scholarly journals 204 Permanent his bundle pacing using stylet-driven lead in patients with right atriomegaly: a single-centre experience

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Leonardo Marinaccio ◽  
Francesco Vetta ◽  
Eros Rocchetto ◽  
Paola Napoli ◽  
Domenico Marchese
Keyword(s):  
The Novel ◽  
Success Rates ◽  
Pacing Threshold ◽  
Lead System ◽  
His Bundle ◽  
His Bundle Pacing ◽  
First Choice ◽  
Single Centre Experience ◽  
Qrs Duration ◽  
Procedural Success

Abstract Aims His bundle pacing (HBP) is becoming an increasing widespread approach for physiological pacing. However, successful HBP procedure could be hampered by limited implantation tools especially in challenging anatomies. We aimed to report our experience with HBP technique using a novel stylet-driven lead system in patients with right atriomegaly. Methods and results Consecutive patients with right atrium (RA) volume >25 ml/m2 in men and >21 ml/m2 in women who underwent permanent HBP for standard indications were enrolled from March 2020 to March 2021. The tool of first choice for HBP attempt was a stylet-driven lead (Solia S 60, Biotronik) delivered via a dedicated introducer sheath (Selectra 3D, Biotronik). The acute, 1-month and 6-month procedural success rates were assessed. We enrolled 24 patients [median age: 75 (70–79) years, 85% men] with an average RA volume of 50.7 ± 7.8 ml/m2. At implant, conduction system pacing using stylet-driven lead was achieved in 21 patients (87%): 12 (50%) selective HBP, 6 (25%) non-selective HBP, and 3 (12.5%) left bundle branch area pacing. In the three failures, HBP was further attempted with a lumen-less lead with fixed helix (SelectSecure 3830, Medtronic) with final procedural success in two cases. In the successful cases, there was a significant reduction of QRS duration between paced and spontaneous beats [152.5 (130–167.5) ms vs. 130 (122.5–137.5) ms, P = 0.003]. No lead dislodgment nor significant pacing threshold increase was observed at 1-month (1.30 ± 0.76 [email protected] vs. 1.32 ± 0.80 [email protected] ms, P > 0.9) and 6-month follow-up (1.30 ± 0.76 [email protected] vs. 1.38 ± 0.97 [email protected] ms, P = 0.66). Conclusions In patients with right atriomegaly, the novel stylet-driven lead system showed high implant success rates with stable pacing thresholds.

P516Permanent his bundle pacing: conclusions from the one-year experience of a romanian center

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
C G Pestrea ◽  
A Gherghina ◽  
F Ortan
Keyword(s):  
Cardiac Pacing ◽  
Ventricular Pacing ◽  
Pacing Threshold ◽  
Bundle Branch Block ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Increased Risk ◽  
Qrs Duration ◽  
Procedural Success ◽  
One Year

Abstract Background Long term right ventricular pacing has been associated with an increased risk of heart failure development due to pacing induced cardiomyopathy. Therefore, alternatives of more physiological pacing have been evaluated. Amongst them, His bundle pacing (HBP) has emerged in the past two decades as the most physiological method of ventricular pacing due to synchronous activation of both ventricles through the intrinsic conduction system. Although there is an already consistent experience in the United States, China and western Europe regarding His bundle pacing, some countries in central and eastern Europe have little or no experience in this matter. We present the results of our one-year experience after implementing His bundle pacing in a tertiary cardiac pacing center in Romania. Material and methods Between July 2018 and October 2019, HBP using the current available dedicated delivery system was attempted in 50 patients with permanent cardiac pacing indications. Patient characteristics and procedural results were analyzed during implant and at 3 months, 6 months and 1 year follow-ups. Results The mean age of the patients was 70,14 ± 10,58 years and 58 % were male. The main indication for cardiac pacing was atrioventricular block (66%) and 96 % received a dual-chamber pacemaker. No ventricular back-up leads were used. The acute procedural success (selective or nonselective His bundle capture) was achieved in 40 patients (80%). The rest of the patients received either right ventricular or left bundle branch pacing. Selective His bundle pacing was seen in 15 out of 40 patients, with nonselective His bundle pacing in the rest. The acute His pacing threshold was 1.77 ± 1.06 V at 1 ms, the sensed R wave amplitude was 4.2 ± 2.27 mV and total fluoroscopy time was 15.95 ± 10.9 min. The paced QRS duration was very similar to the baseline QRS duration in patients without bundle branch block and significantly narrower in patients with bundle branch block morphology (126,6 ± 23 ms vs. 95,5 ± 21,65 ms,  p < 0,001). The presence of a native QRS complex with a bundle branch block morphology was associated with an increased risk of procedural failure, longer fluoroscopy times and higher capture thresholds. Also, pacing threshold (1,91 ± 1,23 vs. 1,62 ± 0,84 V/1ms , p = 0,4) and fluoroscopy times (21,15 ± 10,35 vs. 10,75 ± 8,85 min, p = 0,002) were lower in the second half of the procedures as the learning curve was achieved.  There were no significant changes in pacing and sensing thresholds at 3 months, 6 months and 1 year follow-ups. There was only one case of lead dislodgement a week after the procedure that required reintervention. Conclusion His bundle pacing is feasible and easy to implement in an experienced device implantation center, with a high procedural success rate. Improvement of the procedural parameters is achieved while advancing the learning curve. Proper patient selection could influence the outcomes of the procedure.

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.

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.

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

Circulation ◽  
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.

Pacing parameters and success rates of permanent His-bundle pacing in patients with narrow QRS: a single-centre experience

EP Europace ◽  
2018 ◽  
Vol 21 (5) ◽  
pp. 763-770 ◽  
Author(s):  
Lan Su ◽  
Shengjie Wu ◽  
Songjie Wang ◽  
Zhengxian Wang ◽  
Fangyi Xiao ◽  
...  
Keyword(s):  
Success Rates ◽  
Single Centre ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Narrow Qrs ◽  
Single Centre Experience

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.

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

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
O Yasin ◽  
V Vaidya ◽  
J Tri ◽  
M Van Zyl ◽  
A Ladejobi ◽  
...  
Keyword(s):  
Sinus Rhythm ◽  
Left Ventricular ◽  
Conduction System ◽  
Funding Source ◽  
Activation Pattern ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Surface Ecg ◽  
Qrs Duration ◽  
The Right

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 &lt;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

scholarly journals Learning Curve for Left Bundle Branch Area Pacing – the Experience of a Romanian Academic Center

2021 ◽  
Vol 31 (2) ◽  
pp. 327-334
Author(s):  
Catalin PESTREA ◽  
Alexandra GHERGHINA ◽  
Irina PINTILIE ◽  
Florin ORTAN
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Learning Curve ◽  
Cardiac Pacing ◽  
Cardiac Resynchronization ◽  
Qrs Complex ◽  
Resynchronization Therapy ◽  
Pacing Threshold ◽  
Bundle Branch Block ◽  
His Bundle ◽  
His Bundle Pacing

Introduction: There is an increasing interest in the past decade for more physiological pacing strategies due to detrimental long-term right ventricular pacing. His bundle pacing is the most physiological one, but it has some drawbacks, mainly an increased pacing threshold. Left bundle branch area pacing (LBBAP) emerged in the recent years as the next step in conduction system pacing. We present our initial experience and learning curve with this latter procedure. Material and methods: During January 2019 and February 2021, 20 patients with pacing indications that failed initial permanent His bundle pacing underwent successful LBBAP. Results: The mean age was 65.9 ± 12.7 years. The indications for cardiac pacing were AV block in 14 patients(70%) and cardiac resynchronization therapy in 6 patients (30%). At baseline, normal QRS complex was noted in 9 patients, a left bundle branch block pattern in 10 patients and a right bundle branch block in one patient. A total of 18 dual-chamber and one single chamber pacemakers were implanted and a cardiac resynchronization therapy defibrillator (CRT-D) device. The acute pacing threshold was 0.56±0.2 V at 0.4ms, the sensing threshold was 10.3±3.9 mV and the impedance was 684.9±112.2 Ω. The overall QRS duration decreased after LBBAP from 128.5 ± 27ms to 103.6 ± 17.4ms (p= 0.001). In patients with baseline wide QRS complex there was a highly significant decrease from 148.2 ± 11.6 ms to 104.7 ± 19.4 ms (p<0.001). The fl uoroscopy time, including the time spent for His bundle location, was 13.8 ± 8.5 minutes. The pacing thresholds remained constant after three-months (0.6 ± 0.2 V vs. 0.56 ± 0.2 V at 0.4 ms). We had two intraprocedural septal perforations without any consequences and three micro dislodgements at follow-up with pure left septal capture. Conclusion: Left bundle branch area pacing is a feasible physiological pacing technique with a high success rate and the potential to overcome the limits of permanent His bundle pacing. It can be successfully performed virtually in all types of pacing indications, including cardiac resynchronization therapy as provides a rapid and synchronous activation of the left ventricle.

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