Left bundle branch area (LBBA) pacing is an innovative approach for permanent cardiac pacing. Combining LBBA pacing with an implantable cardioverter-defibrillator (ICD) system can reduce the number of leads required in patients who need both therapies, thereby lowering hardware burden, reducing costs, and potentially improving safety. In this case report, we describe the successful implantation of an ICD lead for LBBA pacing. To our knowledge, this represents the first documented instance of achieving LBBA pacing with an ICD lead positioned using a manually shaped stylet.

Background Left bundle branch pacing (LBBP) is increasingly used for physiological pacing in bradyarrhythmias and is generally safe, though rare complications may arise. Case Summary A 72-year-old woman with sick sinus syndrome underwent LBBP with multiple challenging lead placement attempts. One attempt caused resistance during lead withdrawal. Imaging later revealed a 1.5-mm ventricular septal defect, severe mitral regurgitation from anterior mitral leaflet prolapse, and severe tricuspid regurgitation. Histopathology showed valvular tissue on the lead, suggesting chordal entrapment and septal perforation during manipulation. Discussion This case highlights a unique, previously unreported combination of ventricular septal rupture and valvular injury after LBBP. Take-Home Messages Although rare, conduction system pacing can result in mechanical complications such as septal injury and mitral chordal entrapment. Monitoring of pacing parameters, including abrupt impedance changes or resistance during lead manipulation, may aid in early recognition of tissue entrapment and prevent structural damage.

Transcatheter device closure is the preferred treatment for secundum atrial septal defect (ASD) in young adults with suitable anatomy. In this population, routine coronary angiography is generally not recommended in the absence of ischemic symptoms or conventional cardiovascular risk factors. However, coronary imaging is selectively performed during ASD intervention to delineate anomalous coronary anatomy at risk of device-related compression, and emerging evidence indicates that clinically significant coronary artery disease may occasionally coexist silently in younger adults. We report the case of a 28-year-old asymptomatic woman undergoing transcatheter closure of a large secundum ASD with deficient rims, in whom coronary angiography performed during invasive catheterization unexpectedly revealed critical left main coronary artery stenosis. Intravascular ultrasound (IVUS) confirmed severe luminal compromise, and successful IVUS-guided left main coronary stenting was performed, followed by device-assisted ASD closure in the same procedural session. Retrospective clinical assessment revealed a history of premature sudden cardiac death in a first-degree relative. This case illustrates the potential for occult yet prognostically significant coronary artery disease in young adults undergoing congenital heart interventions and supports a selective, individualized, and context-driven approach to coronary evaluation, consistent with contemporary adult congenital heart disease guidelines.

The Right Ventricular (RV) apex has been the standard site for pacing in symptomatic bradyarrhythmias, but chronic RV pacing can cause adverse effects such as atrial arrhythmias and left ventricular dysfunction. Physiological pacing, including His bundle and left bundle pacing, offers alternatives with fewer complications. We present a 66-year-old male with a dextroposed heart and fibrotic right lung requiring left bundle branch pacing due to a high RV pacing burden. The procedure involved modified lead placement and a medial subclavian vein puncture, successfully achieving good electrical parameters and post-procedural device function, highlighting left bundle branch pacing's feasibility in complex anatomical conditions.

Background: Worsening heart failure (WHF) is characterized by the progression of symptoms in patients with established HF, necessitating intensified treatment, typically with diuretics. Outpatient (OP) management of WHF offers an alternative to hospitalization, as many patients experience a gradual onset of symptoms, allowing timely intervention. However, OP WHF is often underrecognized and excluded from clinical trials, highlighting the need for structured guidance. This expert consensus aims to address this gap by providing clinical practice recommendations for OP WHF management. Methodology: A panel of Indian cardiologists convened for an expert meeting moderated by a leading cardiologist. Based on clinical evidence, expert insights, and live polling, consensus recommendations were developed. Results: Experts agreed that WHF is defined by symptom worsening despite standard HF therapy, decompensation in chronic HF, and an increase in oral or intravenous diuretic dose. Vericiguat was recognized as suitable for patients with reduced eGFR (<30 mL/min/1.73 m²), unlike angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker/angiotensin receptor-neprilysin inhibitor (ACEi/ARB/ARNi) and digoxin. While ACEi/ARB/ARNi doses may be reduced in WHF with worsening renal function, beta-blockers should be maintained as long as possible. OP management should prioritize early vericiguat initiation alongside rapid HF therapy optimization. About 44% of experts recommended initiating vericiguat at the first follow-up (3–7 days postdischarge), whereas 33.3% preferred it as a last-line option. Management of end-stage heart failure with advanced options like assist devices and transplants is needed with failure of drug therapy, persisting end-organ failure, and repeated hospitalization. Conclusion: This consensus highlights early OP department (OPD)-based recognition of WHF, OPD-based structured HF therapy optimization, and early vericiguat initiation to improve WHF management in outpatient settings.

Bradyarrhythmias, characterized by heart rates of <60 bpm due to conduction issues, carry risks of sudden cardiac death and falls. Pacemaker implantation is a standard treatment, but the interplay between bradyarrhythmias, coronary artery disease (CAD), and patient attributes requires further exploration. This study was a retrospective hospital record-based study that analyzed data from 699 patients who underwent pacemaker implantation for symptomatic bradyarrhythmias between February 2019 and February 2022. Clinical parameters, coronary angiography (CAG) findings, ejection fraction, and indications for pacemaker implantation were documented. The relationship between CAD severity, specific bradyarrhythmias, and ejection fraction was explored. Statistical analysis included chi-squared tests and t tests. The mean age of the study population (n = 699) was 66.75 years (male:female ratio, 70:30), with 77.2% having type 2 diabetes and 61.6% being hypertensive. The majority of patients had minor or non-obstructive CAD (61.8%), followed by normal CAG findings (25.75%) and obstructive CAD (12.45%). Complete heart block (CHB) was the primary indication for pacemaker implantation (55.2%), followed by sick sinus syndrome (22.3%). The results did not show any association between ejection fraction and CAG findings. Patients who presented with CHB had a higher incidence of obstructive CAD, indicating greater severity. This study sheds light on the intricate interplay between severe bradyarrhythmias, CAD, and patient characteristics. Our analysis revealed no statistical significance between obstructive CAD and the need for a permanent pacemaker. This makes us question our practice of maintaining a low threshold for coronary angiography during pacemaker implantation. The observed low yield and anticoagulation protocol reassure us of the choice to delay this diagnostic intervention. These insights can guide tailored management strategies, enhancing clinical care approaches for patients with severe bradyarrhythmias necessitating pacemaker implantation.

Background:Ultrathin-strut stents are considered the future of percutaneous coronary intervention for treating coronary artery disease (CAD). These drug-eluting stents with biodegradable-polymer technology have the potential to improve clinical outcomes in CAD patients. Aims:This study aimed to evaluate the safety and performance of newer-generation ultrathin-strut (50 µm) Evermine50 everolimus-eluting stents (EES) in patients with single or multiple long lesions. Methods:This is a prospective, single-arm, multicentre study conducted in India that enrolled 118 patients with de novo coronary lesions. The endpoints were defined based on the major adverse cardiac events (MACE; composite of cardiac death, myocardial infarction [MI] and clinically driven target lesion revascularisation) up to 24-month follow-up. A subset of patients (n=21) underwent angiographic follow-up for a mean follow-up period of 12 mon. Results:A total of 138 lesions were successfully treated in 118 patients, the majority of whom were males (80.51%). The average stent length and diameter deployed were 26.02±9.24 mm and 2.97±0.36 mm, respectively. The results exhibited low MACE at 24-month follow-up (0.87%) with no stent thrombosis and 1 death (0.87%, which was cardiac). The core lab angiographic assessment showed in-segment and in-device late lumen loss of 0.12±0.31 mm and 0.17±0.31 mm, respectively, at a mean follow-up of 12 months, with clinically acceptable outcomes. Conclusions:The Evermine50 EES showed satisfactory primary clinical as well as angiographic outcomes, reaffirming the safety and performance of the world's thinnest-strut stent by exhibiting low rates of MACE at 24-month follow-up with an absence of any stent thrombosis and MI. Clinical Trials Registry-India (CTRI) number: CTRI/2017/02/007781.

Background: Bifurcation lesions pose a high risk for adverse events after percutaneous coronary intervention (PCI). Evidence supporting the benefits of the two-stent strategy (2SS) for treating coronary bifurcation lesions in India is limited. This study aimed to evaluate the clinical outcomes of various 2SSs for percutaneous transluminal coronary angioplasty for bifurcation lesions in India. Materials and Methods: This retrospective, observational, multicentric, real-world study included 64 patients over 8 years. Data on demographics, medical history, PCI procedures, and outcomes were recorded. Descriptive statistics were computed using the SPSS software. Results: Patients (n = 64) had an average age of 65.3 ± 11.1 years, with 78.1% males. Acute coronary syndrome was reported in 18.8%, chronic stable angina in 40.6%, and unstable angina in 34.4% of participants. Two-vessel disease was observed in 98.4% of patients, and 99.4% had true bifurcation lesions. The commonly involved vessels were the left anterior descending artery (50%), left circumflex coronary artery (34.4%), and first diagonal artery (43.8%). Mean percent diameter stenosis was 87.2% ± 10.1%. The mean number of stents used was 2.00 ± 0.34. The 2SS techniques included the T and small protrusion (TAP) (39.1%), double kissing (DK) crush (18.8%), and the culotte techniques (14.1%). Procedural and angiographic success rate was 92.18%. Major adverse cardiovascular events at 1-year follow-up occurred in 7.8% of cases. Conclusion: The 2SS for bifurcation lesions showed favorable in-hospital and follow-up outcomes. Findings can serve as a resource for bifurcation angioplasty in India. Larger real-world studies with robust methodology are needed to validate these results.

Background Atrial septal defect (ASD) closure with significant left-to-right shunt and concurrent comorbidities poses challenges for intervention. A fenestrated atrial septal defect (FASD) device is a viable option for patients who cannot undergo complete occlusion due to hemodynamic and medical reasons. This study explores the use of FASD occluders in patients with secundum ASD and associated comorbidities where complete occlusion is difficult. Methodology This retrospective study collected the details of patients recommended for FASD closure diagnosed with significant secundum ASD and who had additional comorbidities between July 2015 and July 2023 in a tertiary cardiac center in eastern India. Among this cohort, patients who underwent FASD device placement were subjected to a comprehensive analysis.Results In total, 16 patients diagnosed with secundum ASD, characterized by significant left-to-right shunt and concurrent comorbidities, were considered for FASD closure during the study period. Ultimately, 13 patients (first group) underwent fenestrated atrial septal occluder implantation. The average age was 45.07 years, with the majority being females (n = 9). Comorbidities among this cohort included substantial left ventricular diastolic dysfunction (n = 7), left ventricular diastolic dysfunction coupled with moderate pulmonary hypertension (n = 1), severe pulmonary hypertension (n = 1), severe pulmonary valvular stenosis with right ventricular diastolic dysfunction (n = 2), and systemic lupus erythematosus (SLE) (n = 2). From this cohort, three patients did not undergo the intervention. The second group consisted of an elderly patient with severe left ventricular diastolic dysfunction, a young adult with a history of left atrial arrhythmia, and a child with Duchenne muscular dystrophy (DMD). The average ASD size among patients who underwent the intervention was 26.38 mm, with a thick-to-thick dimension measuring 31.15 mm. The procedure was successful in all 13 patients, with the most frequently used device being a 34 mm occluder (range = 28-40 mm). All devices, excluding the initial one, were custom-made atrial septal occluders (Lifetech Scientific). Among the patients, 12 exhibited left-to-right fenestration flow, while one patient experienced fenestration constriction, likely due to occluder overcrowding. The first patient had a handmade 5 mm fenestration in a 40 mm Amplatzer septal occluder, which got closed off at the one-year follow-up. The procedure was well-tolerated hemodynamically in all patients, with no major complications during the peri-procedural period. Short-term follow-up indicated favorable patient progress.Conclusions FASD closure emerges as a pivotal alternative for intricate scenarios involving secundum ASD coupled with concurrent comorbidities, offering individualized tailored solutions. Alongside the conventional associated comorbidities, such as left ventricular diastolic dysfunction and pulmonary hypertension, FASD devices hold the potential to extend their benefits to patients grappling with other complexities, including severe pulmonary valvular stenosis, SLE, predisposition to left atrial arrhythmia, and conditions like DMD. Ensuring meticulous evaluation of patient suitability and providing ongoing vigilant care becomes paramount for achieving optimal outcomes. The validation of these findings and the broadening of the comprehension of this approach necessitate further comprehensive investigations.

Left bundle branch area pacing (LBBAP) is widely used as an alternative to conventional biventricular cardiac resynchronization therapy (BiV-CRT). However, its effectiveness is limited in patients with distal conduction delay in the distal left bundle branch (LBB) or left ventricular Purkinje network. Conventional BiV-CRT based on right ventricular pacing and coronary venous pacing also has limitations, with a significant number of patients experiencing an increase in QRS duration post-CRT. To address these limitations, a combination of LBBAP and BiV pacing, known as LBBAP optimized CRT (LOT-CRT), has shown promising results. There is increasing evidence suggesting that LOT-CRT is more effective than LBBAP or BiV-CRT alone. In this case series, the authors present a series of two cases where they employed LOT-CRT as a treatment approach for patients with heart failure who were symptomatic despite optimal medical therapy. Through these cases, the authors aimed to demonstrate the potential benefits of LOT-CRT in patients with non-LBB block (LBBB) QRS morphology with a QRS duration of less than 150 ms, providing more favorable treatment outcomes for patients with heart failure who are not candidates for conventional CRT due to their non-LBBB QRS morphology.

Background and Objective: Cardiovascular disease (CVD) is a significant cause of morbidity and mortality worldwide, with high-risk patients requiring effective management to reduce their risk of cardiovascular events. Bempedoic acid is a novel therapeutic agent recently approved as an add-on therapy to statins in patients with uncontrolled LDL-c. Bempedoic acid inhibits cholesterol synthesis in the liver, which ultimately reduces the risk of cardiovascular events. Therefore, the present study aims to assess the efficacy and safety of bempedoic acid in patients with uncontrolled LDL-c (Previously on moderate or high-intensity statins) with a high risk of CVD in real-world settings. Methods: This is a multicenter, retrospective, observational study on the data of high-risk-CVD patients collected from Bempedoic Acid on Efficacy and Safety in patients (BEST) Registry. The clinical data of 140 patients who were already on statin therapy and were receiving Bempedoic acid at a dose of 180 mg, along with measurements of the level of LDL-c, HbA1c, HDL, TG, TC, PPPG, FPG, AST, ALT, serum creatinine was taken into consideration. The primary outcome includes a change in LDL-c level, and secondary outcomes involve a change in the level of HbA1c, HDL, TG, TC, PPPG, FPG, AST, ALT, and serum creatinine at week 12 and 24. Adverse events were reported at both time points. Results: A total of 140 patients were included in the present study with a mean age of 51.8 ± 9.2 years and had primary confirmed diagnosis of dyslipidemia with uncontrolled LDL-c. The mean levels of LDL-c decreased from the mean baseline value of 142.67 ± 46.49 mg/dL, to 106.78 ±33.92 mg/d; a statistically significant reduction by 23.23% (p < 0.01) at week 12. Similarly, at week 24, the mean LDL-c value reduced to 90.39 ± 38.89 mg/dL. A 33.38 % decrease was observed (p < 0.01). Other parameters such as non-HDL, FPG, PPPG, AST and serum creatinine also showed statistically significant reduction at week 12 and week 24. Conclusion: The present study demonstrates that bempedoic acid is an effective add-on medication in lowering LDL-c levels in high-risk CVD patients with uncontrolled LDL-c.

Objective Transcatheter atrial septal defect (ASD) device closure in the older population presents a greater challenge due to the long-standing effect of atrial left-to-right shunt. This study analyzes the challenges encountered in transcatheter ASD device closure in older patients in their fifth decade and beyond. Methods Adults aged 40 years and above with significant secundum ASD who underwent transcatheter ASD device closure between June 2015 and April 2021 were analyzed. Challenges were classified as major and minor challenges based on their impact on the alteration of the treatment protocol. Patients were categorized into three subgroups according to age. Group 1 consisted of patients aged 40-49 years (n = 13), Group 2 consisted of patients aged 50-59 years (n = 16), and Group 3 consisted of patients aged 60 years and above (n = 8). Results A total of 37 patients were analyzed. The challenges encountered were arrhythmia, pulmonary hypertension, left ventricular diastolic dysfunction, bleeding, stroke, coronary artery disease (CAD), hypertension, and airway disease. Thirteen percent of challenges were seen in pre-procedure time, whereas 79% of challenges during the procedure and 8% of challenges during post-procedure were seen. Thirty-five patients (94.6%) underwent transcatheter ASD device closure. Two patients (5.4%) did not undergo transcatheter ASD device closure due to severe diastolic dysfunction and associated CAD, respectively. Eleven major challenges were encountered in 10 patients in which one patient had a dual challenge of bleeding and arrhythmia. Thirteen patients (35.1%) had smooth procedures without any challenges encountered. Twenty-seven minor challenges were encountered in 20 patients with some patients having an overlap of multiple major and minor challenges. The patients were doing well at the mean follow-up of 28 months. Conclusions Transcatheter ASD device closure in older patients who are 40 years and above is safe and effective. Such high-risk patients are prone to various challenges that can be effectively managed if optimally monitored on the basis of a proper understanding of the altered physiology and anticipation of the deviated course at various stages of the procedure.

Introduction: Atrioventricular (AV) block is a common problem worldwide requiring permanent pacemaker implantation, which results in a huge economic burden on society. In our country, the major burden is noted in eastern India. The etiopathological correlation of degenerative conduction tissue disorder does o't explain the differential volume of disease. We speculate environmental link, particularly the influence of elevated trace metals in the pathogenesis of this condition. Purpose: The purpose of the study was to investigate and correlate the concentration of trace metals in blood of patients who have received a permanent pacemaker. Materials and Methods: The blood samples of 81 patients who had permanent pacemaker implantation in the past 3 years were collected and levels of various trace metals were evaluated. It was done using inductively coupled plasma mass spectrometry. The values were expressed in μg/l. Results: There were elevated trace metals in 21 patients and 4 among them had an overlap of more than one abnormal values. Strontium (Sr) surprisingly was elevated in a maximum of 11 patients. The most interesting observation was a trend of Sr being elevated in male sex with AV nodal disease. Conclusion: From this study we hypothesize, Sr affects ion channels in conduction tissue due to its close chemical similarity to calcium. In long run, it could have been inducing fibrosis causing AV blocks. Our observation suggests that trace metal screening may be considered in areas with a high prevalence of AV blocks requiring permanent pacemakers.

A 46-year-old lady presented to out-patient department with recurrent episodic palpitations having preexcitation on ECG. She was advised electrophysiology study (EPS) and radiofrequency ablation (RFA) This article is protected by copyright. All rights reserved.

A 9-year-old boy presented with breathing difficulty and episodic palpitation. Cardiac evaluation revealed features suggestive of left atrial myxoma intermittently obstructing the left ventricular inflow in the echocardiogram. The tumor was removed surgically. Histopathology confirmed the diagnosis. Cardiac myxoma is very rare in pediatric age group. High degree of suspicion is required for the diagnosis and management.

Over the past decade, percutaneous left ventricular assist devices (pLVAD), such as the Impella microaxial flow pump (Abiomed), have been increasingly used to provide haemodynamic support during complex and high-risk revascularisation procedures to reduce the risk of intraprocedural haemodynamic compromise and to facilitate complete and optimal revascularisation. A global consensus on patient selection for the use of pLVADs, however, is currently lacking. Access to these devices is different across the world, thus, individual health care environments need to create and refine patient selection paradigms to optimise the use of these devices. The Impella pLVAD has recently been introduced in India and is being used in several centres in the management of high-risk percutaneous coronary intervention (PCI) and cardiogenic shock. With this increasing utilisation, there is a need for a standardised evaluation protocol to guide Impella use that factors in the unique economic and infrastructural characteristics of India's health care system to ensure that the needs of patients are optimally managed. In this consensus document, we present an algorithm to guide Impella use in Indian patients: to establish a standardised patient selection and usage paradigm that will allow both optimal patient outcomes and ongoing data collection.