Feasibility of His‐bundle pacing in patients with conduction disorders following transcatheter aortic valve replacement

Abstract

Background Conduction disorders requiring permanent pacemaker implantation occur frequently after transcatheter aortic valve replacement (TAVR). This multicenter study explored the feasibility and safety of His bundle pacing (HBP) in TAVR patients with a pacemaker indication to correct a TAVR‐induced left bundle branch block (LBBB). Methods Patients qualifying for a permanent pacemaker implant after TAVR were planned for HBP implant. HBP was performed using the Select Secure (3830; Medtronic) pacing lead, delivered through a fixed curve or deflectable sheath (C315HIS or C304; Medtronic). Successful HBP was defined as selective or nonselective HBP, irrespective of LBB recruitment. Successful LBBB correction was defined as selective or nonselective HBP resulting in paced QRS morphology similar to pre‐TAVR QRS and paced QRS duration (QRSd) less than 120 milliseconds with thresholds less than 3.0 V at 1.0‐millisecond pulse width. Results The study enrolled 16 patients requiring a permanent pacemaker after TAVR (age 85 ± 4 years, 31% female, all LBBB; QRSd: 161 ± 14 milliseconds). Capture of the His bundle was achieved in 13 of 16 (81%) patients. HBP with LBBB correction was achieved in 11 of 16 (69%) and QRSd narrowed from 162 ± 14 to 99 ± 13 milliseconds and 134 ± 7 milliseconds during S‐HBP and NS‐HBP, respectively (P = .005). At implantation, mean threshold for LBBB correction was 1.9 ± 1.1 V at 1.0 millisecond. Thresholds remained stable at 11 ± 4 months follow‐up (1.8 ± 0.9 V at 1.0 millisecond, P = .231 for comparison with implant thresholds). During HBP implant, one temporary complete atrioventricular block occurred. Conclusion Permanent HBP is feasible in the majority of patients with TAVR requiring a permanent pacemaker with the potential to correct a TAVR‐induced LBBB with acceptable pacing thresholds.

Feasibility and stability of left bundle branch pacing in patients after prosthetic valve implantation

“…His bundle pacing (HBP) has been a recommended pacing modality for the above‐mentioned patients who have CAs after PVs implantation 19,20 . Given that few nonspecific intraventricular conduction disease or peripheral conduction block may occur in this specific patient population, HBP may have a unique role, as it realizes electrical synchrony via His‐Purkinje system recruitment and QRS correction.…”

“…It has been proved that TAVR valve type and depth of implantation are the most important procedural associations with conduction damage 22 . Pooter et al reported a success rate of 69% in LBBB correction with acceptable pacing thresholds under HBP 20 . Their results suggested that a more significant involvement of CAs at the level of a more distal site in the conduction system may lead to a lower success rate in HBP 18 .…”

Rapid reversal of heart failure by correcting left bundle branch block induced by transcatheter aortic valve replacement

“…Sen et al 8 reported a case of HBP in a patient with TAVR‐induced NO‐LBBB, without correction of LBBB. De Pooter et al 9 reported that HBP with LBBB correction with an acceptable pacing threshold was achieved in 11 of 16 (69%) in patients developing LBBB after TAVR. Chen et al 10 reported the anatomical evaluation of LBBP in an in vivo canine model which said that the HBP lead was located at the right septum on the ventricular aspect of the tricuspid valve, and the LBBP lead was placed deeply with the ring of the lead inside the septum.…”

“…The damage resulting from mechanical displacement during aortic valve deployment might be permanent. Pacing at the His bundle may correct LBBB 8–9 . However, the correction of LBBB by HBP usually requires a higher pacing electrical output, negatively impacting on the therapy effectiveness and device longevity.…”

The search for physiologic pacing post‐TAVR

“…In this issue of the Journal of Cardiovascular Electrophysiology , De Pooter et al 6 report their multicenter experience on His‐bundle pacing (HBP) in 16 patients developing LBBB after TAVR (the Evolut TM R valve; Medtronic, Minneapolis, MN). Successful HBP with LBBB correction with an acceptable pacing threshold was achieved in 11 of 16 (69%).…”