Adopting permanent His bundle pacing: learning curves and medium-term outcomes

Abstract

Aims This study aims to determine procedural characteristics, acute success rates, and medium-term outcomes of consecutive patients undergoing His bundle pacing (HBP); and learning curves of experienced electrophysiologists adopting HBP. Methods and results Consecutive HBP patients at three hospitals were recruited. Clinical characteristics, acute procedural details, and medium-term outcomes were extracted from electronic medical records. Two hundred and thirty-three patients [mean age 74.6 ± 10.1 years, 48% female, 68% narrow QRS, 71% normal left ventricular ejection fraction (LVEF), 55.8% atrioventricular block] underwent HBP. Acute procedural success was 81.1% (mean procedural and fluoroscopic times of 105.5 ± 36.5 and 13.8 ± 9.3 min). Broad QRS was associated with lower HBP success (odds ratio 0.39, P = 0.02). Fluoroscopic and procedural times decreased and plateaued after 30–40 cases per operator. Implant HBP threshold was 1.3 ± 0.7 V at 1.0 ± 0.2 ms and R wave was 5.0 ± 3.9 mV. During follow-up, loss of HBP occurred in a further 12.4% and 11.3% of patients experienced a ≥1 V increase in HBP threshold. Five (2.6%) patients required HBP revision for pacing difficulties. About 8.6% of patients had a >50% decrease in R wave but lead revision for sensing issues was not necessary. On an intention to treat basis, 56.7% of patients in whom HBP was attempted had persisting HBP capture and thresholds of <2 V. Conclusion Physicians adopting HBP should be cognizant of the learning curve and preferentially select non-dependent patients with normal QRS and LVEF, to minimize risk of lead revision. Further rises in HBP threshold may increase battery drain and need for reoperations, important considerations when choosing HBP for cardiac resynchronization therapy.

Pacing Characteristics of His Bundle Pacing vs. Left Bundle Branch Pacing: A Systematic Review and Meta-Analysis

“…As for the fluoroscopy time, Vijayaraman et al ( 21 ) had a longer fluoroscopy time in LBBP than in HBP, contrary to Wu et al ( 22 ). The learning curve of HBP has shown that procedure time and fluoroscopy time were shorter with increasing operator experience ( 32 ). The differences in procedure time and fluoroscopy time in different studies may be related to the skills and experience of different operators.…”

Use of extendable helix leads for conduction system pacing: Differences in lead handling and performance lead design impacts conduction system pacing

“…Consecutive patients at the National University Heart Centre Singapore and Ng Teng Fong General Hospital with an EHL for HBP or LBBP between 2019 and 2022 were included. 1 HBP and LBBP were performed by experienced electrophysiologists with at least 50 cases of CSP implant experience with FHL and in accordance with previous recommendations. 5,6 The choice of FHL or EHL during implant was at…”

“…CSP has traditionally been performed with the SelectSecure 3830 lead with high implant success and low complication rates. 1,2,5 The Solia S and Tendril STS leads, while not new, have been repurposed as potential alternatives and carry major differences in lead design.…”

“…Conduction system pacing (CSP) has gained increasing prominence as a promising alternative to conventional right ventricular pacing (RVP) due to its ability to provide more physiological pacing characteristics. [1][2][3][4] Compared with RVP, CSP employs different pacing lead implant techniques, involving clockwise rotations of the pacing lead through a preshaped sheath directed toward the interventricular septum (IVS). 5,6 Much of the published experience with CSP was with the lumen-less, fixed helix pacing lead (FHL) (SelectSecure 3830, Medtronic Inc.) through the C315His sheath (Medtronic Inc.) in both His-bundle pacing (HBP) and left bundle branch pacing (LBBP).…”

“…5,6 Much of the published experience with CSP was with the lumen-less, fixed helix pacing lead (FHL) (SelectSecure 3830, Medtronic Inc.) through the C315His sheath (Medtronic Inc.) in both His-bundle pacing (HBP) and left bundle branch pacing (LBBP). [1][2][3][4] More recently, the stylet-driven, extendable-retractable helix pacing lead (EHL) has been used as a viable alternative to FHL in CSP, in part since these pre-existing leads already have regulatory approval and thus wider commercial availability. 7 Despite distinct differences in lead structure, EHL and FHL performed comparably in eventual implant success rates and pacing characteristics.…”