Permanent His-bundle pacing: Long-term lead performance and clinical outcomes

139

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: Discussionmentioning

confidence: 99%

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

139

“…Recently, HBP has been noted and its usefulness has been reported. Vijayaraman et al reported that pQRSd form HBP was significantly narrower than that from traditional RVP pacing (124 ± 22 ms and 168 ± 21 ms; P < 0.05) and that HBP was associated with a reduction in death or hospitalization for heart failure as compared to traditional RVP. Permanent HBP is a physiological alternative to RV apical pacing; however, it involves more challenges.…”

Section: Discussionmentioning

confidence: 99%

“…A previous study reported a lead failure rate of 5% for leads that required revisions in the HBP group . Moreover, the His‐bundle capture threshold in the HBP group was significantly higher than the RVP threshold in the RVP group and more patients (9%) underwent pacemaker generator change due to early battery depletion in the HBP group . RV septal pacing is also expected to prevent hemodynamic deterioration associated with RV apical pacing; however, the advantages of the method remain unclear .…”

Section: Discussionmentioning

confidence: 99%

Utility of the combination of simple electrocardiographic parameters for identifying mid‐septal pacing

Matsuo

Shimeno

Yoshiyama

et al. 2019

Introduction The electrocardiograms (ECG) criteria to anchor the lead to the right ventricular septum have not been established. This study aimed to identify ECG criteria of pacing at the right ventricular mid septum (RVMS) and investigate whether the paced QRS duration (pQRSd) from the RVMS was narrow. Methods and results In 42 patients, ECG pacing at the basal anterior wall (BA), mid‐anterior wall (MA), apex (AP), and mid septum (MS) was recorded. The pacing sites were validated by using right ventriculography and computed tomography. We estimated the ECG parameters and compared them among the four pacing sites. The combination of simple four paced‐ECG parameters could reliably confirm the pacing at the RVMS. The area under the receiver‐operating characteristics curve for the number of positive findings among the following: (a) positive QRS in lead aVL, (b) QRS notching in lead I, (c) precordial leads transition at less than V5, and (d) presence of isoelectric QRS in the inferior leads was 0.95 (95% confidence interval, 0.91‐0.98) and the number of positive findings (≥3) had a sensitivity of 83.3% and a specificity of 93.7% for discriminating MS from the other sites. The pQRSd with three or more positive findings was significantly narrower than that with less than three positive findings (≥3: 137.4 ± 9.2 ms, <3: 151.8 ± 13.1 ms, P ≤ .05). Conclusion The combination of ECG parameters can help identify right ventricular mid‐septal pacing. The use of these parameters may enable the implantation of the pacing lead in the RVMS accurately and obtain a narrower QRS duration.

“…Small‐scale studies and anecdotal case reports utilizing HBP suggest that LV function could be protected by this approach and, in some cases of heart failure, LV function significantly improved after HBP . A recent study, comparing RVAp to HBP, showed a significant decline in LVEF in 22% of patients in the RVAp group over 5 years follow‐up, with a decline occurring in only 2% of the HBP group, implying a benefit from HBP potentially preventing or delaying LV dysfunction . In addition, since the first promising studies in the early 90s, pacing technology has improved and although there are remaining concerns over the long‐term lead threshold and the ability to capture the true His pathway, the use of HBP has growing support.…”

mentioning

confidence: 99%

The quest for physiological pacing—Does one size fit all?

Kaye

2019

Pacing is an established and ubiquitous treatment of bradycardias and some types of heart failure. The optimal pacing lead position which maximizes cardiac function and minimizes deterioration of ventricular function remains controversial. The desire to achieve a physiological pacing system that mimics cardiac function has led to the investigation of several potential pacing sites. This editorial provides an overview of past and current pacing lead position and summaries the current and future direction of physiological pacing.