Ultrasound-guided puncture of femoral veins was associated with preferable intra-procedural outcomes, though the major complication rates were not reduced. Both trainees and expert operators benefited from the USG strategy. (www.clinicaltrials.gov ID: NCT02834221).

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Optimization of Left Ventricular Lead PositionBackgroundThe left ventricular (LV) lead local electrogram (EGM) delay from the beginning of the QRS complex (QLV) is considered a strong predictor of response to cardiac resynchronization therapy. We have developed a method for fast epicardial QLV mapping during video-thoracoscopic surgery to guide LV lead placement.MethodsA three-port, video-thoracoscopic approach was used for LV free wall epicardial mapping and lead implantation. A decapolar electrophysiological catheter was introduced through one port and systematically attached to multiple accessible LV sites. The pacing lead was targeted to the site with maximum QLV. The LV free wall activation pattern was analyzed in 16 pre-specified anatomical segments.ResultsWe implanted LV leads in 13 patients with LBBB or IVCD. The procedural and mapping times were 142 ± 39 minutes and 20 ± 9 minutes, respectively. A total of 15.0 ± 2.2 LV segments were mappable with variable spatial distribution of QLV-optimum. The QLV ratio (QLV/QRSd) at the optimum segment was significantly higher (by 0.17 ± 0.08, p < 0.00001) as compared to an empirical midventricular lateral segment. The LV lead was implanted at the optimum segment in 11 patients (at an adjacent segment in 2 patients) achieving a QLV ratio of 0.82 ± 0.09 (range 0.63–0.93) and 99.5 ± 0.6% match with intraprocedural mapping.ConclusionVideo-thoracoscopic LV lead implantation can be effectively and safely guided by epicardial QLV mapping. This strategy was highly successful in targeting the selected LV segment and resulted in significantly higher QLV ratios compared to an empirical midventricular lateral segment.

Background The progression of parasympathetic denervation of the atrioventricular node (AVN) during cardioneuroablation (CNA) can be evaluated by extracardiac vagal stimulation (ECVS). The right vagus nerve is usually used for stimulation (R-ECVS) because the right jugular vein is easily accessible. However, the AVN node is predominantly under the control of the left vagus nerve. Purpose To highlight the importance of left vagus stimulation (L-ECVS) for effective AVN denervation. Methods Both R-ECVS and L-ECVS (frequency: 50 Hz; pulse width: 0.05 ms; output 1 V / 1 kg; max. 70 V, duration 5 s) was attempted in 80 patients (age: 41±12 years, 45% men) undergoing CNA with stepwise strategy consisting of ablation of right anterior ganglionated plexus (RAGP) followed by ablation of posteromedial left ganglionated plexus (PMLGP). The study objective was the AVN response to L-ECVS (evaluated as the max. R-R interval during stimulation train) at the point when AVN non-reactivity to R-ECVS was achieved. Results A total of 59 patients were suitable for the analysis. Of the remaining 21 patients, left (n=14) or right (n=2) jugular veins were not accessible, AVN non-reactivity to L-ECVS was achieved before non-reactivity to R-ECVS (n=4), or AVN denervation was not achieved at all (n=1). At baseline, the AVN response was identical for R-ECVS (max. R-R median: 6.9 s, interquartile range [IQR]: 5.7–8.2 s) and L-ECVS (median: 7.1 s, IQR: 6.0–8.3 s), P=0.44. AVN non-reactivity to R-ECVS was present already at baseline (n=2); was achieved after ablation of RAGP (n=14), after ablation PMLGP (n=38), or after extensive ablation (n=5). At the point of AVN non-reactivity to R-ECVS, the response of AVN to L-ECVS was as follows: none (n=25), 2: 1 AV block (n=13) or complete AV block (n=21). The corresponding median of max. R-R interval was: 1.2 s, IQR: 0.6–4.8 s distributed as shown in Figure 1. Conclusions In 34/59 (58%) patients, significant AVN response to L-ECVS persists after reaching AVN non-reactivity to R-ECVS. Stimulation of both vagal nerves tightens the procedural endpoint and may increase the clinical efficacy of CNA, especially in patients with dominant AVN disorder. Funding Acknowledgement Type of funding sources: None.

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