case_images: PMC11784395_01
case_images: Three-dimensional voltage maps of both ventricles clearly depict the patch area in the basal septal region in the anteroposterior (A), left anterior oblique (B), and right anterior oblique (C) views. The patch area is also shown separately for the morphological left ventricle and morphological right ventricle in the posterolateral (D) and right anterior oblique (E) views, respectively. After implantation deep in the septum, the tip of the pacing electrode in unipolar configuration is seen as a green tag just beneath the scar area in the anteroposterior (F), left anterior oblique (G), and right anterior oblique (H) views. The tip of the atrial pacing electrode in unipolar configuration is observed as a green tag in the right atrial appendage (I). A chest X-ray displays the left-sided implanted cardiac resynchronization device with the atrial, septal, and defibrillator electrodes. The right-sided older generator and pacing electrodes, endocardially on the right side and epicardially on the left side, are visible (J). In the voltage maps, the gray area represents the right atrium, superior vena cava, and inferior vena cava, while meshed gray areas indicate the right atrial appendage and coronary sinus on the right side and the aorta on the left side.
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case_images: This mapping revealed a clear identification of the patch area, which manifested as a scar in the basal septal regions of both ventricles without any discernable retrograde His- or left-bundle potentials (Figures 1A-1E, Videos 1-4). Subsequent clockwise rotations of the pacing electrode from the shaft facilitated deep penetration toward the subendocardial region of the left side of the septum (Figures 1F-1H, Videos 5 and 6). Following this, an active-fixation electrode was implanted into the right atrial appendage, and it was also visible in the three-dimensional map in a unipolar configuration, appearing as a movable tag (Figure 1I, Video 7). A cardiac resynchronization therapy device was also implanted, with the atrial port connected to the atrial lead, the left ventricular port connected to the septal electrode, and the right ventricular sense/pace and defibrillator ports connected to the respective proximal tips of the defibrillator electrode (Figure 1J, Video 9).
case_images: The Advisor  HD Grid mapping catheter is observed during the mapping of the morphological left ventricle. Watch videos here: https://www.dropbox.com/scl/fo/vvqvgduw076pmuxjx22wh/ABJfHtZYTriz0JTd0TxD0jA?rlkey=cyhfzuaxlakk4js9esmj1ywrh&st=90s0tnkl&dl=0. A 360  view of the right heart structures includes a voltage map and scar area of the morphological left ventricle. Watch videos here: https://www.dropbox.com/scl/fo/vvqvgduw076pmuxjx22wh/ABJfHtZYTriz0JTd0TxD0jA?rlkey=cyhfzuaxlakk4js9esmj1ywrh&st=90s0tnkl&dl=0. A 360  view of the left heart structures includes a voltage map and scar area of the morphological right ventricle. Watch videos here: https://www.dropbox.com/scl/fo/vvqvgduw076pmuxjx22wh/ABJfHtZYTriz0JTd0TxD0jA?rlkey=cyhfzuaxlakk4js9esmj1ywrh&st=90s0tnkl&dl=0. A 360  view of the right and left heart structures with voltage maps and scar areas of both the morphological left and right ventricles. Watch videos here: https://www.dropbox.com/scl/fo/vvqvgduw076pmuxjx22wh/ABJfHtZYTriz0JTd0TxD0jA?rlkey=cyhfzuaxlakk4js9esmj1ywrh&st=90s0tnkl&dl=0. Contrast septal angiography shows the deep septal penetration of both poles of the pacing electrode in the left anterior oblique projection. Watch videos here: https://www.dropbox.com/scl/fo/vvqvgduw076pmuxjx22wh/ABJfHtZYTriz0JTd0TxD0jA?rlkey=cyhfzuaxlakk4js9esmj1ywrh&st=90s0tnkl&dl=0. A 360  view of the right and left heart structures includes voltage maps, scar areas of both the morphological left and right ventricles, and the tip of the pacing electrode located at the subendocardial region of the morphological right ventricle in the unipolar configuration, identified as a green tag. Watch videos here: https://www.dropbox.com/scl/fo/vvqvgduw076pmuxjx22wh/ABJfHtZYTriz0JTd0TxD0jA?rlkey=cyhfzuaxlakk4js9esmj1ywrh&st=90s0tnkl&dl=0. A 360  view of the right and left heart structures reveals the tip of the atrial pacing electrode located at the right atrial appendage in the unipolar configuration, marked with a green tag. Watch videos here: https://www.dropbox.com/scl/fo/vvqvgduw076pmuxjx22wh/ABJfHtZYTriz0JTd0TxD0jA?rlkey=cyhfzuaxlakk4js9esmj1ywrh&st=90s0tnkl&dl=0. All implanted and older leads are visible, spanning from the right anterior oblique view to the left anterior oblique view. Watch videos here: https://www.dropbox.com/scl/fo/vvqvgduw076pmuxjx22wh/ABJfHtZYTriz0JTd0TxD0jA?rlkey=cyhfzuaxlakk4js9esmj1ywrh&st=90s0tnkl&dl=0. The final positions of the generator and leads are shown in the antero-posterior projection. Watch videos here: https://www.dropbox.com/scl/fo/vvqvgduw076pmuxjx22wh/ABJfHtZYTriz0JTd0TxD0jA?rlkey=cyhfzuaxlakk4js9esmj1ywrh&st=90s0tnkl&dl=0
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case_images: PMC11784395_01_.jpg
case_images: video1
case_images: This mapping revealed a clear identification of the patch area, which manifested as a scar in the basal septal regions of both ventricles without any discernable retrograde His- or left-bundle potentials (Figures 1A-1E, Videos 1-4). Subsequent clockwise rotations of the pacing electrode from the shaft facilitated deep penetration toward the subendocardial region of the left side of the septum (Figures 1F-1H, Videos 5 and 6). Following this, an active-fixation electrode was implanted into the right atrial appendage, and it was also visible in the three-dimensional map in a unipolar configuration, appearing as a movable tag (Figure 1I, Video 7). A cardiac resynchronization therapy device was also implanted, with the atrial port connected to the atrial lead, the left ventricular port connected to the septal electrode, and the right ventricular sense/pace and defibrillator ports connected to the respective proximal tips of the defibrillator electrode (Figure 1J, Video 9).
case_images: In the surface electrocardiogram during the progression of the septal pacing electrode in the interventricular septum, QRS changes can be observed in derivations V1 and V6.
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case_images: The QRS changes resulting in RBBAP were observed as the septal pacing electrode started from the entry site on the morphological left ventricular septal side, progressed first into the deep septal area, and then captured the conduction system on the morphological right ventricular septal side (Figure 2).
case_images: At the 12-month follow-up, the surface 12-lead electrocardiography reveals selectively stimulated right bundle branch, demonstrating right bundle branch block morphology with earlier activation of the lateral wall of the morphological right ventricle than the right septal endocardium of the morphological left ventricle.
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case_images: At the 12-month follow-up, the ejection fraction had improved from the initial 30% before the upgrade procedure to 40%, and electrocardiography at this time showed the same findings as electrocardiography at implantation (Figure 3).
case_images: Gross anatomy of congenitally corrected transposition of the great arteries and ventricular septal defect. The His bundle, advancing from the front of the pulmonary trunk, then continues in the septal part of the morphological left ventricle (MLV) as the left bundle branch and in the septal part of the MRV as the right bundle branch. There are a total of five pacing electrodes: 1:within the right atrial appendage, 2:right bundle branch area pacing, 3:MLV apical, 4:MLV apical (implantable cardioverter-defibrillator), 5:MRV epicardial. Abbreviations: Ao, aorta; AVN, atrioventricular node; IVS, interventricular septum; LA, left atrium; MLV, morphological left ventricle; MRV, morphological right ventricle; MV, mitral valve; PT, pulmonary trunk; RA, right atrium; TV, tricuspid valve; VSD, ventricular septal defect.
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case_images: The gross anatomy of structural heart disease, the conduction system, and all implanted electrodes are seen in Figure 4.