Permanent His-bundle pacing: a systematic literature review and meta-analysis

145

Background His‐bundle pacing (HBP) provides physiological ventricular activation. Observational studies have demonstrated the techniques’ feasibility; however, data have come from a limited number of centers. Objectives We set out to explore the contemporary global practice in HBP focusing on the learning curve, procedural characteristics, and outcomes. Methods This is a retrospective, multicenter observational study of patients undergoing attempted HBP at seven centers. Pacing indication, fluoroscopy time, HBP thresholds, and lead reintervention and deactivation rates were recorded. Where centers had systematically recorded implant success rates from the outset, these were collated. Results A total of 529 patients underwent attempted HBP during the study period (2014‐19) with a mean follow‐up of 217 ± 303 days. Most implants were for bradycardia indications. In the three centers with the systematic collation of all attempts, the overall implant success rate was 81%, which improved to 87% after completion of 40 cases. All seven centers reported data on successful implants. The mean fluoroscopy time was 11.7 ± 12.0 minutes, the His‐bundle capture threshold at implant was 1.4 ± 0.9 V at 0.8 ± 0.3 ms, and it was 1.3 ± 1.2 V at 0.9 ± 0.2 ms at last device check. HBP lead reintervention or deactivation (for lead displacement or rise in threshold) occurred in 7.5% of successful implants. There was evidence of a learning curve: fluoroscopy time and HBP capture threshold reduced with greater experience, plateauing after approximately 30‐50 cases. Conclusion We found that it is feasible to establish a successful HBP program, using the currently available implantation tools. For physicians who are experienced at pacemaker implantation, the steepest part of the learning curve appears to be over the first 30‐50 cases.

Section: Discussionsupporting

confidence: 73%

Section: Introductionmentioning

confidence: 99%

His bundle pacing, learning curve, procedure characteristics, safety, and feasibility: Insights from a large international observational study

Keene

Arnold

Jastrzębski

et al. 2019

145

“…This approach was technically challenging, time and fluoro consuming. The technical issues observed during the early HBP experience has been partially overcome by the dedicated pacing lead (SelectSecure 3830; Medtronic, Minneapolis, Minnesota) and sheaths (C315His; C304 SelectSite; Medtronic) 7,8,13 . As a matter of a fact, over the recent years, a growing body of evidence has stated the clinical benefits of HBP 3,13–15 .…”

Section: Discussionmentioning

confidence: 99%

“…The technical issues observed during the early HBP experience has been partially overcome by the dedicated pacing lead (SelectSecure 3830; Medtronic, Minneapolis, Minnesota) and sheaths (C315His; C304 SelectSite; Medtronic) 7,8,13 . As a matter of a fact, over the recent years, a growing body of evidence has stated the clinical benefits of HBP 3,13–15 . Abdelrahman et al 16 have highlighted the superiority of HBP compared with the traditional RV pacing sites in terms of a combined end point including all‐cause mortality, HF hospitalizations and upgrading to cardiac resynchronization therapy, during a mean follow‐up of 2 years.…”

Section: Discussionmentioning

confidence: 99%

Electrogram‐only guided approach to His bundle pacing with minimal fluoroscopy: A single‐center experience

Zanon

Marcantoni

Zuin

et al. 2020

Self Cite

Introduction His bundle pacing (HBP) is the most physiological pacing. The standard technique based on fluoroscopic approach might be challenging and fluoro consuming. Targeting the His guided exclusively by the electrical signals could enable a precise lead implant, thus reducing fluoroscopy time (FT) and X‐ray dose, desirable both for patients and operators. The aim of the study is to evaluate the feasibility, efficacy, and safety both acutely and at 30 days of the electrogram (EGM)‐guided HBP with minimal or no fluoroscopy. Methods and Results Between October and December 2018, 41 consecutive patients underwent EGM‐guided HBP. Successful HBP was obtained in 39 (95%) patients, (30 males, 78 ± 10 years). Selective HBP (S‐HBP) was achieved in 23 (59%), nonselective HBP (NS‐HBP) in 16 (41%) patients. The final HBP lead position was reached in 31 (79.4%) patients without fluoroscopy, only guided by electrical signals. In eight patients a minimal fluoroscopy (mean, 8 seconds) has been required. The sheath's cutting and the slack of the lead were routinely performed under fluoroscopy. No difference was observed in FT for HBP lead placement in S‐HBP and NS‐HBP (mean, 8.1 ± 25 vs 7.5 ± 20 seconds, P = .8; median value 0 vs 0 seconds). No differences were observed in FT for the entire procedure, total dose area product and total procedural time in S‐HBP and NS‐HBP. Lead dislodgement occurred in one (2.6%) patient 1 day after the procedure. Conclusions HBP could be performed safely and efficiently using the EGMs, with minimal or no fluoroscopy. Fluoroscopy was required during sheath removal and atrial lead placement.

“…Permanent HBP has been performed for two decades in patients undergoing AV‐node ablation, 23–25 in patients with narrow QRS and normal His‐Purkinje conduction, 26,27 and in those with bundle branch block and complete nodal and infranodal block 28–30 . However, its adoption in patients with heart failure who are candidates for CRT has emerged only in recent years.…”

Section: Discussionmentioning

confidence: 99%

Additional benefits of nonconventional modalities of cardiac resynchronization therapy using His bundle pacing

Coluccia¹,

Vitale²,

Corallo³

et al. 2020

Introduction Dyssynchrony persists in many patients despite cardiac resynchronization therapy (CRT). Aim of this proof‐of‐concept study was to achieve better CRT, with a QRS approximating the normal width and axis, by using His bundle pacing (HBP) and nonconventional pacing configurations. Methods and Results In 20 patients with CRT indications, we performed an acute intrapatient comparison between conventional biventricular (CONV) and three nonconventional pacing modalities: HBP alone, His bundle, and coronary sinus pacing (HBP + CS), and HBP + CS plus right ventricular pacing (TRIPLE). Electrical dyssynchrony was assessed by means of QRS width and axis; “quasi‐normal” axis meant an R/S ratio ≥ 1 in leads I and V6 and ≤1 in V1. Mechanical dyssynchrony was assessed by speckle tracking echocardiography. QRS width was 153 ± 18 ms on CONV, shortened to 137 ± 16 ms on HBP + CS (P = .001) and to 130 ± 14 ms on TRIPLE (P = .001), while it remained unchanged on HBP (159 ± 32 ms; P = .17). The rate of patients with “quasi‐normal” axis was 5% on CONV, and increased to 90% on HBP (P = .0001), to 63% on HBP + CS (P = .001), and to 44% on TRIPLE (P = .02). On radial strain analysis, the time‐to‐peak difference between anteroseptal and posterolateral segments was 143 ± 116 ms on CONV, shortened to 121 ± 127 ms on HBP (P = .79), to 67 ± 70 ms on HBP + CS (P = .02), and to 76 ± 55 ms on TRIPLE (P = .05). On discharge, HBP was chosen in 15% of patients, HBP + CS in 55%, and TRIPLE in 30%; CONV was never chosen. Conclusion Nonconventional modalities of CRT provide acute additional electrical and mechanical resynchronization. An interpatient variability exists.