Novel electroanatomical map for permanent his bundle pacing: the Mont Blanc approach - influence of the learning curve and procedural outcome

Abstract

Aims Pacing the specific conduction system like the Bundle of His (HB) can lead to more physiologic activation patterns compared to traditional right ventricular apical pacing. The aim of this study was to estimate the feasibility and value of electroanatomical mapping (EAM) for HB pacing during the learning curve and its impact on procedural outcome. Methods and results Fifteen consecutive patients were treated using EAM of the His bundle region before implantation. Voltage and activation maps of HB potentials were performed. The activation time from His potential to R wave (ECG-reference) was measured and correlated to the HV interval. The atrial and ventricular potentials were blended so the active window could only see the His potential. After completing the activation map, it was transformed into a peak-to-peak voltage map of the HB. With reversed black and white colour scale, the exact point of the maximal His signal amplitude was visualized. Procedural data for the implantation were analysed using this innovative approach. The average total procedural time and fluoroscopy time was 88.2 ± 19.1 min and 10.9 ± 4.5 min, respectively. The 3D mapping time was 18.4 ± 5.1 min. The 13.9 ± 5.1 His potential points were needed in average to complete the map. No periprocedural complications were seen in this cohort. In 86.7% of cases, His bundle pacing was successful. The average threshold for the His bundle stimulation and the R-wave amplitude was 1.62 ± 1 V (@1.0 ms) and 4.8 ± 3.2 mV, respectively. The pacing impedance was 513.5 ± 102.8 Ω. Average paced QRS complex width was 116.9 ± 20.3ms. On average 2.6 ± 1.6 lead positions were targeted to find the optimal pacing site. Conclusion Electroanatomical mapping-guided implantation of His-bundle leads can facilitate the identification of optimal pacing sites and allow to minimize procedure and fluoroscopy times even during the phase of the learning curve.

His bundle pacing guided by automated intrinsic morphology matching is feasible in patients with narrow QRS complexes

“…The potential benefit (e.g. minimizing procedure and fluoroscopy times) during the learning curve was confirmed by Imnadze et al using His voltage mapping to guide lead positioning 11 . In addition, EAM allows for better visualization and an understanding of the individual anatomy that may be crucial in challenging cases e.g.…”

Is it feasible to perform permanent left bundle branch area pacing, guided only by an electroanatomical mapping system? Proposal of a zero-fluoroscopy approach

“…In published experiences of His bundle pacing with the guidance of a mapping system, the use of fluoroscopy was dramatically reduced but not completely eliminated (with very few exceptions 14 ), as minimal fluoroscopy was used in some phases of the procedure as the vein puncture, the lead screwing, the delivery catheter slitting, the implantation of others leads, and to adjust the tension and the final position of the implanted leads. [9][10][11][12][13] In LBBAP, the mapping system allows to precisely choose the site of lead implantation, by measuring the distance of the initial lead screwing point from the His bundle potential recording J o u r n a l P r e -p r o o f 7 sites and also the depth of lead advancement from that point, inside the interventricular septum.…”

“…Case series and observational and case-control studies, 9 , 10 , 11 , 12 , 13 mainly regarding His bundle pacing, have shown that this approach allows to minimize procedure and fluoroscopy times compared to the conventional fluoroscopy-guided approach. In published experiences of His bundle pacing with the guidance of a mapping system, the use of fluoroscopy was dramatically reduced but not completely eliminated (with very few exceptions 14 ), as minimal fluoroscopy was used in some phases of the procedure, such as the vein puncture, the lead screwing, the delivery catheter slitting, the implantation of others leads, and the adjustment of the tension and the final position of the implanted leads.…”

“…In published experiences of His bundle pacing with the guidance of a mapping system, the use of fluoroscopy was dramatically reduced but not completely eliminated (with very few exceptions 14 ), as minimal fluoroscopy was used in some phases of the procedure, such as the vein puncture, the lead screwing, the delivery catheter slitting, the implantation of others leads, and the adjustment of the tension and the final position of the implanted leads. 9 , 10 , 11 , 12 , 13 …”

Electroanatomical mapping– and CT scan image integration–guided pacing lead implantation: A case series and review of the recent literature

“…Very recently a study was published for selecting optimal His pacing site using EAM in 15 patients, employing EAM mapping and implant at the largest His amplitude signal. 24…”