Prevention of Ventricular Desynchronization by Permanent Para-Hisian Pacing After Atrioventricular Node Ablation in Chronic Atrial Fibrillation

Abstract

Permanent para-Hisian pacing is feasible and safe. Compared with conventional right apical pacing, it allows an improvement in functional and hemodynamic parameters over long-term follow-up.

Improvement of Left Ventricular Function by Permanent Direct His‐Bundle Pacing in a Case with Dilated Cardiomyopathy

“…This agrees with a recent study. 12) On the one hand, pacing therapy enabled us to continue administration -blockers. It is not clear if the documented benefit can be related, at lease in part, to continued administration ofblockers rather than to pacing modality.…”

Permanent Cardiac Pacing in Adults with High Grade Atriovetricular Block and Preserved Left Ventricular Function: Optimal Mode and Site of Pacing

“…Right Ventricular Apical permanent pacing could have negative hemodynamic effects. Initially, attention was directed to RV outflow tract/septum pacing and His/para-Hisian pacing in patients with LV dysfunction ( Mera et al, 1999;Schwaab et al, 1999;Buckingham et al, 1997;Buckingham et al, 1998;de Cock et al, 1998) and latter in preserved LV function patients (Giudici et al, 1997;Karpawich & Mital, 1997;Kolettis et al, 2000;Bourke et al, 2002;Tse et al, 2002;Occhetta et al, 2006;Victor et al, 2006;Yu et al, 2007;Kypta et al, 2008;Flevari et al, 2009;Ng et al, 2009;Dabrowska-Kugacka et al, 2009;Takemoto et al, 2009;Gong et al, 2009;Rosso et al, 2010;Verma et al , 2010;106:806-9;Leong et al, 2010;Cano et al,. 2010;Yoshikawa et al, 2010) while subsequently biventricular stimulation began to emerge as an appealing alternative proposal (Yu et al, 2009;Simantirakis et al, 2009;Doshi et al, 2005).…”

“…It is, however, a complex method that requires longer average implant times, cannot be carried out on all patients and presents high pacing thresholds (Deshmukh et al, 2000;Deshmukh et al, 2004, Zanon et al, 2006. On the contrary, the parahisian pacing, with simpler feasibility and reliability criteria, seems to guarantee an early invasion of the His-Purkinje conduction system, with a physiological ventricular activation, very similar to the one that can be obtained with direct His bundle pacing (Occhetta et al, 2006). The parameters that allow for the direct pacing of the His bundle were defined (Deshmukh et al, 2004): 1. the morphology and the duration of the native QRS and the paced QRS must be identical on the 12 standard ECG derivations 2. the HV interval on the original rhythm and the spike-QRS distance in the paced signal must be equal (with a tolerance margin of 10 ms) 3. the pacing threshold must be high (> 2V), since it must capture a specific non-muscular conduction tissue; 4. the pacing lead should be positioned with the distal pole (screw in) at the same level as one of the two electrodes of a mapping catheter on the His bundle (x-ray in both right and left anterior oblique projections) The criteria for the realization of parahisian pacing are (Deshmukh et al, 2004): the distal pole of the catheter (screw-in) must be positioned as much as possible next to the mapping dipole of the electrophysiological catheter of reference (within 1 cm in the right and left oblique projections) 1. the duration of the paced QRS can be larger than the spontaneous QRS, but the duration must be at least 50 ms shorter than the QRS obtained with the RVA pacing and, in any case, not more than 120-130 ms.…”

“…the interval between the spike and start of paced QRS is less than the HV time of the original rhythm; 4. the pacing threshold must be less than 1 V, since the muscular portion of the interventricular septum is paced. Indication of His or para-His bundle pacing is limited to patients without significant distal conduction abnormalities particularly after ablation of the AV node for chronic atrial fibrillation (Deshmukh et al, 2004, Occhetta et al, 2006. In these selected patients, His or para-His bundle pacing might be optimal (Zanon et al, 2008;Occhetta et al, 2006) but its feasibility is limited by the technical difficulties (Occhetta et al, 2006;Deshmuck et al, 2000;Deshmuck et al, 2004).…”

“…Indication of His or para-His bundle pacing is limited to patients without significant distal conduction abnormalities particularly after ablation of the AV node for chronic atrial fibrillation (Deshmukh et al, 2004, Occhetta et al, 2006. In these selected patients, His or para-His bundle pacing might be optimal (Zanon et al, 2008;Occhetta et al, 2006) but its feasibility is limited by the technical difficulties (Occhetta et al, 2006;Deshmuck et al, 2000;Deshmuck et al, 2004). His bundle pacing in patients has been shown to result in better hemodynamic performance (Deshmukh et al, 2004) and more uniform distribution of perfusion when compared with RV pacing (Deshmuck et al, 2000).…”