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Since the introduction of the implantable cardioverter defibrillator (ICD) by Michel Mirowski in the 1980's, these devices have become an important tenet in management of ventricular arrhythmias1. Numerous observational and randomized trials have demonstrated the superiority of this device over antiarrhythmic drugs in treating ventricular arrhythmias. The clinical implications of these trials are tremendous as sudden cardiac death (SCD) maybe the presenting symptom in these arrhythmias. It is estimated that in the United States alone around 350,000 deaths occur each year due to SCD alone2 . As resuscitation is seldom successful in the community, methods to identify and appropriately treat such patients alone can prevent these events. However, the public health impact of this approach is tremendous, as the ICD is extremely expensive and is out of reach for many individuals. Moreover, not all patients with structural heart disease and ventricular arrhythmias have a malignant outcome. Thus efforts to appropriately stratify patients according to their risk profile and accordingly advocate ICD implant has important fiscal implications for the state with meager health resources, especially in those patients in whom survival benefit with the ICD is modest.

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Competing Interests: Declaration of competing interest None of the authors has anything to disclose.

Background: Pacing from RV mid septum and outflow tract septum has been proposed as a more physiological site of pacing and narrower paced QRS complex duration. The paced QRS morphology and duration in different RV pacing sites is under continued discussion. Hence, this study was designed to address the correlation of pacing sites in right ventricle with paced QRS complex duration., Methods: Two hundred fifty-two consecutive patients who underwent pacemaker implantation were enrolled. Baseline clinical characteristics were recorded for each patient. All patient underwent fluoroscopy, electrocardiogram and echocardiography post pacemaker implantation. Paced QRS duration was calculated from the leads with maximum QRS duration., Results: Mean paced QRS (pQRS) duration was significantly higher in apical septum group with a mean of 148.9 ± 14.8 m s compared to mid septum (139.6 ± 19.9 m s; p-value 0.003) and RVOT septum (139.6 ± 14.8 m s; p-value 0.002) groups, respectively. There was no significant difference between mid-septal and RVOT septal pQRS duration. On multivariate analysis, female gender, baseline QRS duration and RVOT septal pacing were the only predictors for narrow pQRS duration (<150 msec)., Conclusion: RV mid-septal and RVOT septal pacing were associated with significantly lower pQRS duration as compared with apical pacing. Based on multivariate analysis RVOT septal pacing appears to be preferred and more physiological pacing site., (Copyright © 2018 Indian Heart Rhythm Society. Production and hosting by Elsevier B.V. All rights reserved.)

Cardiac implantable electronic device (CIED) procedures are being done by many operators/centers and it is projected that this therapy will remarkably increase in India in the coming years. This document by IHRS, aims at guiding the Indian medical community in the appropriate use and method of implantation with emphasis on implanter training and center preparedness to deliver a safe and effective therapy to patients with cardiac rhythm disorders and heart failure., (Copyright © 2018 Indian Heart Rhythm Society. Production and hosting by Elsevier B.V. All rights reserved.)

Permanent pacing, being non physiological, often results in ventricular dysfunction over time. Narrower paced QRS duration from pacing the right ventricular outflow tract septum, might result in relatively preserved ventricular function over long term follow up.

Total upper body drainage via left superior vena cava into coronary sinus (i.e. absent right superior vena cava) is a rare anomaly and distorts the anatomy of coronary sinus and triangle of Koch. Herewith we are reporting the first report of ablation in a patient with superior vena cava draining into coronary sinus totally. This patient with atrioventricular nodal re-entrant tachycardia, baseline left bundle branch block, transient complete heart block during electrophysiological study and total upper body venous drainage into coronary sinus had successful slow pathway ablation using anatomical approach.

Subclavian route is a standard way of performing a permanent pacemaker. However in cases with superior vena caval or bilateral subclavian occlusion and bilateral infection of pacemaker site, alternative site is warranted. Epicardial route needs general anesthesia and has its own problems. Iliofemoral route has been used previously but has more lead related problems and patient discomfort. Here we are reporting a case in which transiliac pacing was done due to both right and left pacemaker site active infection and to avoid the chance of lead dislodgement, an alpha loop was made in the right atrium.