Author + information
- Received November 14, 2017
- Accepted November 23, 2017
- Published online March 19, 2018.
- Serkan Cay, MD∗ (, )
- Firat Ozcan, MD,
- Ozcan Ozeke, MD,
- Dursun Aras, MD and
- Serkan Topaloglu, MD
- Division of Arrhythmia and Electrophysiology, Department of Cardiology, University of Health Sciences, Yuksek Ihtisas Heart-Education and Research Hospital, Ankara, Turkey
- ↵∗Address for correspondence:
Dr. Serkan Cay, Division of Arrhythmia and Electrophysiology, Department of Cardiology, University of Health Sciences, Yuksek Ihtisas Heart-Education and Research Hospital, 06100, Sihhiye, Ankara, Turkey.
A 63-year-old man with symptomatic atrioventricular block underwent permanent pacemaker implantation. The procedure had 2 stages. In the first stage, detailed 3-dimensional (3D) electroanatomic mapping of right-heart structures with the His cloud was obtained (Figure 1). A rough anatomy of caval veins and the right atrium was performed using a standard steerable decapolar catheter and intracardiac electrocardiograms (ECG) to cannulate the coronary sinus with the same catheter in the left anterior oblique view. With the help of a standard bidirectional quadripolar ablation catheter and simultaneously recorded ECG, detailed anatomic views of all right-heart structures with final comprehensive His cloud formation were obtained. The best selective His bundle pacing sites (equal stimulus-QRS and His-QRS intervals, no myocardial capture with lower pacing amplitudes, and identically paced QRS with the native QRS) were tagged as red on the 3D map. In the second stage, a dual-chamber pacemaker implantation was performed using previously formed 3D map with the strictly limited use of fluoroscopy for axillary vein puncture and final recording (Figure 2). The His bundle region was easily reached using a specialized pre-shaped peel-away catheter (C315-HIS, Medtronic, Minneapolis, Minnesota), and a specialized lumenless thin active-fixation pacing lead (SelectSecure, Medtronic) was localized in the His cloud region. Integrated bipolar sites at the proximal tip of the electrode were connected to the electrophysiology system (WorkMate Claris, St. Jude Medical, St. Paul, Minnesota) both to see the electrode on the 3D map and to obtain intracardiac signals. The lead was screwed to 1 of the best His bundle pacing sites with an R-wave of 5 mV and a capture threshold of 1.25 V at a pulse width of 0.5 ms (Figure 3). A standard active-fixation atrial lead was placed using the 3D map in the right atrial appendage. Implanted leads were finally confirmed using both the 3D map and the fluoroscopy (Figure 4, Online Video 1). Pre- and post-procedure ECG were identical (Figure 5).
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received November 14, 2017.
- Accepted November 23, 2017.
- 2018 American College of Cardiology Foundation