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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this edition of the journal&#44; Saleiro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> report their initial experience with conduction system pacing &#40;CSP&#41; implantation at their institution &#40;and the first published prospective series in Portugal&#41;&#46; A total of 21 patients underwent His bundle pacing &#40;HBP&#41;&#44; among whom the implant success rate was 91&#37;&#59; 23 patients underwent left bundle branch pacing &#40;LBBP&#41; which was successful in all cases&#46; The success rate was superior to that reported previously in multicenter experiences &#40;81&#37; for HBP<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> and 90&#37; for LBBP<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a>&#41;&#44; and is commendable&#44; bearing in mind that the report includes the initial learning curve of the operators&#46; As previously reported elsewhere&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> LBBP was associated with superior electrical parameters and shorter fluoroscopy times&#46; There were no acute complications&#44; but lead revision was required in three &#40;6&#46;5&#37;&#41; patients with HBP due to lead dislodgement &#40;one patient&#41; or increased capture thresholds &#40;two patients&#41;&#44; which is in line with previous data reporting a 6&#37; rate of HBP lead revision&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are several hurdles that need to be overcome when initiating a CSP program&#46; A structured approach may help overcome these hurdles&#44; and may be outlined as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">1&#46;</span></span><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Inform yourself &#40;and get trained&#41;</span></p></li></ul></p><p id="par0020" class="elsevierStylePara elsevierViewall">In a recent European Heart Rhythm Association &#40;EHRA&#41; survey&#44; the main obstacle to adopt CSP is lack of training&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> An EHRA consensus document and practical guide on CSP implantation technique is due for 2023&#44; and will serve as a framework for standardizing the procedure&#46; Simulator-based courses would be ideal to acquire skills in a safe and effective manner&#46; In the meantime&#44; review articles on implantation technique and peer-to-peer exchange of information remain important means of gaining knowledge&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">2&#46;</span></span><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Involve your colleagues &#40;and get them on board&#41;</span></p></li></ul></p><p id="par0030" class="elsevierStylePara elsevierViewall">Conduction system pacing implantation requires a different patient setup compared to standard device implantation&#44; with a 12-lead ECG&#44; different lab setup&#44; new measurements to confirm conduction system capture&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7&#8211;9</span></a> and longer procedure durations&#46; It is in your interest to involve your colleagues in this new adventure &#40;physicians&#44; nurses&#44; technicians&#44; etc&#46;&#41;&#44; as they will play a part in achieving success&#46; Inform them of the rationale for CSP&#44; the procedure steps&#44; and of their tasks &#40;e&#46;g&#46;&#44; which measurements to perform&#41;&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">3&#46;</span></span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Optimize lab setup &#40;to streamline the procedure&#41;</span></p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">Although CSP implantation may be performed in an operating room using pacing system analyzers &#40;PSA&#41;&#44; a mobile C-arm and a standard 12-lead ECG recorder&#44; it is much more comfortable to do the procedure using an electrophysiology recording system&#46; This enables continuous recording&#44; display of filtered and unfiltered electrograms &#40;to evaluate current of injury which is important to recognize LBBP lead perforation<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a>&#41;&#44; and precise measurement of intervals to confirm conduction system capture&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7&#8211;9</span></a> Fluoroscopy systems which display viewing angles and allows the operator to display reference images such as His position&#44; facilitates CSP lead positioning&#46; Y-connectors&#44; which split the signals from the CSP lead to the EP recording system and the PSA are useful to avoid having to continuously exchange cables during the procedure &#40;e&#46;g&#46;&#44; when performing threshold tests&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> shows two different setups&#46;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">4&#46;</span></span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Choose the right patient &#40;and avoid nightmares&#41;</span></p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">It is wise to start with low-risk patients &#40;e&#46;g&#46;&#44; not pacemaker-dependent&#41; to avoid dramatic events which may result from complications &#40;e&#46;g&#46;&#44; lead dislodgement&#41;&#44; which are part of the learning curve&#46; Some operators started CSP in patients who had pacemaker implantation for sick sinus syndrome&#46; Another option is patients in chronic atrial fibrillation who undergo cardiac resynchronization therapy &#40;CRT&#41; implantation&#46; Instead of plugging the atrial port&#44; a CSP lead may be implanted in addition to the right ventricular and coronary sinus leads&#44; which offers the option of His-optimized or left-bundle-optimized CRT &#40;or standard biventricular pacing in case of CSP lead dysfunction&#41; with the safety of backup biventricular pacing&#46;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">5&#46;</span></span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Choose the right tools &#40;to facilitate the procedure&#41;</span></p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">Most CSP implantations are currently performed using the Medtronic 3830 lumenless lead&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> The 4&#46;1F isodiametric profile facilitates penetration of the interventricular septum&#44; and the sturdy design forgives rough handling &#40;e&#46;g&#46;&#44; when repositioning the lead after having screwed it into fibrous tissue&#41;&#46; Stylet-driven leads are also becoming popular&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> as the backup offered by the stylet enables more push to penetrate the interventricular septum for LBBAP&#44; and continuous pacing to monitor changes in QRS morphology&#46; In the event of lead dislodgement&#44; stylet-driven leads may be repositioned to a conventional pacing site &#40;right septum or apex&#41; without having to regain new venous access &#40;contrary to lumenless leads&#41;&#46; Implant success rates were comparable between lumenless and stylet-driven leads in the MELOS registry&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">6&#46;</span></span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Choose the right technique &#40;to maximize safety and efficacy&#41;</span></p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">As mentioned above&#44; the EHRA consensus document and practical guide on CSP implantation due early in 2023 will serve to standardize the procedure&#46; It is important to be fully aware of the criteria which confirm conduction system capture &#40;although this endpoint may not always be reached&#41;&#46; One should avoid performing para-Hissian pacing or deep right ventricular septal pacing &#40;the benefit of which has never been shown&#41;&#46; Transseptal access with LBBP is associated with new complications such as septal perforation or lesions to the coronary vessels&#44; which should be recognized and appropriately managed&#46; As mentioned in the 2021 European Society of Cardiology pacing guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> a backup pacing lead for HBP should be considered in specific situations &#40;e&#46;g&#46;&#44; atrioventricular node ablation&#44; infra-nodal block&#44; pacemaker-dependency&#41;&#46;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">7&#46;</span></span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Set your limits &#40;and respect them&#41;</span></p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">Although it is likely that CSP will replace right ventricular pacing &#40;and&#44; even in some instances&#44; CRT&#41; evidence is still being gathered regarding its superiority over conventional pacing&#46; Therefore&#44; it is useful to limit CSP implant attempts to a reasonable duration &#40;e&#46;g&#46;&#44; 30 minutes&#41;&#44; and to switch to a conventional method if a good result is not achieved by then&#44; instead of insisting any further&#46; This will avoid patient complications and will also be appreciated by your colleagues&#46;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">8&#46;</span></span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Optimize programming and follow-up &#40;to ensure proper patient care&#41;</span></p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">A good CSP program not only depends on successful implantation&#44; but also on proper programming and follow-up&#46; Current devices are not designed for CSP and require adequate programming&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">12&#44;13</span></a> A 12-lead ECG is mandatory for confirming conduction tissue capture during follow-up&#46;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">9&#46;</span></span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Keep track of your results &#40;and monitor your performance&#41;</span></p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall">Prospective data capture &#40;ideally in electronic health records which allow ready data extraction&#44; or e&#46;g&#46;&#44; in an Excel file directly after each implant&#41; allow monitoring of parameters such as implantation volume&#44; success rate&#44; procedure duration&#44; complications etc&#46; and are important for quality control and for clinical research&#46;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">10&#46;</span></span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Stay up to date &#40;and keep evolving&#41;</span></p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">Conduction system pacing is a rapidly evolving field&#44; and the implanting physician should stay informed regarding new techniques which may be useful in daily practice&#46; The device industry is also developing new tools which will facilitate CSP implantation &#40;as was the case with CRT implantation&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">By following these 10 commandments&#44; the device specialist will find the holy grail of a successful CSP program&#44; with minimal penitence&#33;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0120" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">Institutional grants and speaker honoraria from Abbott&#44; Biotronik&#44; Boston Scientific&#44; Medtronic&#44; Microport&#46;</p></span></span>"
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The 10 commandments for setting up a successful conduction system pacing program
Os 10 mandamentos para a criação de um programa de pacing do sistema de condução
Haran Burri
Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Top panel&#58; Conduction system pacing setup at the University Hospital of Geneva in 2017 at the initiation of His bundle pacing&#46; Bottom panel&#58; Conduction system pacing since 2020 in the hybrid electrophysiology&#47;device lab with an optimized setup&#46; <span class="elsevierStyleItalic">Legends&#58;</span> CSP&#58; conduction system pacing&#59; ECG&#58; electrocardiograph&#59; EP system&#58; electrophysiology recording system&#59; PSA&#58; pacing system analyzer&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this edition of the journal&#44; Saleiro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> report their initial experience with conduction system pacing &#40;CSP&#41; implantation at their institution &#40;and the first published prospective series in Portugal&#41;&#46; A total of 21 patients underwent His bundle pacing &#40;HBP&#41;&#44; among whom the implant success rate was 91&#37;&#59; 23 patients underwent left bundle branch pacing &#40;LBBP&#41; which was successful in all cases&#46; The success rate was superior to that reported previously in multicenter experiences &#40;81&#37; for HBP<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> and 90&#37; for LBBP<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a>&#41;&#44; and is commendable&#44; bearing in mind that the report includes the initial learning curve of the operators&#46; As previously reported elsewhere&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> LBBP was associated with superior electrical parameters and shorter fluoroscopy times&#46; There were no acute complications&#44; but lead revision was required in three &#40;6&#46;5&#37;&#41; patients with HBP due to lead dislodgement &#40;one patient&#41; or increased capture thresholds &#40;two patients&#41;&#44; which is in line with previous data reporting a 6&#37; rate of HBP lead revision&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are several hurdles that need to be overcome when initiating a CSP program&#46; A structured approach may help overcome these hurdles&#44; and may be outlined as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">1&#46;</span></span><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Inform yourself &#40;and get trained&#41;</span></p></li></ul></p><p id="par0020" class="elsevierStylePara elsevierViewall">In a recent European Heart Rhythm Association &#40;EHRA&#41; survey&#44; the main obstacle to adopt CSP is lack of training&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> An EHRA consensus document and practical guide on CSP implantation technique is due for 2023&#44; and will serve as a framework for standardizing the procedure&#46; Simulator-based courses would be ideal to acquire skills in a safe and effective manner&#46; In the meantime&#44; review articles on implantation technique and peer-to-peer exchange of information remain important means of gaining knowledge&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">2&#46;</span></span><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Involve your colleagues &#40;and get them on board&#41;</span></p></li></ul></p><p id="par0030" class="elsevierStylePara elsevierViewall">Conduction system pacing implantation requires a different patient setup compared to standard device implantation&#44; with a 12-lead ECG&#44; different lab setup&#44; new measurements to confirm conduction system capture&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7&#8211;9</span></a> and longer procedure durations&#46; It is in your interest to involve your colleagues in this new adventure &#40;physicians&#44; nurses&#44; technicians&#44; etc&#46;&#41;&#44; as they will play a part in achieving success&#46; Inform them of the rationale for CSP&#44; the procedure steps&#44; and of their tasks &#40;e&#46;g&#46;&#44; which measurements to perform&#41;&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">3&#46;</span></span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Optimize lab setup &#40;to streamline the procedure&#41;</span></p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">Although CSP implantation may be performed in an operating room using pacing system analyzers &#40;PSA&#41;&#44; a mobile C-arm and a standard 12-lead ECG recorder&#44; it is much more comfortable to do the procedure using an electrophysiology recording system&#46; This enables continuous recording&#44; display of filtered and unfiltered electrograms &#40;to evaluate current of injury which is important to recognize LBBP lead perforation<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a>&#41;&#44; and precise measurement of intervals to confirm conduction system capture&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7&#8211;9</span></a> Fluoroscopy systems which display viewing angles and allows the operator to display reference images such as His position&#44; facilitates CSP lead positioning&#46; Y-connectors&#44; which split the signals from the CSP lead to the EP recording system and the PSA are useful to avoid having to continuously exchange cables during the procedure &#40;e&#46;g&#46;&#44; when performing threshold tests&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> shows two different setups&#46;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">4&#46;</span></span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Choose the right patient &#40;and avoid nightmares&#41;</span></p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">It is wise to start with low-risk patients &#40;e&#46;g&#46;&#44; not pacemaker-dependent&#41; to avoid dramatic events which may result from complications &#40;e&#46;g&#46;&#44; lead dislodgement&#41;&#44; which are part of the learning curve&#46; Some operators started CSP in patients who had pacemaker implantation for sick sinus syndrome&#46; Another option is patients in chronic atrial fibrillation who undergo cardiac resynchronization therapy &#40;CRT&#41; implantation&#46; Instead of plugging the atrial port&#44; a CSP lead may be implanted in addition to the right ventricular and coronary sinus leads&#44; which offers the option of His-optimized or left-bundle-optimized CRT &#40;or standard biventricular pacing in case of CSP lead dysfunction&#41; with the safety of backup biventricular pacing&#46;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">5&#46;</span></span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Choose the right tools &#40;to facilitate the procedure&#41;</span></p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">Most CSP implantations are currently performed using the Medtronic 3830 lumenless lead&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> The 4&#46;1F isodiametric profile facilitates penetration of the interventricular septum&#44; and the sturdy design forgives rough handling &#40;e&#46;g&#46;&#44; when repositioning the lead after having screwed it into fibrous tissue&#41;&#46; Stylet-driven leads are also becoming popular&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> as the backup offered by the stylet enables more push to penetrate the interventricular septum for LBBAP&#44; and continuous pacing to monitor changes in QRS morphology&#46; In the event of lead dislodgement&#44; stylet-driven leads may be repositioned to a conventional pacing site &#40;right septum or apex&#41; without having to regain new venous access &#40;contrary to lumenless leads&#41;&#46; Implant success rates were comparable between lumenless and stylet-driven leads in the MELOS registry&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">6&#46;</span></span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Choose the right technique &#40;to maximize safety and efficacy&#41;</span></p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">As mentioned above&#44; the EHRA consensus document and practical guide on CSP implantation due early in 2023 will serve to standardize the procedure&#46; It is important to be fully aware of the criteria which confirm conduction system capture &#40;although this endpoint may not always be reached&#41;&#46; One should avoid performing para-Hissian pacing or deep right ventricular septal pacing &#40;the benefit of which has never been shown&#41;&#46; Transseptal access with LBBP is associated with new complications such as septal perforation or lesions to the coronary vessels&#44; which should be recognized and appropriately managed&#46; As mentioned in the 2021 European Society of Cardiology pacing guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> a backup pacing lead for HBP should be considered in specific situations &#40;e&#46;g&#46;&#44; atrioventricular node ablation&#44; infra-nodal block&#44; pacemaker-dependency&#41;&#46;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">7&#46;</span></span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Set your limits &#40;and respect them&#41;</span></p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">Although it is likely that CSP will replace right ventricular pacing &#40;and&#44; even in some instances&#44; CRT&#41; evidence is still being gathered regarding its superiority over conventional pacing&#46; Therefore&#44; it is useful to limit CSP implant attempts to a reasonable duration &#40;e&#46;g&#46;&#44; 30 minutes&#41;&#44; and to switch to a conventional method if a good result is not achieved by then&#44; instead of insisting any further&#46; This will avoid patient complications and will also be appreciated by your colleagues&#46;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">8&#46;</span></span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Optimize programming and follow-up &#40;to ensure proper patient care&#41;</span></p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">A good CSP program not only depends on successful implantation&#44; but also on proper programming and follow-up&#46; Current devices are not designed for CSP and require adequate programming&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">12&#44;13</span></a> A 12-lead ECG is mandatory for confirming conduction tissue capture during follow-up&#46;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">9&#46;</span></span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Keep track of your results &#40;and monitor your performance&#41;</span></p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall">Prospective data capture &#40;ideally in electronic health records which allow ready data extraction&#44; or e&#46;g&#46;&#44; in an Excel file directly after each implant&#41; allow monitoring of parameters such as implantation volume&#44; success rate&#44; procedure duration&#44; complications etc&#46; and are important for quality control and for clinical research&#46;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">10&#46;</span></span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Stay up to date &#40;and keep evolving&#41;</span></p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">Conduction system pacing is a rapidly evolving field&#44; and the implanting physician should stay informed regarding new techniques which may be useful in daily practice&#46; The device industry is also developing new tools which will facilitate CSP implantation &#40;as was the case with CRT implantation&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">By following these 10 commandments&#44; the device specialist will find the holy grail of a successful CSP program&#44; with minimal penitence&#33;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0120" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">Institutional grants and speaker honoraria from Abbott&#44; Biotronik&#44; Boston Scientific&#44; Medtronic&#44; Microport&#46;</p></span></span>"
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Revista Portuguesa de Cardiologia
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