Long-term outcomes of His bundle pacing in patients with heart failure with left bundle branch block

Introduction Left bundle branch pacing (LBBP) is characterized with a low and stable pacing capture threshold, relatively narrow QRS duration due to fast left ventricular activation, and direct excitation of the diseased left bundle branch. This report aims to describe the methods, procedural skills, and clinical implications of performing LBBP implantation. Methods and Results LBBP is achieved by transventricular‐septal approach. There are two methods to identify the location for LBBP lead placement: the single‐lead method and the dual‐lead method. During implantation, the unique transition of the paced QRS morphology and pacing parameter changes are important for guiding the lead ‐ advancement to the left side of the interventricular septum. In our experience, LBBP can be safely performed in most patients requiring pacemaker therapy. Conclusion Clinical development of LBBP is at an early but encouraging phase with increasing clinical use, and a standardized procedure with improved delivery tools and pacing leads is needed, as well as long‐term efficacy and safety.

Section: Introductionmentioning

confidence: 99%

How to implant left bundle branch pacing lead in routine clinical practice

Chen

2019

“…HBP can normalize LBBB in some patients and thus potentially replace biventricular pacing for cardiac resynchronization therapy . Moreover, recent clinical studies have reported high success rates (up to 90%) for correction of LBBB by HBP . This finding suggests that conduction block of the LBB occurs in the proximal portion of the His‐Purkinje system in the majority of cases.…”

Section: Discussionmentioning

confidence: 99%

Longitudinal dissociation and transition in thickness of the His‐Purkinje system cause various QRS waveforms of surface ECG under His bundle pacing: A simulation study based on clinical observations

Okada

Fujiu

Washio

et al. 2019

Aims His bundle pacing (HBP) is a feasible and reliable alternative to conventional right ventricular pacing (RVP), but associated ECG (electrocardiogram) changes have not been well‐studied. This study aimed to determine the mechanisms underlying ECG changes associated with HBP using patient‐specific multiscale heart simulations. Methods ECGs were recorded in two patients who were treated by HBP under a native rhythm and HBP at high and low voltages. We created patient‐specific multiscale simulation heart models of these patients and performed ECG simulation under these conditions. Using these results and detailed information on the electrical field around the pacing lead, we investigated mechanisms underlying the observed ECG changes. Results Heart simulations successfully reproduced ECGs under a native rhythm for both cases. In case 1, nonselective HBP produced a left bundle branch (LBB) block pattern, which was reproduced as a selective right bundle branch (RBB) pacing. However, in case 2, ECG under nonselective HBP showed an RBB block pattern, which could not be reproduced by the commonly used framework. Findings on the electrical field and anatomy of the His bundle and its branches suggested that longitudinal dissociation of the His bundle and transition of thickness in the stem of the LBB caused a conduction delay in the RBB to produce these ECG changes in this patient. Conclusion Variations in the anatomy of the His bundle and its branches may underlie the diverse ECG responses to HBP. These variations should be taken into account when performing this therapy.

“…Likewise, in the present investigation, the lead tip position under the TVA did not affect tricuspid valve function during the follow‐up period, probably due to the small‐diameter pacing lead sitting between the septal leaflet and the anterior leaflet of the tricuspid valve. Thus, the advantage of this technique is to reveal a specific location for HBP, likely making the HBP implantation predictable, especially for vHBP that has recently been thought to be a better HBP option with a low and stable capture threshold, high R‐wave amplitude for pacing management, and the capability to correct left bundle branch block …”

Section: Discussionmentioning

confidence: 99%

Visualization of tricuspid valve annulus for implantation of His bundle pacing in patients with symptomatic bradycardia

Hua

et al. 2019

Self Cite

Background His bundle pacing (HBP) is a physiological pacing modality, but HBP implantation remains a challenge. Objective This study explored the feasibility of using visualization of the tricuspid valve annulus (TVA) to locate the site for HBP. Methods During the lead placement in eight patients with symptomatic bradycardia, the TVA and tricuspid septal leaflet was revealed by contrast injection in the right ventricle under the fluoroscopic right anterior oblique view, and the target site for HBP was identified near the intersection of the tricuspid septal leaflet and the interventricular septum. On the basis of the imaging marker, the pacing lead was placed for HBP at either the atrial (aHBP) or ventricular side (vHBP). Results During the implantation, the pacing lead placement was attempted for aHBP in two patients, vHBP in five patients, and first for aHBP then vHBP in one patient. The aHBP was selective and had a capture threshold of 1.6 ± 0.5 V@ 1.0ms and R‐wave amplitude of 1.2 ± 0.4 mV. Ventricular‐side His bundle capture was selective in four patients and nonselective in two patients. The vHBP capture threshold was 0.8 ± 0.4 V@ 1.0ms (P < .05 vs aHBP) and R‐wave amplitude was 4.1 ± 1.5 mV (P < .05 vs aHBP). At the final pacing programming of 3.0 V@ 1.0ms, vHBP was nonselective in all six patients and aHBP remained selective in two patients. Pacing parameters remained stable at 3 months. Conclusion The location of the TVA and tricuspid septal leaflet revealed by right ventriculography can be used as a landmark to identify the HBP site.