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Frontiers in Cardiovascular Medicine 2021Cardiac pacing is an effective therapy for treating patients with bradycardia due to sinus node dysfunction or atrioventricular block. However, traditional right... (Review)
Review
Cardiac pacing is an effective therapy for treating patients with bradycardia due to sinus node dysfunction or atrioventricular block. However, traditional right ventricular apical pacing (RVAP) causes electric and mechanical dyssynchrony, which is associated with increased risk for atrial arrhythmias and heart failure. Therefore, there is a need to develop a physiological pacing approach that activates the normal cardiac conduction and provides synchronized contraction of ventricles. Although His bundle pacing (HBP) has been widely used as a physiological pacing modality, it is limited by challenging implantation technique, unsatisfactory success rate in patients with wide QRS wave, high pacing capture threshold, and early battery depletion. Recently, the left bundle branch pacing (LBBP), defined as the capture of left bundle branch (LBB) via transventricular septal approach, has emerged as a newly physiological pacing modality. Results from early clinical studies have demonstrated LBBP's feasibility and safety, with rare complications and high success rate. Overall, this approach has been found to provide physiological pacing that guarantees electrical synchrony of the left ventricle with low pacing threshold. This was previously specifically characterized by narrow paced QRS duration, large R waves, fast synchronized left ventricular activation, and correction of left bundle branch block. Therefore, LBBP may be a potential alternative pacing modality for both RVAP and cardiac resynchronization therapy with HBP or biventricular pacing (BVP). However, the technique's widespread adaptation needs further validation to ascertain its safety and efficacy in randomized clinical trials. In this review, we discuss the current knowledge of LBBP.
PubMed: 33834042
DOI: 10.3389/fcvm.2021.630399 -
European Heart Journal Oct 2022Permanent transseptal left bundle branch area pacing (LBBAP) is a promising new pacing method for both bradyarrhythmia and heart failure indications. However, data... (Observational Study)
Observational Study
AIMS
Permanent transseptal left bundle branch area pacing (LBBAP) is a promising new pacing method for both bradyarrhythmia and heart failure indications. However, data regarding safety, feasibility and capture type are limited to relatively small, usually single centre studies. In this large multicentre international collaboration, outcomes of LBBAP were evaluated.
METHODS AND RESULTS
This is a registry-based observational study that included patients in whom LBBAP device implantation was attempted at 14 European centres, for any indication. The study comprised 2533 patients (mean age 73.9 years, female 57.6%, heart failure 27.5%). LBBAP lead implantation success rate for bradyarrhythmia and heart failure indications was 92.4% and 82.2%, respectively. The learning curve was steepest for the initial 110 cases and plateaued after 250 cases. Independent predictors of LBBAP lead implantation failure were heart failure, broad baseline QRS and left ventricular end-diastolic diameter. The predominant LBBAP capture type was left bundle fascicular capture (69.5%), followed by left ventricular septal capture (21.5%) and proximal left bundle branch capture (9%). Capture threshold (0.77 V) and sensing (10.6 mV) were stable during mean follow-up of 6.4 months. The complication rate was 11.7%. Complications specific to the ventricular transseptal route of the pacing lead occurred in 209 patients (8.3%).
CONCLUSIONS
LBBAP is feasible as a primary pacing technique for both bradyarrhythmia and heart failure indications. Success rate in heart failure patients and safety need to be improved. For wider use of LBBAP, randomized trials are necessary to assess clinical outcomes.
Topics: Humans; Female; Aged; Bundle of His; Cardiac Pacing, Artificial; Bundle-Branch Block; Bradycardia; Electrocardiography; Heart Failure; Treatment Outcome
PubMed: 35979843
DOI: 10.1093/eurheartj/ehac445 -
Heart Rhythm Sep 2023Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that...
Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.
Topics: Child; Humans; Bundle of His; Treatment Outcome; Cardiac Conduction System Disease; Cardiac Resynchronization Therapy; Heart Failure; Electrocardiography
PubMed: 37283271
DOI: 10.1016/j.hrthm.2023.03.1538 -
Europace : European Pacing,... Apr 2023Conduction system pacing (CSP) has emerged as a more physiological alternative to right ventricular pacing and is also being used in selected cases for cardiac...
EHRA clinical consensus statement on conduction system pacing implantation: endorsed by the Asia Pacific Heart Rhythm Society (APHRS), Canadian Heart Rhythm Society (CHRS), and Latin American Heart Rhythm Society (LAHRS).
Conduction system pacing (CSP) has emerged as a more physiological alternative to right ventricular pacing and is also being used in selected cases for cardiac resynchronization therapy. His bundle pacing was first introduced over two decades ago and its use has risen over the last five years with the advent of tools which have facilitated implantation. Left bundle branch area pacing is more recent but its adoption is growing fast due to a wider target area and excellent electrical parameters. Nevertheless, as with any intervention, proper technique is a prerequisite for safe and effective delivery of therapy. This document aims to standardize the procedure and to provide a framework for physicians who wish to start CSP implantation, or who wish to improve their technique.
Topics: Humans; Latin America; Canada; Heart Conduction System; Cardiac Conduction System Disease; Cardiac Resynchronization Therapy; Bundle of His
PubMed: 37061848
DOI: 10.1093/europace/euad043 -
Journal of the American College of... Aug 2018Traditional right ventricular (RV) pacing for the management of bradyarrhythmias has been pursued successfully for decades, although there remains debate regarding... (Review)
Review
Traditional right ventricular (RV) pacing for the management of bradyarrhythmias has been pursued successfully for decades, although there remains debate regarding optimal pacing site with respect to both hemodynamic and clinical outcomes. The deleterious effects of long-term RV apical pacing have been well recognized. This has generated interest in approaches providing more physiological stimulation, namely, His bundle pacing (HBP). This paper reviews the anatomy of the His bundle, early clinical observations, and current approaches to permanent HBP. By stimulating the His-Purkinje network, HBP engages electrical activation of both ventricles and may avoid marked dyssynchrony. Recent studies have also demonstrated the potential of HBP in patients with underlying left bundle branch block and cardiomyopathy. HBP holds promise as an attractive mode to achieve physiological pacing. Widespread adaptation of this technique is dependent on enhancements in technology, as well as further validation of efficacy in large randomized clinical trials.
Topics: Arrhythmias, Cardiac; Bundle of His; Bundle-Branch Block; Cardiac Pacing, Artificial; Cardiac Resynchronization Therapy; Cardiac Resynchronization Therapy Devices; Electrocardiography; Humans
PubMed: 30115232
DOI: 10.1016/j.jacc.2018.06.017 -
Journal of Arrhythmia Oct 2020Junctional ectopic tachycardia (JET) is a tachyarrhythmia arising from the atrioventricular node and His bundle area. Enhanced normal automaticity has been postulated as... (Review)
Review
Junctional ectopic tachycardia (JET) is a tachyarrhythmia arising from the atrioventricular node and His bundle area. Enhanced normal automaticity has been postulated as the mechanism of JET in the majority of patients. It is more common in children and can be seen as congenital or in postoperative settings. It is often a narrow complex tachycardia but can present as a wide complex tachycardia as a result of aberrant conduction. Its differentiation from other arrhythmias especially atrioventricular nodal reentrant tachycardia (AVNRT) can be challenging. Medical treatment of JET is difficult, and catheter ablation remains the mainstay of treatment in refractory cases with a high risk of atrioventricular block and recurrence.
PubMed: 33024461
DOI: 10.1002/joa3.12410 -
JACC. Clinical Electrophysiology Sep 2021This study sought to assess the predictive value of the proposed electrocardiogram and intracardiac electrogram characteristics for confirmation of left bundle branch...
OBJECTIVES
This study sought to assess the predictive value of the proposed electrocardiogram and intracardiac electrogram characteristics for confirmation of left bundle branch (LBB) capture.
BACKGROUND
Previously proposed criteria to distinguish left bundle branch pacing (LBBP) and left ventricular septum (LVS) pacing (LVSP) have not been fully validated.
METHODS
A His bundle pacing lead, an LBBP lead, and a multielectrode catheter at the LVS were placed. Direct LBB capture was defined as demonstration of retrograde His potential on the His bundle pacing lead and/or anterograde left conduction system potentials on the multielectrode catheter during LBBP. The routinely used parameters-His, LBB potential, time from stimulus to peak ventricular activation (Stim-LVAT), and paced QRS morphology during LVSP and LBBP at various depths and outputs were analyzed.
RESULTS
Thirty patients (21 non-left bundle branch block [LBBB], 9 LBBB) who demonstrated direct LBB capture using the defined criteria were included. The proportion of paced right bundle branch block was 100% during LBB capture in all patients compared to 23.4% in non-LBBB and 44.4% in LBBB during LVSP. LBB potential was recorded in all patients during intrinsic rhythm (non-LBBB group) or His corrective pacing in LBBB. Paced QRS duration was longer during selective LBBP compared to nonselective LBBP or LVSP only. All patients with characteristics of selective LBBP or abrupt decrease in Stim-LVAT of ≥10 ms demonstrated LBB capture.
CONCLUSIONS
Direct LBB capture can be confirmed by recording retrograde His potential and anterograde left conduction system potentials. Abrupt decrease in Stim-LVAT of ≥10 ms and demonstration of selective LBBP could be used as simple criteria to confirm LBB capture.
Topics: Bundle of His; Bundle-Branch Block; Cardiac Pacing, Artificial; Heart Rate; Humans; Ventricular Septum
PubMed: 33933414
DOI: 10.1016/j.jacep.2021.02.018