His bundle pacing, learning curve, procedure characteristics, safety, and feasibility: Insights from a large international observational study

Abstract

Background His‐bundle pacing (HBP) provides physiological ventricular activation. Observational studies have demonstrated the techniques’ feasibility; however, data have come from a limited number of centers. Objectives We set out to explore the contemporary global practice in HBP focusing on the learning curve, procedural characteristics, and outcomes. Methods This is a retrospective, multicenter observational study of patients undergoing attempted HBP at seven centers. Pacing indication, fluoroscopy time, HBP thresholds, and lead reintervention and deactivation rates were recorded. Where centers had systematically recorded implant success rates from the outset, these were collated. Results A total of 529 patients underwent attempted HBP during the study period (2014‐19) with a mean follow‐up of 217 ± 303 days. Most implants were for bradycardia indications. In the three centers with the systematic collation of all attempts, the overall implant success rate was 81%, which improved to 87% after completion of 40 cases. All seven centers reported data on successful implants. The mean fluoroscopy time was 11.7 ± 12.0 minutes, the His‐bundle capture threshold at implant was 1.4 ± 0.9 V at 0.8 ± 0.3 ms, and it was 1.3 ± 1.2 V at 0.9 ± 0.2 ms at last device check. HBP lead reintervention or deactivation (for lead displacement or rise in threshold) occurred in 7.5% of successful implants. There was evidence of a learning curve: fluoroscopy time and HBP capture threshold reduced with greater experience, plateauing after approximately 30‐50 cases. Conclusion We found that it is feasible to establish a successful HBP program, using the currently available implantation tools. For physicians who are experienced at pacemaker implantation, the steepest part of the learning curve appears to be over the first 30‐50 cases.

Left bundle branch pacing: A comprehensive review

“…The implantation technique is challenging with a longer learning curve. 38 HBP has low sensed R wave amplitude, which may result in atrial oversensing and ventricular undersensing. High pacing thresholds either at the time of implantation or during follow-up may result in early battery depletion and pulse generator change in 5%-10% of patients.…”

Electrogram‐only guided approach to His bundle pacing with minimal fluoroscopy: A single‐center experience

“…A recent large multicentre study showed a mean FT 11.7 ± 12 minutes for HBP irrespective of the underlying rhythm. FT reduced with greater experience, plateauing after 30 to 50 cases 23 . We did not observe any significant difference in FT among different pacing indications, although subjects with SSS had 100% success and this is probably due to the small population.…”

“…FT reduced with greater experience, plateauing after 30 to 50 cases. 23 We did not observe any significant difference in FT among different pacing indications, although subjects with SSS had 100% success and this is probably due to the small population. Our data are in line with the results from Bhatt et al 22 where patients with more complex AV conduction disturbance had more prolonged procedure time.…”

Seeking the sweet spot for left bundle branch pacing

“…High (approximately 7%) requirement for lead revision. 12,13 Backup ventricular leads may be indicated in case of sensing issues or for patient safety, resulting in more endovenous material, higher cost, and more complex programming. 11 Risk of compromise of lead function with AV node ablation (due to proximity of ablation site to pacing lead).…”