Procedural Logistics of Physiological (His-bundle or Left Septal) Pacing

AbstractBackgroundDuring permanent non-selective (ns) His bundle (HB) pacing, it is crucial to confirm HB capture / exclude that only right ventricle (RV)-myocardial septal pacing is present. Because the effective refractory period (ERP) of the working myocardium is different than the ERP of the HB, we hypothesized that it should be possible to differentiate ns-HB capture from RV-myocardial capture using programmed extra-stimulus technique.MethodsIn consecutive patients during HB pacemaker implantation, programmed HB pacing was delivered from the screwed-in HB pacing lead. Premature beats were introduced at 10 ms steps during intrinsic rhythm and also after a drive train of 600 ms. The longest coupling interval that resulted in an abrupt change of QRS morphology was considered equal to ERP of HB or RV-myocardium.ResultsProgrammed HB pacing was performed from 50 different sites in 32 patients. In 34/36 cases of ns-HB pacing, the RV-myocardial ERP was shorter than HB ERP (271.8±38 ms vs 353.0±30 ms, p < 0.0001). Programmed HB pacing using a drive train resulted in a typical abrupt change of paced QRS morphology: from ns-HB to RV-myocardial QRS (34/36 cases) or to selective HB QRS (2/36 cases). Programmed HB pacing delivered during supraventricular rhythm resulted in obtaining selective HB QRS in 20/34 and RV-myocardial QRS in 14/34 of the ns-HB cases. In RV-myocardial only pacing cases (“false ns-HB pacing”, n=14), such responses were not observed – the QRS morphology remained stable. Therefore, the PHB pacing correctly diagnosed all ns-HB cases and all RV-myocardial pacing cases.ConclusionsA novel maneuver for the diagnosis of HB capture, based on the differences in ERP between HB and myocardium was formulated, assessed and found as diagnostically valuable. This method is unique in enabling to visualize selective HB QRS in patients with otherwise obligatory ns-HB pacing (RV-myocardial capture threshold < HB capture threshold).What this study addsProgrammed His bundle pacing – a novel and straightforward method for unquestionable diagnosis of His bundle capture during non-selective pacing was developed and assessed.A method for visualization of selective HB capture QRS in patients with obligatory non-selective pacing (myocardial capture threshold < His bundle capture threshold) was discovered and physiology behind it explained.

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Posterior right ventricular outflow tract septal pacing using His-bundle catheter guidance – Is it the closest we get to LV pacing?

Indian Heart Journal ◽

10.1016/j.ihj.2021.11.154 ◽

2021 ◽

Vol 73 ◽

pp. S77-S78

Author(s):

Prayaag R. Kini ◽

Reeta P. Varyani ◽

B. Barooah

Keyword(s):

Right Ventricular ◽

Right Ventricular Outflow Tract ◽

Ventricular Outflow Tract ◽

Outflow Tract ◽

His Bundle ◽

Septal Pacing

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Electro-energetics of Biventricular, Septal and Conduction System Pacing

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.2021.30 ◽

2021 ◽

Vol 10 (4) ◽

pp. 250-257

Author(s):

Frits W Prinzen ◽

Joost Lumens ◽

J�rgen Duchenn ◽

Kevin Vernooy

Keyword(s):

Cardiac Mechanics ◽

Left Ventricular ◽

Future Research ◽

Stroke Work ◽

His Bundle ◽

Local Contraction ◽

Cardiac Pump Function ◽

Septal Pacing ◽

Length Changes ◽

Mechanical Synchrony

Abnormal electrical activation of the ventricles creates abnormalities in cardiac mechanics. Local contraction patterns, as reflected by strain, are not only out of phase, but also show opposing length changes in early and late activated regions. Consequently, the efficiency of cardiac pump function (the amount of stroke work generated by a unit of oxygen consumed), is approximately 30% lower in dyssynchronous than in synchronous hearts. Maintaining good cardiac efficiency appears important for long-term outcomes. Biventricular, left ventricular septal, His bundle and left bundle branch pacing may minimise the amount of pacing-induced dyssynchrony and efficiency loss when compared to conventional right ventricular pacing. An extensive animal study indicates maintenance of mechanical synchrony and efficiency during left ventricular septal pacing and data from a few clinical studies support the idea that this is also the case for left bundle branch pacing and His bundle pacing. This review discusses electro-mechanics and mechano-energetics under the various paced conditions and provides suggestions for future research.

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Novel implant technique for septal pacing. A noninvasive approach to nonselective his bundle pacing

Journal of Electrocardiology ◽

10.1016/j.jelectrocard.2020.09.008 ◽

2020 ◽

Vol 63 ◽

pp. 35-40

Author(s):

Ortega Daniel ◽

Logarzo Emilio ◽

Barja Luis ◽

Paolucci Analía ◽

Mangani Nicolás ◽

...

Keyword(s):

His Bundle ◽

His Bundle Pacing ◽

Septal Pacing ◽

Implant Technique

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Novelties in cardiac pacing. Left bundle branch pacing, a step-by-step guide

In a good rythm ◽

10.5604/01.3001.0015.4536 ◽

2021 ◽

Vol 2 (59) ◽

pp. 27-41

Author(s):

Marek Jastrzębski

Keyword(s):

Cardiac Pacing ◽

Left Ventricular ◽

Conduction System ◽

Target Area ◽

His Bundle ◽

His Bundle Pacing ◽

Septal Pacing ◽

Rotation Technique ◽

Ventricular Activity ◽

Pace Mapping

Left bundle branch pacing (LBBP) technique is a new method for conduction system pacing that is useful for both bradyarrhythmia and heart failure indications. LBBP, while less physiological than His bundle pacing, offers several practical advantages. Namely, lower and stable pacing thresholds, good sensing of the intrinsic ventricular activity and easiness in localizing the pacing target. The LBBP method more often than His bundle pacing results in engagement of the conduction system distal to the area of the block. A step-by-step approach to LBBP was described. Attention was given to the following phases of the procedure: 1) localization of the target area on the septum, 2) the lead rotation technique with an interpretation of the lead responses (drill effect, screwdriver effect, entanglement effect), 3) methods for monitoring the lead depth in the septum to avoid perforation (fixation beats, continuous pace mapping, impedance), and 4) methods to differentiate between LBBP and left ventricular septal pacing.

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