrated a lower risk of new-onset AF (adjusted hazard ratio [HR], 0.53; 95% CI, 0.28-0.99; =0.046) compared with traditional RVP. This benefit was observed with His or RVP burden exceeding 20% (HR, 0.29; 95% CI, 0.13-0.64; =0.002), ≥40% (HR, 0.31; =0.007), ≥60% (HR, 0.35; =0.015), and ≥80% (HR, 0.40; =0.038). There was no difference with His or RV pacing burden <20% (HR, 0.613; 95% CI, 0.213-1.864; =0.404). In patients with a prior history of AF, there was no difference in AF progression (=0.715); however, in a subgroup of patients with a pacing burden ≥40%, HBP demonstrated a trend toward a lower risk of AF progression (HR, 0.19; 95% CI, 0.03-1.16; =0.072). Conclusions HBP demonstrated a lower risk of new-onset AF compared with RVP, which was primarily observed at a higher pacing burden.
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http://dx.doi.org/10.1161/JAHA.120.018478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763709PMC
November 2020

His bundle pacing: Tips and tricks.

Pacing Clin Electrophysiol 2021 01 26;44(1):26-34. Epub 2020 Nov 26.

Section of Electrophysiology, Division of Cardiology, Department of Medicine, Rush University Medical center, Chicago, Illinois.

His bundle (HB) pacing is an established modality for achieving physiological pacing with a low risk of long-term lead-related complications. The development of specially designed lead and delivery tools has improved the feasibility and safety of HB pacing (HBP). Knowledge of the anatomy of HB region and the variations is essential for successful implantation. Newer delivery systems have further improved procedural outcomes. Challenging implant cases can be successfully performed by reshaping the current sheaths, using "sheath in sheath" technique or "two-lead implantation technique." Special attention to the lead parameters at implant, programming, and follow-up is necessary for successful long-term outcomes with HBP. Widespread use of HBP by electrophysiologists and further advances in dedicated delivery systems and leads are essential to further improve the effectiveness of the implantation.
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http://dx.doi.org/10.1111/pace.14108DOI Listing
January 2021

Correlation Between Exercise Metabolic Equivalents and Risk Factors in Nonathletes With Atrial Fibrillation.

Am J Cardiol 2021 01 16;138:128-129. Epub 2020 Oct 16.

Division of Cardiology, Rush University Medical Center, Kellogg/Chicago, Illinois. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2020.10.028DOI Listing
January 2021

Safety and Effectiveness of Hydroxychloroquine and Azithromycin Combination Therapy for Treatment of Hospitalized Patients with COVID-19: A Propensity-Matched Study.

Cardiol Ther 2020 Dec 14;9(2):523-534. Epub 2020 Oct 14.

Department of Cardiology, Rush University Medical Center, Chicago, IL, USA.

Introduction: We sought to determine the effectiveness and safety of hydroxychloroquine-azithromycin (HCQ-AZM) therapy in hospitalized patients with COVID-19.

Methods: This was a retrospective cohort study of 613 patients hospitalized (integrated health system involving three hospitals) for RT-PCR-confirmed COVID-19 infection between March 1, 2020 and April 25, 2020. Intervention was treatment with HCQ-AZM in hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Outcomes of interest were in-hospital all-cause mortality, cardiovascular mortality, pulseless electrical activity (PEA) arrest, non-lethal arrhythmias, and length of hospital stay. Secondary measures included in-hospital corrected QT (QTc) interval parameters and serum biomarkers levels.

Results: Propensity-matched groups were composed of 173 patients given HCQ-AZM and 173 matched patients who did not receive treatment. There was no significant difference in in-hospital mortality (odds ratio [OR] 1.52; 95% confidence interval [CI] 0.80-2.89; p = 0.2), PEA arrest (OR 1.68, CI 0.68-4.15; p = 0.27), or incidence of non-lethal arrhythmias (10.4% vs. 6.8%; p = 0.28). Length of hospital stay (10.5 ± 7.4 vs. 5.8 ± 6.1; p < 0.001), peak CRP levels (252 ± 136 vs. 166 ± 124; p < 0.0001), and degree of QTc interval prolongation was higher for the HCQ-AZM group (28 ± 32 vs. 9 ± 32; p < 0.0001), but there was no significant difference in incidence of sustained ventricular arrhythmias (2.8% vs. 1.7%; p = 0.52). HCQ-AZM was stopped in 10 patients because of QT interval prolongation and 1 patient because of drug-related polymorphic ventricular tachycardia.

Conclusion: In this propensity-matched study, there was no difference in in-hospital mortality, life-threatening arrhythmias, or incidence of PEA arrest between the HCQ-AZM and untreated control groups. QTc intervals were longer in patients receiving HCQ-AZM, but only one patient developed drug-related ventricular tachycardia.
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http://dx.doi.org/10.1007/s40119-020-00201-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7556606PMC
December 2020

Late-onset interventricular septal perforation from left bundle branch pacing.

HeartRhythm Case Rep 2020 Sep 17;6(9):627-631. Epub 2020 Jun 17.

Rush University Medical Center, Chicago, Illinois.

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http://dx.doi.org/10.1016/j.hrcr.2020.06.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7498514PMC
September 2020

Sensors for rate-adaptive pacing: How they work, strengths, and limitations.

J Cardiovasc Electrophysiol 2020 11 8;31(11):3009-3027. Epub 2020 Oct 8.

Department of Medicine, Section of Electrophysiology, Arrhythmia and Pacemaker Services, Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA.

Chronotropic incompetence is the inability of the sinus node to increase heart rate commensurate with increased metabolic demand. Cardiac pacing alone may be insufficient to address exercise intolerance, fatigue, dyspnea on exertion, and other symptoms of chronotropic incompetence. Rate-responsive (adaptive) pacing employs sensors to detect physical or physiological indices and mimic the response of the normal sinus node. This review describes the development, strengths, and limitations of a variety of sensors that have been employed to address chronotropic incompetence. A mini-tutorial on programming rate-adaptive parameters is included along with emphasis that patients' lifestyles and underlying medical conditions require careful consideration. In addition, special sensor applications used to respond prophylactically to physiologic signals are detailed and an in-depth discussion of sensors as a potential aid in heart failure management is provided.
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http://dx.doi.org/10.1111/jce.14733DOI Listing
November 2020

Cryoballoon Ablation and Bipolar Voltage Mapping in Patients With Left Atrial Appendage Occlusion Devices.

Am J Cardiol 2020 11 28;135:99-104. Epub 2020 Aug 28.

Division of Cardiology, Rush University Medical Center, Chicago, Illinois.

Left atrial appendage occlusion is utilized as a second line therapy to long-term oral anticoagulation in appropriately selected patients with atrial fibrillation (AF). We examined the feasibility of cryoballoon (CB) pulmonary vein isolation (PVI) subsequent to Watchman device implantation. The study prospectively identified patients with Watchman devices (>90 days old) who underwent CB-PVI ablation between 2018 and 2019. Twelve consecutive patients (male 50%; mean age 71 ± 9 years; CHADS-VASc score 3.4 ± 1.1) underwent CB-PVI procedures after Watchman device implantation (mean 182 ± 82 days). Acute PVI was achieved in 100% of patients. All patients had evidence of complete (n = 9) or partial (n = 3) endothelialization of the surface of the Watchman device with conductive tissue properties demonstrated during electrophysiologic testing. There were no major procedure-related complications including death, stroke, pericardial effusion, device dislodgment, device thrombus, or new or increasing peri-device leak. Mean peri-device leak size (45-day postimplant: 0.06 ± 0.09 mm vs Post-PVI: 0.04 ± 0.06 mm; p = 0.61) remained unchanged. Two patients had recurrence of AF after the 90-day blanking period (13.2 ± 6.6 months). One patient underwent a redo ablation procedure for recurrent AF. This pilot study suggests the potential feasibility of CB-PVI ablation in patients with chronic Watchman left atrial appendage occlusion devices. Larger prospective studies are needed to confirm the clinical efficacy and safety of this approach.
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http://dx.doi.org/10.1016/j.amjcard.2020.08.045DOI Listing
November 2020

Lithium-Induced Brugada Pattern: A Case Report and Review of Literature.

Cureus 2020 Jul 23;12(7):e9351. Epub 2020 Jul 23.

Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, USA.

Lithium-induced type 1 Brugada pattern in asymptomatic patients is an uncommon occurrence that is challenging to manage and to estimate the risk of sudden cardiac death (SCD). We describe a case of a 74-year-old woman who presented with type 1 Brugada pattern while on lithium therapy. Her lithium level was within the therapeutic range at the time of presentation. There was no evidence of ventricular ectopy or malignant arrhythmias. Review of electrocardiogram (ECG) prior to initiation of lithium therapy demonstrated type 3 Brugada pattern. Lithium was promptly discontinued, and the patient was closely monitored in the hospital for 48 hours with serial ECGs and telemetry, as her lithium levels decreased. The Brugada pattern resolved on day 10 of discontinuation of lithium therapy and no further intervention was performed. Early diagnosis and prompt discontinuation of lithium leads to the resolution of type 1 Brugada pattern and may reduce the risk of SCD. The case highlights the importance of obtaining baseline ECG when initiating lithium especially in patients with type 2 or 3 Brugada pattern and provides an overview of the serial changes in ECG pattern until resolution following discontinuation of lithium. Electrophysiology study for risk stratification in asymptomatic patients does not appear to provide any additional benefit.
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http://dx.doi.org/10.7759/cureus.9351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444957PMC
July 2020

A systematic review and meta-analysis comparing second-generation cryoballoon and contact force radiofrequency ablation for initial ablation of paroxysmal and persistent atrial fibrillation.

J Cardiovasc Electrophysiol 2020 10 23;31(10):2559-2571. Epub 2020 Jul 23.

Division of Electrophysiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA.

Introduction: Cryoballoon ablation (CBA) and radiofrequency ablation (RFA) are the preferred modalities for catheter ablation of atrial fibrillation (AF). Technological advances have improved procedural outcomes, warranting an updated comparison. We sought to evaluate the efficacy and safety of CBA-2nd generation (CBA-2G) in comparison to RFA-contact force (RFA-CF) in patients with AF.

Methods: MEDLINE, Cochrane, and ClinicalTrials.gov databases were searched until 03/01/2020 for relevant studies comparing CBA-2G versus RFA-CF in patients undergoing initial catheter ablation for AF.

Results: A total of 17 studies, involving 11 793 patients were included. There was no difference between the two groups in the outcomes of freedom from atrial arrhythmia (p = .67) and total procedural complications (p = .65). There was a higher incidence of phrenic nerve palsy in CBA-2G (odds ratio: 10.7; 95% confidence interval [CI]: 5.85 to 19.55; p < .001). Procedure duration was shorter (mean difference: -31.32 min; 95% CI: -40.73 to -21.92; p < .001) and fluoroscopy duration was longer (+3.21 min; 95% CI: 1.09 to 5.33; p = .003) in CBA-2G compared to RFA-CF. In the subgroup analyses of patients with persistent AF and >1 freeze lesion delivered per vein, there was no difference in freedom from atrial arrhythmia.

Conclusions: In AF patients undergoing initial ablation, CBA-2G and RFA-CF were equally efficacious. The procedure duration was shorter, but with a higher incidence of phrenic nerve palsy in CBA-2G. In patients with persistent AF, there was no difference in the efficacy between CBA-2G or RFA-CF techniques.
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http://dx.doi.org/10.1111/jce.14676DOI Listing
October 2020

His-Purkinje Conduction System Pacing Following Transcatheter Aortic Valve Replacement: Feasibility and Safety.

JACC Clin Electrophysiol 2020 06 6;6(6):649-657. Epub 2020 May 6.

Rush University Medical Center, Chicago, Illinois, USA.

Objectives: This study aimed to assess the feasibility and success rates of permanent His-Purkinje conduction system pacing (HPCSP) in patients requiring pacing after transcatheter aortic valve replacement (TAVR).

Background: TAVR is associated with increased risk for atrioventricular block. HPCSP has the potential to reduce electromechanical dyssynchrony associated with right ventricular pacing. The feasibility and safety of HPCSP in this population are unknown.

Methods: Consecutive patients requiring pacemakers after TAVR in whom His bundle pacing (HBP) and/or left bundle branch area pacing (LBBAP) was attempted at 5 centers were included in the study. Implant success rates, pacing characteristics, QRS duration, and left ventricular ejection fraction were assessed. Any procedure-related complications, lead revisions, heart failure hospitalizations, and deaths were documented.

Results: HPCSP was successful in 55 of 65 (85%) patients studied. HBP was successful in 29 of 46 patients (63%), and LBBAP was successful in 26 of 28 (93%) patients in whom it was attempted. HBP was more successful in patients with Sapien valves than in those with CoreValves (69% vs. 44%; p < 0.05). LBBAP was associated with lower pacing thresholds and higher R-wave amplitudes at implantation compared with HBP (0.64 ± 0.3 at 0.5 ms vs. 1.4 ± 0.8 at 1 ms; p < 0.001; 14 ± 8 mV vs. 5.5 ± 5.6 mV; p < 0.001). Pacing thresholds remained stable and left ventricular ejection fraction remained unchanged during a mean follow-up of 12 ± 13.7 months.

Conclusions: HPCSP is feasible in the majority of patients requiring pacemakers post-TAVR. Success rates of HBP were lower in patients with CoreValves compared to Sapien valves. LBBAP was associated with higher success rates and lower pacing thresholds compared with HBP.
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http://dx.doi.org/10.1016/j.jacep.2020.02.010DOI Listing
June 2020

Comparison between minimal fluoroscopy and conventional approaches for visually guided laser balloon pulmonary vein isolation ablation.

J Cardiovasc Electrophysiol 2020 07 4;31(7):1608-1615. Epub 2020 Jun 4.

Division of Cardiology, Rush University Medical Center, Chicago, Illinois.

Introduction: Although balloon-based techniques, such as the laser balloon (LB) ablation have simplified pulmonary vein isolation (PVI), procedural fluoroscopy usage remains higher in comparison to radiofrequency PVI approaches due to limited 3-dimensional mapping system integration.

Methods: In this prospective study, 50 consecutive patients were randomly assigned in alternating fashion to a low fluoroscopy group (LFG; n = 25) or conventional fluoroscopy group (CFG; n = 25) and underwent de novo PVI procedures using visually guided LB technique.

Results: There was no statistical difference in baseline characteristics or cross-overs between treatment groups. Acute PVI was accomplished in all patients. Mean follow up was 318 ± 69 days. Clinical recurrence of atrial fibrillation after PVI was similar between groups (CFG: 19% vs LFG: 15%; P = .72). Total fluoroscopy time was significantly lower in the LFG than the CFG (1.7 ± 1.4  vs 16.9 ± 5.9 minutes; P < .001) despite similar total procedure duration (143 ± 22 vs 148 ± 22 minutes; P = .42) and mean LA dwell time (63 ± 15 vs 59 ± 10 minutes; P = .28). Mean dose area product was significantly lower in the LFG (181 ± 125 vs 1980 ± 750 μGym ; P < .001). Fluoroscopy usage after transseptal access was substantially lower in the LFG (0.63 ± 0.43 vs 11.70 ± 4.32 minutes; P < .001). Complications rates were similar between both groups (4% vs 2%; P = .57).

Conclusions: This study demonstrates that LB PVI can be safely achieved using a novel low fluoroscopy protocol while also substantially reducing fluoroscopy usage and radiation exposure in comparison to conventional approaches for LB ablation.
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http://dx.doi.org/10.1111/jce.14546DOI Listing
July 2020

Supplemental Radiofrequency Ablation After Acutely Unsuccessful Cryoballoon Pulmonary Vein Isolation is Associated With Increased Risk of Recurrent Atrial Fibrillation.

J Am Heart Assoc 2020 05 12;9(10):e015979. Epub 2020 May 12.

Division of Cardiology Rush University Medical Center Chicago IL.

Background Cryoballoon (CB) ablation is widely performed for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Anatomic variations in patient pulmonary vein (PV) anatomy are believed to impact short- and long-term procedural success of CB PVI. Methods and Results We hypothesized that failure of initial PV isolation with a standard technique (ie, requiring >2 freeze cycles per PV and/or radiofrequency ablation [RFA] to achieve PV isolation) during index CB PVI procedures would be associated with decreased freedom from AF. We examined a cohort of 177 consecutive patients with drug-refractory AF who underwent CB PVI with a 28-mm balloon second-generation CB device. Mean follow-up time was 19±9 months. Forty-three patients had AF recurrence after the 90-day blanking period after ablation. In 40 patients, acute isolation of one or more PVs could not be achieved by CB ablation with the standard technique (single freeze with or without bonus freeze). To obtain complete acute PVI, 15 patients received extra freeze applications, 20 required supplemental RFA, and 5 received both extra freeze applications and supplemental RFA. Multivariate regression analysis revealed supplemental RFA use during index CB PVI procedures was independently associated with a threefold increased risk of AF recurrence (adjusted hazard ratio, 3.01; 1.45-10.87; =0.003). Conclusions Use of supplemental RFA during CB PVI procedures to assist with isolation of one or more PVs was independently associated with increased risk of AF recurrence. Use of additional freezes to achieve PVI did not increase the risk for recurrent AF.
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http://dx.doi.org/10.1161/JAHA.120.015979DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660892PMC
May 2020

Near-zero Fluoroscopic Approach for Laser Balloon Pulmonary Vein Isolation Ablation: A Case Study.

J Innov Card Rhythm Manag 2020 Apr 15;11(4):4069-4074. Epub 2020 Apr 15.

Division of Internal Medicine, Section of Cardiology, Rush University Medical Center, Chicago, IL, USA.

Fluoroscopy remains a cornerstone imaging modality for catheter placement and positioning in electrophysiology device and ablation procedures. However, efforts are being made to reduce the cumulative exposure to radiation in the patient and physician alike. We present the case of a 59-year-old male patient with hypertension, chronic kidney disease, and paroxysmal atrial fibrillation who underwent successful near-fluoroless laser balloon (LB) pulmonary vein isolation (PVI) ablation. Though this case demonstrates the usage of a novel protocol for near-fluoroless LB ablation that resulted in successful, uncomplicated acute PVI, the feasibility and safety of this technique should be validated in a larger series or prospective comparative study.
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http://dx.doi.org/10.19102/icrm.2020.110402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192128PMC
April 2020

Permanent His Bundle Pacing: A programming and troubleshooting guide.

Indian Pacing Electrophysiol J 2020 May - Jun;20(3):121-128. Epub 2020 Apr 30.

Rush University Medical Center, Chicago, IL, USA. Electronic address:

Permanent His Bundle Pacing (HBP) has recently gained popularity. However, implanting physicians and those who perform the device checks must invest in additional education in order to accurately program these devices, identify changes in morphology and perform troubleshooting to help achieve the best outcomes for the patients. This paper reviews key aspects of HBP and provides the educational tools for successful HBP follow-up and troubleshooting.
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http://dx.doi.org/10.1016/j.ipej.2020.04.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7244879PMC
April 2020

Permanent Conduction System Pacing for Congenitally Corrected Transposition of the Great Arteries.

Heart Rhythm 2020 Feb 10. Epub 2020 Feb 10.

University of Chicago Medicine, Chicago, IL.

Background: Congenitally corrected transposition of the great arteries (CCTGA) is associated with spontaneous AV block and pacing-induced cardiomyopathy. His bundle pacing (HBP) is a potential alternative to conventional CRT.

Objectives: To determine the outcomes of HBP for CCTGA.

Methods: Retrospective data were collected from 10 international centers.

Results: HBP or left bundle branch pacing (LBBP) was attempted for 15 CCTGA patients (median 23 yrs, 87% male). Prior surgery had been performed in 5 and chronic ventricular pacing in 6. Conduction system pacing (HBP=11, LBBP=2; non-selective in 10, selective in 3) was acutely successful in 13 (86%) without complication. In 9 cases, electro-anatomical mapping was available and identified the distal His bundle and proximal LBBs within the morphologic LV below the pulmonary valve separate from the mitral annulus. The median implant HV interval was 42 ms (IQR 35 - 48), R wave 6 mV (IQR 5 - 18) and threshold 0.5V (IQR 0.5 - 1.2) at median 0.5 ms. The QRSd was unchanged as compared to junctional escape rhythm (124 vs 110 ms, p=0.17) and decreased significantly compared to baseline ventricular pacing (112 vs 164 ms, p<0.01). At a median of 8 months, all patients were alive without significant change in pacing threshold or lead dysfunction. NYHA class improved in 5 patients.

Conclusions: Permanent conduction system pacing is feasible in CCTGA by either HBP or proximal LBBP. Narrow paced QRS and stable lead thresholds were observed at intermediate follow-up. Unique anatomical characteristics may favor this approach over conventional CRT.
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http://dx.doi.org/10.1016/j.hrthm.2020.01.033DOI Listing
February 2020

Permanent conduction system pacing for congenitally corrected transposition of the great arteries: A Pediatric and Congenital Electrophysiology Society (PACES)/International Society for Adult Congenital Heart Disease (ISACHD) Collaborative Study.

Heart Rhythm 2020 Mar 13. Epub 2020 Mar 13.

University of Chicago Medicine, Chicago, Illinois.

Background: Congenitally corrected transposition of the great arteries (CCTGA) is associated with spontaneous atrioventricular block and pacing-induced cardiomyopathy. Conduction system pacing is a potential alternative to conventional cardiac resynchronization therapy (CRT).

Objective: The purpose of this study was to determine the outcomes of conduction system pacing for CCTGA.

Methods: Retrospective data were collected from 10 international centers.

Results: His bundle (HBP) or left bundle branch pacing (LBBP) was attempted in 15 CCTGA patients (median age 23 years; 87% male). Previous surgery had been performed in 8 and chronic ventricular pacing in 7. Conduction system pacing (11 HBP, 2 LBBP 2; nonselective in 10, selective in 3) was acutely successful in 13 (86%) without complication. In 9 cases, electroanatomic mapping was available and identified the distal His bundle and proximal left bundle branches within the morphologic left ventricle below the pulmonary valve separate from the mitral annulus. Median implant HV interval was 42 ms (interquartile range [IQR] 35-48), R wave 6 mV (IQR 5-18), and threshold 0.5 V (IQR 0.5-1.2) at median 0.5 ms. QRSd was unchanged compared to junctional escape rhythm (124 vs 110 ms; P = .17) and decreased significantly compared to baseline ventricular pacing (112 vs 164 ms; P <.01). At a median of 8 months, all patients were alive without significant change in pacing threshold or lead dysfunction. New York Heart Association functional class improved in 5 patients.

Conclusion: Permanent conduction system pacing is feasible in CCTGA by either HBP or proximal LBBP. Narrow paced QRS and stable lead thresholds were observed at intermediate follow-up. Unique anatomic characteristics may favor this approach over conventional CRT.
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http://dx.doi.org/10.1016/j.hrthm.2020.01.033DOI Listing
March 2020

Electrophysiological characteristics and clinical values of left bundle branch current of injury in left bundle branch pacing.

J Cardiovasc Electrophysiol 2020 04 10;31(4):834-842. Epub 2020 Feb 10.

Department of Cardiovascular, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.

Background: Left bundle branch pacing (LBBP) is emerging as a novel option for physiological ventricular pacing. The impact of current of injury (COI) at left bundle branch (LBB) has not been previously evaluated.

Methods: Consecutive patients with QRS duration less than 120 milliseconds referred for LBBP in whom LBB potentials were recorded were included from August 2018 to March 2019. We recorded LBB COI during LBBP and assessed its impact on the pacing parameters and complications during implantation and at short term follow-up.

Results: A total of 115 patients with an identifiable LBB potential at implant were included. LBB COI was confirmed in 77 (67.0%) of these patients. Three types of LBB COI were observed. LBB was captured in all patients at a pacing threshold less than 1.5 V/0.5 ms in COI(+) patients, while present in only 29 patients without an LBB COI(-) (100% vs 76.3%; P < .001). There was no significant difference between COI(+) and COI(-) patients in LBB bundle capture threshold (0.64 ± 0.24 vs 0.74 ± 0.26 V/0.5 ms). Selective LBBP was more common in COI(+) group than COI(-) group (54.5% vs 0%; P < .001). Pacing parameters were stable and no lead perforation or dislodgements were observed during follow-up.

Conclusions: LBB COI is commonly observed during LBBP in cases with an identifiable LBB potential and can be associated with a low LBB capture threshold and demonstrable selective capture of the LBB acutely and during follow-up. A COI does not preclude safe and stable LBBP pacing.
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http://dx.doi.org/10.1111/jce.14377DOI Listing
April 2020

Sex differences in rates and causes of 30-day readmissions after cardiac electronic device implantations: insights from the Nationwide Readmissions Database.

Int J Cardiol 2020 03 10;302:67-74. Epub 2019 Dec 10.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, UK; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK; Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK. Electronic address:

Background: Women undergoing cardiac implantable electronic device (CIED) implantation are at a higher risk of procedure-related complications. The present study examined sex differences in rates and causes of 30-day readmissions following CIED implantation.

Methods: Using the United States Nationwide Readmissions Database (NRD), all adults who had undergone CIED implantation (cardiac resynchronization therapy (CRT), permanent pacemakers (PPM) and implantable cardioverter defibrillators (ICD)) between January 2010 and September 2015 were included. We compared rates, trends and causes of 30-day readmissions between sexes, and examined associations between sex and outcomes (adjusted odds ratios (aOR) and 95% confidence intervals (CI)).

Results: Out of 1,155,992 index hospitalizations for CIED implantation, 43.1% of the patients were women. All-cause 30-day readmissions were persistently higher in women than men but declined in both sexes over the study period, more so in women (women vs. men; 2010: 15.0% vs. 14.1%; 2015: 13.7% vs.13.4%). Women were at higher odds of readmission due to cardiac (aOR 1.22, 95%CI 1.20-1.24) and device-related complications (aOR 1.18, 95%CI 1.15-1.20) compared to men, but no difference odds of all-cause readmission were found between sexes (women: aOR 0.998, 95%CI 0.997-1.008). The most common cardiac and non-cardiac causes of readmission were heart failure and infection, respectively, and these were similar in both sexes (men vs. women: 17.8% vs. 17.6% and 10.7% vs. 10.8%, respectively).

Conclusion: Women are persistently at higher risk of readmission due to cardiac causes and device-related complications compared to men over a six-year period, but no difference in all-cause readmissions was found between sexes.
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http://dx.doi.org/10.1016/j.ijcard.2019.12.012DOI Listing
March 2020
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