His‐bundle pacing: A novel treatment for left bundle branch block‐mediated cardiomyopathy

Abstract

Background: Chronic left bundle branch block (LBBB) can lead to LBBB-mediated cardiomyopathy from left ventricular dysynchrony. His-bundle pacing (HBP) results in direct electrical synchrony using the native His-Purkinje system, providing a novel treatment for this cardiomyopathy. Objective: To assess the feasibility of HBP for cardiac resynchronization therapy (CRT) in LBBB-mediated cardiomyopathy patients. Methods: Retrospective database review was conducted on patients who underwent CRT by the HBP capable provider at Indiana University Health and Eskenazi Hospital from August 2015 to August 2017. A subset of patients who met the predefined syndrome criteria of LBBB-mediated cardiomyopathy who underwent HBP were identified. Clinical, echocardiographic, and electrocardiographic variables were extracted at baseline and follow-up. Results: Nine patients had cardiomyopathy and LBBB. Among those two were lost to follow-up. Seven patients were included in the analysis. The average time from device implantation to the last follow-up was 14.5 months. Left ventricular ejection fraction improved on average from 25% to 50% (p = .0001). The left ventricular endsystolic dimension decreased from 47 to 37 mm (p = .003) and the left ventricular end-diastolic dimension decreased from 55 to 48 mm (p = .03). QRS duration with HBP-CRT decreased from 152 to 115 ms. New York Heart Association classification improved from an average of 2.7-2. Conclusion: HBP is a viable technique for pursuing CRT in patients with LBBBmediated cardiomyopathy.

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

“…Patients with impaired LV function, evidenced by LVEF between 36% and 50%, and electrical dyssynchrony, evidenced by LBBB, may benefit from CPP. Three relatively large observational studies 52,58,66 and several smaller cohort studies 25,45,63–65 have shown that CPP can significantly improve symptoms and LVEF in this population. A prospective observational study 46 of 632 consecutive patients showed that LBBAP was successful in 98%, had stable pacing parameters over 2 years of follow‐up, and improved the LVEF in patients who had a QRS duration >120 ms at baseline (48% to 58%; p < .001). Rising thresholds occurred in only 1% of patients, and only 2 patients required lead revision.…”

“…Patients with impaired LV function, evidenced by LVEF between 36% and 50%, and electrical dyssynchrony, evidenced by LBBB, may benefit from CPP. Three relatively large observational studies 52,58,66 and several smaller cohort studies 25,45,[63][64][65] The randomized PREVENT-HF trial 38 of 108 patients with mean baseline normal LVEF did not show benefit of BiV pacing over RVP but did not show harm. Additional LV lead placement is associated with longer procedure time, higher procedure-related complications (eg, venous occlusion and infection), and an increased risk of an additional lead to extract should that be required.…”

“…In patients with an indication for permanent pacing with LVEF 36%–50% who are anticipated to require less than substantial ventricular pacing, a CSP lead with HBP or LBBAP may be considered as an alternative to an RVP lead. 40,52 2bC‐LD3. In patients with an indication for permanent pacing, LVEF 36%–50% and LBBB, and who are anticipated to require less than substantial ventricular pacing, CPP may be considered to potentially improve symptoms and LVEF. 25,45,52,58,63–66 2bC‐LD4. In patients who are undergoing permanent pacing with normal LVEF and are anticipated to require less than substantial ventricular pacing, an LBBAP lead may be considered as an alternative to an RVP lead. 46,52 3: No BenefitB‐R5.…”

His Bundle Pacing – Stand-alone or adjunctive physiological pacing: a systematic review

“…Records identified through PubMed (Including Medline) online database. We reviewed 13 studies (1,11,(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28) (651 patients) (Table 2) which explored the effect of HBP as an alternative to CRT in patients with CRT indications.…”

Short QRS Duration After His-Purkinje Conduction System Pacing Predicts Left Ventricular Complete Reverse Remodeling in Patients With True Left Bundle Branch Block and Heart Failure

“…Several studies have illustrated that His-Purkinje conduction system pacing (HPCSP), including His bundle pacing (HBP) and left bundle branch pacing (LBBP), could be a better option for CRT (4)(5)(6)(7)(8). Singh et al demonstrated that normalized LVEF was found in 71.43% of patients with LBBB-induced cardiomyopathy after HPCSP (9). How can the proportion of LV complete reverse remodeling with normalized LVEF and LV end-diastolic diameter (LVEDD) be maximized?…”