His Bundle
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Mohan N. Viswanathan ◽  
Beixin Julie He ◽  
Raphael Sung ◽  
Kurt S. Hoffmayer ◽  
Nitish Badhwar ◽  

In this review, we emphasize the unique value of recording the activation sequence of the His bundle or right bundle branch (RB) for diagnoses of various supraventricular and fascicular tachycardias. A close analysis of the His to RB (H-RB) activation sequence can help differentiate various forms of supraventricular tachycardias, namely atrioventricular nodal reentry tachycardia from concealed nodofascicular tachycardia, a common clinical dilemma. Furthermore, bundle branch reentry tachycardia and fascicular tachycardias often are included in the differential diagnosis of supraventricular tachycardia with aberrancy, and the use of this technique can help the operator make the distinction between supraventricular tachycardias and these other forms of ventricular tachycardias using the His-Purkinje system. We show that this technique is enhanced by the use of multipolar catheters placed to span the proximal His to RB position to record the activation sequence between proximal His potential to the distal RB potential. This allows the operator to fully analyze the activation sequence in sinus rhythm as compared to that during tachycardia and may help target ablation of these arrhythmias. We argue that 3 patterns of H-RB activation are commonly identified—the anterograde H-RB pattern, the retrograde H-RB (right bundle to His bundle) pattern, and the chevron H-RB pattern (simultaneous proximal His and proximal RB activation)—and specific arrhythmias tend to be associated with specific H-RB activation sequences. We show that being able to record and categorize this H-RB relationship can be instrumental to the operator, along with standard pacing maneuvers, to make an arrhythmia diagnosis in complex tachycardia circuits. We highlight the importance of H-RB activation patterns in these complex tachycardias by means of case illustrations from our groups as well as from prior reports.

2021 ◽  
Vol 16 (11-12) ◽  
pp. 349-349
Miroslav Geček ◽  
Tomislav Pijetlović ◽  
Gordana Hursa ◽  
Sanja Keleković

Connor Oates ◽  
Iwanari Kawamura ◽  
Mohit turagam ◽  
Marie-Noelle Langan ◽  
Mary McDonaugh ◽  

Background: Increasing interest in physiological pacing has been countered with challenges such as accurate lead deployment and increasing pacing thresholds with His-bundle pacing (HBP). More recently, left bundle branch area pacing (LBBAP) has emerged as an alternative approach to physiologic pacing. Objective: To compare procedural outcomes and pacing parameters at follow-up during initial adoption of HBP and LBBAP at a single center. Methods: Retrospective review, from September 2016 to January 2020, identified the first 50 patients each who underwent successful HBP or LBBAP. Pacing parameters were then assessed at first follow-up after implantation and after approximately one year, evaluating for acceptable pacing parameters defined as sensing R-wave amplitude >5 mV, threshold <2.5 V @ 0.5 ms and impedance between 400 and 1200 Ohms. Results: The HBP group was younger with lower ejection fraction compared to LBBP (73.2±15.3 vs 78.2±9.2 years, p=0.047; 51.0±15.9% vs 57.0±13.1%, p = 0.044). Post-procedural QRS widths were similarly narrow (119.8±21.2 vs. 116.7±15.2ms; p = 0.443) in both groups. Significantly fewer patients with HBP met the outcome for acceptable pacing parameters at initial follow-up (56.0% vs 96.4%, p = 0.001) and most recent follow-up (60.7% vs 94.9%, p = <0.001; at 399±259 vs. 228±124 days, p = <0.001). More HBP patients required lead revision due to early battery depletion (0 vs 13.3%, at an average of 664 days). Conclusion: During initial adoption, as compared with LBBAP, HBP is associated with a significantly higher frequency of unacceptable pacing parameters, energy consumption, and lead revisions.

Kazumasa Suga ◽  
Hiroyuki Kato ◽  
Yasuya Inden ◽  
Satoshi Yanagisawa ◽  
Hisashi Murakami ◽  

Masako Baba ◽  
Kentaro Yoshida ◽  
Osamu Igawa ◽  
Masayoshi Yamamoto ◽  
Akihiko Nogami ◽  

Abstract Background A number of heart failure patients (HF) do not fully benefit from cardiac resynchronization therapy (CRT). Although His bundle pacing (HBP) have been developed as an alternative strategy, its role for treating advanced cardiomyopathy remains unclear. Case summary We previously reported a patient with lamin A/C cardiomyopathy (Eur Heart J Case Rep. 2020; 4:1-9). He had turned non-response to conventional biventricular pacing (BVP), and an upgrade to CRT combining para-His bundle pacing (HBP) and left ventricular (LV) pacing had markedly improved his HF status. In the present report, we assessed the autopsy and histological findings of this patient. A histological examination of both the LV and right ventricular (RV) apex pacing regions exhibited extensive scarring. Although a distinct conduction system was not identified in the alternative para-HBP region, the RV endocardium had more viable myocytes in this region. Discussion In patients with advanced cardiomyopathy accompanied by extensive fibrosis, RV apex pacing, delivered from scar tissue, can render conventional BVP ineffective. Additionally, HBP alone can not provide adequate resynchronization under the presence of diffuse injury of the His-Purkinje system. In these circumstances, combined para-HB and LV pacing may facilitate electrical and mechanical resynchronization of the ventricles and may be attributed to favourable CRT response in advanced HF, even if para-HBP fails to directly capture the conduction system.

2021 ◽  
Vol 8 ◽  
Wei Hua ◽  
Xi Liu ◽  
Min Gu ◽  
Hong-xia Niu ◽  
Xuhua Chen ◽  

Introduction: His bundle pacing (HBP) is the most widely used physiological pacing modality, but difficulties in locating the His bundle lead to high fluoroscopic exposure. An electroanatomical mapping (EAM) system can be an efficient tool to achieve HBP implantation with near-zero fluoroscopic visualization.Methods: In the study, 20 patients who had indications for pacemaker implantation were prospectively enrolled and underwent HBP implantation either with the conventional fluoroscopy approach (the standard group) or guided by a novel KODEX-EPD mapping system (the EAM-guided group). The success rate, procedural details, pacing parameters, and procedure-related complications were compared between the two groups.Results: In the study, 20 consecutive patients were randomized with 10 patients in each group. HBP was successfully achieved in nine patients in the standard group and nine patients in the EAM-guided group. The procedural time was similar between the EAM-guided group vs. the standard group (85.40 ± 22.34 vs. 86.50 ± 15.05 min, p = 0.90). In comparison with the standard group, the EAM-guided group had a significant shorter total fluoroscopic time (FT) (1.45 ± 0.58 vs. 12.36 ± 5.46 min, p &lt; 0.01) and His lead fluoroscopic time (HL-FT) (0.84 ± 0.56 vs. 9.27 ± 5.44 min, p &lt; 0.01), while lower total fluoroscopic dose (3.13 ± 1.24 vs. 25.38 ± 11.15 mGy, p &lt; 0.01) and His lead fluoroscopic dose (1.85 ± 1.17 vs. 19.06 ± 11.03 mGy, p &lt; 0.01). No significant differences were observed in paced QRS duration and pacing parameters between the two groups. During a 3-month follow-up, one patient had a capture threshold increased &gt;1 V/1.0 ms in the standard group, while no other complications were recorded in either group.Conclusion: The KODEX-EPD system could facilitate HBP implantation with significantly reduced FT and dose without compromising the procedural time.

2021 ◽  
Vol 44 (10) ◽  
pp. 1786-1789
Jalaj Garg ◽  
Siddharth Shah ◽  
Kuldeep Shah ◽  
Mohit K. Turagam ◽  
Andrea Natale ◽  

2021 ◽  
Vol 17 ◽  
Callan Gavaghan

: Pacemaker induced cardiomyopathy (PICM) is commonly defined as a reduction in left ventricular (LV) function in the setting of right ventricular (RV) pacing. This condition may be associated with the onset of clinical heart failure in those affected. Recent studies have focused on potential methods of identifying patients at risk of this condition, in addition to hypothesizing the most efficacious ways to manage these patients. Newer pacing options, such as His bundle pacing, may avoid the onset of PICM entirely.

Kohei Ishibashi ◽  
Kenichiro Yamagata ◽  
Keisuke Kiso ◽  
Yoshifumi Nouno ◽  
Nobuhiko Ueda ◽  

Marek Jastrzębski ◽  
Paweł Moskal ◽  
Piotr Kukla ◽  
Agnieszka Bednarek ◽  
Grzegorz Kiełbasa ◽  

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