Assessing Reduction in Left Ventricular Activation Time with His-Bundle Pacing Utilizing a Novel Left Lateral Accessory Pathway Model

2011 ◽  
Vol 02 (02) ◽  
Author(s):  
Tahmeed Contractor ◽  
Gopi Krishna Panicker ◽  
Behzad Pavri ◽  
Yash Lokhandwala
Heart Rhythm ◽  
2021 ◽  
Vol 18 (8) ◽  
pp. S27
Author(s):  
Ahran Arnold ◽  
Matthew J. Shun-Shin ◽  
Daniel Keene ◽  
James P. Howard ◽  
Ji-Jian Chow ◽  
...  

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
A Arnold ◽  
MJ Shun-Shin ◽  
D Keene ◽  
JP Howard ◽  
J Chow ◽  
...  

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 < 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


2021 ◽  
Author(s):  
Ahran D. Arnold ◽  
Matthew J. Shun-Shin ◽  
Nadine Ali ◽  
Daniel Keene ◽  
James P. Howard ◽  
...  

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Shakeel Jamal ◽  
Beth Bailey ◽  
Rehan Mahmud

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.


Author(s):  
Marek Jastrzebski ◽  
Pawel Moskal ◽  
Piotr Kukla ◽  
Agnieszka Bednarek ◽  
Grzegorz Kielbasa ◽  
...  

Background: During non-selective His bundle (HB) pacing, it is clinically important to confirm His bundle capture vs. right ventricular septal (RVS) capture. The present study aimed to validate the hypothesis that during HB capture left ventricular lateral wall activation time, approximated by the V6 R-wave peak time (V6RWPT), will not be longer than the corresponding activation time during native conduction. Methods: Consecutive patients with permanent HB pacing were recruited; cases with abnormal His-ventricle interval or left bundle branch block were excluded. Two corresponding intervals were compared: stimulus-V6RWPT and native HBpotential-V6RWPT. Difference between these two intervals (delta V6RWPT), diagnostic of lack of HB capture, was identified using receiver operating characteristic (ROC) curve analysis. Results: A total of 723 ECGs (219 with native rhythm, 172 with selective HB, 215 with non-selective HB, and 117 with RVS capture) were obtained from 219 patients. The native HB-V6RWPT, non-selective-, and selective-HB paced V6RWPT were nearly equal, while RVS V6RWPT was 32.0 (±9.5) ms longer. The ROC curve analysis indicated delta V6RWPT > 12 ms as diagnostic of lack of HB capture (specificity of 99.1% and sensitivity of 100%). A blinded observer correctly diagnosed 96.7% (321/332) of ECGs using this criterion. Conclusions: We validated a novel criterion for HB capture that is based on the physiological left ventricular activation time as an individualized reference. HB capture can be diagnosed when paced V6RWPT does not exceed the value obtained during native conduction by more than 12 ms, while longer paced V6RWPT indicates RVS capture.


2021 ◽  
Author(s):  
Marek Jastrzebski ◽  
Pawel Moskal ◽  
Piotr Kukla ◽  
Agnieszka Bednarek ◽  
Grzegorz Kielbasa ◽  
...  

Aims: During non-selective His bundle (HB) pacing, it is clinically important to confirm His bundle capture vs. right ventricular septal (RVS) capture. The present study aimed to validate the hypothesis that during HB capture left ventricular lateral wall activation time, approximated by the V6 R-wave peak time (V6RWPT), will not be longer than the corresponding activation time during native conduction. Methods: Consecutive patients with permanent HB pacing were recruited; cases with abnormal His-ventricle interval or left bundle branch block were excluded. Two corresponding intervals were compared: stimulus-V6RWPT and native HBpotential-V6RWPT. Difference between these two intervals (delta V6RWPT), diagnostic of lack of HB capture, was identified using receiver operating characteristic (ROC) curve analysis. Results: A total of 723 ECGs (219 with native rhythm, 172 with selective HB, 215 with non-selective HB, and 117 with RVS capture) were obtained from 219 patients. The native HB-V6RWPT, non-selective-, and selective-HB paced V6RWPT were nearly equal, while RVS V6RWPT was 32.0 (+/-9.5) ms longer. The ROC curve analysis indicated delta V6RWPT > 12 ms as diagnostic of lack of HB capture (specificity of 99.1% and sensitivity of 100%). A blinded observer correctly diagnosed 96.7% (321/332) of ECGs using this criterion. Conclusion: We validated a novel criterion for HB capture that is based on the physiological left ventricular activation time as an individualized reference. HB capture can be diagnosed when paced V6RWPT does not exceed the value obtained during native conduction by more than 12 ms, while longer paced V6RWPT indicates RVS capture.


2018 ◽  
Vol 7 (2) ◽  
pp. 103 ◽  
Author(s):  
Nadine Ali ◽  
Daniel Keene ◽  
Ahran Arnold ◽  
Matthew Shun-Shin ◽  
Zachary I Whinnett ◽  
...  

Biventricular pacing has revolutionised the treatment of heart failure in patients with sinus rhythm and left bundle branch block; however, left ventricular-lead placement is not always technically possible. Furthermore, biventricular pacing does not fully normalise ventricular activation and, therefore, the ventricular resynchronisation is imperfect. Right ventricular pacing for bradycardia may cause or worsen heart failure in some patients by causing dyssynchronous ventricular activation. His bundle pacing activates the ventricles via the native His-Purkinje system, resulting in true physiological pacing, and, therefore, is a promising alternate site for pacing in bradycardia and traditional CRT indications in cases where it can overcome left bundle branch block. Furthermore, it may open up new indications for pacing therapy in heart failure, such as targeting patients with PR prolongation, but a narrow QRS duration. In this article we explore the physiology, technology and potential roles of His bundle pacing in the prevention and treatment of heart failure.


2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
F Zanon ◽  
L Marcantoni ◽  
G Pastore ◽  
E Baracca ◽  
C Picariello ◽  
...  

Abstract Introduction His bundle pacing (HBP) allows physiological ventricular activation and prevents the electrical and mechanical desynchronization generally induced by myocardial stimulation, which can increase the risk of atrial fibrillation and heart failure. On the other hand, reliable HBP capture often requires higher energy than conventional myocardial pacing. This reduces the expected life of the stimulator and might limit the diffusion of HBP in the clinical practice. Purpose Decreasing HBP current drain by careful management of stimulation safety margin and pulse duration. Methods In 28 patients undergoing DDD pacing with HBP, a third lead was implanted in RV apex to provide back-up pacing on demand. HBP and apical leads were connected, respectively, to the V1 and V2 channels of a 3-chamber stimulator. When HBP was effective, apical sensing occurred within the VV delay and prevented V2 stimulation. In contrast, in case of HBP failure, V2 sensing was missing and apical back-up pacing was promptly delivered at the end of the VV delay. The availability of a back-up pulse on demand allowed reducing the HBP safety margin with no risk. Furthermore, the individual HBP strength-duration curve was derived in the aim of optimizing the Hisian pulse parameters, which are the major determinants of the device current drain. Results Correct back-up inhibition by successful HBP and stimulation in the event of capture loss was achieved in all the patients. The latency from Hisian pacing to apical sensing averaged 96±14 ms. According to the pacemaker counters, no back-up pulse was delivered in daily life in 59% of patients. In the remaining, the prevalence of back-up stimulation never exceeded 15% of paced ventricular cycles. The high HBP threshold was essentially due to an increased rheobase (1.2±0.6 V), while the chronaxie ranged from 0.30 to 0.53 ms in 71% of patients (median 0.44 ms), exceeding 0.6 ms only in 29% of the cases. An average current saving of 5.4±3.0 μA was obtained at the expense of a mild reduction in HBP safety margin (from 1.6±0.2 to 1.4±0.1 times). HBP and apical back-up Conclusions Back-up stimulation on demand is a reliable option to decrease HBP current drain and prolong the stimulator service life with full safety. In most of the cases, significant saving can be achieved by pulse shortening, as the chronaxie time is in the same range as with myocardial stimulation and longer pulses are not required. A pulse duration exceeding 0.6 ms is indicated in less than 1/3 of the implants.


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 ◽  
...  

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.


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