Eric Lim

EP at National Heart Center Singapore. Views expressed here are my own and don’t represent the institution. Interested in mapping and conduction system pacing.

[Eric Lim @ericlim1975]

@Carissa12399g @mike_lean @danealson @_shannonmillard @AMatthews0 @Hapa_EP @javadm20 @Yogesh_EP @forkknifecab_EP @pjsm83 @ALFIEEP1 @hikmetyorgun @da_silvr @AbbottCardio I think that layering peak frequency as part of an emphasis map is helpful in appreciating the three dimensional nature of the circuit. For myself, I find it helps to determine the optimal ablation strategy.

[Eric Lim @ericlim1975]

@JRgar10 @murphy_lzy Hope you recovered from the jet lag Dr Rodriguez! and had a safe flight home. It was good of you to make the long flight to come.

[Eric Lim @ericlim1975]

@MRazminia That's very reassuring!

[Eric Lim @ericlim1975]

@MRazminia Thanks. I guess you probably place ICE through the same TSP as the Faradrive? Although I have done this also, I do have concerns aboutiatrogenic ASDs when placing both a 10Fr ICE plus the Faradrive (ID 13Fr) together through the same puncture. Is this a concern for you?

[Eric Lim @ericlim1975]

@MRazminia Do you do this through a single transseptal puncture site? If so do you worry about the size of the hole needed to accommodate both a Faradrive and ICE catheter?

[Eric Lim @ericlim1975]

@EduardoSaad3 @Drdevignair @MRazminia @LuigiDiBiaseMD @natale_md @BidmcCvi @BIDMCVFellows @LAHRSonline1 Very nice images. Do you place the ICE in LA through the same or separate transseptal puncture as the Faradrive?

[Eric Lim @ericlim1975]

@Hapa_EP @EPWaveDoc @naijaQRS @javadm20 @CarinaHardy4 @ECG_Emily @jeffrey_vinocur @Ed_Gerst @dkenigsberg @B_Naz_MD @PennEPFellows This seems like a nice case for PFA with Farapulse. Pretty easy and safe to do the PVI plus take out the posterior wall with just a few additional lesions.

[Eric Lim @ericlim1975]

@chris_monkhouse @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip I did use a Tyrx. Wondering what I’ll find at his follow up.

[Eric Lim @ericlim1975]

1/ I wonder what #Epeeps would do for a 62yo male patient with NICMP, LBBB QRSd >200ms, LVIDd 71mm, LVEF12%? Conventional CRT, LBB-CRT, LOT-CRT, too advanced for CRT? For CRT, any vendor preferences? @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip @chris_monkhouse

[Eric Lim @ericlim1975]

@James_Elliott01 @finnakerstrom @enes_elvin @riley_guntrip @chris_monkhouse I agree LOT-CRT has a lot of added baggage and I’ve tended to avoid them after going through a stretch of time trying them. At the end of this case, my regret is that I did not test adequately the LBB-CRT configuration and kept to that. Perhaps others can learn from my mistake.

[Eric Lim @ericlim1975]

@curilakarol @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip @chris_monkhouse Retrospectively, I would have tested impact of optimizing AV delay after getting the LBB lead in, since LBBP-CRT with RBB fusion gave such a nice result (without CS lead). But like others in this thread, I was convinced I needed a LOT-CRT. Turned out I was wrong - lesson learned.

[Eric Lim @ericlim1975]

@JoelSimonEP @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip @chris_monkhouse Hi, yes there’s a ICD lead but it’s a DF1 lead. Defib part is connected to DF1 port for shocking but the LBB lead is connected to the pace-sense port. So pacing occurs via the LBB lead and the RV defib lead can shock but can’t pace. Allows connection to a standard DF1 CRTD PG.

[Eric Lim @ericlim1975]

6/ Actually, with CSP lead only+RBB fusion, we got a QRS almost as good. Previous morphology slightly nicer I think but is this worth the complexity of a LOT-CRT cf. LBB-CRT? (Would be a no from me). Overall, I thought this was an interesting case worth sharing with #Epeeps.

[Eric Lim @ericlim1975]

5/ This was the final optimised result with both LBB and CS lead pacing, and after adjusting VV plus the AV delay (which Biotronik allows via the autoAdapt %). It does look very good, with a QRS of around 110ms. But what if I had only used a CSP lead (or CS lead)?

[Eric Lim @ericlim1975]

@pjsm83 @finnakerstrom @James_Elliott01 @enes_elvin @riley_guntrip @chris_monkhouse Thanks! How would you decide when it is good enough to stop and when would you keep going to the next step? Any preference for lead and/or vendor for such cases?

[Eric Lim @ericlim1975]

@enes_elvin @finnakerstrom @James_Elliott01 @riley_guntrip @chris_monkhouse Haha. Thanks. I did the case last week and found the result … surprising. Just curious what majority #Epeeps are doing as I struggle now with deciding between options for these types of cases. I’ll post the result over the next day or two.