Left bundle branch pacing versus left ventricular septal pacing as a primary procedural endpoint during left bundle branch area pacing: Evaluation of two different implant strategies

INTRODUCTION

Implant procedure features and clinical implications of left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP) have not been yet fully described. We sought to compare two different left bundle branch area pacing (LBBAP) implant strategies: the first one accepting LVSP as a procedural endpoint and the second one aiming at achieving LBBP in every patient in spite of evidence of previous LVSP criteria.

METHODS

LVSP was accepted as a procedural endpoint in 162 consecutive patients (LVSP strategy group). In a second phase, LBBP was attempted in every patient in spite of achieving previous LVSP criteria (n = 161, LBBP strategy group). Baseline patient characteristics, implant procedure, and follow-up data were compared.

RESULTS

The final capture pattern was LBBP in 71.4% and LVSP in 24.2% in the LBBP strategy group compared to 42.7% and 50%, respectively, in the LVSP strategy group. One hundred and eighty-four patients (57%) had proven LBB capture criteria with a significantly shorter paced QRS duration than the 120 patients (37%) with LVSP criteria (115 ± 9 vs. 121 ± 13 ms, p < .001). Implant parameters were comparable between the two strategies but the LBBP strategy resulted in a higher rate of acute septal perforation (11.8% vs. 4.9%, p = .026) without any clinical sequelae. Patients with CRT indications significantly improved left ventricular ejection fraction (LVEF) during follow-up irrespective of the capture pattern (from 35 ± 11% to 45 ± 14% in proven LBBP, p = .024; and from 39 ± 13% to 47 ± 12% for LVSP, p = .003). The presence of structural heart disease and baseline LBBB independently predicted unsuccessful LBB capture.

CONCLUSION

The LBBP strategy was associated with comparable implant parameters than the LVSP strategy but resulted in higher rates of septal perforation. Proven LBB capture and LVSP showed comparable effects on LVEF during follow-up.

Acute performance of stylet driven leads for left bundle branch area pacing: A comparison with lumenless leads

Background

Lumenless leads (LLLs) are widely used for left bundle branch area pacing (LBBAP). Recently, stylet-driven leads (SDLs) have also been used for LBBAP.

Objective

The purpose of this study was to evaluate the acute performance of SDLs during LBBAP in comparison with LLLs.

Methods

Consecutive patients undergoing LBBAP for bradycardia or cardiac resynchronization therapy indications at 2 high-volume, early conduction system pacing adopters, tertiary centers were included from January 2019 to July 2023. Patients received either SDLs or LLLs at the discretion of the implanting physician. Acute performance and follow-up data of both lead types were evaluated.

Results

A total of 925 LBBAP implants were included, 655 using LLLs and 270 using SDLs. Overall, LBBAP acute success was significantly higher with LLLs than SDLs (95.3% vs 85.1%, respectively; P <.001) even after the learning curve (97% vs 86%; P = .013). LLLs were implanted in more mid-basal septal positions in comparison with SDLs, which tended to be implanted in more inferior and mid-apical septal positions. Acute lead-related complications were higher with SDLs than LLLs (15.9% vs 6.1%, respectively; P <.001) with 15 cases of lead damage during implant (4.4% vs 0.5%; P <.001) but decreased with acquired experience and were comparable in the last 100 patients included in each group. Lead implant and fluoroscopy times were shorter for SDLs, with lead dislodgment occurring in 0.9% with LLLs and 1.5% with SDLs (P = .489).

Conclusion

Acute lead performance proved to be different between LLLs and SDLs. A specific learning curve should be considered for SDLs even for implanters with extensive previous experience with LLLs.

Conduction System Pacing for Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT) via biventricular pacing (BiVP-CRT) is considered a mainstay treatment for symptomatic heart failure patients with reduced ejection fraction and wide QRS. However, up to one-third of patients receiving BiVP-CRT are considered non-responders to the therapy. Multiple strategies have been proposed to maximize the percentage of CRT responders including two new physiological pacing modalities that have emerged in recent years: His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). Both pacing techniques aim at restoring the normal electrical activation of the ventricles through the native conduction system in opposition to the cell-to-cell activation of conventional right ventricular myocardial pacing. Conduction system pacing (CSP), including both HBP and LBBAP, appears to be a promising pacing modality for delivering CRT and has proven to be safe and feasible in this particular setting. This article will review the current state of the art of CSP-based CRT, its limitations, and future directions.

Prótesis unicompartimental de rodilla. Resultados clínico-radiográficos y análisis de la supervivencia del implante

Objetivo: Evaluar los resultados clínicos y radiográficos en pacientes sometidos a artroplastia unicompartimental de rodilla, así como la tasa de complicaciones y la supervivencia del implante. Materiales y Métodos: Estudio descriptivo retrospectivo de 68 pacientes consecutivos (70 rodillas) sometidos a artroplastia unicompartimental de rodilla entre 2013 y 2020, con un seguimiento medio de 57.7 meses (rango 24-105) y una media de la edad de 61 años (rango 34-79). El 46,5% eran hombres. El índice demasa corporal medio era de 29,9 (rango 20-39). El diagnóstico más frecuente fue la artrosis del compartimento femorotibial medial con un varo <7°. Los resultados se evaluaron con la escala analógica visual para dolor y el Knee Society Score (KSS). Se evaluó la incidencia de complicaciones y la tasa de supervivencia del implante. Resultados: La disminución media en la escala analógica visual para dolor fue de 4,4 ± 1,9. Las puntuaciones medias posoperatorias en las escalas funcional y clínica del KSS fueron de 77,4 ± 13,7 y 70,2 ± 17,7, respectivamente. La tasa de complicaciones posquirúrgicas fue del 7% (5 casos). La tasa de reintervención quirúrgica fue del 15,5% (11 pacientes): nueve casos por persistencia del dolor, uno por rigidez articular y otro por aflojamiento aséptico. Conclusiones: La artroplastia unicompartimental de rodilla es una opción terapéutica eficaz para pacientescon gonartrosis unicompartimental de rodilla; se logran buenos resultados clínicos con una aceptable tasa de complicaciones; sin embargo, la tasa de revisión del implante es considerable. Nivel de Evidencia: IV

[First case series of femoral lengthening using a Precice® intramedullary nail in our center]

INTRODUCTION

femoral lengthening using an intramedullary nail is one of the surgical options in the treatment of severe lower limb dysmetria in routine clinical practice.

MATERIAL AND METHODS

a retrospective descriptive study was carried out on a series of five patients with a mean age of 15.4 years, who underwent femoral lengthening surgery using a Precice® intramedullary nail. The etiology in all cases was idiopathic. Preoperative and definitive postoperative theoretical lengthening or dysmetry was measured, as well as lengthening accuracy, distraction rate and index (mm/day and days/cm, respectively) and consolidation index (days/cm). Intraoperative and postoperative complications were identified in all cases.

RESULTS

mean follow-up was 21 months (12-42), with no loss to follow-up. The mean duration of the surgical procedure was 126 minutes (105-160). The preoperative theoretical dysmetry was 38 ± 2.7 mm. The final mean lengthening was 41 ± 7.5 mm. The mean accuracy was 108% (91-125) and the distraction rate was 0.9 ± 0.4 mm/day. The distraction rate was 13.9 ± 5.1 days/cm and the consolidation rate was 26.6 ± 9.1 days/cm. Bone consolidation was observed in all patients with a mean of 113 ± 58 days. Regarding complications, a total of four minor muscular complications were found.

CONCLUSION

the Precice® intramedullary nail is a good treatment option for cases of severe femoral shortening, providing good clinical and radiological results with a low rate of complications and implant failure.

Impact of Circulatory Assistance in the Early Evolution After Heart Transplantation. Unicentric Experience

BACKGROUND

Heart transplantation (HT) is the reference treatment for patients with terminal heart failure. In recent years there has been a progressive increase in HT procedures in patients who have a circulatory support (CS).

METHODS

This is a retrospective single-center study of 293 consecutive patients who underwent HT from 2009 to 2018, analyzing the evolution of the 2 cohorts: patients with and without CS as a bridge to HT. Baseline and evolutionary clinical data collected following the usual follow-up protocol were recorded, including clinical events observed during the follow-up 1 year after the procedure.

RESULTS

The subgroup of patients transplanted with CS showed a higher incidence of primary graft failure, frequent infection, and mortality. A tendency toward lower cardiac allograft vasculopathy was observed in this subgroup. Mechanical ventilation added to the CS resulted in a higher incidence of primary graft failure, infection, and renal dysfunction. The CS variable as a bridge to HT was shown to be predictive of 1-year mortality in both univariate (odds ratio, 1.84; 95% confidence interval, 1.03-3.3; P = .038) and multivariate (odds ratio, 2.1; 95% confidence interval, 1.01-4.3; P = .047) analyses.

CONCLUSIONS

In our experience, CS as a bridge to HT results in a higher incidence of primary graft failure, frequent infection, and mortality at 1-year follow-up. Mechanical ventilation added to CS has a clear unfavorable prognostic impact. CS as a bridge to HT was shown to be predictive of 1-year mortality in both univariate and multivariate analyses.

[Pyknodysostosis: extreme cause of sleep apnea]

We describe a twentieth month old infant who had a pycnodysostosis syndrome. This malformation shows a loss of the normal mandible angle with generalized bone hyperdensification. The first produced and airway obstruction, with special relevance during sleeping hours. A polysomnography revealed an obstructive sleep apnea syndrome. The respiratory picture deteriorated with worsening of the airway obstruction, hypoxemia and finally pulmonary hypertension and cor pulmonale. A tracheostomy was performed, with resolution of the sleep apnea and pulmonary hypertension. The etiology, pathophysiologic consequences and surgical treatment of obstructive sleep apnea syndrome is reviewed.

[Embryoclinical correlation ofmaxillofacial abnormalities]

Most publications on maxillofacial malformation are based on their topography and terminology. The list of authors is endless in most cases there are only minor variants. Thus, we are attempting to establish the embryoclinical correlation of maxillofacial malformations produced by changes in the structures of the cephalic pole of the embryo. For such systematization we have considered the following items: 1. Changes in the frontal structure. 2. Changes in upper maxillary structures. 3. Changes in the lower maxillary or mandibular structures. 4. Pathologic associations. In each of these buttons, the structures produced or correlated with them are subsequently analyzed, the same as basic changes and clinical syndromes produced by them and resulting in an embryoclinical systematization.

[Congenital monomorph adenoma of the parotid gland (author's transl)]

Congenital monomorph tubular adenoma is a very infrequent tumor. Usually diagnosis is an operative finding. Together with its' infrequency, rapid rate of growth, differential diagnosis with other vascular tumors, specially cystic lymphangioma, and its surgical excision avoiding lesion of the facial nerve, account for this publication.

[Iatrogenic evolutive skull fracture (author's transl)]

A case of growing skull fracture secondary to a maxilofacial operation is reported. Frequency, clinical symptoms, phisiopathology and treatment of growing skull fractures are reviewed and the rarity of the iatrogenic mechanism is stressed.

[Oral-facial-digital syndrome in male (author's transl)]

One case of oral-facial-digital syndrome (Papillon-Léage and Psaume) is presented. This is the second one reported on a patient with normal male karyotipe. Clinical data and genetic aspects are commented in relation with this new case in a 46 XY male.