Massive His bundle injury current corresponds with acute trauma and slowing of conduction that has to subside before pacing threshold assessment

2018 ◽  
Vol 30 (3) ◽  
pp. 440-441 ◽  
Author(s):  
Marek Jastrzębski ◽  
Paweł Moskal ◽  
Danuta Czarnecka
Keyword(s):  
Pacing Threshold ◽  
Acute Trauma ◽  
His Bundle ◽  
Threshold Assessment

Abstract 17180: Longitudinal Dissociation in the His Bundle: Persistent Bundle Branch Block Can be Corrected by Permanent His Bundle Pacing

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Pugazhendhi Vijayaraman ◽  
Kenneth A Ellenbogen ◽  
Gopi Dandamudi
Keyword(s):  
Main Body ◽  
Exclusion Criteria ◽  
Pacing Threshold ◽  
Bundle Branch Block ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Number Of Patients ◽  
Pacing Lead ◽  
Qrs Duration ◽  
Longitudinal Dissociation

Introduction: Focal disease in the main body of the His bundle (HB) is the cause for majority of the bundle branch block (BBB) patterns on EKG. Temporary distal HB pacing (HBP) has previously been shown to correct BBB in high number of patients. Anecdotal reports have confirmed abolition of BBB by permanent HBP. Hypothesis: The aim of our study is to report the incidence of correction of BBB during permanent HBP in patients undergoing pacemaker (PM) implantation. Methods: Permanent HBP was attempted in 185 patients referred for PM implantation. Pts with QRS duration (d) ≥110 ms and BBB were included in the study. Pts with normal QRS or CHB were excluded. HBP was performed using the Medtronic SelectSecure 3830 pacing lead. Baseline QRSd, paced QRSd, correction of BBB and HB pacing threshold were recorded. Results: Fifty patients met the inclusion-exclusion criteria. Mean age 73±12 yrs; men 65%, HTN 81%, DM 30%, CAD 38%, AF 42%, SSS 39%, AV disease 61%, RBBB 31, LBBB 14, IVCD 5). Permanent HBP was successful in correcting BBB in 42 (84%) patients. Underlying BBB was corrected by HBP in 29 of 31 (94%) patients with RBBB; 11 of 14 (79%) patients with LBBB; 1 of 5 (20%) patients with IVCD. Baseline QRSd improved from 141±15 ms to 124±17 ms. HBP threshold at implant was 1.5±1.3 V @ 0.5 ms. Conclusions: Permanent HBP corrected underlying BBB in the vast majority of patients with right or left BBB (40 of 45, 89%) compared to only 1 of 5 (20%) patients with IVCD. This confirms that focal disease in the main HB is the cause for BBB in the patients referred for PM implantation.

scholarly journals Learning Curve for Left Bundle Branch Area Pacing – the Experience of a Romanian Academic Center

2021 ◽  
Vol 31 (2) ◽  
pp. 327-334
Author(s):  
Catalin PESTREA ◽  
Alexandra GHERGHINA ◽  
Irina PINTILIE ◽  
Florin ORTAN
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Learning Curve ◽  
Cardiac Pacing ◽  
Cardiac Resynchronization ◽  
Qrs Complex ◽  
Resynchronization Therapy ◽  
Pacing Threshold ◽  
Bundle Branch Block ◽  
His Bundle ◽  
His Bundle Pacing

Introduction: There is an increasing interest in the past decade for more physiological pacing strategies due to detrimental long-term right ventricular pacing. His bundle pacing is the most physiological one, but it has some drawbacks, mainly an increased pacing threshold. Left bundle branch area pacing (LBBAP) emerged in the recent years as the next step in conduction system pacing. We present our initial experience and learning curve with this latter procedure. Material and methods: During January 2019 and February 2021, 20 patients with pacing indications that failed initial permanent His bundle pacing underwent successful LBBAP. Results: The mean age was 65.9 ± 12.7 years. The indications for cardiac pacing were AV block in 14 patients(70%) and cardiac resynchronization therapy in 6 patients (30%). At baseline, normal QRS complex was noted in 9 patients, a left bundle branch block pattern in 10 patients and a right bundle branch block in one patient. A total of 18 dual-chamber and one single chamber pacemakers were implanted and a cardiac resynchronization therapy defibrillator (CRT-D) device. The acute pacing threshold was 0.56±0.2 V at 0.4ms, the sensing threshold was 10.3±3.9 mV and the impedance was 684.9±112.2 Ω. The overall QRS duration decreased after LBBAP from 128.5 ± 27ms to 103.6 ± 17.4ms (p= 0.001). In patients with baseline wide QRS complex there was a highly significant decrease from 148.2 ± 11.6 ms to 104.7 ± 19.4 ms (p<0.001). The fl uoroscopy time, including the time spent for His bundle location, was 13.8 ± 8.5 minutes. The pacing thresholds remained constant after three-months (0.6 ± 0.2 V vs. 0.56 ± 0.2 V at 0.4 ms). We had two intraprocedural septal perforations without any consequences and three micro dislodgements at follow-up with pure left septal capture. Conclusion: Left bundle branch area pacing is a feasible physiological pacing technique with a high success rate and the potential to overcome the limits of permanent His bundle pacing. It can be successfully performed virtually in all types of pacing indications, including cardiac resynchronization therapy as provides a rapid and synchronous activation of the left ventricle.

scholarly journals 283 His bundle pacing: safety, performance, and clinical outcomes in a single-centre experience

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Lorenzo Bartoli ◽  
Giuseppe Pio Piemontese ◽  
Giulia Massaro ◽  
Andrea Angeletti ◽  
Giovanni Statuto ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Significant Rise ◽  
Safety Performance ◽  
Lead Extraction ◽  
Complication Rates ◽  
Pacing Threshold ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Lead Dislodgement

Abstract Aims Permanent His bundle pacing (HBP) is a more physiological technique for cardiac stimulation and has recently emerged as an alternative for anti-bradycardia pacing and cardiac resynchronization therapy (CRT). Its main advantages over ‘classical’ pacing are both its protective role over pacing-induced cardiomyopathy and the possibility of resynchronization by normalization of His-Purkinje activation. To evaluate the intermediate-term outcomes of HBP in terms of safety, performance, and clinical outcomes. Methods and results Between December 2018 and July 2020, we enrolled a series of consecutive patients with indication for pacing in whom HBP was attempted. A specific lead (3830 Select Secure MRI SureScan) and sheath (C315His) was used. At follow-up clinical, safety and performance outcomes were evaluated. A significant rise in HBP pacing threshold was defined as an increase of at least 1 V@1ms in the minimum voltage that could produce an effective myocardial depolarization. Remote or in-hospital device interrogation was performed by an experienced electrophysiologist. HBP was attempted in 99 patients and all implantations were performed by the same two operators. Eighty-two procedures were successful (83%). The main reasons for HBP failure were high pacing-thresholds (n = 8, 47%), infra-Hisian block (n = 5, 29,4%), difficult HB location (n = 3, 17,6%), unsatisfactory sensing (n = 1, 5,9%), or lead instability (n = 1, 5,9%). During a mean follow-up of 9.5 ± 5.9 months, the overall technical and clinical complication rates were 39% and 13.3%, respectively. Three (3.6%) patients underwent His lead extraction and subsequent conventional right ventricular septum (RV) lead implantation because of lead dislodgement (n = 2) or rise in pacing threshold (n = 1), while two (2.4%) patients required His lead repositioning because of lead dislodgement (n = 1) and phrenic nerve stimulation (n = 1). Nineteen patients (23.2%) experienced a significant rise in Hisian pacing threshold and 1 of these patients also had poor sensing parameters. Oversensing was noted in 8 (9.7%) patients and in 7 of them (87.5%) it was due to both atrioventricular and ventriculoatrial crosstalk events. As regards clinical outcomes, seven patients (8.5%) were diagnosed with new onset atrial fibrillation (AF), one of them complicated by stroke. Three patients (3.6%) were hospitalized for acute heart failure, one of them after His lead dislodgement. Finally, five patients (6.1%) died during follow-up, but no death was related to cardiovascular events. Conclusions HBP is an effective technique to obtain a more physiological cardiac pacing, but it is limited by a moderate rate of procedural failure and follow-up complications, mainly rising in pacing threshold and oversensing events. This is probably due to suboptimal implantation tools and lack of specific programming algorithms. New dedicated tools, increased experience, knowledge of device limitations, and optimal programming are needed to improve future outcomes.

Comparison of electrical characteristics between atrial and ventricular side His-bundle pacing in bradycardia patients

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
X Liu ◽  
M Gu ◽  
Y.R Hu ◽  
W Hua ◽  
S Zhang
Keyword(s):  
Wave Amplitude ◽  
Electrical Characteristics ◽  
Pacing Threshold ◽  
His Bundle ◽  
His Bundle Pacing ◽  
Tricuspid Valve Annulus ◽  
Echocardiographic Parameters ◽  
Pacing Lead ◽  
R Wave Amplitude

Abstract Background His-bundle pacing (HBP) is recognized as the most physiological way of pacing but with less study focused on electrical characteristics in different site. Purpose We aimed to evaluate the differences of pacing and echocardiographic parameters between atrial and ventricular side His-bundle pacing. Methods Patients who successfully underwent HBP implantation from September 2018 to August 2019 were retrospectively analyzed. All patients were assigned to atrial-side HBP (aHBP) group or ventricular-side HBP (vHBP) group according to the location of the His-bundle pacing lead, which was confirmed by two methods including postoperative echocardiography and visualization of tricuspid valve annulus (TVA). The pacing and echocardiographic parameters were compared between two groups during the procedure and at 3-month follow-up. Results A total of 71 bradycardia patients who successfully underwent HBP implantation and confirmed lead position were included. Among them, twenty-seven were assigned to aHBP group and the other 44 were assigned to vHBP group with no significant differences in baseline clinical characteristics between two groups. During the procedure, the proportion of selective HBP was significantly higher (77.8% vs. 11.4%; P&lt;0.01) and the intra-procedural HV intervals was significantly longer (50.85±6.53 ms vs. 42.95±6.02 ms, P&lt;0.01) in aHBP group than in vHBP group. The capture threshold in vHBP group was significantly lower than in aHBP group at implantation (0.92±0.22 V/1.0ms vs. 1.05±0.26 V/1.0ms, P=0.03) and remain significantly difference after 3-month follow-up (0.98±0.23 V/1.0ms vs. 1.15±0.44 V/1.0ms, P=0.03). The R-wave amplitude was significantly higher in vHBP group than in aHBP group at implantation (5.82±2.52 mV vs. 3.74±1.81 mV, P&lt;0.01), and these differences still persisted during follow-up (5.88±2.51 mV vs. 3.67±1.61 mV, P&lt;0.01). During 3-month follow-up, an increase in the capture threshold &gt;1 V/1.0ms was seen in 2 cases in aHBP group while all patients remained stable in vHBP group. One patient developed a pocket hematoma in aHBP group compared to none in vHBP group. None of deterioration of tricuspid regurgitation and other procedure-related complications were observed during 3-month follow-up. Conclusions Ventricular side His-bundle pacing can achieve favourable pacing parameters including a lower pacing threshold and a higher R-wave amplitude than atrial side His-bundle pacing, which may be an ideal pacing strategy for patients in need of ventricular pacing. Funding Acknowledgement Type of funding source: None

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.

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