scholarly journals What is the mechanism of narrow paced QRS duration during left bundle branch area pacing? A case report

2020 ◽  
Vol 4 (4) ◽  
pp. 1-5
Author(s):  
Yusuke Hayashi ◽  
Kenji Shimeno ◽  
Kenichi Nakatsuji ◽  
Takahiko Naruko
Keyword(s):  
Case Report ◽  
Three Dimensional ◽  
Left Ventricular ◽  
Conduction System ◽  
Conduction Time ◽  
Activation Time ◽  
Activation Patterns ◽  
Stimulus Interval ◽  
Ventricular Activation ◽  
Qrs Duration

Abstract Background Although left bundle branch area pacing (LBBAP) can capture the His-Purkinje conduction system and create a narrower paced QRS duration, its mechanism has not been investigated. In this case report, ventricular activation patterns were evaluated using three-dimensional electroanatomical mapping during LBBAP and right ventricular septal pacing (RVSP). Case summary An 81-year-old woman with sick sinus syndrome received LBBAP, followed 4 months later with atrial fibrillation ablation. We compared ventricular activation patterns during RVSP and LBBAP using a three-dimensional electro-anatomical mapping system. Paced QRS durations during RVSP and LBBAP were 163 ms and 115 ms, respectively. The activation pattern and the total left ventricular (LV) activation time were similar during RVSP and LBBAP (86 and 73 ms, respectively), despite the conduction system capture during LBBAP. The stimulus interval to the latest LV activation point during RVSP was 117 ms, and transseptal conduction time was 31 ms (117 − 86 ms). Discussion Although LBBAP could capture the His-Purkinje conduction system, neither ventricular activation patterns nor total activation time changed dramatically. The mechanism of narrower paced QRS duration during LBBAP compared to that during RVSP can be attributable to passing over the slow transseptal conduction.

scholarly journals Bilateral Bundle Branch Area Pacing to Achieve Physiological Conduction System Activation

2020 ◽  
Vol 13 (8) ◽  
Author(s):  
Jinxuan Lin ◽  
Keping Chen ◽  
Yan Dai ◽  
Qi Sun ◽  
Yuqiu Li ◽  
...  
Keyword(s):  
Right Ventricular ◽  
Right Bundle Branch Block ◽  
Left Ventricular ◽  
Conduction System ◽  
Conduction Delay ◽  
Activation Time ◽  
Bundle Branch Block ◽  
Ventricular Activation ◽  
Qrs Duration ◽  
The Right

Background: Left bundle branch pacing (LBBP) is a technique for conduction system pacing, but it often results in right bundle branch block morphology on the ECG. This study was designed to assess simultaneous pacing of the left and right bundle branch areas to achieve more synchronous ventricular activation. Methods: In symptomatic bradycardia patients, the distal electrode of a bipolar pacing lead was placed at the left bundle branch area via a transventricular-septal approach. This was used to pace the left bundle branch area, while the ring electrode was used to pace the right bundle branch area. Bilateral bundle branch area pacing (BBBP) was achieved by stimulating the cathode and anode in various pacing configurations. QRS duration, delayed right ventricular activation time, left ventricular activation time, and interventricular conduction delay were measured. Pacing stability and short-term safety were assessed at 3-month follow-up. Results: BBBP was successfully performed in 22 of 36 patients. Compared with LBBP, BBBP resulted in greater shortening of QRS duration (109.3±7.1 versus 118.4±5.7 ms, P <0.001). LBBP resulted in a paced right bundle branch block configuration, with a delayed right ventricular activation time of 115.0±7.5 ms and interventricular conduction delay of 34.0±8.8 ms. BBBP fully resolved the right bundle branch block morphology in 18 patients. In the remaining 4 patients, BBBP partially corrected the right bundle branch block with delayed right ventricular activation time decreasing from 120.5±4.7 ms during LBBP to 106.1±4.2 ms during BBBP ( P =0.005). Conclusions: LBBP results in a relatively narrow QRS complex but with an interventricular activation delay. BBBP can diminish the delayed right ventricular activation, producing more physiological ventricular activation. Graphic Abstract: A graphic abstract is available for this article.

scholarly journals Comparing Ventricular Synchrony in Left Bundle Branch and Left Ventricular Septal Pacing in Pacemaker Patients

2021 ◽  
Vol 10 (4) ◽  
pp. 822
Author(s):  
Luuk I.B. Heckman ◽  
Justin G.L.M. Luermans ◽  
Karol Curila ◽  
Antonius M.W. Van Stipdonk ◽  
Sjoerd Westra ◽  
...  
Keyword(s):  
Left Ventricular ◽  
Activation Time ◽  
Ventricular Synchrony ◽  
Septal Pacing ◽  
Ventricular Activation ◽  
Qrs Morphology ◽  
Conversion Matrix ◽  
Qrs Duration ◽  
The Right ◽  
Electrophysiological Effects

Background: Left bundle branch area pacing (LBBAP) has recently been introduced as a novel physiological pacing strategy. Within LBBAP, distinction is made between left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP, no left bundle capture). Objective: To investigate acute electrophysiological effects of LBBP and LVSP as compared to intrinsic ventricular conduction. Methods: Fifty patients with normal cardiac function and pacemaker indication for bradycardia underwent LBBAP. Electrocardiography (ECG) characteristics were evaluated during pacing at various depths within the septum: starting at the right ventricular (RV) side of the septum: the last position with QS morphology, the first position with r’ morphology, LVSP and—in patients where left bundle branch (LBB) capture was achieved—LBBP. From the ECG’s QRS duration and QRS morphology in lead V1, the stimulus- left ventricular activation time left ventricular activation time (LVAT) interval were measured. After conversion of the ECG into vectorcardiogram (VCG) (Kors conversion matrix), QRS area and QRS vector in transverse plane (Azimuth) were determined. Results: QRS area significantly decreased from 82 ± 29 µVs during RV septal pacing (RVSP) to 46 ± 12 µVs during LVSP. In the subgroup where LBB capture was achieved (n = 31), QRS area significantly decreased from 46 ± 17 µVs during LVSP to 38 ± 15 µVs during LBBP, while LVAT was not significantly different between LVSP and LBBP. In patients with normal ventricular activation and narrow QRS, QRS area during LBBP was not significantly different from that during intrinsic activation (37 ± 16 vs. 35 ± 19 µVs, respectively). The Azimuth significantly changed from RVSP (−46 ± 33°) to LVSP (19 ± 16°) and LBBP (−22 ± 14°). The Azimuth during both LVSP and LBBP were not significantly different from normal ventricular activation. QRS area and LVAT correlated moderately (Spearman’s R = 0.58). Conclusions: ECG and VCG indices demonstrate that both LVSP and LBBP improve ventricular dyssynchrony considerably as compared to RVSP, to values close to normal ventricular activation. LBBP seems to result in a small, but significant, improvement in ventricular synchrony as compared to LVSP.

Abstract 15430: Comparison of Ventricular Activation Time in Sinus and His Bundle Paced Beats

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Shakeel Jamal ◽  
Beth Bailey ◽  
Rehan Mahmud
Keyword(s):  
Comparative Analysis ◽  
Left Ventricular ◽  
Conduction Time ◽  
Activation Time ◽  
Excitation Wave ◽  
His Bundle ◽  
Purkinje System ◽  
Ventricular Activation ◽  
The Relationship ◽  
Lower Voltage

Introduction: The relationship between conduction time of a sinus impulse and a paced impulse from His bundle to peak of left ventricular activation (HVAT) has not been systematically studied. Hypothesis: To perform a comparative analysis of HVAT of sinus and paced impulse in non-selective (NS) His bundle pacing (HBP) and selective (S)-HBP. Furthermore, to determine if pacing voltage and presence of His Purkinje system (HPS) disease affects HVAT. Methods: In 102 consecutive patients a comparative analysis of native HVAT and paced HVAT at higher (5-volt) and lower voltage (1-volt) was done in all patients and in groups subdivided into NS-HBP, S-HBP, with and without HPS disease. Results: Compared to sinus HVAT (105.9 ± 24.0 ms), paced HVAT was shorter at 5-volt (97.2 ± 17.9 ms) ( p<0.01 ) and longer at 1-volt ( p<0.01 ). This voltage effect was significant only in NS-HBP (-15.8 ± 15.7 ms, p<0.01 ) but not in selective-HBP (-6.2± 13.6 ms p=0.16 ). In NS-HBP, decrease in HVAT caused by 5-volt was the same in normal vs diseased HPS (-14.5 ± 12.8 vs-13.2 ±16.3 ms). Conclusions: 1) Compared to sinus HVAT, NS-HBP HVAT is significantly shorter at 5-volt, however, tends to prolong at 1-volt.2) The 1-volt to 5-volt HVAT decrease appears to be similar both normal and diseased NS-HBP thus not related to correction of HPS delay. 3) The voltage related decrease in HVAT is significant in presence of pre-excitation wave seen in NS-HBP and is not significant in S-HBP.

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 &lt; 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

scholarly journals Polarity reversal lowers activation time during diastolic field stimulation of the rabbit ventricles: insights into mechanisms

2008 ◽  
Vol 295 (4) ◽  
pp. H1626-H1633 ◽  
Author(s):  
M. M. Maleckar ◽  
M. C. Woods ◽  
V. Y. Sidorov ◽  
M. R. Holcomb ◽  
D. N. Mashburn ◽  
...  
Keyword(s):  
Three Dimensional ◽  
Left Ventricular ◽  
Uniform Field ◽  
Activation Time ◽  
Activation Patterns ◽  
Reversed Polarity ◽  
3D Volume ◽  
Activation Times ◽  
The Right ◽  
Activation Delay

To fully characterize the mechanisms of defibrillation, it is necessary to understand the response, within the three-dimensional (3D) volume of the ventricles, to shocks given in diastole. Studies that have examined diastolic responses conducted measurements on the epicardium or on a transmural surface of the left ventricular (LV) wall only. The goal of this study was to use optical imaging experiments and 3D bidomain simulations, including a model of optical mapping, to ascertain the shock-induced virtual electrode and activation patterns throughout the rabbit ventricles following diastolic shocks. We tested the hypothesis that the locations of shock-induced regions of hyperpolarization govern the different diastolic activation patterns for shocks of reversed polarity. In model and experiment, uniform-field monophasic shocks of reversed polarities (cathode over the right ventricle is RV−, reverse polarity is LV−) were applied to the ventricles in diastole. Experiments and simulations revealed that RV− shocks resulted in longer activation times compared with LV− shocks of the same strength. 3D simulations demonstrated that RV− shocks induced a greater volume of hyperpolarization at shock end compared with LV− shocks; most of these hyperpolarized regions were located in the LV. The results of this study indicate that ventricular geometry plays an important role in both the location and size of the shock-induced virtual anodes that determine activation delay during the shock and subsequently affect shock-induced propagation. If regions of hyperpolarization that develop during the shock are sufficiently large, activation delay may persist until shock end.

Ventricular activation is impaired in aged rat hearts

2008 ◽  
Vol 295 (6) ◽  
pp. H2336-H2347 ◽  
Author(s):  
Stefano Rossi ◽  
Silvana Baruffi ◽  
Andrea Bertuzzi ◽  
Michele Miragoli ◽  
Domenico Corradi ◽  
...  
Keyword(s):  
Ventricular Arrhythmias ◽  
Elderly Population ◽  
The Elderly ◽  
Ventricular Myocardium ◽  
Conduction System ◽  
Aged Rats ◽  
Activation Time ◽  
Activation Patterns ◽  
Electrophysiological Properties ◽  
Ventricular Activation

Ventricular arrhythmias are frequently observed in the elderly population secondary to alterations of electrophysiological properties that occur with the normal aging process of the heart. However, the underlying mechanisms remain poorly understood. The aim of the present study was to determine specific age-related changes in electrophysiological properties and myocardial structure in the ventricles that can be related to a structural-functional arrhythmogenic substrate. Multiple unipolar electrograms were recorded in vivo on the anterior ventricular surface of four control and seven aged rats during normal sinus rhythm and ventricular pacing. Electrical data were related to morphometric and immunohistochemical parameters of the underlying ventricular myocardium. In aged hearts total ventricular activation time was significantly delayed (QRS duration: +69%), while ventricular conduction velocity did not change significantly compared with control hearts. Moreover, ventricular activation patterns displayed variable numbers of epicardial breakthrough points whose appearance could change with time. Morphological analysis in aged rats revealed that heart weight and myocyte transverse diameter increased significantly, scattered microfoci of interstitial fibrosis were mostly present in the ventricular subendocardium, and gap junction connexin expression decreased significantly in ventricular myocardium compared with control rats. Our results show that in aged hearts delayed total ventricular activation time and abnormal activation patterns are not due to delayed myocardial conduction and suggest the occurrence of impaired impulse propagation through the conduction system leading to uncoordinated myocardial excitation. Impaired interaction between the conduction system and ventricular myocardium might create a potential reentry substrate, contributing to a higher incidence of ventricular arrhythmias in the elderly population.

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 Conduction System Pacing for Post Transcatheter Aortic Valve Replacement Patients: Comparison With Right Ventricular Pacing

2021 ◽  
Vol 8 ◽  
Author(s):  
Hong-Xia Niu ◽  
Xi Liu ◽  
Min Gu ◽  
Xuhua Chen ◽  
Chi Cai ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Right Ventricular ◽  
Transcatheter Aortic Valve Replacement ◽  
Left Ventricular ◽  
Conduction System ◽  
Ventricular Pacing ◽  
Right Ventricular Pacing ◽  
Transcatheter Aortic Valve ◽  
Qrs Duration

Introduction: For patients who develop atrioventricular block (AVB) following transcatheter aortic valve replacement (TAVR), right ventricular pacing (RVP) may be associated with adverse outcomes. We assessed the feasibility of conduction system pacing (CSP) in patients who developed AVB following TAVR and compared the procedural and clinical outcomes with RVP.Methods: Consecutive patients who developed AVB following TAVR were prospectively enrolled, and were implanted with RVP or CSP. Procedural and clinical outcomes were compared among different pacing modalities.Results: A total of 60 patients were enrolled, including 10 who were implanted with His bundle pacing (HBP), 20 with left bundle branch pacing (LBBP), and 30 with RVP. The HBP group had significantly lower implant success rate, higher capture threshold, and lower R-wave amplitude than the LBBP and RVP groups (p &lt; 0.01, respectively). The RVP group had a significantly longer paced QRS duration (153.5 ± 6.8 ms, p &lt; 0.01) than the other two groups (HBP: 121.8 ± 8.6 ms; LBBP: 120.2 ± 10.6 ms). During a mean follow-up of 15.0 ± 9.1 months, the LBBP group had significantly higher left ventricular ejection fraction (LVEF) (54.9 ± 6.7% vs. 48.9 ± 9.1%, p &lt; 0.05) and shorter left ventricular end-diastolic diameter (LVEDD) (49.7 ± 5.6 mm vs. 55.0 ± 7.7 mm, p &lt; 0.05) than the RVP group. While the HBP group showed trends of higher LVEF (p = 0.016) and shorter LVEDD (p = 0.017) than the RVP group. Four patients in the RVP group died—three deaths were due to progressive heart failure and one was due to non-cardiac reasons. One death in the LBBP group was due to the non-cardiac reasons.Conclusions: CSP achieved shorter paced QRS duration and better cardiac structure and function in post-TAVR patients than RVP. LBBP had a higher implant success rate and better pacing parameters than HBP.

862Syncav with multipoint pacing improves acute left ventricular hemodynamics

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
A Chow ◽  
P Waddingham ◽  
T Betts ◽  
J Mangual ◽  
N Badie ◽  
...  
Keyword(s):  
Biventricular Pacing ◽  
Pressure Change ◽  
Left Ventricular ◽  
Maximum Pressure ◽  
Conduction Time ◽  
Multipoint Pacing ◽  
Surface Ecg ◽  
Intrinsic Conduction ◽  
Qrs Duration ◽  
Incremental Improvement

Abstract Funding Acknowledgements Abbott Introduction SyncAV has been shown to improve electrical synchronization by automatically adjusting atrioventricular delay (AVD) according to the intrinsic atrioventricular conduction time. Additional incremental electrical synchronization may be gained by the addition of second left ventricular (LV) pulse with MultiPoint Pacing (MPP). While the electrical synchronization benefits of SyncAV have been previously explored, there has been no assessment of the acute hemodynamic impact of SyncAV with or without MPP. Objective  Evaluate the acute LV hemodynamic impact of SyncAV with and without MPP. Methods Heart failure patients with LBBB and QRS duration (QRSd) &gt; 140 ms undergoing CRT-P/D implant with a quadripolar LV lead were enrolled in this prospective study. A guidewire or catheter with pressure transducer was placed in the LV chamber and the maximum pressure change (dP/dtmax) was recorded during the following pacing modes:  intrinsic conduction, conventional biventricular pacing with SyncAV (BiV + SyncAV), and MPP with SyncAV (MPP + SyncAV). Twelve-lead surface ECG was used to determine the patient-tailored SyncAV offset that minimized QRSd. Results Twenty-seven patients (67% male, 44% ischemic, 30 ± 7% ejection fraction) completed the acute recordings. Relative to the intrinsic QRSd of 163 ms, BiV + SyncAV reduced QRSd by 21.5% to 124 ms (p &lt; 0.001 vs. intrinsic) and MPP + SyncAV reduced QRSd by 26.6% to 120 ms (p &lt; 0.05 vs. BiV + SyncAV). Beyond electrical synchronization, SyncAV significantly improved acute hemodynamics. Relative to the intrinsic dP/dtmax of 842 mmHg/s, BiV + SyncAV elevated dP/dtmax by 6.3% to 900 mmHg/s (p &lt; 0.001 vs. intrinsic) and MPP + SyncAV elevated dP/dtmax by 8.8% to 926 mmHg/s (p &lt; 0.005 vs. BiV + SyncAV). Despite both QRSd and dP/dtmax improvement with SyncAV and MPP, correlation between electrical and hemodynamic measurements was poor (R2 = 0.0 for BiV + SyncAV, R2 = 0.1 for MPP + SyncAV). Conclusion SyncAV may significantly improve acute LV hemodynamics in addition to electrical synchrony in LBBB patients. Further incremental improvement was achieved by combining SyncAV with MPP. Abstract Figure.

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