P6020His bundle pacing in patients with abnormal versus intact atrioventricular conduction: from the IMAGE-HBP Study

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J A Y Koneru ◽  
G O P I Dandamudi ◽  
F A I Z Subzposh ◽  
R K S Shepard ◽  
G K Kalahasty ◽  
...  
Keyword(s):  
Statistical Tests ◽  
Adverse Outcomes ◽  
Cardiac Conduction ◽  
Electrical Performance ◽  
Av Node ◽  
Bundle Branch Block ◽  
Right Ventricular Pacing ◽  
His Bundle ◽  
Av Conduction ◽  
Qrs Duration

Abstract Background Frequent right ventricular pacing causes ventricular dyssynchrony and adverse outcomes. His bundle pacing (HBP) offers a physiological alternative. HBP electrical performance characteristics with cardiac conduction system abnormalities are not well established. Purpose To compare HBP implant procedure related parameters in patients with abnormal atrioventricular (AV) conduction versus those with intact AV conduction. Methods Patients prospectively enrolled in the IMAGE-HBP study undergoing implant attempt with a SelectSecure 3830 lead placed at the putative His-bundle location were included in the analysis. Patients were divided into groups based on AV conduction status. Implant characteristics and electrical performance of the pacemaker were tabulated and compared between the two groups with formal statistical tests. Results Among 60 patients (age 74.7 years old and 60% male), 29 patients (48%) had abnormal AV conduction at or below the AV node (18 with AV block of which 5 also had bundle branch block (BBB), 6 with SND and BBB, and 5 with AV node ablation). The remaining 31 patients (52%) had intact AV conduction. Procedure times were not significantly different between the groups (P=0.26). Selective HBP was achieved in 20.7% of abnormal AV conduction patients and 45.2% of intact AV conduction patients (P=0.06); the remaining patients had non-selective HBP. There were no differences detected in pacing characteristics at implant and paced QRS durations by AV conduction status. Patient with intact AV conduction (N=31) Patients with abnormal AV conduction at or below AV node (N=29) Procedure time in minutes (mean ± SD, Median, IQR) 99±38; 87 [43, 180] 108±32; 108 [65, 182] Fluoroscopy time in minutes (mean ± SD, Median, IQR) 15±12; 11 [3, 50] 16±9; 13 [4, 36] Number of fixation attempts 3.0±2.2 2.2±2.0 sHBP PCT N=14 N=6 V at 0.5ms 1.8±0.9 1.7±1.2 V at 1.0ms 1.6±1.2 1.2±0.8 nsHBP PCT N=17 N=22 V at 0.5ms 2.2±1.9 1.7±1.3 V at 1.0ms 1.5±1.1 1.3±1.1 His signal recorded, number 30 (96.8%) 28 (96.6%) H-QRS interval, ms 46±7 48±13 His Injury of Current, N (%) 23 (74.2%) 18 (62.1%) Baseline Intrinsic QRS, ms 96±16 107±22 Paced QRS duration, ms (from HBP at 1.0ms) 119±23 121±19 Conclusions Selective and non-selective HBP are achievable in bradycardic patients with abnormal and intact AV conduction, including those with BBB. There were no major differences in HBP implant parameters between patients with abnormal AV conduction and those with intact AV conduction.

scholarly journals His bundle pacing after failure of cardiac resynchronization therapy: a case study

2020 ◽  
Vol 48 (5) ◽  
pp. 030006052092349
Author(s):  
Katarína Koščová ◽  
Milan Chovanec ◽  
Jan Petrů ◽  
Lucie Šedivá ◽  
Libor Dujka ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Cardiac Pacing ◽  
Cardiac Resynchronization ◽  
Ventricular Pacing ◽  
Resynchronization Therapy ◽  
Bundle Branch Block ◽  
Right Ventricular Pacing ◽  
His Bundle ◽  
His Bundle Pacing

His bundle pacing is a relatively new method of cardiac pacing. This method is used in patients with atrioventricular block to prevent heart failure associated with right ventricular pacing, and in patients with bundle branch block and cardiomyopathy. We report a patient with cardiomyopathy and left bundle branch block with failure of cardiac resynchronization therapy. Permanent His bundle pacing was associated with clinical improvement and improvement of parameters of cardiac function.

Effect of disopyramide and disobutamide on conduction in perfused rabbit hearts

1981 ◽  
Vol 59 (11) ◽  
pp. 1192-1195
Author(s):  
Peter E. Dresel ◽  
Keith D. Cameron
Keyword(s):  
Antiarrhythmic Agent ◽  
Conduction System ◽  
Atrioventricular Conduction ◽  
Cardiac Conduction ◽  
Conduction Time ◽  
Related Effect ◽  
Av Node ◽  
His Bundle ◽  
Time Changes ◽  
His Bundle Recording

The effects of disopyramide (DP) and a new antiarrhythmic agent, disobutamide (DB) on cardiac conduction were studied using His bundle recording from modified rabbit Langendorff preparations electrically driven at 3 and 4 Hz. Both disopyramide (4–16 μg/mL) and disobutamide (1–30 μg/ml) slowed conduction throughout the atrioventricular conduction system, i.e., SA, AH, and HV intervals were increased in a dose-related manner. Conversion of the conduction time changes to percent changes indicates that disobutamide has a relatively equal effect on each part of the system whereas disopyramide exhibited significantly less effect on AV nodal conduction. Slowing of conduction in the AV node by DP was clearly related to rate. Changes in SA and HV intervals were rate related to a lesser degree. No such rate-related effect was evident with disobutamide. Block of atrial conduction occurred in two out of six hearts when the rate was increased at 8 μg/mL of DP and in three additional hearts at 16 μg/mL. This was interpreted to indicate a change in atrial excitability such that 2 × threshold currents no longer excited the tissues. This was not observed at any concentration of DB.

scholarly journals P1500 Reptilian heart in a man

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
E O Ozpelit ◽  
E E O Ozcan ◽  
M E O Ozpelit ◽  
N O Ozgul
Keyword(s):  
Human Evolution ◽  
Peak Velocity ◽  
Pulmonary Regurgitation ◽  
Maximum Velocity ◽  
Heart Model ◽  
Av Node ◽  
His Bundle ◽  
Diastolic Velocity ◽  
Qrs Duration ◽  
The One

Abstract 40 year old man admitted to hospital due to tachycardia episode. His normal ECG was consistent with RBBB with a QRS duration of 200msec. He had undergone a VSD operation when he was 6. He had a 3/6 systolic murmor . On TTE, there was a VSD patch and a residual tiny VSD with a L-R shunt. The maximum systolic gradient of VSD shunt was measured as 92mmHg .There was also moderate tricuspid regurgitation (TR) with a peak velocity of 5.1m/sec and estimated sPAP of 103mmHg. Considering the measured sPAP and the VSD shunt gradients, his systolic blood pressure (SBP)should approximately be equal to sum of those two ( 103+ 92 = 195mmHg). However his BP was 140/90mmHg.When we examined his heart for a possible explanation for this inconsistency, we noticed a systolic aliasing inside the RV with a maximum velocity of 3.1m/sec and systolic gradient of 38mmHg. However the chamber with lower pressure (P) was the one to which the VSD shunt was directed, and this chamber was in direct continuity with pulmonary artery. So to confirm the P in this chamber we also used pulmonary regurgitation flow and measured a peak diastolic velocity of 3.8m/sec, meaning a mean PAP of 60mmHg .Cardiac catheterization also confirmed a sPAP of 116mmHg and mPAP of 65mmHg. The systolic aortic P was 145mmHg and systolic LV P was 152mmHg. So the unexpectedly high gradient of VSD shunt was still a mystery for us. While searching the literature to explain this , we noticed that the patients’ heart was resembling the reptilian heart model. The reptilian heart has two atria and one ventricle with 3 segments seperated via muscular ridges. In our patients’ heart ,the small chamber with high P in the RV was the cavum venosum, the larger chamber of RV with VSD was the cavum pulmonale, and the left ventricle was the cavum arteriosum. (Fig) The reptilian hearts typically have noncompacted myocardium which was actually the case in our patient. The reptilian hearts also have unique conduction system with no AV node and His bundle, and slow depolarization of ventricle from left to right. When we performed EPS, we found that the patient had no AV node and His bundle. Bringing together all these findings, we conclude that the patient has a reptilian heart with all anatomical, electrical and physiological features. And the answer to the mystery of inconsistent P recordings was hidden in ECG. The RBBB with very long QRS duration causes a delay between contraction of ventricles resulting in a dynamic P gradient between ventricles. We demonstrated this dinamic bidirectional shunt on CW recording when we obtained a more optimal recording of the shunt flow.This case demonstrates us one more evidence of human evolution; arising from single cell and developing to fish, to reptiles and to mammals. The evolution takes place again and again during neonatal life. If there is an embryological arrest, as occured in our patient, we can easily see the clues of this amazing human evolution. Abstract P1500 Figure

6119Correction of transcatheter aortic valve replacement induced left bundle branch block by His bundle pacing

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J De Pooter ◽  
S Calle ◽  
M Coeman ◽  
T Philipsen ◽  
P Gheeraert ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Left Bundle Branch Block ◽  
Transcatheter Aortic Valve Replacement ◽  
Permanent Pacemaker ◽  
Bundle Branch Block ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Transcatheter Aortic Valve ◽  
Qrs Duration

Abstract Background Left bundle branch block (LBBB) occurs frequently after transcatheter aortic valve replacement (TAVR) and is associated with increased risk of permanent pacemaker implantation, heart failure hospitalization and sudden cardiac death. This pilot study explored the feasibility of TAVR-induced LBBB correction with His bundle pacing (HBP). Methods Patients with TAVR -induced LBBB and postoperative need for permanent pacemaker implant were planned for electrophysiology study and HBP. Patients with persistent high degree AV-block were excluded. HBP was performed using the Select Secure pacing lead, delivered through a fixed curve or a deflectable sheath. Successful HBP was defined as correction of LBBB by selective or non-selective HBP with LBBB correction thresholds less than 3.5V at 1.0ms at implant. Results The study enrolled 6 patients (mean age 85±2.5 years, 50% male). Mean QRS duration was 152±10ms, PR-interval 212±12ms AH-interval 166±16ms and HV-interval 62±12ms. Successful HBP was achieved in 5/6 (83%) patients. Mean QRS duration decreased from 153±11ms to 88±14ms (p=0.002). At implantation, mean threshold for LBBB correction was 1.6±1.0V (unipolar) and 2.2±1.3V (bipolar) at 1.0ms. Periprocedural, two complete AV-blocks occurred, both spontaneously resolved by the end of the procedure. Thresholds remained stable at 1 month follow up: 1.8±1.0V (unipolar) and 2.3±1.5V (bipolar) at 1.0ms. Figure 1 Conclusion Permanent His bundle pacing can safely correct TAVR-induced LBBB in the majority of patients. Further studies are needed to assess potential benefits of His bundle pacing over conventional right ventricular pacing in this population.

Abstract 17180: Longitudinal Dissociation in the His Bundle: Persistent Bundle Branch Block Can be Corrected by Permanent His Bundle Pacing

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Pugazhendhi Vijayaraman ◽  
Kenneth A Ellenbogen ◽  
Gopi Dandamudi
Keyword(s):  
Main Body ◽  
Exclusion Criteria ◽  
Pacing Threshold ◽  
Bundle Branch Block ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Number Of Patients ◽  
Pacing Lead ◽  
Qrs Duration ◽  
Longitudinal Dissociation

Introduction: Focal disease in the main body of the His bundle (HB) is the cause for majority of the bundle branch block (BBB) patterns on EKG. Temporary distal HB pacing (HBP) has previously been shown to correct BBB in high number of patients. Anecdotal reports have confirmed abolition of BBB by permanent HBP. Hypothesis: The aim of our study is to report the incidence of correction of BBB during permanent HBP in patients undergoing pacemaker (PM) implantation. Methods: Permanent HBP was attempted in 185 patients referred for PM implantation. Pts with QRS duration (d) ≥110 ms and BBB were included in the study. Pts with normal QRS or CHB were excluded. HBP was performed using the Medtronic SelectSecure 3830 pacing lead. Baseline QRSd, paced QRSd, correction of BBB and HB pacing threshold were recorded. Results: Fifty patients met the inclusion-exclusion criteria. Mean age 73±12 yrs; men 65%, HTN 81%, DM 30%, CAD 38%, AF 42%, SSS 39%, AV disease 61%, RBBB 31, LBBB 14, IVCD 5). Permanent HBP was successful in correcting BBB in 42 (84%) patients. Underlying BBB was corrected by HBP in 29 of 31 (94%) patients with RBBB; 11 of 14 (79%) patients with LBBB; 1 of 5 (20%) patients with IVCD. Baseline QRSd improved from 141±15 ms to 124±17 ms. HBP threshold at implant was 1.5±1.3 V @ 0.5 ms. Conclusions: Permanent HBP corrected underlying BBB in the vast majority of patients with right or left BBB (40 of 45, 89%) compared to only 1 of 5 (20%) patients with IVCD. This confirms that focal disease in the main HB is the cause for BBB in the patients referred for PM implantation.

scholarly journals Functional mathematical model of dual pathway AV nodal conduction

2011 ◽  
Vol 300 (4) ◽  
pp. H1393-H1401 ◽  
Author(s):  
A. M. Climent ◽  
M. S. Guillem ◽  
Y. Zhang ◽  
J. Millet ◽  
T. N. Mazgalev
Keyword(s):  
Atrial Fibrillation ◽  
Mathematical Model ◽  
Refractory Period ◽  
Effective Refractory Period ◽  
Atrial Pacing ◽  
Wave Fronts ◽  
Av Node ◽  
Inferior Margin ◽  
His Bundle ◽  
Av Conduction

Dual atrioventricular (AV) nodal pathway physiology is described as two different wave fronts that propagate from the atria to the His bundle: one with a longer effective refractory period [fast pathway (FP)] and a second with a shorter effective refractory period [slow pathway (SP)]. By using His electrogram alternance, we have developed a mathematical model of AV conduction that incorporates dual AV nodal pathway physiology. Experiments were performed on five rabbit atrial-AV nodal preparations to develop and test the presented model. His electrogram alternances from the inferior margin of the His bundle were used to identify fast and slow wave front propagations. The ability to predict AV conduction time and the interaction between FP and SP wave fronts have been analyzed during regular and irregular atrial rhythms (e.g., atrial fibrillation). In addition, the role of dual AV nodal pathway wave fronts in the generation of Wenckebach periodicities has been illustrated. Finally, AV node ablative modifications have been evaluated. The model accurately reproduced interactions between FP and SP during regular and irregular atrial pacing protocols. In all experiments, specificity and sensitivity higher than 85% were obtained in the prediction of the pathway responsible for conduction. It has been shown that, during atrial fibrillation, the SP ablation significantly increased the mean HH interval (204 ± 39 vs. 274 ± 50 ms, P < 0.05), whereas FP ablation did not produce significant slowing of ventricular rate. The presented mathematical model can help in understanding some of the intriguing AV node mechanisms and should be considered as a step forward in the studies of AV nodal conduction.

Differential effect of verapamil isomers on sinus node and AV junctional region

1983 ◽  
Vol 244 (1) ◽  
pp. H80-H88
Author(s):  
H. O. Gloor ◽  
F. Urthaler
Keyword(s):  
Sinus Rhythm ◽  
Sinus Node ◽  
Conduction Time ◽  
Av Node ◽  
Junctional Rhythm ◽  
His Bundle ◽  
Sinus Node Artery ◽  
Rate Dependent ◽  
Av Conduction ◽  
Differential Responsiveness

The l- and d-isomers of verapamil were selectively perfused into the sinus node artery and atrioventricular (AV) node artery of 48 dogs. Injection of l-verapamil into the sinus node artery during sinus rhythm and into the AV node artery during AV junctional rhythm depresses both sinus rhythm and AV junctional rhythm significantly more than does the d-isomer. l-Verapamil is three to four times more powerful than d-verapamil. Injection of the isomers into the AV node artery during sinus rhythm rapidly impairs AV conduction. Increments in conduction time are measured exclusively at the level of the A-H interval of the His bundle electrogram, and l-verapamil is six times more powerful than d-verapamil. Neither d- nor l-verapamil in concentrations that exert a profound negative chronotropic effect or cause AV block, has any significant effect on transatrial or His bundle conduction. Thus these concentrations of d-verapamil have little or no significant effect on the fast sodium channel, but both verapamil isomers affect the slow channel. The main difference in action between l- and d-verapamil appears to be only quantitative in nature. The sinus node is significantly more sensitive to the negative chronotropic action of verapamil than is the AV junctional pacemaker, and this differential responsiveness appears to be related to the different intrinsic rates of the two pacemakers. During sinus rhythm (either in the presence or absence of atropine) sinus node automaticity is less affected than AV conduction when verapamil is given parenterally. We propose that this greater negative dromotropic effect of verapamil is also in part due to a rate-dependent process, since during sinus rhythm AV junctional cells have to be depolarized at frequencies significantly higher than their intrinsic rates.

scholarly journals Can atrioventricular node ablation be safely performed in patients with permanent His bundle pacing? Data from a multicentric registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
C Chaumont ◽  
N Auquier ◽  
A Mirolo ◽  
E Popescu ◽  
A Milhem ◽  
...  
Keyword(s):  
Right Ventricular ◽  
Rate Control ◽  
Atrioventricular Node ◽  
Atrial Arrhythmia ◽  
Av Node ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Ventricular Lead ◽  
Qrs Duration

Abstract Introduction Ventricular rate control is essential in the management of atrial fibrillation. Atrioventricular node ablation (AVNA) and ventricular pacing can be an effective option when pharmacological rate control is insufficient. However, right ventricular pacing (RVP) induces ventricular desynchronization in patients with normal QRS and increases the risk of heart failure on long term. His bundle pacing (HBP) is a physiological alternative to RVP. Observational studies have demonstrated the feasibility of HBP but there is still very limited data about the feasibility of AVNA after HBP. Purpose To evaluate feasibility and safety of HBP followed by AVNA in patients with non-controlled atrial arrhythmia. Methods We included in three hospitals between september 2017 and december 2019 all patients who underwent AVNA for non-controlled atrial arrhythmia after permanent His bundle pacing. No back-up right ventricular lead was implanted. AVNA procedures were performed with 8 mm-tip ablation catheter. Acute HBP threshold increase during AVNA was defined as a threshold elevation &gt;1V. His bundle capture (HBC) thresholds were recorded at 3 months follow-up. Results AVNA after HBP lead implantation was performed in 45 patients. HBP and AVNA were performed simultaneously during the same procedure in 10. AVNA was successful in 32 of 45 patients (71%). Modulation of the AV node conduction was obtained in 7 patients (16%). The mean procedure duration was 42±24min, and mean fluoroscopy duration was 6.4±8min. A mean number of 7.7±9.9 RF applications (347±483 sec) were delivered to obtain complete / incomplete AV block. Acute HBC threshold increase occurred in 8 patients (18%) with return to baseline value at day 1 in 5 patients. There was no lead dislodgment during the AVNA procedures. Mean HBC threshold at implant was 1.26±[email protected] and slightly increased at 3 months follow-up (1.34±[email protected]). AV node re-conduction was observed in 5 patients (16% of the successful procedures) with a second successful ablation procedure in 4 patients. No ventricular lead revision was required during the follow-up period. The baseline native QRS duration was 102±21 ms and the paced QRS duration was 107±18 ms. Conclusion AVNA combined with HBP for non-controlled atrial arrhythmia is feasible and does not compromise HBC but seems technically difficult with significant AV nodal re-conduction rate. The presence of a back-up right ventricular lead could have changed our results and therefore would require further evaluation. Unipolar HBP after AV node ablation Funding Acknowledgement Type of funding source: None

scholarly journals A case of infra-nodal Wenckebach conduction block with alternating bundle branch block

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Pichmanil Khmao ◽  
Chun Hwang ◽  
Hui-Nam Pak
Keyword(s):  
Conduction Block ◽  
Conduction Delay ◽  
Av Node ◽  
Bundle Branch Block ◽  
Case Presentation ◽  
Short Cycle ◽  
Purkinje System ◽  
Av Conduction ◽  
Premature Beats ◽  
Decremental Conduction

Abstract Background Atrioventricular (AV) node normally has decremental conduction property and a longer refractory period than His-Purkinje system (HPS). This results in AV conduction delay or block at the level of AV node in response to short-coupled atrial premature beats. Prolonged refractoriness in HPS can produce unusual physiological patterns of AV conduction such as conduction delay or infra-nodal block in the distal elements of HPS. Case presentation We present a case in which atrial premature stimulation produces infra-nodal Wenckebach conduction block which initiates long-short cycle sequence within the bundle branches resulted in alternating bundle branch block and atypical pattern of Ashman phenomenon. Conclusions This case highlights the importance of recognizing the unusual physiological AV conduction patterns of HPS. The long-short cycle sequence in the bundle branches of distal HPS and linking phenomenon can result in alternating bundle branch block without the presence of HPS disease.

P4528Feasibility and safety of left bundle branch area pacing by transvenous approach through the interventricular septum in patients with left bundle branch block

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
W J Huang ◽  
S J Wu ◽  
L Su ◽  
X Y Chen ◽  
B N Cai ◽  
...  
Keyword(s):  
Success Rate ◽  
Left Bundle Branch Block ◽  
Wave Amplitude ◽  
Interventricular Septum ◽  
Bundle Branch Block ◽  
His Bundle ◽  
Qrs Duration ◽  
Transvenous Approach ◽  
R Wave Amplitude

Abstract Background His bundle pacing (HBP) has been shown to correct left bundle branch block (LBBB), however it often requires high pacing output and the success rate is variable. Objective To assess the feasibility and safety of left bundle branch area pacing (LBBAP) in patients with LBBB. Methods From Apr 2014 to Aug 2018, patients with LBBB from multicenters indicated for CRT or pacing therapy were included. LBBAP was performed by advancing the MDT 3830 lead deep into the septum about 1 cm distal to the His bundle region (Figure 1F). Pacing characteristics, success rate, threshold and R-wave amplitude were assessed. Results A total of 94 patients aged 68.3±10.7 y with the native QRS duration of 167.2±17.2 ms were included. In 92 patients, LBBAP was successfully achieved and demonstrated RBBB pattern during unipolar tip pacing (UTP), with the paced QRS duration of 116.4±12.6ms (Figure 1C). Fusion of LBBAP and native conduction via the RBB eliminated RBBB and resulted in an average QRS duration of 103.2±10.1 ms (Figure 1D). LBB potential could be recorded from the LBB lead during correction of LBBB by HBP in 21 patients who used two leads method (His lead and LBB lead, Figure 1B). Output dependent selective and non-selective LBBAP were demonstrated in 48 patients (Figure 1C, D). The LBB capture threshold by UTP was 0.53±0.18V/0.5ms at acute and 0.62±0.17V/0.5ms at 6 months and 0.65±0.2V/0.5ms at 1 year. The R-wave amplitude were 11.4±5.2mV, 12.4±5.8mV and 12.0±5.8mV at acute, 6 month and 1 year. During follow-up, only one patient had an increase in LBB capture threshold to 2.5V/0.5ms at 3 months and there were no other complications such as dislodgment, infections, embolism or stroke associated with the implantation. Conclusion Permanent LBBAP is feasible and safe in patients with LBBB.

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