Anatomic, Radiologic and Electrocardiographic Considerations for Conduction System Pacing

His bundle pacing and left bundle branch pacing are complementary implantation techniques that combine into conduction system pacing, which allows maintaining or recovering physiological activation of the heart. We selected cases from the electrophysiological laboratory of the University Hospital in Krakow to present theoretical and practical aspects of conduction system pacing using fluoroscopy images, ECG and EGM recordings.

Lead and delivery system for His Bundle Pacing (HBP)

Lead and delivery system for His Bundle Pacing (HBP)

Novelties in cardiac pacing. Left bundle branch pacing, a step-by-step guide

Left bundle branch pacing (LBBP) technique is a new method for conduction system pacing that is useful for both bradyarrhythmia and heart failure indications. LBBP, while less physiological than His bundle pacing, offers several practical advantages. Namely, lower and stable pacing thresholds, good sensing of the intrinsic ventricular activity and easiness in localizing the pacing target. The LBBP method more often than His bundle pacing results in engagement of the conduction system distal to the area of the block. A step-by-step approach to LBBP was described. Attention was given to the following phases of the procedure: 1) localization of the target area on the septum, 2) the lead rotation technique with an interpretation of the lead responses (drill effect, screwdriver effect, entanglement effect), 3) methods for monitoring the lead depth in the septum to avoid perforation (fixation beats, continuous pace mapping, impedance), and 4) methods to differentiate between LBBP and left ventricular septal pacing.

Causes of Failures and Complications in Stimulation of the Conduction System Pacing

Conductive system stimulation relies on the direct stimulation of His-Purkinje’s specialized cardiac conduction system for physiological activation of the ventricles, as opposed to asynchronous activation induced by conventional myocardial stimulation. Since the first report of permanent His bundle stimulation in 2000, the stylet-based technique has undergone significant advances in technology. Single-center observational studies have now been supported by large multicenter, international registries, meta-analysis and the first randomised controlled trials. New evidence has elucidated mechanisms of HBP and illustrated the nature and magnitude of its potential benefits for preventing pacing-induced cardiomyopathy and correcting bundle branch block. Left bundle branch pacing (LBBP) is a newer technique in which the lead is fixed deep into the left side of the intraventricular septum to allow capture of the left bundle, distal to the His bundle. LBBP holds promise as a method for physiological pacing that overcomes some of the fixation, threshold and sensing challenges of HBP.

Conduction system pacing in heart failure patients

Direct conduction system pacing delivers more physiological cardiac activation and can potentially correct intraventricular conduction disturbances and restore normal activation pathways. Permanent pacing that maintains cardiac electromechanical synchrony is essential in heart failure and reduced left ventricular ejection fraction. Conduction system pacing has recently emerged as an alternative to right ventricular pacing and biventricular resynchronization therapy. In this article, we review conduction system pacing in heart failure patients.

Why pacing of conduction system?

Cardiac pacing since the 50th of the last century is the standard of care for patients with bradycardia. The aims of this therapy have changed over the decades from a life-saving option to achieve the most physiologic “prosthesis” of the conduction system in patients with atrioventricular blocks and improve depolarization sequence in those with heart failure and intraventricular conduction abnormalities. In the last years, direct conduction system pacing methods are developing very quickly. His bundle pacing, direct left bundle branch pacing with its modifications were introduced into clinical practice. Lack of big, randomized trials and technical aspects of these new modes of pacing caused that these methods haven’t achieved a high class of recommendation in recently published guidelines of the European Society of Cardiology.

CRT operator challenges during procedure… tips and tricks

In addition to pharmacological treatment, cardiac resynchronization therapy is an important method of heart failure treating. It’s indicated for patients with advanced heart failure, decreased left ventricular ejection fraction, a wide QRS syndrome, and the presence of left ventricular dyssynchrony despite optimal pharmacotherapy. The procedure is technically difficult and laden with many possible complications. Based on our own experience, this paper presents management with one of the periprocedural complications – dissection of the coronary sinus.

Pulsed field ablation – new perspective in atrial fibrillation therapy

Atrial fibrillation (AF) is one of the most important problems in cardiology. Thermal ablation therapies are “gold standard” to treat symptomatic patients. Despite the improvements, both success rate and safety are limited by their thermal nature. Pulsed filed ablation is a new non-thermal ablation method. It is based on the phenomenon of unrecoverable permeabilization of cell membranes caused by pulses of high voltage (irreversible electroporation). Several preclinical studies suggest its safety. Clinical trials published so far have showed high efficacy. Further studies especially with longer follow-up period are needed.

Analgosedation approaches in the Electrophysiology Laboratory – a review of currently used techniques – part 1

Clinical electrophysiology (EP) had undergone tremendous technological development in the last years. Along with more and more complex EP procedures, including advanced radiofrequency catheter ablations, the need for a safe and effective analgetic and sedation approach become imperative. Sedation in the EP laboratory range from intravenous sedation techniques to general anesthesia. In our review, we discuss current analgosedation approaches in the EP lab, with particular emphasis on the type of procedure performed.

European Society of Cardiology guidelines for ablation of atrial fibrillation – a subjective opinion

European Society of Cardiology guidelines for ablation of atrial fibrillation – a subjective opinion