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.

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 A network meta-analysis and systematic review of change in QRS duration after left bundle branch pacing, His bundle pacing, biventricular pacing, or right ventricular pacing in patients requiring permanent pacemaker

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Nithi Tokavanich ◽  
Narut Prasitlumkum ◽  
Wimwipa Mongkonsritragoon ◽  
Wisit Cheungpasitporn ◽  
Charat Thongprayoon ◽  
...  
Keyword(s):  
Right Ventricular ◽  
Biventricular Pacing ◽  
Meta Analysis ◽  
Mean Difference ◽  
Ventricular Pacing ◽  
Right Ventricular Pacing ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Significant Difference ◽  
Qrs Duration

AbstractCardiac dyssynchrony is the proposed mechanism for pacemaker-induced cardiomyopathy, which can be prevented by biventricular pacing. Left bundle branch pacing and His bundle pacing are novel interventions that imitate the natural conduction of the heart with, theoretically, less interventricular dyssynchrony. One of the surrogate markers of interventricular synchrony is QRS duration. Our study aimed to compare the change of QRS duration before and after implantation between types of cardiac implantable electronic devices (CIEDs): left bundle branch pacing versus His bundle pacing versus biventricular pacing and conventional right ventricular pacing. A literature search for studies that reported an interval change of QRS duration after CIED implantation was conducted utilizing the MEDLINE, EMBASE, and Cochrane databases. All relevant works from database inception through November 2020 were included in this analysis. A random-effects model, Bayesian network meta-analysis was used to analyze QRS duration changes (eg, electrical cardiac synchronization) across different CIED implantations. The mean study sample size, from 14 included studies, was 185 subjects. The search found 707 articles. After exclusions, 14 articles remained with 2,054 patients. The His bundle pacing intervention resulted in the most dramatic decline in QRS duration (mean difference, − 53 ms; 95% CI − 67, − 39), followed by left bundle branch pacing (mean difference, − 46 ms; 95% CI − 60, − 33), and biventricular pacing (mean difference, − 19 ms; 95% CI − 37, − 1.8), when compared to conventional right ventricle apical pacing. When compared between LBBP and HBP, showed no statistically significant wider QRS duration in LBBP with mean different 6.5 ms. (95% CI − 6.7, 21). Our network meta-analysis found that physiologic pacing has the greatest effect on QRS duration after implantation. Thus, HBP and LBBP showed no significant difference between QRS duration after implantation. Physiologic pacing interventions result in improved electrocardiography markers of cardiac synchrony, narrower QRS duration, and might lower electromechanical dyssynchrony.

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

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

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 &gt;25 ml/m2 in men and &gt;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 &gt; 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 &lt; 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.

Permanent His bundle pacing: shaping the future of physiological ventricular pacing

2019 ◽  
Vol 17 (1) ◽  
pp. 22-36 ◽  
Author(s):  
Parikshit S. Sharma ◽  
Pugazhendhi Vijayaraman ◽  
Kenneth A. Ellenbogen
Keyword(s):  
Ventricular Pacing ◽  
His Bundle ◽  
His Bundle Pacing ◽  
The Future

scholarly journals Author Correction: Permanent His bundle pacing: shaping the future of physiological ventricular pacing

2019 ◽  
Vol 16 (12) ◽  
pp. 760-760 ◽  
Author(s):  
Parikshit S. Sharma ◽  
Pugazhendhi Vijayaraman ◽  
Kenneth A. Ellenbogen
Keyword(s):  
Ventricular Pacing ◽  
His Bundle ◽  
His Bundle Pacing ◽  
The Future

scholarly journals P410Pacing from his bundle area in patients with severe conduction disease and high burden of the right ventricular pacing

EP Europace ◽  
2018 ◽  
Vol 20 (suppl_1) ◽  
pp. i76-i76
Author(s):  
K Curila ◽  
D Herman ◽  
P Stros ◽  
J Zdarska ◽  
R Prochazkova ◽  
...  
Keyword(s):  
Right Ventricular ◽  
Ventricular Pacing ◽  
Right Ventricular Pacing ◽  
High Burden ◽  
His Bundle ◽  
The Right

scholarly journals Alternative sites of ventricular pacing: His bundle pacing

2020 ◽  
Vol 90 (2) ◽  
Author(s):  
Francesco Vetta ◽  
Leonardo Marinaccio ◽  
Giampaolo Vetta
Keyword(s):  
Heart Failure ◽  
Biventricular Pacing ◽  
Scientific Evidence ◽  
Cardiac Pacing ◽  
Cardiac Conduction ◽  
Cardiac Resynchronization ◽  
Conduction Delay ◽  
Ventricular Pacing ◽  
His Bundle ◽  
His Bundle Pacing

Since its introduction right ventricular apical (RVA) pacing has been the mainstay in cardiac pacing. However, in recent years there has been an upsurge of interest in permanent His bundle pacing (HBP), given the scientific evidence of the harmful role of dyssynchronous ventricular activation, induced by RVA pacing, in promoting the onset of heart failure and atrial fibrillation. After an intermediate period in which attention was focused on algorithms aimed at minimizing ventricular pacing, with partially inadequate and harmful results, scientific attention shifted to HBP, which proved to ensure a physiological electro-mechanical activation of the ventricles. The encouraging results obtained have allowed the introduction of HBP in recent guidelines for cardiac pacing in patients with bradicardia and cardiac conduction delay. Recent studies have also demonstrated the potential of HBP in patients with left bundle branch block and heart failure. HBP is promising as an attractive way to achieve physiological stimulation in patients with an indication for cardiac resynchronization therapy (CRT). Comparative studies of HB-CRT and biventricular pacing have shown similar results in numerically modest cohorts, although HB-CRT has been shown to promote better ventricular electrical resynchronization as demonstrated by a greater QRS narrowing. A widespread use of this pacing tecnique also depends on improvements in technology, as well as further validation of effectiveness in large randomised clinical trials

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