Cardiac resynchronization therapy with His bundle pacing

Abstract

Aims:A novel therapy offering cardiac resynchronization therapy (CRT) with an additional lead placed in His bundle has been reported in a few case reports and case series as improving the hemodynamical and clinical condition of patients with permanent atrial fibrillation (AF) in whom other therapeutic methods have not been successful. Methods:Fourteen consecutive patients with permanent AF, heart failure (HF), bundle branch block (BBB) with QRS complex width >130 ms, and impaired left ventricular ejection fraction (LVEF) underwent implantation of implantable cardioverter defibrillator (ICD)/CRT systems with His bundle pacing (HBP). During the follow-up, we assessed the efficacy of ICD/CRT systems with HBP in HF treatment. Results:The study cohort consisted of 14 patients with the mean age of 67.35 ± 10 years. The mean duration of QRS was 159.2 ± 28.6 ms, mean LVEF was 24.36 ± 10.7%, and mean follow-up duration was 14.4 months. One patient died due to HF aggravation during the follow-up. In the remaining 13 patients, the mean LVEF significantly improved from 24% to 38%, P = 0.0015. The left ventricular end-diastolic dimension decreased from 72 mm to 59 mm, P < 0.001; left ventricular end-systolic dimension decreased from 59 mm to 47 mm, P = 0.0026. The mean QRS duration shortened from 159 ms to 128 ms, P = 0.016. The mean percentage of HBP reached 97%. As a result, 92.3% of patients demonstrated significant improvement in the New York Heart Association functional class, P < 0.001. Conclusion:The use of atrial channel for HBP, choice of optimal ICD/CRT pacing configuration, and optimization of pharmacological therapy resulted in a substantial narrowing of QRS width and clinical improvement in left ventricular mechanical function during the follow-up. K E Y W O R D Satrial fibrillation, bundle branch block, cardiac resynchronization therapy, His bundle pacing, pacemaker 1 BACKGROUND Cardiac resynchronization therapy (CRT) is an acknowledged therapeutic choice for patients with sinus rhythm, congestive heart failure (HF) in the New York Heart Association (NYHA) class II-IV, wide QRS > 130 ms, and reduced left ventricular ejection fraction (LVEF) ≤35%, who remain symptomatic despite optimal medical therapy. 1,2 CRT in patients with permanent atrial fibrillation (AF) is usually less effective compared to patients in sinus rhythm. 1-3 The reasons for a less favorable response to CRT in that population are complex. 4 The greatest magnitude of benefit from CRT tends to be observed in those who are paced at >98% of the time.The findings from the RAFT-AF study showed that it was challenging to achieve the appropriate target of biventricular pacing in patients with permanent AF to the extent that only one-third of the study population reached nearly 100% pacing. 5 Irregular and fast ventricular response in AF induces changes in the myocardium referred to as a tachycardiomyopathy 6 and is increasing the risk of inappropriate therapies from implantable cardioverter defibrillator (ICD). 7 Additionally, patients with CRT derive ...

Additional benefits of nonconventional modalities of cardiac resynchronization therapy using His bundle pacing

“…We observed better acute results in terms of ECG and echocardiographic outcomes on combining HBP with CS pacing (with or without concomitant RV pacing). Our results are consistent with those of others 35,36 . In a study by Vijayaraman et al 35 involving 27 patients, baseline QRS width was 183 ± 27 ms and significantly narrowed to 162 ± 17 ms during CONV, to 151 ± 24 ms during HBP, and further to 120 ± 16 ms during HBP + CS.…”

“…HBP has been studied by some authors as an alternative to conventional CRT 30–34 and by others in conjunction with CS pacing 35,36 . In an acute hemodynamic study, His resynchronization delivered better ventricular resynchronization and greater improvement in hemodynamic parameters than biventricular pacing 31 .…”

“…In a study by Vijayaraman et al 35 involving 27 patients, baseline QRS width was 183 ± 27 ms and significantly narrowed to 162 ± 17 ms during CONV, to 151 ± 24 ms during HBP, and further to 120 ± 16 ms during HBP + CS. In a study by Boczar et al, 36 14 patients with permanent atrial fibrillation, heart failure, and wide QRS underwent implantation of ICD/CRT systems that delivered HBP (HBP alone in 3 cases and HBP + CS in 11 cases). Compared with the baseline, the mean QRS width shortened from 159 to 128 ms.…”

Systolic aortic root motion predicts response to cardiac resynchronization therapy

“…They demonstrated that 88.9% of the patients’ LVEF had been improved more than 50% over baseline at 1‐year follow‐up during HBP . In another prospective study showed that the use of atrial channel for HBP provided narrowing of QRS width and clinical improvement in left ventricular mechanical function …”

Study design and protocol for evaluating the long‐term prognosis of patients receiving his bundle pacing: A multicenter observational study

“…The updated ACC/AHA/HRS practice guideline suggested that using HBP and cardiac resynchronization therapy (CRT) is reasonable in patients with atrioventricular block as an indication for permanent pacing with an LVEF of 36%‐50% and expected ventricular pacing of >40% . Additionally, HBP may serve as an alternative therapeutic option in patients with bundle branch block and heart failure with reduced ejection fraction, which is a traditional indication for CRT . Left bundle branch block was successfully corrected with QRS duration narrowing with the use of HBP in a large number of patients recent study .…”