Direct Visualization of the His Bundle Pacing Lead Placement by 3-Dimensional Electroanatomic Mapping

Abstract

Background: His bundle pacing (HBP) remains technically challenging and is currently guided by electrograms and 2-dimensional fluoroscopy. Our objective was to describe a new technique for HBP directly guided by electroanatomic mapping (EAM). Methods: Twenty-eight patients were included. The atrioventricular septum was mapped via EAM, and His bundle (HB) electrograms, selective, and nonselective HB capture sites were tagged. Pacing leads were connected to EAM, navigated to tagged HB target sites and deployed. Intracardiac electrograms and pacing parameters were recorded. Lead location was tagged on the cloud of HB sites, which was divided into 3 arbitrary segments. In 5 patients, atrioventricular nodal ablation was performed with direct visualization of the HBP lead by EAM. Results: Reproducible navigation of the pacing lead to predetermined HBP locations guided by EAM was achieved in all patients. The lead was successfully deployed in 25 patients. HB cloud area was 360 (212) mm 2 . There was no correlation between HBP threshold and lead location on the His cloud. The intracardiac electrograms atrial/ventricular ratio at the lead deployment site correlated with its EAM position on the His cloud ( P =0.045). Procedure, fluoroscopy, and mapping times were 116.0 (38.8), 8.6 (6.3), and 9.0 (11.4) minutes, respectively. HBP threshold at implant was 1.5 (2.3) V at 1.5 (1.0) ms. Distance between HB lead and ablation sites was 10.0 (1.3) mm in patients undergoing atrioventricular nodal ablation. Conclusions: Direct guidance of HBP by EAM allows for direct visualization of the pacing lead on the HB cloud and reproducible navigation to predetermined HB capture sites. Intracardiac electrograms atrial/ventricular ratio at the lead deployment site correlates with His cloud location. EAM can be applied during standard HBP procedures or combined with atrioventricular nodal ablation.

Permanent His-bundle pacing using stylet-directed, active-fixation leads placed via coronary sinus sheaths compared to conventional lumen-less system

“…In most patients, electroanatomic mapping of the interatrial septum using the EnSite Precision system (Abbott, Des Plaines, IL) was performed in order to characterize the HB region and ultimately to visualize the lead tip during lead placement ( Supplementary Figure 1). 25 Leads evaluated in this series included the 5.8F model 7742 Ingevity (Boston Scientific), which has a 1.8-mm (4.5-mm 2 ) extendable-retractable, electrically active helix; the 5.1F model 4471 FINELINE II (Boston Scientific), which has a 1.6-mm fixed, nonconductive helix extending from a 5-mm 2 cylindrical electrode situated at the end of the lead body; and the SelectSecure 3830 (Medtronic PLC), which has a 1.8-mm electrically active helical electrode (Figure 3). All leads are steroid eluting, although the location of the steroid differs.…”

High efficiency and workflow of His bundle pacing and atrioventricular node ablation guided by three‐dimensional mapping system

“…Recent reports have described using 3‐D mapping to implant HBP leads 13–15 . Orlov et al 16 described a series of 25 patients for whom HBP lead was implanted with fluoroscopy time averaging 8.6 minutes using Ensite system. Similarly, in the present study, the fluoroscopy time was 6.1 ± 3.2 minutes mainly for HBP and RV pacing implantation and AVN ablation with CARTO system.…”

“…The leads may be dislocated after fixation. So we performed HBP and AVN ablation in the same session, 15,16,18 with the RV pacing for standby application, which is relatively safer than only HBP without RV lead. It is of a very low probability to occur that HBP and RV both dislodge.…”

His bundle pacing insights from electroanatomical mapping: Topography and pacing targets

“…2 Since then, HBP has evolved into an effective and widely accepted procedure, 3,4 leading to clinical benefits superior to right ventricular (RV) pacing. [5][6][7][8] While HBP success has been reported as high as 93%-96%, 9 there is an incomplete understanding of the optimal pacing location and related anatomical characteristics. Currently, the target area is identified using either a multipolar electrode catheter or the pacing lead itself to perform point-by-point electrogram mapping.…”

“…Implantation techniques for these leads were recently described. 7 In brief, coronary sinus guiding sheaths (Acuity Pro CS-EH-S-R; Boston Scientific) were used to direct the lead to the HB capture area. Lead placement was assisted by EAM to generate a 3D map of the AV septum and surrounding areas.…”