scholarly journals B-PO05-183 HIS BUNDLE PACING IN NONAGENARIANS. SUCCESS RATES, SAFETY AND EFFECT ON VENTRICULAR ACTIVATION PARAMETERS

Heart Rhythm ◽  
2021 ◽  
Vol 18 (8) ◽  
pp. S446
Author(s):  
Rehan Mahmud ◽  
Stacey Kukla ◽  
Brenda Harris ◽  
Brittany Phillips ◽  
Sharon Hakes
Keyword(s):  
Activation Parameters ◽  
Success Rates ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Ventricular Activation

P6547The energy cost of His bundle pacing can be curtailed

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
F Zanon ◽  
L Marcantoni ◽  
G Pastore ◽  
E Baracca ◽  
C Picariello ◽  
...  
Keyword(s):  
Pulse Duration ◽  
Safety Margin ◽  
Significant Saving ◽  
His Bundle ◽  
His Bundle Pacing ◽  
On Demand ◽  
Mild Reduction ◽  
Ventricular Activation ◽  
The Individual ◽  
Current Drain

Abstract Introduction His bundle pacing (HBP) allows physiological ventricular activation and prevents the electrical and mechanical desynchronization generally induced by myocardial stimulation, which can increase the risk of atrial fibrillation and heart failure. On the other hand, reliable HBP capture often requires higher energy than conventional myocardial pacing. This reduces the expected life of the stimulator and might limit the diffusion of HBP in the clinical practice. Purpose Decreasing HBP current drain by careful management of stimulation safety margin and pulse duration. Methods In 28 patients undergoing DDD pacing with HBP, a third lead was implanted in RV apex to provide back-up pacing on demand. HBP and apical leads were connected, respectively, to the V1 and V2 channels of a 3-chamber stimulator. When HBP was effective, apical sensing occurred within the VV delay and prevented V2 stimulation. In contrast, in case of HBP failure, V2 sensing was missing and apical back-up pacing was promptly delivered at the end of the VV delay. The availability of a back-up pulse on demand allowed reducing the HBP safety margin with no risk. Furthermore, the individual HBP strength-duration curve was derived in the aim of optimizing the Hisian pulse parameters, which are the major determinants of the device current drain. Results Correct back-up inhibition by successful HBP and stimulation in the event of capture loss was achieved in all the patients. The latency from Hisian pacing to apical sensing averaged 96±14 ms. According to the pacemaker counters, no back-up pulse was delivered in daily life in 59% of patients. In the remaining, the prevalence of back-up stimulation never exceeded 15% of paced ventricular cycles. The high HBP threshold was essentially due to an increased rheobase (1.2±0.6 V), while the chronaxie ranged from 0.30 to 0.53 ms in 71% of patients (median 0.44 ms), exceeding 0.6 ms only in 29% of the cases. An average current saving of 5.4±3.0 μA was obtained at the expense of a mild reduction in HBP safety margin (from 1.6±0.2 to 1.4±0.1 times). HBP and apical back-up Conclusions Back-up stimulation on demand is a reliable option to decrease HBP current drain and prolong the stimulator service life with full safety. In most of the cases, significant saving can be achieved by pulse shortening, as the chronaxie time is in the same range as with myocardial stimulation and longer pulses are not required. A pulse duration exceeding 0.6 ms is indicated in less than 1/3 of the implants.

scholarly journals B-AB14-01 LEFT VENTRICULAR ACTIVATION TIME AND PATTERN ARE PRESERVED BY BOTH SELECTIVE AND NON-SELECTIVE HIS BUNDLE PACING

Heart Rhythm ◽  
2021 ◽  
Vol 18 (8) ◽  
pp. S27
Author(s):  
Ahran Arnold ◽  
Matthew J. Shun-Shin ◽  
Daniel Keene ◽  
James P. Howard ◽  
Ji-Jian Chow ◽  
...  
Keyword(s):  
Left Ventricular ◽  
Activation Time ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Ventricular Activation

scholarly journals Non-selective and selective His bundle pacing both preserve left ventricular activation time and pattern

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
A Arnold ◽  
MJ Shun-Shin ◽  
D Keene ◽  
JP Howard ◽  
J Chow ◽  
...  
Keyword(s):  
Right Ventricular ◽  
Left Ventricular ◽  
Public Institution ◽  
Activation Time ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Ventricular Activation ◽  
Qrs Duration ◽  
Left And Right ◽  
The Impact

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): British Heart Foundation Background: His bundle pacing can be achieved in two ways selective His bundle pacing, where the His bundle is captured alone, and non-selective His bundle pacing, where local myocardium is also captured resulting a pre-excited ECG appearance. We assessed the impact of this ventricular pre-excitation on left and right ventricular dys-synchrony. Methods We recruited patients who displayed both selective and non-selective His bundle pacing. We performed non-invasive epicardial electrical mapping to determine left and right ventricular activation times and patterns. Results In the primary analysis (n = 20, all patients), non-selective His bundle pacing did not prolong LVAT compared to select His bundle pacing by a pre-specified non-inferiority margin of 10ms (LVAT prolongation: -5.5ms, 95% confidence interval (CI): -0.6 to -10.4, non-inferiority p < 0.0001). Non-selective His bundle pacing did not prolong right ventricular activation time (4.3ms, 95%CI: -4.0 to 12.8, p = 0.296) but did prolong QRS duration (22.1ms, 95%CI: 11.8 to 32.4, p = 0.0003). In patients with narrow intrinsic QRS (n = 6), non-selective His bundle pacing preserved left ventricular activation time (-2.9ms, 95%CI: -9.7 to 4.0, p = 0.331) but prolonged QRS duration (31.4ms, 95%CI: 22.0 to 40.7, p = 0.0003) and mean right ventricular activation time (16.8ms, 95%CI: -5.3 to 38.9, p = 0.108) compared to selective His bundle pacing. Activation pattern of the left ventricular surface was unchanged between selective and non-selective His bundle pacing. Non-selective His bundle pacing produced early basal right ventricular activation, which was not observed with selective His bundle pacing. Conclusions Compared to selective His bundle pacing, local myocardial capture during non-selective His bundle pacing produces right ventricular pre-excitation resulting in prolongation of QRS duration. However, non-selective His bundle pacing preserves the left ventricular activation time and pattern of selective His bundle pacing. When choosing between selective and non-selective His bundle pacing, left ventricular dyssynchrony is not an important factor. Abstract Figure: Selective vs Non-Selective HBP

Cryoablation vs. radiofrequency ablation of the atrioventricular node in patients with His-bundle pacing

EP Europace ◽  
2020 ◽  
Author(s):  
Alwin Zweerink ◽  
Elise Bakelants ◽  
Carine Stettler ◽  
Haran Burri
Keyword(s):  
Radiofrequency Ablation ◽  
Atrioventricular Node ◽  
Complete Loss ◽  
Success Rates ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Acute Success ◽  
Redo Procedure ◽  
Biplane Fluoroscopy

Abstract Aims Radiofrequency ablation (RFA) of the atrioventricular node (AVN) with His-bundle pacing (HBP) can cause rise in capture thresholds. Cryoablation (CRYO) may offer reversibility in case of threshold rise but has never been tested for AVN ablation in this setting. Our aim was to compare procedural characteristics and outcome of CRYO compared with RFA for AVN ablation in patients with HBP. Methods and results Forty-four patients with HBP underwent AVN ablation for an ‘ablate and pace’ indication. Cryoablation was performed in the first 22 patients and RFA in the following 22 patients. Procedural characteristics, success rates, and change in His capture thresholds were compared between groups. Distance from the ablation site to the His lead was measured using biplane fluoroscopy. Acute success was 100% with both strategies. Median procedural duration was significantly longer for CRYO {50 [interquartile range (IQR) 38–63] min} compared with RFA [36 (IQR, 30–41) min; P = 0.027]. An acute threshold rise of ≥1 V was observed in four CRYO (one complete loss of capture) and three RFA patients (P = 0.38), with all of the applications being within 6 mm of the His lead tip. During follow-up, nine patients had AVN re-conduction (six CRYO vs. three RFA; P = 0.58), but only four patients required a redo procedure (all CRYO; P = 0.09). Conclusion Cryoablation does not offer any advantage over RFA for AVN ablation in patients with HBP and tended to require more redo procedures. If possible, a distance of ≥6 mm should be maintained from the His lead tip to avoid a rise in capture thresholds.

scholarly journals B-PO04-031 DIFFERENT BASAL VENTRICULAR ACTIVATION BETWEEN LEFT BUNDLE BRANCH AREA AND HIS BUNDLE PACING

Heart Rhythm ◽  
2021 ◽  
Vol 18 (8) ◽  
pp. S292
Author(s):  
Toshiaki Sato ◽  
Kyoko Soejima ◽  
Takato Mohri ◽  
Yumi Katsume ◽  
Mika Tashiro ◽  
...  
Keyword(s):  
His Bundle ◽  
His Bundle Pacing ◽  
Ventricular Activation

scholarly journals Left Ventricular Activation Time and Pattern Are Preserved With Both Selective and Non-Selective His Bundle Pacing

2021 ◽  
Author(s):  
Ahran D. Arnold ◽  
Matthew J. Shun-Shin ◽  
Nadine Ali ◽  
Daniel Keene ◽  
James P. Howard ◽  
...  
Keyword(s):  
Left Ventricular ◽  
Activation Time ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Ventricular Activation

304Cryoablation versus Radiofrequency Ablation of the Atrioventricular Node in Patients with His-bundle Pacing

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
A Zweerink ◽  
E Bakelants ◽  
C Stettler ◽  
H Burri
Keyword(s):  
Radiofrequency Ablation ◽  
Atrioventricular Node ◽  
P Value ◽  
Success Rates ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Total Procedure Time ◽  
Redo Procedure ◽  
Procedural Success ◽  
Transient Elevation

Abstract Background Atrioventricular node (AVN) ablation in the setting of His bundle pacing (HBP) may be challenging due to risk of compromising the function of the His lead. Cryoablation (CRYO) may offer theoretical advantages over conventional radiofrequency ablation (RFA), due to absence of shunting of current to the His lead, more discrete lesions, and potential reversibility in case of transient elevation of capture thresholds. However, CRYO has never been tested for AVN ablation in this setting. Purpose To compare procedural characteristics and outcome of CRYO compared to RFA for AVN ablation in patients with HBP. Methods Thirty-five patients (age 76 ± 8 yrs, 23% male) with HBP underwent AVN ablation for an "ablate and pace" indication. CRYO was performed in the first 22 pts and RFA in the following 13 pts. Procedure and fluoroscopy times, change in His threshold and success rates were compared between groups. Results The acute procedural success rate was 100% for both strategies without any major complications. There were no significant differences in procedure characteristics and outcome between CRYO and RFA, except for significantly shorter application times with RFA and a trend to more frequent reconduction and requirement for a redo procedure with CRYO (see table). All recurrences occurred within one month after ablation. Conclusion CRYO does not seem to offer any advantage over RFA for AVN ablation in patients with HBP, and does not avoid rise of His capture thresholds. Moreover, the recurrence rate may be higher with CRYO leading to more redo procedures. Table Parameter CRYO (22 pts) RFA (13 pts) P-value Total procedure time (min) 50 [38 - 63] 40 [33 - 53] 0.257 Fluoroscopy time (min) 5.0 [2.2 - 5.4] 3.5 [1.9 - 9.0] 0.578 Expo Rx (mcGy.cm2) 237 [110 - 525] 139 [65 - 721] 0.468 Number of applications (n) 6 [3 - 11] 4 [1 - 15] 0.371 Total application time (min) 17 [9 - 29] 3 [1 - 9] 0.001 His threshold pre-ablation (V) 1.63 [0.75 - 3.44] 0.75 [0.53 - 1.63] 0.180 His threshold post-ablation (V) 1.88 [0.75 - 3.81]* 1.25 [0.63 - 3.50] 0.389 His threshold change (V) 0.00 [0.00 - 0.31]* 0.00 [0.00 - 0.75] 0.933 His threshold rise ≥1 volt (n) 4 (18%)* 3 (23%) 0.726 Acute procedural success (n) 22 (100%) 13 (100%) 1.000 AV reconduction during follow-up (n) 5 (23%) 1 (8%) 0.254 AV reconduction needing redo procedure (n) 3 (14%) 0 0.146 Interquartile range is shown in square brackets. *one loss of capture.

scholarly journals The Emerging Role of Cardiac Conduction System Pacing as a Treatment for Heart Failure

2020 ◽  
Vol 17 (5) ◽  
pp. 288-298
Author(s):  
Nadine Ali ◽  
Mathew Shun Shin ◽  
Zachary Whinnett
Keyword(s):  
Heart Failure ◽  
Cardiac Function ◽  
Left Bundle Branch Block ◽  
Conduction System ◽  
Cardiac Conduction ◽  
Bundle Branch Block ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Patients With Heart Failure ◽  
Ventricular Activation

Abstract Purpose of Review The aim of cardiac resynchronization therapy (CRT) is to improve cardiac function by delivering more physiological cardiac activation to patients with heart failure and conduction abnormalities. Biventricular pacing (BVP) is the most commonly used method for delivering CRT; it has been shown in large randomized controlled trials to significantly improve morbidity and mortality in patients with heart failure. However, BVP delivers only modest reductions in ventricular activation time and is only beneficial in patients with prolonged QRS duration. In this review, we explore conduction system pacing as a method for delivering more effective ventricular resynchronization and to extend pacing therapy for heart failure to patients without left bundle branch block (LBBB). Recent Findings The aim of conduction system pacing is to provide physiological ventricular activation by directly stimulating the conduction system. Current modalities include His bundle and left conduction system pacing. His bundle pacing is the most established method; it has the potential to correct left bundle branch block and deliver more effective ventricular resynchronization than BVP. This translates into greater acute haemodynamic improvements and observational data suggests that His-CRT results in improvements in cardiac function and symptoms. AV-optimized His bundle pacing is being investigated in patients with heart failure and long PR interval without LBBB, to see if this improves exercise capacity. More recently, a technique for pacing the left bundle branch has been developed. Early studies show potential advantages including low and stable capture thresholds. Summary Conduction system pacing can deliver more effective ventricular resynchronization than BVP, which has the potential to deliver greater improvements in cardiac function. It may also provide the opportunity to extend pacing therapy for heart failure to patients who do not have LBBB. Further data is required from randomized trials to assess these promising pacing techniques.

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