Sequential His bundle and left ventricular pacing for cardiac resynchronization

Abstract

Introduction Fusion of left ventricular pacing with intrinsic conduction provides superior resynchronization compared to biventricular pacing. His bundle pacing (HBP) preserves intrinsic conduction and allows for constant fusion with left ventricular pacing. This study evaluated sequential His bundle and left ventricular pacing for cardiac resynchronization therapy (CRT). Methods In patients referred for CRT, sequential His bundle and left ventricular pacing was performed when HBP did not correct the QRS. At implant, QRS duration and area were compared between biventricular pacing and His bundle and left ventricular pacing. Devices were programmed for His and left ventricular pacing. Functional status and echocardiography were evaluated in follow up. Results Twenty‐one patients, seven female, 70.7 ± 9.9 years, 57% with nonischemic cardiomyopathy were included. Baseline QRS duration was 170 ± 21 ms and was 157 ± 16 ms with HBP. Biventricular pacing resulted in a QRS duration of 141 ± 15 ms and decreased to 110 ± 14 ms with His bundle and left ventricular pacing (p < .0005). His bundle and left ventricular pacing resulted in a smaller paced QRS area (38.5 ± 22.6 µVs) compared to biventricular pacing (67.5 ± 24.0 µVs) and baseline (78.1 ± 28.1 µVs; p < .0005). Left ventricular ejection fraction increased from 27.6 ± 6.4% to 41.1 ± 12.5 (at 25 mean months, p = .001) and functional class improved from 3.1 ± 0.5 to 2.1 ± 0.8 (at mean 32 months, p < .001). Conclusions Sequential His bundle and left ventricular pacing results in superior electrical synchrony in patients with indication for CRT when HBP does not correct the QRS and resulted in promising clinical and echocardiographic response rates.

Next‐level examination of His‐optimized cardiac resynchronization therapy by noninvasive electrocardiographic activation mapping

“…This study confirms previous findings of a feasibility study by Vijayaramanet al 2 showing that HOT‐CRT was superior to biventricular pacing in terms of QRSd. Moreover, this study extends previous findings by additional vectorcardiography (VCG) analysis in a subset of 17 patients showing that QRS area was shorter with HOT‐CRT compared with biventricular pacing (39 ± 23 vs. 68 ± 24 μVs; p < .01) 1 . VCG reflects the magnitude and direction of the heart's electrical activity in three (X, Y, and Z) spatial planes compared with the one‐dimensional projection of each lead of a standard 12‐lead electrocardiogram (ECG).…”

“…With great interest, we have read the recent report by Deshmukh et al 1 entitled “Sequential His bundle and left ventricular pacing for cardiac resynchronization.” In this retrospective study, 21 patients referred for cardiac resynchronization therapy (CRT) were included in whom His bundle pacing (HBP) did not correct the underlying conduction disorder and an additional left ventricular lead was implanted to deliver His‐optimized CRT (HOT‐CRT). Baseline QRS duration (QRSd) narrowed from 170 ± 21 to 157 ± 16 ms with HBP and further to 110 ± 14 ms with HOT‐CRT compared with 141 ± 15 ms with biventricular pacing.…”

Is His‐optimized superior to conventional cardiac resynchronization therapy in improving heart failure? Results from a propensity‐matched study

“…His bundle pacing (HBP), alone or optimized in association with coronary sinus pacing (HBP+LV) has recently been proposed as an effective alternative to conventional CRT 7–15 . However, these studies are small and mainly descriptive 16 …”

Response to: Next‐level examination of His‐optimized cardiac resynchronization therapy by noninvasive electrocardiographic activation mapping

“…In that series, HBP alone corrected the QRSd to an even greater degree than conventional biventricular pacing, whereas in our cohort, selective HBP resulted in minimal or no change in QRSd. 1,2 Our study, therefore, demonstrates that even when HBP does not modify a wide QRSd, it still provides a superior alternative to right ventricular pacing for electrical resynchronization.…”