How To Do Left Bundle Branch Pacing

00:41:00
https://www.youtube.com/watch?v=YGZHraI72ak

Résumé

TLDRThis session on left bundle branch pacing features Dr. Paul Foley and Dr. Marek Jatreski discussing the technique's importance in cardiac pacing. They outline the physiological benefits of conduction system pacing over traditional methods, particularly in patients with bradycardia and heart failure. Dr. Foley emphasizes the need for precise lead placement to avoid complications, while Dr. Jatreski breaks down the procedure into four key steps: identifying the target area, lead insertion, monitoring lead depth, and confirming successful capture. The session highlights the challenges and future directions of this evolving technique in cardiac care.

A retenir

  • 🎤 Introduction to left bundle branch pacing
  • 🩺 Importance of conduction system pacing
  • 📈 Indications for pacing: bradycardia, heart failure
  • 🔍 Steps in left bundle branch pacing
  • ⚙️ Challenges in the procedure
  • 📊 Confirming successful capture
  • 💡 Physiological pacing benefits
  • ⚠️ Risks of overscrewing
  • 🧬 Impact of scar tissue on pacing
  • 🔮 Future of conduction system pacing

Chronologie

  • 00:00:00 - 00:05:00

    In this session, experts discuss left bundle branch pacing, highlighting its importance in treating patients with bradycardia, heart failure, and defibrillator needs. Dr. Paul Foley introduces conduction system pacing, emphasizing its role in minimizing right ventricular pacing, which can lead to cardiomyopathy. He outlines the physiological pacing's potential benefits, including improved outcomes in heart failure patients and reduced hospitalization rates.

  • 00:05:00 - 00:10:00

    Dr. Foley elaborates on the challenges of right ventricular pacing, noting that a significant percentage of patients require upgrades to biventricular pacing. He discusses the importance of understanding the pacing system's anatomy and the need for precise device selection to avoid complications. The session emphasizes the need for thorough follow-up and monitoring to ensure effective pacing and patient safety.

  • 00:10:00 - 00:15:00

    The discussion transitions to the technical aspects of left bundle branch pacing, with Dr. Marek Jatreski sharing his experience. He outlines a four-step approach to the procedure: identifying the target area, lead insertion techniques, monitoring lead depth, and confirming successful capture of the left bundle branch. He emphasizes the importance of anatomical landmarks and ECG analysis during the procedure.

  • 00:15:00 - 00:20:00

    Dr. Jatreski explains the significance of the target area near the His bundle and the use of fluoroscopy and ECG to guide lead placement. He discusses the tools available for the procedure, including the sheath and delivery catheter, and the importance of understanding the lead's response during insertion to ensure proper placement.

  • 00:20:00 - 00:25:00

    The session highlights the need for careful monitoring of lead insertion to prevent overscrewing and potential complications. Dr. Jatreski introduces the concept of 'screw beads' as indicators of successful lead placement, emphasizing their presence in successful cases and their absence in unsuccessful attempts.

  • 00:25:00 - 00:30:00

    Dr. Jatreski discusses the challenges posed by scar tissue in the septum, which can hinder lead advancement. He shares insights on how to navigate these challenges and the importance of recognizing the difference between myocardial and conduction system capture during the procedure.

  • 00:30:00 - 00:35:00

    The conversation shifts to the confirmation of left bundle branch capture, with Dr. Jatreski explaining the differential output maneuver and the use of programmed stimulation to verify successful pacing. He emphasizes the need for a thorough understanding of the pacing system's physiology to achieve optimal results.

  • 00:35:00 - 00:41:00

    The session concludes with a discussion on the future of conduction system pacing, with both experts expressing optimism about its potential benefits over traditional pacing methods. They highlight the importance of ongoing research and clinical trials to further validate these techniques and improve patient outcomes.

Afficher plus

Carte mentale

Vidéo Q&R

  • What is left bundle branch pacing?

    Left bundle branch pacing is a technique used to stimulate the left bundle branch of the heart's conduction system to improve cardiac function.

  • What are the indications for conduction system pacing?

    Indications include bradycardia, heart failure requiring resynchronization, and patients needing defibrillators.

  • What are the main steps in left bundle branch pacing?

    The main steps are identifying the target area, lead insertion, monitoring lead depth, and confirming capture.

  • What challenges are associated with left bundle branch pacing?

    Challenges include longer procedure times, the need for specialized equipment, and ensuring correct lead placement.

  • How do you confirm successful capture in left bundle branch pacing?

    Successful capture is confirmed through ECG changes and programmed stimulation techniques.

  • What is the significance of physiological pacing?

    Physiological pacing aims to minimize pacing-induced cardiomyopathy and improve cardiac function.

  • What is the role of the his bundle in pacing?

    The his bundle is a key structure in the conduction system that can be targeted for pacing to improve heart function.

  • What are the risks of overscrewing during lead placement?

    Overscrewing can lead to perforation of the heart wall, which is a serious complication.

  • How does scar tissue affect pacing?

    Scar tissue can hinder lead progression and affect the quality of pacing, potentially leading to suboptimal outcomes.

  • What is the future of conduction system pacing?

    The future includes advancements in technology and techniques to improve the efficacy and safety of pacing.

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  • 00:00:00
    [Music]
  • 00:00:08
    i'd like to welcome you all to
  • 00:00:11
    this session on how to do left bundle
  • 00:00:14
    branch pacing it is a pleasure for me to
  • 00:00:17
    welcome
  • 00:00:18
    dr paul foley who is very experienced
  • 00:00:21
    in planter in both crt and imagine
  • 00:00:25
    conducting tissue pacing
  • 00:00:29
    we also have dr marek and
  • 00:00:32
    jatreski who will talk to us about his
  • 00:00:36
    experience
  • 00:00:37
    with handling leads and using catheters
  • 00:00:41
    and really the nitty gritty as to how to
  • 00:00:44
    perform
  • 00:00:46
    left bundle branch area pacing
  • 00:00:50
    so i would like to welcome paul to
  • 00:00:54
    give us an overview of conducting
  • 00:00:56
    conduction system
  • 00:00:58
    pacing thank you thank you paco
  • 00:01:01
    and uh it's great honor to give this
  • 00:01:04
    talk and thank you for the welcome
  • 00:01:06
    so i'm talking about perspectives on
  • 00:01:07
    conduction system pacing
  • 00:01:09
    by which obviously we refer to his
  • 00:01:11
    bundle and left conducting
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    system pacing and
  • 00:01:16
    there are obviously three main
  • 00:01:17
    indications for pacing
  • 00:01:19
    bradycardia those patients with heart
  • 00:01:22
    failure who need cardiac
  • 00:01:23
    resynchronization devices
  • 00:01:25
    and patients who need defibrillators and
  • 00:01:28
    often those
  • 00:01:29
    indications uh more than one indication
  • 00:01:32
    is present in
  • 00:01:33
    the patients so where does physiological
  • 00:01:36
    pacing come in
  • 00:01:37
    the first major indication where it
  • 00:01:40
    could be considered is atrial
  • 00:01:41
    ventricular block
  • 00:01:42
    and patients with very pronounced
  • 00:01:44
    first-degree av
  • 00:01:45
    block may experience right ventricular
  • 00:01:48
    pacing
  • 00:01:48
    even in the face of algorithms designed
  • 00:01:51
    to minimize it because davy block is so
  • 00:01:54
    prolonged in patients with two to one
  • 00:01:57
    and complete av block or those patients
  • 00:01:59
    who've had navy node ablation
  • 00:02:01
    these patients expect to have very high
  • 00:02:03
    burden of right ventricular pacing
  • 00:02:05
    and we know that can be associated with
  • 00:02:07
    patiently induced cardiomyopathy
  • 00:02:10
    there's also a group of patients who've
  • 00:02:11
    had left ventricular leads implanted
  • 00:02:13
    and these uh for whatever reason aren't
  • 00:02:15
    working so that may be because they
  • 00:02:17
    can't get their
  • 00:02:18
    anatomical constraints and maybe the
  • 00:02:20
    threshold is high
  • 00:02:22
    or another problem is obviously phrenic
  • 00:02:24
    nerve pacing
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    and so in this situation physiological
  • 00:02:27
    pacing can
  • 00:02:29
    serve as sort of bailout strategy and
  • 00:02:32
    lastly
  • 00:02:34
    left ventricular and right ventricle
  • 00:02:35
    pacing is well established in randomized
  • 00:02:37
    clinical trials but there are a number
  • 00:02:38
    of studies
  • 00:02:39
    comparing biventure pacing with
  • 00:02:42
    physiological pacing
  • 00:02:43
    suggesting similar outcomes in terms of
  • 00:02:46
    left ventricular remodeling
  • 00:02:47
    or possibly better remodeling and a
  • 00:02:50
    narrow qrs
  • 00:02:51
    and this is an area of uh active study
  • 00:02:53
    but still
  • 00:02:54
    present the major guidelines would
  • 00:02:57
    suggest for patients heart failure in
  • 00:02:59
    that bundle
  • 00:03:00
    these patients should have crt
  • 00:03:04
    so is right ventricular pacing a problem
  • 00:03:06
    well we talked about
  • 00:03:07
    uh pacing-induced cardiomyopathy which
  • 00:03:09
    occurs in approximately 20
  • 00:03:11
    of patients and this is a very nice
  • 00:03:13
    study from cougars group
  • 00:03:14
    united states where one hospital
  • 00:03:16
    undertook normal
  • 00:03:18
    right ventricular apron based pacing and
  • 00:03:20
    the other hospital undertook his bundle
  • 00:03:22
    of pacing
  • 00:03:23
    and what they saw was a reduction the
  • 00:03:26
    primary endpoint of heart
  • 00:03:27
    death heart failure hospitalization or
  • 00:03:30
    upgrading to bio-ventricular pacing
  • 00:03:32
    by around 30 and in fact if you look to
  • 00:03:35
    those patients receiving over 40
  • 00:03:37
    right ventricular apical pacing there
  • 00:03:39
    was a significant reduction
  • 00:03:41
    in the risk of heart failure
  • 00:03:42
    hospitalization which was even present
  • 00:03:45
    if you look to those patients receiving
  • 00:03:47
    only 20 percent now obviously for
  • 00:03:49
    patients there are
  • 00:03:50
    options in terms of instead of right
  • 00:03:53
    ventricular equal pacing it will
  • 00:03:54
    lead so there's lead list pacing and
  • 00:03:56
    cardiac resynchronization
  • 00:03:58
    pacing and the other question
  • 00:04:01
    arises is how much a problem is how
  • 00:04:04
    often do upgrades occur
  • 00:04:06
    and if we look at the esc survey from
  • 00:04:08
    2019
  • 00:04:09
    about 30 percent of the patients
  • 00:04:11
    undergoing crt were actually upgrades
  • 00:04:13
    from pre-existing
  • 00:04:14
    right ventricular april based system and
  • 00:04:17
    there's obviously a procedure timer says
  • 00:04:18
    that around 90 minutes
  • 00:04:20
    approximately six percent of patients
  • 00:04:22
    had complications and the pace qrs
  • 00:04:24
    is actually reasonably broad at 137
  • 00:04:27
    milliseconds
  • 00:04:28
    so it may be but implanting a
  • 00:04:30
    physiological base
  • 00:04:31
    pacing system from the start would
  • 00:04:33
    reduce the risk of the patient needing
  • 00:04:35
    an upgrade to 500 pesos
  • 00:04:37
    now this sounds very attractive but
  • 00:04:39
    there are challenges
  • 00:04:40
    we know the procedure time tends to be
  • 00:04:42
    long with physiological based
  • 00:04:44
    pacing you need a certain level of
  • 00:04:46
    implant equipment
  • 00:04:47
    often ep systems although a patient
  • 00:04:51
    patient analyzer can be used there's
  • 00:04:54
    the level of knowledge based on so need
  • 00:04:57
    to understand the signals that are
  • 00:04:58
    coming back
  • 00:04:59
    and particularly that's important uh
  • 00:05:01
    when the patient's being followed up
  • 00:05:03
    it's very important to select the
  • 00:05:04
    correct device so if you look at his
  • 00:05:06
    bundle pacing the
  • 00:05:07
    history may be implanted into the atrial
  • 00:05:09
    port the right ventricular port
  • 00:05:11
    or the left ventricular port and so the
  • 00:05:14
    device
  • 00:05:15
    you select will be important
  • 00:05:17
    particularly because you need to avoid
  • 00:05:19
    ventricular safety pasting for his
  • 00:05:21
    bundle systems
  • 00:05:23
    his bundle pacing itself is associated
  • 00:05:25
    with slightly higher thresholds
  • 00:05:26
    and that can have implications of the
  • 00:05:28
    battery life the r waves tend to be
  • 00:05:30
    lower typically around two millivolts
  • 00:05:32
    there's always a question about will the
  • 00:05:34
    hv block distal to where the lead is
  • 00:05:37
    implanted occur
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    later on you need to be absolutely
  • 00:05:40
    certain the patient's getting his
  • 00:05:41
    capture
  • 00:05:42
    and it's not sexual pacing and a
  • 00:05:44
    follow-up
  • 00:05:45
    there are changes in in the follow-up
  • 00:05:48
    pattern so remote follow-up
  • 00:05:50
    isn't really an option for these
  • 00:05:52
    patients and that's uh obviously an
  • 00:05:53
    important consideration
  • 00:05:54
    moment during covert uh auto capture
  • 00:05:58
    does not work and as we said ventricular
  • 00:06:00
    safety pacing
  • 00:06:02
    for his fundamental systems isn't
  • 00:06:03
    applicable and the numbers of patients
  • 00:06:06
    involved in the trials about uh 1438
  • 00:06:10
    published cases
  • 00:06:11
    largest series of 304 but no major
  • 00:06:14
    randomized clinical trials
  • 00:06:16
    left bundle branch pacing which america
  • 00:06:18
    is going to talk about shortly
  • 00:06:20
    uh again it's very important to get the
  • 00:06:22
    correct position
  • 00:06:23
    it's slightly more attractive in terms
  • 00:06:24
    of thresholds tend to be
  • 00:06:26
    a lot lower so analogous to right
  • 00:06:28
    ventricular april pacing
  • 00:06:30
    and the r wave sensing is normal our way
  • 00:06:34
    but there is the attendant risk of
  • 00:06:36
    perforation and the numbers of patients
  • 00:06:38
    implanted in in the
  • 00:06:40
    case reports and case series is around
  • 00:06:41
    530 of the largest series
  • 00:06:44
    being so far 100 and again no randomised
  • 00:06:46
    clinical trials
  • 00:06:48
    in this area
  • 00:06:51
    now we talked about the looking at
  • 00:06:54
    signals
  • 00:06:55
    there is a level of precision uh which
  • 00:06:58
    is required for physiological pacing
  • 00:07:00
    which is beyond that
  • 00:07:02
    the right ventricular april based pacing
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    so this
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    the first schematic on the left you see
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    the outputs on the y axis
  • 00:07:09
    and the four different positions where
  • 00:07:12
    there are multiple different thresholds
  • 00:07:13
    that can be obtained and that's
  • 00:07:15
    important during follow-up to be aware
  • 00:07:17
    of what you're
  • 00:07:19
    what you're seeing and also at the time
  • 00:07:20
    of implantation
  • 00:07:22
    america has done some very impressive
  • 00:07:24
    work
  • 00:07:25
    on looking at program stimulation to
  • 00:07:27
    confirm that you're in the his bundle
  • 00:07:30
    rather than the myocardium so there's
  • 00:07:32
    the fatigue ability when the hispanic
  • 00:07:34
    stimulated and not seen when the mark
  • 00:07:36
    harden is stimulated
  • 00:07:37
    extra stimuli and there are various
  • 00:07:39
    morphological features
  • 00:07:41
    which again it's very important to be
  • 00:07:42
    sure that the
  • 00:07:45
    the lead is in the correct position
  • 00:07:46
    because actually it can be quite hard to
  • 00:07:48
    differentiate between
  • 00:07:49
    non-selective hispanic capture and
  • 00:07:51
    myocardial capture
  • 00:07:53
    so you're looking for a very steep um
  • 00:07:56
    peak for non-selective capture rather
  • 00:07:59
    than a slight plateau and myocardial
  • 00:08:01
    catcher
  • 00:08:02
    the absence of a notch in v1 in the
  • 00:08:05
    s wave and also the qrs duration should
  • 00:08:08
    be narrow
  • 00:08:11
    so moving on to uh left
  • 00:08:14
    um conducting system pacing which
  • 00:08:16
    america is going to talk about
  • 00:08:18
    again the same position is required so
  • 00:08:20
    uh
  • 00:08:21
    this is a lead so the lead in these
  • 00:08:24
    schematics one is in the left conductive
  • 00:08:26
    system the other is
  • 00:08:27
    left ventricular septum and you can see
  • 00:08:29
    the qrs morphology
  • 00:08:30
    is very similar and the qrs duration
  • 00:08:34
    is the same but when high fidelity
  • 00:08:37
    mapping is undertaken
  • 00:08:39
    in the patients where the non-selective
  • 00:08:41
    left conducting system is stimulated
  • 00:08:44
    the pukenji activation is prior to the
  • 00:08:46
    qrs
  • 00:08:47
    and that's shown the red arrows whereas
  • 00:08:49
    when is the
  • 00:08:50
    leaders in the left ventricular septum
  • 00:08:52
    stimulating left conducting system
  • 00:08:54
    the kinji fibers are within the qrs
  • 00:08:57
    onset
  • 00:08:58
    and the left ventricular activation time
  • 00:08:59
    is shorter if you're
  • 00:09:01
    in the left conducting system rather
  • 00:09:03
    than the left ventricular septum
  • 00:09:05
    and this is just to say that there is a
  • 00:09:07
    level of complexity
  • 00:09:09
    to physiological pacing which is greater
  • 00:09:12
    than that with standard right
  • 00:09:14
    pacing so thank you very much
  • 00:09:19
    thank you paul that's a very nice
  • 00:09:20
    overview this is clearly very exciting
  • 00:09:23
    from the
  • 00:09:24
    scientific point of view it's very early
  • 00:09:26
    days
  • 00:09:27
    but it is really very encouraging and
  • 00:09:30
    opens up
  • 00:09:31
    a whole lot of new questions i think as
  • 00:09:33
    well i think from the clinical point of
  • 00:09:36
    view
  • 00:09:36
    um there is a great excitement as to
  • 00:09:40
    whether this is superior to right
  • 00:09:42
    ventricular pacing i agree with you that
  • 00:09:45
    there is some data out there to show
  • 00:09:47
    that right ventricular pacing is
  • 00:09:48
    detrimental
  • 00:09:50
    um but i i do wonder whether this is
  • 00:09:53
    due to an underlying cardiomyopathy
  • 00:09:57
    i think that if you look at right
  • 00:09:59
    ventricular pacing in a completely
  • 00:10:01
    healthy ventricle i don't i can't see
  • 00:10:04
    anything from the literature to
  • 00:10:06
    confidently say that right ventricular
  • 00:10:08
    pacing is detrimental
  • 00:10:11
    but yes of course we all see patients
  • 00:10:13
    who
  • 00:10:14
    have a right ventricular pacing induced
  • 00:10:16
    cardiomyopathy
  • 00:10:19
    i think obviously this is something that
  • 00:10:22
    i'm sure marek will will
  • 00:10:23
    will cover um there are
  • 00:10:27
    slight worries about the fact that we
  • 00:10:30
    are dealing with
  • 00:10:31
    imperfect technology and in mature
  • 00:10:33
    technology at the moment
  • 00:10:35
    and there's clearly a need to work on
  • 00:10:38
    both
  • 00:10:39
    the devices and the leads and
  • 00:10:42
    in my experience also the
  • 00:10:46
    catheters the guiding catheters and the
  • 00:10:49
    wires and various other things so
  • 00:10:51
    without um
  • 00:10:54
    and discussing anymore i'd like to
  • 00:10:57
    welcome professor marek
  • 00:10:58
    and jackie who will take us through
  • 00:11:01
    left bundle branch pacing thank you
  • 00:11:04
    marek
  • 00:11:05
    hello everybody thank you for the
  • 00:11:09
    kind invitation my task
  • 00:11:12
    is to tell you in a few words how to do
  • 00:11:15
    left bundle branch pacing
  • 00:11:18
    this is a very new tech technique
  • 00:11:21
    and i do not claim that i have all the
  • 00:11:23
    answers and i know how to do it
  • 00:11:25
    best every operator have a slightly
  • 00:11:28
    different
  • 00:11:28
    approach sometimes quite different
  • 00:11:30
    approach and i'm not claiming mine is
  • 00:11:33
    the best
  • 00:11:34
    but this is i will just share with you
  • 00:11:36
    the experience that i have
  • 00:11:38
    the first left bundle branch pacemaker i
  • 00:11:41
    implanted was
  • 00:11:42
    always almost two years ago since that
  • 00:11:44
    time in my lab we have implanted over
  • 00:11:46
    300
  • 00:11:47
    such devices so that gives me certain
  • 00:11:50
    room
  • 00:11:53
    where i can move the experience they
  • 00:11:55
    have that i can share with you
  • 00:11:58
    and because of the time frame i have
  • 00:12:00
    decided to
  • 00:12:01
    break down this complex procedure into
  • 00:12:04
    four simple steps
  • 00:12:06
    so okay these are my
  • 00:12:10
    moderate disclosures and let's move to
  • 00:12:14
    the
  • 00:12:14
    to these four steps so i think the whole
  • 00:12:18
    procedure
  • 00:12:19
    rests on four pillars first you need to
  • 00:12:22
    identify the target area
  • 00:12:24
    on the mid sector you need to
  • 00:12:27
    know how to get there and where it is
  • 00:12:30
    then you need to
  • 00:12:31
    learn how to screw the lead it is very
  • 00:12:34
    important it's not a simple task like
  • 00:12:36
    you have with active fixation lead where
  • 00:12:38
    you just
  • 00:12:39
    do a few rotations and and that's it
  • 00:12:42
    you need to know how to interpret
  • 00:12:44
    responses to lead rotation
  • 00:12:46
    because that's crucial to success we'll
  • 00:12:49
    talk about that
  • 00:12:50
    then you need to monitor delete depth
  • 00:12:52
    during screwing
  • 00:12:53
    to prevent over screwing because if you
  • 00:12:56
    go
  • 00:12:56
    too deep you'll end in the left
  • 00:12:58
    ventricle that's something we don't want
  • 00:13:00
    to
  • 00:13:01
    so that's again a very important
  • 00:13:04
    step of the procedure and then the final
  • 00:13:07
    step
  • 00:13:08
    that been very important for me from the
  • 00:13:11
    scientific point of view because we
  • 00:13:13
    publish a lot about that is to how to
  • 00:13:15
    confirm
  • 00:13:16
    that the acute endpoint of the procedure
  • 00:13:19
    was actually achieved
  • 00:13:20
    how to confirm like battle branch
  • 00:13:22
    capture because it's not like
  • 00:13:24
    just rv procedure you implant you have a
  • 00:13:26
    captcha and that's it
  • 00:13:28
    no you need to confirm that you capture
  • 00:13:30
    the structure
  • 00:13:31
    that you are interested in this
  • 00:13:33
    conduction system
  • 00:13:35
    okay so let's go to the step one
  • 00:13:39
    uh the target area where it is so the
  • 00:13:42
    target area
  • 00:13:42
    is on the septum and it's
  • 00:13:46
    close to the his bundle area marked with
  • 00:13:48
    the red
  • 00:13:49
    dot it's close to the tricuspid
  • 00:13:52
    annulus marked with this yellow line
  • 00:13:57
    it's pretty vast area actually the area
  • 00:13:59
    that i marked is
  • 00:14:01
    perhaps bigger than most operators would
  • 00:14:03
    agree
  • 00:14:04
    the best part is close to the his one
  • 00:14:06
    two centimeters from the historic the
  • 00:14:08
    proximal
  • 00:14:09
    bundle but sometimes it is more
  • 00:14:11
    difficult to get that than to the other
  • 00:14:13
    parts of the arborization of left bundle
  • 00:14:15
    and i do not hesitate to use those areas
  • 00:14:18
    so very often we go slightly more
  • 00:14:20
    optical and slightly more inferior to
  • 00:14:22
    get the left bundle
  • 00:14:24
    and the cures obtained from from those
  • 00:14:27
    areas are also excellent so how do you
  • 00:14:30
    know on the floor where that area is
  • 00:14:33
    well you can use the the contrast as you
  • 00:14:35
    see in this picture in the middle of
  • 00:14:37
    this slide
  • 00:14:38
    but i use that very very rarely actually
  • 00:14:41
    a good implant and knows where the
  • 00:14:42
    tricaster drink is
  • 00:14:44
    judging by the movement of the sheep
  • 00:14:47
    looking at the endocrine
  • 00:14:49
    potential the potential and the hl
  • 00:14:50
    potential
  • 00:14:52
    and sometimes you see the his potential
  • 00:14:54
    so you also know where is the
  • 00:14:55
    upper part of the tricaster ring and
  • 00:14:57
    that's enough you don't need to use the
  • 00:14:59
    contrast
  • 00:15:00
    you most of the time you don't need to
  • 00:15:02
    even identify the his
  • 00:15:03
    to know what the left bundle branch area
  • 00:15:05
    is just
  • 00:15:06
    the tricuspid ring is the perfect
  • 00:15:09
    anatomical marker
  • 00:15:10
    how to get there we do not have
  • 00:15:12
    dedicated tools
  • 00:15:13
    uh as you have heard a moment ago but we
  • 00:15:17
    still have our tools that are not that
  • 00:15:18
    bad we use the
  • 00:15:19
    sheath the heat sheath from the select
  • 00:15:22
    secure family from medtronic
  • 00:15:24
    which is designed for his but it also
  • 00:15:26
    directs you very well
  • 00:15:28
    on the septum because of this second
  • 00:15:30
    septal curve
  • 00:15:32
    and that's enough to get the left bundle
  • 00:15:34
    in majority of cases
  • 00:15:36
    sometimes when there is unfavorable
  • 00:15:38
    anatomy
  • 00:15:39
    the rotation of the heart that somehow
  • 00:15:41
    makes this shift not very useful
  • 00:15:44
    i use the s10 delivery catheter
  • 00:15:47
    which allows us to target the slightly
  • 00:15:50
    more inferior septum on the septum that
  • 00:15:53
    is slightly
  • 00:15:54
    more rotated than usually but we
  • 00:15:56
    definitely need
  • 00:15:58
    a different shape my ideal sheath would
  • 00:16:00
    be
  • 00:16:01
    i would have slightly bigger diameter
  • 00:16:04
    inside in
  • 00:16:05
    bigger lumen would be more sturdy
  • 00:16:08
    because the
  • 00:16:08
    the obstacle to implantation is is the
  • 00:16:11
    kinking
  • 00:16:11
    and if you have to rotate the sheath
  • 00:16:14
    very strongly
  • 00:16:15
    it prevents the leak freely moving
  • 00:16:17
    inside and that's the
  • 00:16:18
    biggest obstacle to implant the
  • 00:16:22
    the lead in difficult anatomies the
  • 00:16:25
    second
  • 00:16:25
    marker and you uh the second tool that
  • 00:16:28
    you use to define your target area
  • 00:16:31
    is the ecg that you see on the right
  • 00:16:33
    part of the slide
  • 00:16:35
    and when you choose your target area
  • 00:16:38
    judging by a floor or image then you do
  • 00:16:41
    the
  • 00:16:42
    initial pace mapping and you obs you you
  • 00:16:45
    analyze the based qrs and this based qrs
  • 00:16:48
    should be compatible with the
  • 00:16:50
    mid central area that is the polarity of
  • 00:16:53
    the qrs in lead
  • 00:16:55
    2 and lead 3 should be discarded
  • 00:16:58
    leak 2 should be always positive while
  • 00:17:00
    lead 3 should always have some negative
  • 00:17:03
    component
  • 00:17:04
    i'm not saying it should be completely
  • 00:17:05
    negative like in this example
  • 00:17:07
    but it should have a negative component
  • 00:17:09
    and that's a perfect position
  • 00:17:11
    if you pay attention to lead v1 you will
  • 00:17:14
    see this famous
  • 00:17:16
    notch at the nadio and that's a good
  • 00:17:18
    thing to have
  • 00:17:19
    but it's not obligatory another thing
  • 00:17:22
    that you sometimes observe
  • 00:17:23
    is that the qrs like you can appreciate
  • 00:17:26
    indeed before
  • 00:17:27
    v5 is already quite nice it's slightly
  • 00:17:30
    more narrow than in other
  • 00:17:32
    areas i don't know why is that
  • 00:17:35
    maybe this is some distant capture of
  • 00:17:37
    the left bundle already or maybe this is
  • 00:17:39
    some kind of non-selective
  • 00:17:40
    sculpture but this us is nicer and
  • 00:17:43
    that's the perfect spot
  • 00:17:45
    to screw the lead inside the septum if
  • 00:17:48
    you have this floor
  • 00:17:49
    this ecg you just go to the
  • 00:17:52
    next step and this next step
  • 00:17:55
    is to rotate the delete
  • 00:17:59
    and uh here i have to go to one of the
  • 00:18:02
    studies that we published on left valley
  • 00:18:04
    branch pacing and that
  • 00:18:06
    study came out of our need two years ago
  • 00:18:08
    when he
  • 00:18:09
    when we did start this procedure i was
  • 00:18:11
    puzzled why sometimes it is so easy
  • 00:18:14
    to achieve left panel branch facing just
  • 00:18:16
    a few rotations
  • 00:18:17
    and it's done and sometimes you fight
  • 00:18:20
    and fight and have problems
  • 00:18:23
    sometimes delete will not progress you
  • 00:18:25
    you you
  • 00:18:26
    rotate the lead you see the torque build
  • 00:18:28
    up in the lead as you see in the
  • 00:18:30
    inferior right part of the slide the
  • 00:18:33
    lead is
  • 00:18:34
    completely is is
  • 00:18:37
    the torque is there you see the force of
  • 00:18:39
    your rotations there and they do not
  • 00:18:41
    transmit to the heart
  • 00:18:42
    why is that and sometimes there the
  • 00:18:46
    torque the attention
  • 00:18:47
    immediately transmitted severely hard so
  • 00:18:49
    we did this cadaver model
  • 00:18:51
    in this model we used freshly heart from
  • 00:18:55
    freshly diseased people
  • 00:18:56
    suicide victims characters and victims
  • 00:19:00
    we use the same lead the 3830 model
  • 00:19:03
    and we use the same delivery sheath and
  • 00:19:05
    the same
  • 00:19:06
    operator was handling ensuring that the
  • 00:19:10
    pressure the the support was more or
  • 00:19:12
    less the same as doing real life
  • 00:19:14
    procedure
  • 00:19:15
    and we observed three types of responses
  • 00:19:18
    two types of effects
  • 00:19:19
    and actually they resemble very very
  • 00:19:22
    much what we did observe during real
  • 00:19:24
    life procedures
  • 00:19:25
    so the first response effect was the
  • 00:19:29
    thing we call entanglement effect you
  • 00:19:32
    can't progress because the endocardium
  • 00:19:35
    wraps around the helix around the lead
  • 00:19:38
    and prevents progression of the lead
  • 00:19:41
    inside the septum your if you have a
  • 00:19:44
    such response
  • 00:19:45
    that your torque does not transmit my
  • 00:19:48
    advice is not to find with that position
  • 00:19:50
    you have to find another position
  • 00:19:52
    that was a very common response of set
  • 00:19:55
    on on the cadaver model
  • 00:19:56
    but it's also observed in real life the
  • 00:19:59
    second response is
  • 00:20:01
    you rotate the lead you see the torque
  • 00:20:04
    build up and it's released
  • 00:20:05
    so it goes inside of the heart but it's
  • 00:20:08
    not changing the cures
  • 00:20:09
    on fluoro you see no lead movement and
  • 00:20:12
    most likely you have a drill response
  • 00:20:15
    drill effect you are just moving in the
  • 00:20:17
    same position and drilling a hole in the
  • 00:20:19
    septum this is a bad thing
  • 00:20:21
    because firstly you will not get to the
  • 00:20:23
    left bundle and secondly
  • 00:20:24
    the lead and the myocardium are very
  • 00:20:27
    loosely connected and
  • 00:20:28
    it might dislodge later on the the
  • 00:20:31
    response the effect that we look for is
  • 00:20:33
    the screwdriver effect you rotate and
  • 00:20:35
    each rotation
  • 00:20:36
    after initial torque buildup is
  • 00:20:38
    transmitted to the heart
  • 00:20:40
    and actually results in a deeper and
  • 00:20:42
    deeper position of delete that's the
  • 00:20:44
    the kind of response that we want but at
  • 00:20:47
    the same time this is the kind of
  • 00:20:48
    response that is also
  • 00:20:50
    risky because you can
  • 00:20:53
    open screw you can end in left ventricle
  • 00:20:55
    so that
  • 00:20:57
    makes us go once you understand these
  • 00:20:59
    responses
  • 00:21:00
    you need to differentiate actually
  • 00:21:02
    between the screwdriver and the drill
  • 00:21:04
    because both behave the same in your
  • 00:21:06
    hands both
  • 00:21:07
    result in the transmission of the torque
  • 00:21:10
    the difference you can observe
  • 00:21:12
    and differentiate between these the
  • 00:21:14
    difference you can differentiate these
  • 00:21:16
    two by looking at the
  • 00:21:17
    ecg and plural and this is what we will
  • 00:21:20
    discuss in the next slide
  • 00:21:24
    so how to differentiate between these
  • 00:21:26
    two responses and how to ensure
  • 00:21:29
    that you do not end as this
  • 00:21:32
    one of these two leads that you see on
  • 00:21:33
    our cadillac model that went so smoothly
  • 00:21:35
    to deception
  • 00:21:36
    that it ended in the left ventricle how
  • 00:21:38
    to stop at the sub-endocardial layer
  • 00:21:41
    close to the left ventricle but not into
  • 00:21:43
    that ventricle
  • 00:21:44
    and the the the the the mainstream
  • 00:21:48
    technique
  • 00:21:49
    is space mapping the pace mapping the
  • 00:21:52
    perfect thing would be to have constant
  • 00:21:54
    face mapping while scrolling
  • 00:21:55
    uh for this we need some kind of
  • 00:21:57
    revolving adapter that you could connect
  • 00:22:00
    the external pacemaker with the digital
  • 00:22:02
    pin of delete unfortunately we
  • 00:22:03
    did the manufacturers the industry still
  • 00:22:06
    does not produce a thing like that
  • 00:22:08
    i have modified several shock alligator
  • 00:22:12
    clips to produce a kind of revolving
  • 00:22:14
    tool and that would enable
  • 00:22:18
    a continuous face mapping while the
  • 00:22:20
    elite progresses inside the septum but
  • 00:22:22
    they are all far from being perfect
  • 00:22:25
    so i rely mainly on interrupted pacing
  • 00:22:28
    but here this ecg was taken from a
  • 00:22:31
    patient where continuous pacing was done
  • 00:22:34
    while the lead progresses and it is very
  • 00:22:37
    very important to be familiar with the
  • 00:22:39
    change of the paste cures patterns you
  • 00:22:42
    start with this pattern on the
  • 00:22:44
    left where you see broad qrs notched qrs
  • 00:22:48
    and in v1 you can appreciate in this red
  • 00:22:50
    circle that trees are not at the medium
  • 00:22:54
    when you get deeper the cure should
  • 00:22:58
    change and that's the difference between
  • 00:22:59
    the
  • 00:23:00
    screwdriver effect and the drill
  • 00:23:03
    response
  • 00:23:04
    because in the drill response the qrs
  • 00:23:06
    will not change here it changes
  • 00:23:08
    and you see that the the notch in v1
  • 00:23:10
    disappears
  • 00:23:11
    the keywords becomes slightly more
  • 00:23:13
    spanky slightly more smooth
  • 00:23:16
    you add one or two more rotations and
  • 00:23:18
    then you see that the curious is
  • 00:23:20
    very spiky and at the end of the qrs and
  • 00:23:23
    v1 slide
  • 00:23:24
    r prime appears if you add
  • 00:23:27
    still few more rotations you will
  • 00:23:29
    observe that the
  • 00:23:30
    big r at the end of the qrs is present
  • 00:23:34
    and you have
  • 00:23:35
    full blown right bundle branch block
  • 00:23:37
    pattern in b1
  • 00:23:38
    and that's the keywords that you like
  • 00:23:40
    and this is the moment you stop
  • 00:23:42
    once you have a qrs that is compatible
  • 00:23:45
    with left bundle branch capture that is
  • 00:23:46
    nice
  • 00:23:47
    it's smooth it's narrow that's the way
  • 00:23:51
    uh to know that you should stop and that
  • 00:23:53
    still is the mainstay technique to
  • 00:23:56
    to prevent overscrewing you either do it
  • 00:23:58
    continuously or more
  • 00:23:59
    commonly in an interrupted fashion after
  • 00:24:02
    a few
  • 00:24:03
    rotations you check the qrs you add more
  • 00:24:05
    rotation
  • 00:24:06
    or not that's the best thing uh
  • 00:24:09
    that we have and some people will tell
  • 00:24:12
    you that the
  • 00:24:13
    monitoring impedance is important i
  • 00:24:15
    never did that 300 cases
  • 00:24:17
    no monitoring of impedance and it works
  • 00:24:19
    so i don't think that's really necessary
  • 00:24:21
    based keywords morphology is the best
  • 00:24:24
    however
  • 00:24:25
    right now i rely a little bit more on
  • 00:24:27
    the thing that you see here i call
  • 00:24:29
    and this screw bits of when you
  • 00:24:33
    go with the lead deep inside the septum
  • 00:24:35
    you irritate the tissues
  • 00:24:37
    and this irritation causes premature
  • 00:24:39
    complexes
  • 00:24:41
    and if you look at them for example this
  • 00:24:43
    is a classical example
  • 00:24:44
    of a shower of premature beasts from the
  • 00:24:47
    septum
  • 00:24:47
    you will see that in this patient with
  • 00:24:49
    left bundle branch qrs
  • 00:24:52
    suddenly a curious appears with r
  • 00:24:55
    at the end of the keywords in d1 these
  • 00:24:57
    are gross and in the middle you see
  • 00:25:00
    a cure that is completely right bundle
  • 00:25:02
    branch
  • 00:25:03
    morphology which is exactly
  • 00:25:07
    the indication that you want to have
  • 00:25:10
    that your lead tip the helix is
  • 00:25:13
    irritating
  • 00:25:14
    the sub-endocardial layer on the left
  • 00:25:16
    side and that's the
  • 00:25:18
    perfect indication that you should stop
  • 00:25:20
    tearing
  • 00:25:21
    that's the only actually tool that i
  • 00:25:23
    very of use right now
  • 00:25:25
    you do rotations you observe you look
  • 00:25:27
    for screw bits if you have them
  • 00:25:29
    you don't need to have anything more
  • 00:25:31
    because if when you start face mapping
  • 00:25:34
    at that moment you will have a curious
  • 00:25:35
    morphology which will be identical to
  • 00:25:37
    your last screw bit
  • 00:25:39
    and that's the information that if you
  • 00:25:42
    don't have them
  • 00:25:43
    you need to add more screws if you have
  • 00:25:45
    them you need to stop to prevent over
  • 00:25:47
    screwing to
  • 00:25:47
    you to prevent perforation
  • 00:25:51
    so the screw bits are the way to go for
  • 00:25:52
    me right now and interrupted
  • 00:25:54
    or continuous phase mapping is another
  • 00:25:58
    way to prevent um overscrewing
  • 00:26:02
    and of course you have other tools
  • 00:26:05
    the plural and the and the kind of
  • 00:26:07
    signal from the pacing leak
  • 00:26:09
    to prevent um going too deep
  • 00:26:13
    especially lao is very very useful on
  • 00:26:16
    lao you directly see the progression of
  • 00:26:19
    the lead and if you are not sure
  • 00:26:21
    if you have a screwdriver response or
  • 00:26:24
    drill response from your lead lao
  • 00:26:28
    will tell you the truth because in the
  • 00:26:30
    drill response there is no
  • 00:26:31
    movement of delete to the left while in
  • 00:26:34
    the screwdriver
  • 00:26:35
    each rotation will move slightly delete
  • 00:26:38
    deep to the left
  • 00:26:39
    so leo is 30 is obligatory during
  • 00:26:43
    implantation especially in difficult
  • 00:26:44
    cases when you do not get the
  • 00:26:46
    bundle during your first attempt
  • 00:26:49
    another thing is to look for the left
  • 00:26:51
    bundle uh potential on delete because if
  • 00:26:53
    it's there
  • 00:26:54
    it's again a proof that you are in this
  • 00:26:57
    sub-endocardial layer because that's the
  • 00:26:58
    only
  • 00:26:59
    area where you can record it so you when
  • 00:27:01
    you have left bundle potential of
  • 00:27:03
    archangel potential
  • 00:27:04
    that's again an indicator to stop
  • 00:27:07
    absolutely stop
  • 00:27:08
    uh screwing because if you do not if you
  • 00:27:10
    will go
  • 00:27:11
    to look for a nicer potential your
  • 00:27:14
    chances of perforation are skyrocketing
  • 00:27:17
    uh when it comes to left bundle branch
  • 00:27:19
    potential it is very important
  • 00:27:20
    to recognize it not only when it's nice
  • 00:27:24
    big and almost like his potential but
  • 00:27:26
    also recognize it when it's small
  • 00:27:28
    like here on the far right
  • 00:27:31
    when you see a potential that is not
  • 00:27:34
    much bigger than the artifact level
  • 00:27:36
    it's already a good sign and you need
  • 00:27:39
    a clean signal for this very often the
  • 00:27:41
    potential even
  • 00:27:42
    when it's big is completely buried with
  • 00:27:45
    the v
  • 00:27:46
    in the v potential as you see in the
  • 00:27:47
    middle example
  • 00:27:49
    uh this is because there's a kind of
  • 00:27:51
    injury and the kind of injury
  • 00:27:53
    somehow merges the left bundle potential
  • 00:27:55
    and the
  • 00:27:56
    ventricular potential into one complex
  • 00:27:58
    you need to
  • 00:27:59
    be able to see the potential inside you
  • 00:28:03
    see
  • 00:28:03
    similar situation on the on the left
  • 00:28:05
    where the
  • 00:28:06
    potential is moderate but again linked
  • 00:28:09
    with db potential by the kind of injury
  • 00:28:11
    and the trick to see that is to
  • 00:28:15
    measure the potential
  • 00:28:18
    to qrs to see that this is not a curious
  • 00:28:21
    it starts much
  • 00:28:22
    before the cures you know this is a
  • 00:28:23
    potential
  • 00:28:25
    okay so when you other
  • 00:28:30
    you need to finalize the procedure with
  • 00:28:33
    the
  • 00:28:34
    fourth step the step to confirm that you
  • 00:28:37
    have left bundle branch capture
  • 00:28:39
    the mainstay technique for this known
  • 00:28:41
    from the his bundle
  • 00:28:43
    uh arena was the differential output
  • 00:28:45
    maneuver just
  • 00:28:46
    go down with the output of up with the
  • 00:28:48
    output i want to observe the change in
  • 00:28:50
    curves morphology
  • 00:28:51
    this is based on very simple premise
  • 00:28:54
    that there is a difference
  • 00:28:55
    in captured threshold between the
  • 00:28:57
    myocardium and the conduction system
  • 00:28:59
    and yes you can use that technique in my
  • 00:29:01
    experience this technique works
  • 00:29:03
    only in 22 of the cases in all other
  • 00:29:06
    cases the thresholds are equal
  • 00:29:09
    when it works it looks like that the qrs
  • 00:29:12
    on the right of this example on the
  • 00:29:14
    right you see
  • 00:29:15
    non-selective qrs that transitions into
  • 00:29:17
    selected cures in d1 there is an obvious
  • 00:29:20
    change from
  • 00:29:21
    small r sometimes almost absent r to
  • 00:29:24
    full blown right bundle branch block
  • 00:29:26
    pattern
  • 00:29:26
    on the left you see myocardial response
  • 00:29:29
    when the non-selected qrs transitions
  • 00:29:31
    into broader qrs
  • 00:29:33
    that still has in v1 kind of right
  • 00:29:36
    bundle branch morphology
  • 00:29:37
    but it's much broader sometimes not and
  • 00:29:39
    this is loss
  • 00:29:41
    of conduction system capture and you
  • 00:29:43
    have only myocardial
  • 00:29:44
    capture even if you have this response
  • 00:29:48
    during the procedure it will not be
  • 00:29:49
    there
  • 00:29:50
    next day the thresholds will be almost
  • 00:29:52
    all almost
  • 00:29:53
    always equal and this is why you need a
  • 00:29:55
    different technique to confirm
  • 00:29:57
    that you have reached your endpoint the
  • 00:30:01
    the capture of the left bundle and for
  • 00:30:03
    this we
  • 00:30:04
    are using in every case programmed deep
  • 00:30:07
    septal stimulation the technique that we
  • 00:30:09
    developed last year and published it
  • 00:30:11
    in the jc is
  • 00:30:15
    in my opinion necessary in vast majority
  • 00:30:18
    of cases
  • 00:30:20
    it's also based on very simple uh
  • 00:30:23
    uh premise that there's a difference in
  • 00:30:26
    in refractoriness between myocardial
  • 00:30:29
    tissue and
  • 00:30:30
    conducting conducting system in between
  • 00:30:32
    left bundle and the adjacent myocardium
  • 00:30:35
    and even if there are no differences or
  • 00:30:37
    the differences are small
  • 00:30:38
    you can produce the differences by using
  • 00:30:40
    different pacing techniques
  • 00:30:42
    here you see in the lower example uh
  • 00:30:46
    classic drive 600 milliseconds drive
  • 00:30:49
    and then a premature um that you will
  • 00:30:53
    find the left bundle refractory and
  • 00:30:57
    myocardium responsive and you will see a
  • 00:31:00
    change in qs morphology from
  • 00:31:02
    in v1 from right bundle to left bundle
  • 00:31:05
    type that means you have lost left
  • 00:31:06
    bundle
  • 00:31:07
    and this is a proof that you had left
  • 00:31:09
    bundle to begin with
  • 00:31:10
    and this is a response to this
  • 00:31:12
    diagnostic of uh reaching the endpoint
  • 00:31:14
    you will see
  • 00:31:15
    that the keywords will change from uh
  • 00:31:18
    narrow
  • 00:31:19
    and short time to peak in v6 to
  • 00:31:23
    long time in in total peak in v6
  • 00:31:28
    you will see all many different
  • 00:31:30
    morphological changes
  • 00:31:33
    and much nicer response also diagnostic
  • 00:31:37
    is a selective response for example here
  • 00:31:39
    how did we get the selective response
  • 00:31:41
    this
  • 00:31:42
    despite sometimes that refractoriness of
  • 00:31:44
    left bundle is longer
  • 00:31:46
    how is that possible is it possible by
  • 00:31:49
    using a different facing protocols for
  • 00:31:51
    example here a
  • 00:31:52
    very long cycle length of the intrinsic
  • 00:31:55
    rhythm
  • 00:31:56
    makes the refractoriness of the
  • 00:31:59
    myocardial tissue quite long and then
  • 00:32:02
    you
  • 00:32:02
    provide first premature which shortens
  • 00:32:05
    the refractoriness
  • 00:32:07
    but only of the left bundle not of the
  • 00:32:09
    myocardium
  • 00:32:10
    because the myocardium needs many cycles
  • 00:32:12
    to shorten refractoriness while the
  • 00:32:14
    conduction system needs just one cycle
  • 00:32:16
    to shorten the fracturings
  • 00:32:18
    so the next premature will find the
  • 00:32:20
    myocardium refractory
  • 00:32:22
    and left bundle responsive and you will
  • 00:32:24
    have a selective response
  • 00:32:26
    with this typical full-blown right-bound
  • 00:32:29
    launch block pattern the shovel-like
  • 00:32:31
    deflection instead of small deflection
  • 00:32:33
    at the end of d1
  • 00:32:34
    and you will have a selective response
  • 00:32:36
    which is very
  • 00:32:37
    elegant way to prove that you have a
  • 00:32:39
    left bundle branch block capture
  • 00:32:42
    so that technique we use
  • 00:32:45
    if it's not working because sometimes
  • 00:32:48
    you can't really see the difference in
  • 00:32:49
    refractoriness
  • 00:32:50
    then we use more advanced facing
  • 00:32:52
    protocols and you see an example of that
  • 00:32:54
    here
  • 00:32:55
    we publish that in jc for example here
  • 00:32:57
    you see a fast drive
  • 00:32:58
    10 opposed to increase the refractories
  • 00:33:00
    of blood bundle and then
  • 00:33:02
    myocardial response we don't
  • 00:33:05
    have time to go into details but it's
  • 00:33:08
    based on very simple physiology
  • 00:33:10
    that you should know if you want to be
  • 00:33:14
    successful in using program stimulation
  • 00:33:16
    or valid branch pacing
  • 00:33:18
    and once you have that once you have
  • 00:33:20
    confirmation of the bundle branch
  • 00:33:22
    capture
  • 00:33:22
    that's the end of it all you need to do
  • 00:33:24
    right now is to
  • 00:33:26
    put the device into the pocket close the
  • 00:33:28
    incision and go home
  • 00:33:30
    because rest is a quite standard
  • 00:33:32
    procedure
  • 00:33:34
    so that's the way i do it thank you very
  • 00:33:36
    much
  • 00:33:38
    thank you marek that was excellent uh
  • 00:33:41
    it's
  • 00:33:42
    brilliant to have that sort of insight
  • 00:33:44
    into
  • 00:33:45
    into left bundle branch area pacing
  • 00:33:48
    um some questions i mean i actually i
  • 00:33:52
    tend to use the steerable catheter
  • 00:33:55
    by default actually i find that
  • 00:33:58
    it gives you more support uh i put the
  • 00:34:01
    035 wire through the
  • 00:34:04
    through the guide and get into
  • 00:34:07
    the right ventricle uh very easily uh
  • 00:34:10
    and then remove the wire and then i can
  • 00:34:13
    use contrast now
  • 00:34:14
    i i i find contrast useful actually um
  • 00:34:18
    so as you screw in the lead you can use
  • 00:34:21
    a little bit of contrast
  • 00:34:23
    uh in the steerable catheter that will
  • 00:34:26
    give you
  • 00:34:27
    uh what will tell you um that you're up
  • 00:34:31
    about the distance between your
  • 00:34:33
    opposition to the septum
  • 00:34:35
    and how far the lead has gone through
  • 00:34:37
    particularly on the
  • 00:34:38
    lao um i also find that
  • 00:34:42
    i mean sometimes this these procedures
  • 00:34:46
    are done
  • 00:34:47
    as a redo as you know a salvage
  • 00:34:49
    procedure
  • 00:34:50
    and you have to go from the right i also
  • 00:34:53
    find that this theorem
  • 00:34:55
    is is good what are your thoughts about
  • 00:34:58
    this theorem rather than the pre-shaped
  • 00:35:01
    i would love to have a steerable sheet
  • 00:35:03
    that is
  • 00:35:04
    good enough to use it the the sheet that
  • 00:35:07
    has
  • 00:35:08
    um separate curves apart from the
  • 00:35:11
    rv curve and we do not have that we have
  • 00:35:14
    only
  • 00:35:15
    304 that we use occasionally for the his
  • 00:35:18
    bundle pacing this is terrible we do not
  • 00:35:20
    have the
  • 00:35:20
    steerable with the second care of the
  • 00:35:22
    separate caf which is
  • 00:35:24
    available in some countries but not in
  • 00:35:27
    poland
  • 00:35:28
    and i do not have experience with that
  • 00:35:30
    certainly the future
  • 00:35:32
    um belongs to this derivative i agree
  • 00:35:34
    with you
  • 00:35:36
    paul what's your um experience with the
  • 00:35:39
    steerable rather than the pre-shaped
  • 00:35:41
    the tendency is the pre-shaped catheter
  • 00:35:43
    as the um
  • 00:35:45
    first choice and usually gone to the
  • 00:35:48
    steerable where we've had difficulties
  • 00:35:50
    so
  • 00:35:50
    um i think it's just what i'm familiar
  • 00:35:52
    with i was interested in marek's comment
  • 00:35:55
    about the screw beads
  • 00:35:57
    and just wondered how often you see
  • 00:35:59
    those mark when you're
  • 00:36:00
    doing left bubble implantation well at
  • 00:36:03
    the beginning when i
  • 00:36:04
    was not looking at them actively i just
  • 00:36:07
    upset them from time to time but
  • 00:36:09
    right now i actually doing a research on
  • 00:36:12
    that
  • 00:36:12
    and i have to tell you that it's present
  • 00:36:14
    in over 90
  • 00:36:16
    of the cases and in nearly 100 of the
  • 00:36:19
    successful sites
  • 00:36:20
    so it's always there if you don't see
  • 00:36:22
    screw bits the chances that you are
  • 00:36:24
    there are very small on the other hand
  • 00:36:26
    when you see them
  • 00:36:26
    this is 100 certain that you are there
  • 00:36:30
    so they are always there look at your
  • 00:36:31
    procedures if you have them recorded
  • 00:36:34
    look at them you will be surprised that
  • 00:36:36
    where they were always there sometimes
  • 00:36:38
    one bit that you missed but it was there
  • 00:36:42
    also marek the the other question is
  • 00:36:45
    scar
  • 00:36:46
    so some authors have uh placed
  • 00:36:49
    some hope in the
  • 00:36:52
    um in the notion that we can circumvent
  • 00:36:55
    scar
  • 00:36:55
    with left thunder branch area facing or
  • 00:36:58
    even his pacing as opposed to crt
  • 00:37:00
    which as you know there is some evidence
  • 00:37:02
    to show that if you pace
  • 00:37:04
    uh scar it um it's suboptimal
  • 00:37:08
    but actually uh pacing a septal scar
  • 00:37:11
    which is very common particularly in
  • 00:37:12
    patients who have had a
  • 00:37:14
    an lady infact um it's all
  • 00:37:17
    it's likely to be also a problem
  • 00:37:21
    do you have any views about scar in
  • 00:37:24
    relation to
  • 00:37:26
    positions or the screwing or the
  • 00:37:29
    stability i'm
  • 00:37:33
    not sure what causes the entanglement
  • 00:37:35
    effect this is why
  • 00:37:36
    sometimes you can't really progress with
  • 00:37:38
    the lead and i think that apart from
  • 00:37:40
    some kind of
  • 00:37:41
    you know panzer myocardium endocardium
  • 00:37:44
    this car might be the answer
  • 00:37:46
    if you have a very fibrous scale scar on
  • 00:37:49
    the
  • 00:37:50
    septum you may not be able to progress
  • 00:37:52
    with the lead
  • 00:37:53
    and then you need to go slightly deeper
  • 00:37:55
    to find the area or you can go deep into
  • 00:37:57
    the septum do not fight with a very
  • 00:37:59
    dense scalp
  • 00:38:00
    but if you go into this car and i think
  • 00:38:02
    i did that a few times
  • 00:38:04
    then you might be surprised that the
  • 00:38:06
    cures is very handy
  • 00:38:08
    you are on the left side and you
  • 00:38:11
    are not happy with the cures because
  • 00:38:13
    there is simply no
  • 00:38:15
    a life conducting tissue and you are
  • 00:38:18
    capturing some
  • 00:38:19
    a few microfibers that are there but the
  • 00:38:22
    cures is poor
  • 00:38:23
    and if you go further down the road you
  • 00:38:26
    will have a nicer cures actually
  • 00:38:28
    that's my observation you know these few
  • 00:38:31
    cases when i
  • 00:38:32
    did this so marek with
  • 00:38:35
    uh bradley pacing uh how
  • 00:38:38
    how how are you um dealing with this are
  • 00:38:42
    you putting
  • 00:38:42
    an rb leading as well or
  • 00:38:46
    two leads or are you just leaving the
  • 00:38:48
    the
  • 00:38:49
    left bundle lead well i
  • 00:38:53
    my lab completely converted to
  • 00:38:54
    conduction system basically we did not
  • 00:38:56
    do rv pacing for an indication apart as
  • 00:38:59
    a bailout for if
  • 00:39:00
    everything else fails so we start with
  • 00:39:02
    the hiss we don't play with
  • 00:39:04
    it too long if it's not there just go
  • 00:39:06
    for the left bundle
  • 00:39:07
    and finish the procedure and all
  • 00:39:09
    procedures
  • 00:39:10
    regardless of the indication is it's crt
  • 00:39:13
    heart failure
  • 00:39:14
    or just sick sinus or heavy blood will
  • 00:39:16
    receive a conduction system facing
  • 00:39:18
    even the youngest residents who did
  • 00:39:21
    start
  • 00:39:22
    this year pacemaker implantation they do
  • 00:39:24
    not learn the classic technique they
  • 00:39:26
    only do conduction system pacing it can
  • 00:39:28
    be done by inexperienced operators it's
  • 00:39:30
    a
  • 00:39:30
    technique that is quite easy actually
  • 00:39:34
    i'm sorry are we paid no rv leads to
  • 00:39:36
    answer your question
  • 00:39:37
    no no needs classic no and paul was your
  • 00:39:40
    practice
  • 00:39:42
    uh currently we are doing a fair amount
  • 00:39:44
    of hispanic placing
  • 00:39:45
    uh for um patients of first degree av
  • 00:39:49
    blog
  • 00:39:49
    or nara cures complete heart blog
  • 00:39:54
    well we're still i guess waiting for
  • 00:39:57
    randomized clinical trials to be
  • 00:39:59
    absolutely certain that um we
  • 00:40:03
    it is the right thing to do for every
  • 00:40:04
    patient are you worried about
  • 00:40:06
    uh pacemaker dependency in these
  • 00:40:09
    patients
  • 00:40:11
    in the patients who are having hispanic
  • 00:40:12
    system uh i mean
  • 00:40:14
    that is a potential problem we always
  • 00:40:16
    check that
  • 00:40:17
    we have one-to-one conduction
  • 00:40:21
    when we when we pace at high outputs uh
  • 00:40:25
    higher sorry at some high rates um
  • 00:40:28
    and we check the hpv interval well i
  • 00:40:30
    think
  • 00:40:31
    um this is being uh very helpful um
  • 00:40:35
    i i i it's a very nice explanation of
  • 00:40:38
    the
  • 00:40:38
    technique i'm very grateful to uh
  • 00:40:41
    professor gerzerski
  • 00:40:42
    and to dr paul foley for this session
  • 00:40:45
    which i i hope that you find
  • 00:40:49
    very useful i certainly did many things
Tags
  • left bundle branch pacing
  • conduction system pacing
  • bradycardia
  • heart failure
  • pacemaker
  • lead placement
  • physiological pacing
  • his bundle
  • cardiac resynchronization
  • medical technology