Background: Increasing interest in physiological pacing has been countered with challenges such as accurate lead deployment and increasing pacing thresholds with His-bundle pacing (HBP). More recently, left bundle branch area pacing (LBBAP) has emerged as an alternative approach to physiologic pacing. Objective: To compare procedural outcomes and pacing parameters at follow-up during initial adoption of HBP and LBBAP at a single center. Methods: Retrospective review, from September 2016 to January 2020, identified the first 50 patients each who underwent successful HBP or LBBAP. Pacing parameters were then assessed at first follow-up after implantation and after approximately one year, evaluating for acceptable pacing parameters defined as sensing R-wave amplitude >5 mV, threshold <2.5 V @ 0.5 ms and impedance between 400 and 1200 Ohms. Results: The HBP group was younger with lower ejection fraction compared to LBBP (73.2±15.3 vs 78.2±9.2 years, p=0.047; 51.0±15.9% vs 57.0±13.1%, p = 0.044). Post-procedural QRS widths were similarly narrow (119.8±21.2 vs. 116.7±15.2ms; p = 0.443) in both groups. Significantly fewer patients with HBP met the outcome for acceptable pacing parameters at initial follow-up (56.0% vs 96.4%, p = 0.001) and most recent follow-up (60.7% vs 94.9%, p = <0.001; at 399±259 vs. 228±124 days, p = <0.001). More HBP patients required lead revision due to early battery depletion (0 vs 13.3%, at an average of 664 days). Conclusion: During initial adoption, as compared with LBBAP, HBP is associated with a significantly higher frequency of unacceptable pacing parameters, energy consumption, and lead revisions.

An 84-year-old man with persistent AF (CHA2DS2-Vasc 6) was referred because of a migrated 24-mm Watchman implanted 7 months prior. Transesophageal echo (TEE) showed device malposition and protrusion outside the LAA along with a 90º tilt and peri-device leak (Figure, Movies 1-3). Under general anesthesia, an extraction was performed using TEE, intracardiac echocardiographic and fluoroscopy. Using a femoral arterial approach, a 27-mm Watchman was positioned in ascending aorta for cerebroembolic protection, never released from the connecting wire (WAASP technique, Movies 4-5) (1). A 23-Fr non-deflectable sheath (Micra, Medtronic, MN) was advanced into right atrium, through which a 12-Fr deflectable sheath (Flexcath Advance, Medtronic) was placed transeptal. A 2.4 mm x 20 cm Raptor grasping device (US Endoscopy, Mentor, Ohio; Figure) was advanced through 12 Fr sheath to grasp the Watchman device. With sustained traction, the device was dislodged from the LAA into the 23 Fr sheath (Figure, Movie 6). A new 24 mm Watchman was then placed and the temporary Watchman in the aorta was removed. A follow up TEE showed stable position without significant peri-device leak. This case demonstrates the safety and feasibility of malpositioned Watchman extraction re-implantation in the same setting (2).

Introduction: Hydroxychloroquine (HCQ) alone or in combination with azithromycin (AZ) is one of the many therapies being explored for the treatment of Coronavirus 2019 (COVID-19). We performed a systematic review regarding the effects of HCQ versus HCQ+AZ on corrected QT interval (QTc) and cardiovascular outcomes. Methods: We performed a systematic search, using PubMed, EMBASE, SCOPUS, and Google Scholar from inception to May 3rd, 2020, with studies fulfilling the following inclusion criteria: (1) compared HCQ versus HCQ+AZ in COVID-19; (2) reported change in QTc interval and/or cardiovascular outcomes. The primary outcome was change in QTc (maximum QTc–baseline QTc) and incidence of TdP in COVID-19 patients on HCQ vs. HCQ+AZ. Results: A statistically significant change in QTc interval was observed with HCQ+AZ compared to HCQ alone (WMD 9.13 ms, 95%CI 3.74-14.01, p=0.01, I2=29.04%). However, no significant difference in the risk of development of QTc>500 ms was observed between two groups (10.6% in HCQ vs. 14.7% in HCQ+AZ, RR 0.71, 95% CI 0.32-1.59, p =0.40, I2 = 35.8%). Also, no significant difference in risk of TdP was observed between the two groups (0% vs. 0.5%, risk difference -0.002,95% CI-0.02 to 0.02, p=0.83, I2 =0%, respectively). However, one patient experienced TdP, three days after discontinuation of HCQ+AZ for prolonged QTc (499 ms). Conclusion: The risk/benefit of HCQ and AZ should be carefully contemplated, given the risk of QTc prolongation. Until further safety data is available, we recommend close monitoring of QTc interval and electrolytes, avoiding drug-drug interactions in these high-risk patient populations.