CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 3, July/August 2023 AFRICA 191 cases with different pacing indications. Here we share our early experience using a standard 5.6F, Solia S 60, IS-1, ProMRI bipolar pacing lead and an 8.7F Selectra 3D introducer guide, 32–39-cm working length with 40/55/65-mm proximal radii (Biotronik). In all patients, the implant technique was similar. A venogram was performed to elucidate the cephalic/axillary/subclavian vein anatomy. Two to three guidewires were passed down to the inferior vena cava to ensure venous anatomy and thus avoid arterial puncture. The active fixation atrial lead was first placed at the RV apex as a back-up pace lead in case of inadvertent CHB during His mapping. Post HBP, the atrial lead was repositioned from the RV apex to the right atrium. If the QRS duration (QRSd) was reduced by at least 20 ms or 20%, the LV lead was not implanted, and the third guidewire was removed. If the QRSd was not shortened by the set pre-implant expectation, the LV lead was implanted as per the His-optimised CRT (HOT-CRT) technique.10 His mapping was performed in a unipolar configuration and done prior to active fixation, as is generally performed for HBP. In the first two patients, the stylet was not curved distally. The desired ECG was a small ‘A’, clear His and large ‘V’. The Solia S60 lead helix was extended using the fixation tool (10 to 15 turns) to expose and anchor the distal helix, followed by an additional six to nine clockwise turns on the fixated stylet guide to build up inner coil tension on the helix. Lastly the lead body was turned clockwise (five to six turns) for final fixation of the lead. The stylet guide was removed and the stylet pulled back by approximately 10 cm to avoid inadvertent dislodgement during sheath removal. The guide was then retrieved approximately 2–3 cm, exposing the lead tip. If the lead remained in place, a marker of acute stability, then the guide was slit and removed, followed by total withdrawal of the stylet. Patient 1 This was a 76-year-old male patient with CHB and pre-existing RVOP (VVIR), a paced QRSd of 196 ms (Fig. 2A), previous coronary artery bypass grafting, chronic AF and HF and New York Heart Association (NYHA) class III on optimal Fig. 1. A: The delivery catheter Selectra 3D (Biotronik SE & Co. KG, Berlin, Germany), with a double curve to all septal positioning. Note the standard screw lead exposed at the end of the delivery. B: The standard stylet-driven 6F lead inside the Selectra catheter. C: The standard stylet-driven 6F lead inside the Selectra catheter. Note at the tip of the lead the fixation tool to screw the retractable helix.7 A B C Fig. 2. A. Baseline paced (VVIR) ECG, QRSd = 196 ms. B. Current of His bundle injury during deployment of Biotronik Solia S pacing lead at the His bundle. C. Biotronik Solia S pacing lead at the His bundle and the pre-existing RV lead. D. NS-HBP post-implant, QRSd = 106 ms. A C B D
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