Step-wise Approach to Permanent His Bundle Pacing

Abstract

ABSTRACT. There has been a recent upsurge of interest in permanent His bundle pacing, given increased understanding and appreciation of the role dyssynchronous ventricular activation plays in congestive heart failure and atrial fibrillation. Permanent His bundle pacing gives implanters the ability to avoid causing ventricular dyssynchrony in patients dependent on ventricular pacing, and can provide an alternative means to implementing cardiac resynchronization therapy in patients with bundle branch disease and congestive heart failure. This paper describes a step-wise approach to implanting permanent His bundle pacing leads, with a clear demonstration of techniques and observations encountered during the course of typical His bundle lead implantations, including consideration of potential pitfalls and workarounds.

Permanent His-bundle pacing using stylet-directed, active-fixation leads placed via coronary sinus sheaths compared to conventional lumen-less system

“…Packaged preformed J-stylets occasionally were successful without the need for alteration, but they typically were reformed to include a secondary posteriorly directed curve in order to orient the lead tip along the perceived HB axis 5 and to provide support (Supplementary Figure 2). Delivery of the 3830 lead with the C315 sheath was performed according to previously described methods, 8,9,23,26 Once a promising site was identified by a distinct HB potential, pacing was attempted before fixation using either the model EP-4 stimulator (Abbott) or the pacing system analyzer (PSA). In cases with no visible HB potential, pace mapping was attempted and guided by 12-lead electrocardiogram and criteria for selective (S) or nonselective (NS) HBP.…”

“…The implant technique for non-SDLs has been previously described. 8,9 Importantly, to maximize the working lengths of the 59-cm model 7742 and 58-cm model 4471 leads for use within the 50-cm Acuity Pro guide catheters, the anchoring sleeves were temporarily removed by either sliding over the distal tip or cutting the sleeve using the slitting tool packaged with the Acuity Pro guide catheter. Slitting of the guide catheter was performed before reattachment of the suture sleeve, and standard tie-down methods were used.…”

“…Deliverability of the 3830 lead to the anterior septum for HBP was further facilitated by the specifically shaped model C315 guide catheter (Medtronic). 8,9 Recent reports have demonstrated a high degree of success in bypassing intra-and infrahisian conduction block, including left bundle branch block (LBBB) with a pacemaker lead. [10][11][12][13][14] Moreover, patients with a pacemaker indication have shown improved clinical response and greater 5-year survival with PHBP compared to right ventricular (RV) pacing.…”

“…15 In patients with heart failure and LBBB, PHBP has been shown to achieve cardiac resynchronization therapy (CRT), 11,[16][17][18][19][20][21] and some investigators have suggested PHBP as first-line therapy. 21,22 Detailed how-to publications 8,9,23 and a recent guidance publication have further contributed to adoption of PHBP use. 24 Although the "stylet-less" 3830 lead and the C315/C304 guide catheter family have been used in .99% of PHBP cases, its ability to adapt to anatomic variations (eg, dilated right atrium, superior right-sided venous approach) is limited.…”

Subvalvular His bundle pacing for pseudo-pacemaker syndrome and mitral regurgitation

“…Subvalvular HBP has previously been described as a viable option. 8 In these cases, the lead is located in the membranous septum accessed from the ventricle. A backup RV lead can be considered, as the long-term thresholds of the subvalvular His lead are unknown, but this may come at an increased risk of lead-induced tricuspid regurgitation.…”