Hyper-response to cardiac resynchronization with permanent His bundle pacing: Is parahisian pacing sufficient? Olujimi A. Ajijola, MD, PhD, Jorge Romero,

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Hyper-response to cardiac resynchronization with permanent His bundle pacing: Is parahisian pacing sufficient? Olujimi A. Ajijola, MD, PhD, Jorge Romero, MD, Gabriel Vorobiof, MD, William M. Suh, MD, Kalyanam Shivkumar, MD, PhD, FHRS, Roderick Tung, MD, FHRS HeartRhythm Case Reports Volume 1, Issue 6, Pages 429-433 (November 2015) DOI: 10.1016/j.hrcr.2015.05.006 Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 1 Intracardiac recording and fluoroscopic appearance of parahisian pacing site. A: Intracardiac electrograms (lower tracing) obtained at a site in the high septum where the His bundle pacing lead was deployed. The His bundle electrogram is indicated by the arrow. The surface electrocardiogram (ECG; upper tracing) is also shown. B: Fluoroscopic appearance of the final position of the permanent His bundle pacing lead and the atrial and ventricular leads in a shallow right anterior oblique projection. HeartRhythm Case Reports 2015 1, 429-433DOI: (10.1016/j.hrcr.2015.05.006) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 2 Electrocardiographic and echocardiographic impact of parahisian pacing. The left panel shows the surface QRS before and after permanent His bundle pacing (PHBP) was implemented. The QRS duration narrowed from 198 ms to 123 ms following PHBP. The right panel demonstrates the diastolic and systolic transthoracic echocardiographic images obtained in the apical 4-chamber projection before and after PHBP, with respective endocardial tracings using Simpson’s method. HeartRhythm Case Reports 2015 1, 429-433DOI: (10.1016/j.hrcr.2015.05.006) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 3 Impact of parahisian pacing on regional left ventricular (LV) deformation on echocardiographic strain imaging. The top panels on the left and right show longitudinal (3-chamber) images of the left ventricle at peak contraction before and after initiation of parahisian pacing. Regional LV deformation is shown for each region (expressed in negative % deformation). The bottom panels show regional strain profiles of each region before and after parahisian pacing; these are more uniform following pacing. BIS = basal inferoseptal; MIS = mid inferoseptal; ApS = apicoseptum, ApL = apicolateral; MAL = mid anterolateral; BAL = basal anterolateral. HeartRhythm Case Reports 2015 1, 429-433DOI: (10.1016/j.hrcr.2015.05.006) Copyright © 2015 Heart Rhythm Society Terms and Conditions