Concealed left bundle branch potential during physiological pacing
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CASE REPORTS
Concealed left bundle branch potential during physiological pacing Shunmuga Sundaram Ponnusamy 1
&
Pugazhendhi Vijayaraman 2
Received: 6 October 2020 / Accepted: 19 October 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
A 70-year-old gentleman presented to us with recurrent syncope, intermittent left bundle branch block (LBBB) (Fig. 1a) and left ventricular ejection fraction of 35%. He had undergone percutaneous coronary intervention for inferior wall myocardial infarction 5 months ago. Holter monitoring showed intermittent LBBB and highgrade AV block. A3830 Selectsecure tm lead was deployed using C315-His sheath to capture the left bundle branch (LBB) [1]. Electrocardiography showed narrow QRS duration during the procedure. After 4 rapid rotations, LBB potential was noted (Fig. 2a) but the peak left ventricular activation time (pLVAT) at 2 V/0.5 ms pac-
ing output was 93 ms. One more rotation resulted in negative LBB current of injury (LBB-COI) with disappearance of LBB potential (Fig. 2b) but pLVAT improved to 53 ms at 2 V/0.5 ms. Resurgence of concealed LBB potential was noted after 20 min. A predominant negative deflection followed by sharp high frequency biphasic potential was observed (Fig. 2c–f), which was different from the three types of LBB-COI described by Su et al. [2]. This type IV LBB-COI pattern concealing the LBB potential has to be considered before repositioning the lead due to sudden loss of LBB potential during deployment.
Fig. 1 a Baseline 12 lead electrocardiography showed complete left bundle branch block with Q waves in inferior leads. b Post LBBP ECG showed narrow paced QRS with duration of 108 ms
* Shunmuga Sundaram Ponnusamy [email protected] 1
Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamilnadu, India
2
Geisinger Commonwealth School of Medicine, Geisinger Heart Institute, MC 36-10, 1000 E Mountain Blvd, Wilkes-Barre, PA 18711, USA
J Interv Card Electrophysiol
Fig. 2 Concealed left bundle branch potential. a After 4 rotations, LBB potential (LBB Po) was noted but pLVAT was 93 ms at 2 V/0.5 ms. b One more rotation was given resulted in LBB COI with disappearance of LBB potential with improvement in pLVAT to 53 ms at 2 V/0.5 ms. c–f
Gradual resurgence from a predominantly negative deflection to sharp high frequency biphasic LBB potential after 45 min. His Po His bundle potential, COI current of injury, LBB CON concealed LBB potential within the current of injury
Authors’ contribution SSP: Consultant: Medtronic PV: Honoraria, consultant, research, fellowship support: Medtronic, consultant: Boston Scientific, Abbott, Biotronik, Eaglepoint LLC
References 1.
Compliance with ethical standards 2. Ethical approval The study was conducted after getting the ethical committee approval. Conflict of interest The authors declare that they have no conflict of interest. The paper is not under consideration elsewhere. None of the paper’s contents have been previously published. All authors have
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