The Atrioventricular Conduction Axis and its Implications for Permanent Pacing

Extensive knowledge of the anatomy of the atrioventricular conduction axis, and its branches, is key to the success of permanent physiological pacing, either by capturing the His bundle, the left bundle branch or the adjacent septal regions. The inter-individual variability of the axis plays an important role in underscoring the technical difficulties known to exist in achieving a stable position of the stimulating leads. In this review, the key anatomical features of the location of the axis relative to the triangle of Koch, the aortic root, the inferior pyramidal space and the inferoseptal recess are summarised. In keeping with the increasing number of implants aimed at targeting the environs of the left bundle branch, an extensive review of the known variability in the pattern of ramification of the left bundle branch from the axis is included. This permits the authors to summarise in a pragmatic fashion the most relevant aspects to be taken into account when seeking to successfully deploy a permanent pacing lead.

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Overcoming left bundle branch block by permanent His bundle pacing: Evidence of longitudinal dissociation in the His via recordings from a permanent pacing lead

HeartRhythm Case Reports ◽

10.1016/j.hrcr.2017.08.002 ◽

2017 ◽

Vol 3 (11) ◽

pp. 499-502 ◽

Cited By ~ 11

Author(s):

Parikshit S. Sharma ◽

Kristin Ellison ◽

Hena N. Patel ◽

Richard G. Trohman

Keyword(s):

Left Bundle Branch Block ◽

Bundle Branch Block ◽

His Bundle ◽

His Bundle Pacing ◽

Permanent Pacing ◽

Pacing Lead ◽

Longitudinal Dissociation

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Physiological Pacing: A New Road to Future

Indian Journal of Clinical Cardiology ◽

10.1177/2632463620978045 ◽

2021 ◽

pp. 263246362097804

Author(s):

Vanita Arora ◽

Pawan Suri

Keyword(s):

Side Effects ◽

Fibrous Tissue ◽

Cardiac Pacing ◽

His Bundle ◽

Anatomy And Physiology ◽

Long Term Follow Up ◽

Pacing Lead ◽

The Right

Anatomy and physiology are the basis of human body functioning and as we have progressed in management of various diseases, we have understood that physiological intervention is always better than an anatomical one. For more than 50 years, a standard approach to permanent cardiac pacing has been an anatomical placement of transvenous pacing lead at the right ventricular apex with a proven benefit of restoring the rhythm. However, the resultant ventricular dyssynchrony on the long-term follow-up in patients requiring more than 40% ventricular pacing led to untoward side effects in the form of heart failure and arrhythmias. To counter such adverse side effects, a need for physiological cardiac pacing wherein the electrical impulse be transmitted directly through the normal conduction system was sought. His bundle pacing (HBP) with an intriguing alternative of left bundle branch pacing (LBBP) is aimed at restoring such physiological activation of ventricles. HBP is safe, efficacious, and feasible; however, localization and placement of a pacing lead at the His bundle is challenging with existing transvenous systems due to its small anatomic size, surrounding fibrous tissue, long-learning curve, and the concern remains about lead dislodgement and progressive electrical block distal to the HBP lead. In this article, we aim to take the reader through the challenging journey of HBP with focus upon the hardware and technique, selective versus nonselective HBP, indications and potential disadvantages, and finally the future prospects.

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Physiological (His-bundle or Left Septal) Pacing – Lead Stability Study

Heart Lung and Circulation ◽

10.1016/j.hlc.2021.06.160 ◽

2021 ◽

Vol 30 ◽

pp. S164

Author(s):

C. Chow ◽

P. Crane ◽

H. Lim ◽

U. Mohamed

Keyword(s):

Stability Study ◽

His Bundle ◽

Septal Pacing ◽

Pacing Lead

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The His Bundle Electrogram in Impaired Atrioventricular Conduction

The Myocardium - Advances in Cardiology ◽

10.1159/000395472 ◽

2015 ◽

pp. 279-289

Author(s):

David Hunt ◽

J. T. Lie ◽

Jitu Vohra ◽

Graeme Sloman

Keyword(s):

Atrioventricular Conduction ◽

His Bundle

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Congenitally corrected transposition with atrioventricular septal defect

Cardiology in the Young ◽

10.1017/s1047951100007137 ◽

1998 ◽

Vol 8 (4) ◽

pp. 472-478 ◽

Cited By ~ 4

Author(s):

Fause Attie ◽

Pedro Iturralde ◽

Carlos Zabal ◽

Maria Rijlaarsdam ◽

Alfonso Buendia ◽

...

Keyword(s):

Septal Defect ◽

Atrioventricular Septal Defect ◽

Atrioventricular Conduction ◽

Atrioventricular Valve ◽

His Bundle ◽

Electrophysiological Studies ◽

Congenitally Corrected Transposition ◽

Atrial Stimulation ◽

Common Atrioventricular Valve ◽

Corrected Transposition

AbstractWe describe 4 cases of congenitally corrected transposition associated with atrioventricular septal defect, diagnosed by echocardiography and angiocardiography. Two had usual atrial arrangement and two had mirror imaged atrial arrangement. All cases were associated with subpulmonary valvar stenosis. All patients presented with cyanosis and were in sinus rhythm. Atrioventricular septal defect with common atrioventricular junction was easily diagnosed on the basis of a common atrioventricular valve permitting interatrial and interventricular communications. All patients had balanced right and left ventricles. The echocardiographic recognition of the ventricles was based on the presence of the moderator band within the morphologically right ventricle, the characteristics of the apical septal trabeculations, and the shape of the ventricles. Angiocardiographic recognition of the ventricles was achieved on the basis of right and left ven-triculography.In one case with usual atrial arrangement, we recorded two His bundle potentials, one anteriorly and another posteriorly. Atrial stimulation revealed blocked atrioventricular conduction at the level of the pos terior bundle, and normal atrioventricular conduction through the anterior bundle. In both cases with atrial mirror-imagery, only a posterior His bundle potential was found, with normal atrioventricular conduction revealed by atrial stimulationThe clinical course with this combination depends on the other lesions present in addition to the common atrioventricular valve. Our electrophysiological studies show that the conduction system in presence of a common atrioventricular valve is as expected for congenitally corrected transposition with two atrioventric ular valves.

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Intrapulmonary artery coiling of a permanent pacing lead

Clinical Cardiology ◽

10.1002/clc.4960170809 ◽

1994 ◽

Vol 17 (8) ◽

pp. 451-452 ◽

Cited By ~ 1

Author(s):

J. A. Trigano ◽

R. Batsou ◽

P. Lauribe ◽

F. Paganelli ◽

R. Gérard ◽

...

Keyword(s):

Permanent Pacing ◽

Pacing Lead

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A Study of Atrioventricular Conduction in Man Using Premature Atrial Stimulation and His Bundle Recordings

Circulation ◽

10.1161/01.cir.40.1.61 ◽

1969 ◽

Vol 40 (1) ◽

pp. 61-69 ◽

Cited By ~ 49

Author(s):

ANTHONY N. DAMATO ◽

SUN H. LAU ◽

ROBERT D. PATTON ◽

CHARLES STEINER ◽

WALTER D. BERKOWITZ

Keyword(s):

Atrioventricular Conduction ◽

His Bundle ◽

Atrial Stimulation

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Catheterization Technique for Laser Photoahlation of Atrioventricular Conduction from the Aortic Root in Dogs

Pacing and Clinical Electrophysiology ◽

10.1111/j.1540-8159.1993.tb01601.x ◽

1993 ◽

Vol 16 (3) ◽

pp. 401-406 ◽

Cited By ~ 7

Author(s):

LASZLO LITTMANN ◽

ROBERT H. SVENSON ◽

CHI HUI CHUANG ◽

PAL KEMPLER ◽

ROBERT SPLINTER ◽

...

Keyword(s):

Aortic Root ◽

Atrioventricular Conduction ◽

Catheterization Technique

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Effect of disopyramide and disobutamide on conduction in perfused rabbit hearts

Canadian Journal of Physiology and Pharmacology ◽

10.1139/y81-185 ◽

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.

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