Activation pattern during his pacing: how close are we to normal physiology?

Abstract Background His bundle pacing aims to mimic the activation pattern of normal conduction to maintain ventricular synchrony. However, selective His capture can be challenging, and the activation sequence during His pacing may not replicate normal conduction. Purpose Compare the right ventricular (RV) and left ventricular (LV) activation pattern in sinus rhythm and His bundle pacing. Methods Baseline LV and RV map was created in sinus rhythm using Rhythmia mapping system (Boston Scientific Corporation) in canine animal model. Medtronic 3830 lead was placed near the bundle of His under fluoroscopic, intracardiac echocardiogram, and electroanatomic guidance. Conduction system capture was confirmed by observing a QRS duration <120ms and an isoelectric segment between pacing artifact and QRS on surface ECG. Repeat LV and RV activation map was obtained during His pacing. Average QRS, HV and pacing to V intervals were calculated with standard deviation. Results Mapping was performed successfully in four animals. At baseline, the average QRS duration was 44±2.6ms and HV interval was 32±4.2ms. Earliest site of myocardial activation was in the mid-septal LV region. The earliest RV myocardial activation was also at the septum closer to the apex, but later than the LV (Figure1A). With His pacing, the average QRS duration was 70±17.0ms and the average stim to V interval was 31±8.7ms. During His pacing, the earliest site of activation was in the RV septum, with an activation pattern from base to apex in both the RV and LV. Conclusion Unlike normal physiology, the activation pattern during conduction system pacing is from base to apex with earliest site in the RV. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Mayo Clinic

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His bundle pacing preserves left ventricular ejection fraction in patients with conduction disease and high risk of development pacing induced cardiomyopathy

European Heart Journal ◽

10.1093/ehjci/ehaa946.0774 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J Mizner ◽

K Curila ◽

P Stros ◽

R Prochazkova ◽

J Vesela ◽

...

Keyword(s):

High Risk ◽

Ejection Fraction ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Blood Levels ◽

Funding Source ◽

Ventricular Ejection Fraction ◽

His Bundle ◽

His Bundle Pacing ◽

Galectin 3

Abstract Background His bundle pacing (HBP), contrary to right ventricular myocardial pacing (RVP), offers the most physiological activation of both ventricles and may not lead to pacing induced cardiomyopathy. The change in myocardial structure in failing heart due to myocardial pacing should be reflected in plasmatic levels of collagen metabolism biomarkers and inflammation markers. Purpose To compare a difference in the left ventricular ejection fraction (LVEF) and levels of selected biomarkers between two groups: HBP and RVP (preferably septal). Methods Eighty-six patients with conduction disease indicated to permanent cardiac pacing were randomized to HBP or RVP. Only high-risk patients for pacing induced cardiomyopathy development were included. Blood sampling and echocardiography were performed on the consequent day and 180 days after the pacemaker implantation. The measured biomarkers were: matrix metalloproteinase 9 (MMP-9), tissue inhibitor of metalloproteinase 1 (TIMP-1), galectin-3 (GAL3), ST2/IL-33R (ST2/IL) and TGF-beta 1 (TGFβ1). Statistical analysis included Students t-test, Fishers exact test and Chi-squared test. The p<0.05 was considered to be statistically significant. Results First group included 39 patients with HBP (selective or non-selective His bundle capture) and 47 patients with RVP. Both groups were similar with respect to gender, LVEF, QRS duration and the baseline levels of evaluated biomarkers. In both groups, there was a high burden of ventricular pacing after 6 months (above 90%) (p = NS). The ejection fraction of the left ventricle did not change in the HBPgroup (60 vs 60%, p=0,3), but it decreased significantly in the RVP group (59 vs 56%, p=0,004). The decline in the LVEF of at least 5% occurred in 12 patients (26%) from RVP group, compared to 3 patients (8%) in HBP group (p=0,03). The blood levels of dMMP-9 (p=0,02), TIMP-1 (p=0,003), ST2/IL (p=0,003) and TGFβ1 (p=0,021) declined significantly after 180 days in the HBP group, decline of Galectin 3 was nonsignificant. In the RVP group, there was a significant decline in blood levels of MMP-9 (p=0,014), TIMP-1 (p=0,001) and ST2/IL (p= 0,04), decline of Galectin 3 and TGFβ1 was nonsignificant. The biomarker level difference was not statistically significant between the two groups. Conclusion His bundle pacing, contrary to right ventricular myocardial pacing, preserves LVEF in patients with high risk of pacing induced cardiomyopathy development. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Charles University research programme. Q38. UNCE/MED/002

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Abstract 13804: Correlation between Electrocardiographic Features and Local Activation Pattern in Arrhythmogenic Right Ventricular Dysplasia

Circulation ◽

10.1161/circ.130.suppl_2.13804 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Tanyanan Tanawuttiwat ◽

Anneline S Te Riele ◽

Binu Philips ◽

Cynthia A James ◽

Brittney Murray ◽

...

Keyword(s):

Right Ventricular ◽

Arrhythmogenic Right Ventricular Dysplasia ◽

Anterior Wall ◽

Activation Pattern ◽

S Wave ◽

Basal Angle ◽

Right Ventricular Dysplasia ◽

Surface Ecg ◽

Qrs Duration ◽

The Right

Background: Depolarization abnormalities in the terminal portion of the QRS are frequently seen in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C). The purpose of this study was to correlate the electroanatomic activation pattern of the RV endocardium and epicardium to the surface ECG. Methods: Thirty consecutive ARVD/C patients (Mean age 33.1 +/- 11.2 years, 16 (53%) men) underwent detailed endocardial and epicardial electroanatomical mapping (EAM). Local sinus rhythm activation was annotated at the sharpest intrinsic deflection of the bipolar electrogram, including late potentials. ECG features were classified into 5 major patterns; 1. Normal QRS (12 patients) 2. Epsilon wave (5 patients) 3. Incomplete RBBB (5 patients) 4. Atypical complete RBBB (6 patients) and 5. Prolonged terminal activation duration (TAD) (2 patients) Results: The earliest endocardial and epicardial RV activation occurred on the mid anteroseptal wall on all ECG patterns. Figure 1 represented activation area (purple) after the QRS or during the delayed depolarization phase. Nearly all endocardial and epicardial RV was activated well within the QRS duration in patients with normal QRS but was activated during R’ in patients with CRBBB. The delayed activation during Epsilon wave consistently occurred in basal anterior wall and basal angle of RV. In patients with TAD, the activation of RVOT and basal angle RV represented slurred S wave. Conclusion: ECG features in ARVD/C are correlated with late activation in specific regions of RV and total endocardial activation time. The delay activation of basal anterior wall and basal angle of RV represents the Epsilon wave in the right precordial ECG.

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

EP Europace ◽

10.1093/europace/euab116.379 ◽

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

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Acute hemodynamic effects of his bundle pacing vs. left ventricular or right ventricular apical or outflow tract pacing in patients with normal QRS duration

Heart Rhythm ◽

10.1016/j.hrthm.2005.02.026 ◽

2005 ◽

Vol 2 (5) ◽

pp. S5

Author(s):

Luigi Padeletti ◽

Randy A. Lieberman ◽

Antonio Michelucci ◽

Andrea Collella ◽

Kenneth Jackson ◽

...

Keyword(s):

Right Ventricular ◽

Left Ventricular ◽

Outflow Tract ◽

Hemodynamic Effects ◽

His Bundle ◽

His Bundle Pacing ◽

Qrs Duration

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Electrode Model and Simulation of His- Bundle Pacing for Cardiac Resynchronization Therapy

Current Directions in Biomedical Engineering ◽

10.1515/cdbme-2020-3142 ◽

2020 ◽

Vol 6 (3) ◽

pp. 555-558

Author(s):

Domenic Pascual ◽

Matthias Heinke ◽

Reinhard Echle ◽

Johannes Hörth

Keyword(s):

Cardiac Resynchronization Therapy ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Left Ventricular Ejection ◽

Resynchronization Therapy ◽

Electrical Field ◽

His Bundle ◽

His Bundle Pacing ◽

Surface Ecg ◽

Electrical Pacing

AbstractA disturbed synchronization of the ventricular contraction can cause a highly developed systolic heart failure in affected patients with reduction of the left ventricular ejection fraction, which can often be explained by a diseased left bundle branch block (LBBB). If medication remains unresponsive, the concerned patients will be treated with a cardiac resynchronization therapy (CRT) system. The aim of this study was to integrate His-bundle pacing into the Offenburg heart rhythm model in order to visualize the electrical pacing field generated by His-Bundle-Pacing. Modelling and electrical field simulation activities were performed with the software CST (Computer Simulation Technology) from Dessault Systèms. CRT with biventricular pacing is to be achieved by an apical right ventricular electrode and an additional left ventricular electrode, which is floated into the coronary vein sinus. The non-responder rate of the CRT therapy is about one third of the CRT patients. His- Bundle-Pacing represents a physiological alternative to conventional cardiac pacing and cardiac resynchronization. An electrode implanted in the His-bundle emits a stronger electrical pacing field than the electrical pacing field of conventional cardiac pacemakers. The pacing of the Hisbundle was performed by the Medtronic Select Secure 3830 electrode with pacing voltage amplitudes of 3 V, 2 V and 1,5 V in combination with a pacing pulse duration of 1 ms. Compared to conventional pacemaker pacing, His-bundle pacing is capable of bridging LBBB conduction disorders in the left ventricle. The His-bundle pacing electrical field is able to spread via the physiological pathway in the right and left ventricles for CRT with a narrow QRS-complex in the surface ECG.

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557 His bundle pacing: how to troubleshoot the implantation of a ventricular back-up lead

European Heart Journal Supplements ◽

10.1093/eurheartj/suab127.032 ◽

2021 ◽

Vol 23 (Supplement_G) ◽

Author(s):

Giuseppe Pio Piemontese ◽

Lorenzo Bartoli ◽

Giovanni Statuto ◽

Andrea Angeletti ◽

Giulia Massaro ◽

...

Keyword(s):

Signal Amplitude ◽

Right Atrial ◽

Intrinsic Activity ◽

Variable Degree ◽

Dual Chamber ◽

His Bundle ◽

His Bundle Pacing ◽

Sensitivity Setting ◽

Qrs Duration ◽

The Right

Abstract Aims Interest in permanent His bundle pacing (HBP) as a means of both preventing pacing-induced cardiomyopathy and providing physiological resynchronization by normalization of His-Purkinje activation is constantly growing. Current devices are not specifically designed for HBP, which gives rise to programming challenges. To evaluate the critical troubleshooting HBP options in patients with permanent atrial fibrillation (AF) and variable degree of atrio-ventricular block (AVB) who receive HBP through a lead connected to the atrial port, and an additional ventricular ‘backup’. Methods and results Between December 2018 and July 2021, 156 consecutive patients with indication for pacing underwent HBP. Among these, 37 had permanent AF with documented symptomatic pauses. Fourteen of them received a dual-chamber device which was used to place a backup right ventricle (RV) lead; in this scenario, the His lead is implanted in the right atrial (RA) port, the RV lead in the RV port. Depending on the presence of an additional left ventricle (LV) lead, either a dual-chamber and a CRT device can be used. In this context, the events marked as atrial sensed (As) or paced (Ap) are indeed ventricular, so that sensing is more complex. A clinical scenario is atrial activity oversensed on the His channel (As) leading to RV dyssynchronous pacing in the ventricular safety pacing (VSP) window. A second one is intrinsic QRS undersensing causing inappropriate His pacing. The interplay of intrinsic ventricular activity (rate, signal amplitude, and slew rate on both the His and the ventricular channel) and of the HV interval may be of key importance to troubleshoot As–Vp (atrial sensed–ventricular paced) (Figure 1A) as well as Vs–Ab (ventricular sensed–atrial blanking period) sequences (Figure 1B). Changing sensitivity and sensing configuration may help to fix these issues. DVI(R) mode programming may indeed prove safer than DDD(R) in the setting of preserved intrinsic activity or in the event of intermittent His capture loss. Paced AV delay should be programmed slightly longer than H-V+QRS duration to avoid unnecessary RV pacing with pseudo-fusion (too short) (Figure 2A) and possibly R/T events (too long). Stability of H-V interval and of QRS duration must be verified at each device follow-up by decremental His pacing to ensure consistent sensitivity of the ventricular signal beyond stable His capture, that may be challenged by infra-Hisian block (Figure 2B). Conclusions Owing to the absence of HBP-specific devices, HBP shall be made safe and effective by careful troubleshooting, consisting of sensitivity setting, paced AV interval and mode programming. 557 Figure

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Abstract 2170: Unipolar Pace Mapping With the Medtronic SelectSecure 3830 Lead System can Accurately Locate the HIS Bundle for Permanent HIS Bundle Pacing

Circulation ◽

10.1161/circ.118.suppl_18.s_680-d ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Stanley Tung ◽

Kesava Rajagopalan ◽

Jonathan Affolter ◽

Santabhanu Chakrabarti ◽

Lynn Davenport

Keyword(s):

Ventricular Pacing ◽

Wide Spread ◽

Lead System ◽

His Bundle ◽

His Bundle Pacing ◽

Qrs Duration ◽

The Mean ◽

Right Ventricular Apical Pacing ◽

The Right ◽

Pace Mapping

Introduction: Permanent HIS Bundle pacing (HBP) is one of the most physiological ventricular pacing strategies available. Its wide spread adoption is limited due to challenges in HIS mapping, and requires femoral EP mapping to guide lead placement. We investigate whether unipolar pace mapping (PM) using the lead alone is a viable technique to locate the HB for lead deployment. Methods: Patients indicated for ventricular pacing were approached for HBP. An active fixation lead (SelectSecure®3830, Medtronic) inserted through its deflectable sheath was advanced to the right atrium via left pectoral approach.The cathode tip was positioned just outside the tip of the sheath. Unipolar PM was applied at 5V/0.5ms along the tricuspid septal annulus in anterior posterior direction. At the location with 12/12 ECG match to intrinsic QRS, and with pace to QRS delay >30ms, the lead was fixed. Unipolar sensing for HB electrogram was performed with the Medtronic 2090 analyzer (unfiltered, variable gain, sweep speed 50mm/sec). HBP implant thresholds, HB lead implant and fluoroscopy times, intrinsic and paced HV intervals, pre and post QRS and PR intervals were collected. Paired Student t -test was used for analysis. Results: 22 patients (16 male, mean age 69 yrs) underwent HBP. 19 patients had successful HBP, with 3 patients having para-Hisian septal pacing. The mean HBP implants threshold, HB lead implant and fluoroscopy times were 1.67±44V/0.6ms, 43±26min, and 13±12min respectively. The mean intrinsic and paced HV intervals were 60 and 44 ms respectively. After HBP, the QRS duration decreased from 160±44 to 132±43ms (p<0.01). HBP corrected one RBBB, one LBBB, and three right ventricular apical pacing complexes to normal (<120ms) and accounted for the shorter post HBP mean QRS duration. 8 patients presented with PR intervals ≥200msec and had their PR interval narrowed from a mean of 326±141 to 174±21ms (p<0.05). Conclusions: Unipolar PM of the His bundle using the Medtronic SelectSecure® lead system alone can accurately locate the HB for HBP with acceptable implant time and pacing thresholds. HBP also has the potential value of AVN and ventricular electrical resynchronization benefit. More data with longer-term follow up are needed before considering wide spread adoption.

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Upgrade of cardiac resynchronization therapy by utilizing additional His-bundle pacing in a patient with lamine A/C cardiomyopathy: an autopsy case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab356 ◽

2021 ◽

Author(s):

Masako Baba ◽

Kentaro Yoshida ◽

Osamu Igawa ◽

Masayoshi Yamamoto ◽

Akihiko Nogami ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Present Report ◽

Biventricular Pacing ◽

Scar Tissue ◽

Left Ventricular ◽

Conduction System ◽

Cardiac Resynchronization ◽

Resynchronization Therapy ◽

His Bundle ◽

His Bundle Pacing

Abstract Background A number of heart failure patients (HF) do not fully benefit from cardiac resynchronization therapy (CRT). Although His bundle pacing (HBP) have been developed as an alternative strategy, its role for treating advanced cardiomyopathy remains unclear. Case summary We previously reported a patient with lamin A/C cardiomyopathy (Eur Heart J Case Rep. 2020; 4:1-9). He had turned non-response to conventional biventricular pacing (BVP), and an upgrade to CRT combining para-His bundle pacing (HBP) and left ventricular (LV) pacing had markedly improved his HF status. In the present report, we assessed the autopsy and histological findings of this patient. A histological examination of both the LV and right ventricular (RV) apex pacing regions exhibited extensive scarring. Although a distinct conduction system was not identified in the alternative para-HBP region, the RV endocardium had more viable myocytes in this region. Discussion In patients with advanced cardiomyopathy accompanied by extensive fibrosis, RV apex pacing, delivered from scar tissue, can render conventional BVP ineffective. Additionally, HBP alone can not provide adequate resynchronization under the presence of diffuse injury of the His-Purkinje system. In these circumstances, combined para-HB and LV pacing may facilitate electrical and mechanical resynchronization of the ventricles and may be attributed to favourable CRT response in advanced HF, even if para-HBP fails to directly capture the conduction system.

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Electrocardiographic characterization of non-selective His bundle pacing. Validation of novel diagnostic criteria

10.1101/631481 ◽

2019 ◽

Cited By ~ 1

Author(s):

Marek Jastrzębski ◽

Paweł Moskal ◽

Karol Curila ◽

Kamil Fijorek ◽

Piotr Kukla ◽

...

Keyword(s):

Sensitivity And Specificity ◽

Left Ventricular ◽

Peak Time ◽

List Type ◽

Intraventricular Conduction ◽

His Bundle ◽

His Bundle Pacing ◽

Conduction Disturbances ◽

Surface Ecg ◽

Ecg Criteria

AbstractAimsPermanent His bundle (HB) pacing is usually accompanied by simultaneous capture of the adjacent right ventricular (RV) myocardium - this is described as a non-selective (ns)-HB pacing. Our aim was to identify ECG criteria for loss of HB capture during ns-HB pacing.MethodsConsecutive patients with permanent HB pacing were recruited. Surface 12-lead ECGs during ns-HB pacing and loss of HB capture (RV-only capture) were obtained. ECG criteria for loss/presence of HB capture were identified. In the validation phase these criteria and the “HB ECG algorithm” were tested by two blinded observers using a separate, sizable set of ECGs.ResultsA total of 353 ECG (226 ns-HB and 128 RV-only) were obtained from 226 patients with permanent HB pacing devices. QRS notch/slur in left ventricular leads and R-wave peak time in lead V6 were identified as the best features for differentiation. The 2-step HB ECG algorithm based on these features correctly classified 87.1% of cases with sensitivity and specificity of 93.2% and 83.9%, respectively. Moreover, the proposed criteria for definitive diagnosis of ns-HB capture (no QRS slur/notch in leads I, V1, V4-V6 and the R-wave peak time in V6 ≤ 100 ms) presented 100% specificity.ConclusionA novel ECG algorithm for the diagnosis of loss of HB capture and novel criteria for definitive confirmation of HB capture were formulated and validated. Practical application of these criteria during implant and follow-up of patients with HB pacing devices is feasible.Condensed AbstractThe 2-step ECG algorithm for loss of His bundle capture based on surface ECG analysis is proposed and validated. This method correctly classified 87.1% of cases with a sensitivity and specificity of 93.2% and 83.9%, respectively.What’s NewThis is the first study that analyzes QRS characteristics during non-selective His bundle pacing in a sizable cohort of patients.Precise criteria and a novel algorithm for electrocardiographic diagnosis of loss of HB capture during presumed non-selective HB pacing were validated.QRS notch/slur in left ventricular leads was identified as a simple and reproducible feature indicating loss of HB capture or lack/loss of correction of intraventricular conduction disturbances.Assessment of R-wave peak time in lead V6 rather than QRS duration for diagnosis of ns-HB pacing was validated.

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Troubleshooting Programming of Conduction System Pacing

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.2021.16 ◽

2021 ◽

Vol 10 (2) ◽

pp. 85-90

Author(s):

Elise Bakelants ◽

Haran Burri

Keyword(s):

Sinus Rhythm ◽

Heart Rhythm ◽

Conduction System ◽

Atrial Arrhythmia ◽

Dual Chamber ◽

Single Chamber ◽

His Bundle ◽

His Bundle Pacing ◽

Device Programming

Conduction system pacing (CSP) comprises His bundle pacing and left bundle branch area pacing and is rapidly gaining widespread adoption. Effective CSP not only depends on successful system implantation but also on proper device programming. Current implantable impulse generators are not specifically designed for CSP. Either single chamber, dual chamber or CRT devices can be used for CSP depending on the underlying heart rhythm (sinus rhythm or permanent atrial arrhythmia) and the aim of pacing. Different programming issues may arise depending on the device configuration. This article aims to provide an update on practical considerations for His bundle and left bundle branch area pacing programming and follow-up.

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