Introduction: Endomyocardial fibrosis (EMF) is characterized by patchy fibrotic thickening of the endocardial and myocardial layers of the heart. Although Sinus node dysfunction and tachyarrhythmia - atrial fibrillation, ventricular tachycardia, have been commonly reported, complete heart block complicating EMF is rare. Transvenous pacing is technically limited by fibrotic obliteration of the affected ventricle that results in poor lead parameters, and alternative pacing strategy like epicardial pacing may be required in many. Methods and Results: We present two cases of EMF with complete heart block that were managed by left ventricular pacing through the coronary sinus. Conclusion: EMF provides unique challenges to endocardial pacing. Transvenous epicardial pacing through CS tributary using an LV lead can provide a safe and effective alternative mode of pacing with optimal long-term pacing outcome.

A document by Krishna Kumar Mohanan Nair. Click on the document to view its contents.

Clot in transit represent the embolized fragment of deep vein thrombosis seen in cardiac chamber during its transit. Impending paradoxical emboli is seen in situation with high right atrial pressure than left atrium where clot gets caught in the patent foramen ovale or rarely atrial septal defect. High mortality of upto 18% has been seen in patients with paradoxical embolus in transit. Current case demonstrates patient with acute massive pulmonary embolism with large clot in transit seen in right side of heart extending across atrial septum to the left side of heart, extending across the aorta valve.

A 57 year old lady with no underlying structural heart disease presented with recurrent episodes of paroxysmal palpitation with documented adenosine responsive narrow QRS tachycardia. 12 lead surface electrocardiograms showed no pre-excitation. She underwent an electrophysiology (EP) study. Anterograde study demonstrated dual AV physiology. A regular narrow QRS tachycardia similar to clinical tachycardia was induced in the EP study with atrial pacing protocols. Ventricular overdrive pacing (VOD) was performed during the tachycardia. What are the circuits involved in the tachycardia?