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Skeete J, Huang HD, Mazur A, Sharma PS, Engelstein E, Trohman RG, Larsen TR. Evolving Concepts in Cardiac Physiologic Pacing in the Era of Conduction System Pacing. Am J Cardiol 2024; 212:51-66. [PMID: 38012990 DOI: 10.1016/j.amjcard.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/22/2023] [Accepted: 11/11/2023] [Indexed: 11/29/2023]
Abstract
Cardiac physiologic pacing (CPP) has become a well-established therapy for patients with cardiomyopathy (left ventricular ejection fraction <35%) in the presence of a left bundle branch block. In addition, CPP can be highly beneficial in patients with pacing-induced cardiomyopathy and patients with existing cardiomyopathy expected to have a right ventricular pacing burden of >40%. The benefits of CPP with traditional biventricular pacing are only realized if adequate resynchronization can be achieved. However, left ventricular lead implantation can be limited by individual anatomic variation within the coronary venous system and can be adversely affected by underlying abnormal myocardial substrate (i.e., scar tissue), especially if located within the basal lateral wall. In the last 7 years the investigation of conduction system pacing (CSP) and its potential salutary benefits are being realized and have led to a rapid evolution in the field of cardiac resynchronization pacing. However, supportive evidence for CSP for patients eligible for cardiac resynchronization remains limited compared with data available for biventricular cardiac resynchronization, mostly derived from leading CSP investigative centers. In this review, we perform an up-to-date comprehensive review of the available literature on CPP.
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Affiliation(s)
- Jamario Skeete
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Henry D Huang
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Alex Mazur
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Parikshit S Sharma
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Erica Engelstein
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Richard G Trohman
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Timothy R Larsen
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois.
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De Pooter J, Bulava A, Gras D, Timmer S, Chin-Pang Chan G, Clementy N, Pathak RK, Healy S, Lüsebrink U, Zanon F. Utility of a guiding catheter for conduction system pacing: An early multicenter experience. Heart Rhythm O2 2024; 5:8-16. [PMID: 38312208 PMCID: PMC10837172 DOI: 10.1016/j.hroo.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background Conduction system pacing (CSP), either as His bundle pacing (HBP) or as left bundle branch area pacing (LBBAP), may be superior to right ventricular apical or septal pacing. Objective The study sought to present acute results for a new guiding catheter (Biotronik Selectra 3D) designed for CSP implantations of a retractable screw-in lead (Biotronik Solia S). Methods The primary endpoint of the prospective, international nonrandomized BIO|MASTER.Selectra 3D study was freedom from catheter-related serious adverse device effects (SADEs) within 1 week of lead implantation. Results Of 157 enrolled patients, CSP was achieved in 147 (93.6%) patients. No SADEs occurred within 7 days. LBBAP was achieved in 82 patients (45 as crossover from an HBP attempt) and HBP in 65 (44.2%) patients. In centers considering both HBP and LBBAP, the CSP implantation success approached 99%. Successful CSP implantations lasted on average ∼50 minutes (fluoroscopy ∼6 minutes). Most procedures (87.9%) needed only 1 catheter, even after switch from HBP to LBBAP. The catheter's handling was rated largely positive. In patients without bundle branch block, mean QRS duration increased from 106 ms (intrinsic) to 122 ms (CSP) (P = .001). In patients with bundle branch block, mean QRS duration decreased from 151 ms (intrinsic) to 137 ms (CSP) (P = .004). Conclusion The Selectra 3D catheter is a valuable tool for HBP and LBBAP implantations of the stylet-supported pacemaker leads. When implanters considered both HBP and LBBAP, the success rate was ∼99%. Flexibility to change between different approaches may be advisable in heterogeneous and challenging areas, such as CSP implantations.
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Affiliation(s)
| | - Alan Bulava
- České Budějovice Hospital, Faculty of Health and Social Sciences, Cardiology, University of South Bohemia, České Budějovice, Czech Republic
| | - Daniel Gras
- Hôpital Privé du Confluent, Cardiology, Nantes, France
| | - Stefan Timmer
- Noordwest Ziekenhuisgroep, Cardiology, Alkmaar, the Netherlands
| | | | - Nicolas Clementy
- Centre Hospitalier Régional Universitaire de Tours, Cardiology, Chambray-lès-Tours, France
| | - Rajeev K Pathak
- Canberra Heart Rhythm, Australian National University, Cardiology, Garran, Australian Capital Territory, Australia
| | - Stewart Healy
- Monash Medical Centre, Cardiology, Melbourne, Victoria, Australia
| | - Ulrich Lüsebrink
- Universitätsklinikum Gießen und Marburg, Kardiologie, Marburg, Germany
| | - Francesco Zanon
- Santa Maria della Misericordia, Arrhythmia and Electrophysiology Unit, Rovigo, Italy
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Nam MCY, O'Sullivan P, Tonchev I, Moore BM, Watts T, Wynn G, Lee G, Joshi S, Stevenson I. His bundle combined with deep septal left bundle branch area pacing for atrial fibrillation prior to atrioventricular node ablation. J Arrhythm 2022; 39:27-33. [PMID: 36733330 PMCID: PMC9885312 DOI: 10.1002/joa3.12800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 11/17/2022] [Accepted: 11/25/2022] [Indexed: 12/15/2022] Open
Abstract
Background To mitigate the risk of dyssynchrony-induced cardiomyopathy, international guidelines advocate His bundle pacing (HBP) with a ventricular backup lead prior to atrioventricular node ablation in treatment-refractory atrial fibrillation and normal left ventricular ejection fraction. As a result of concerns with long-term pacing parameters associated with HBP, this case series reports an adopted strategy of HBP combined with deep septal left bundle branch area pacing (dsLBBAP) in this patient cohort, enabling intrapatient comparison of the two pacing methods. Methods and Results Eight patients aged 72 ± 10 years (left ventricular ejection fraction 53 ± 4%) underwent successful combined HBP and dsLBBAP implant prior to AV node ablation. Intrinsic QRS duration was 118 ± 46 ms. When compared to dsLBBAP, HBP had lower sensed ventricular amplitude (2.4 ± 1.1 vs. 15 ± 5.3 V, p = .001) and lower lead impedance (522 ± 57 vs. 814 ± 171ohms, p = .02), but shorter paced QRS duration (101 ± 20 vs. 119 ± 17 ms, p = .02). HBP pacing threshold was 1.0 ± 0.6 V at 1 ms pulse width, and dsLBBAP pacing threshold was 0.5 ± 0.2 V at 0.4 ms pulse width. Five patients underwent cardiac CT showing adequate dsLBBAP ventricular septal penetration (8.6 ± 1.3 mm depth, 2.4 ± 0.5 mm distance from left ventricular septal wall). No complications occurred during a mean follow-up duration of 121 ± 92 days. Conclusions Combined HBP and dsLBBAP pacing is a feasible approach as a pace and ablate strategy for atrial fibrillation refractory to medical therapy.
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Affiliation(s)
- Michael C. Y. Nam
- Department of CardiologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | | | - Ivaylo Tonchev
- Department of CardiologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Benjamin M. Moore
- Department of CardiologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Troy Watts
- Department of CardiologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Gareth Wynn
- Department of CardiologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Geoff Lee
- Department of CardiologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Subodh Joshi
- Department of CardiologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Irene Stevenson
- Department of CardiologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
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Mirolo A, Chaumont C, Auquier N, Savoure A, Godin B, Vandevelde F, Eltchaninoff H, Anselme F. Left bundle branch area pacing in patients with baseline narrow, left, or right bundle branch block QRS patterns: insights into electrocardiographic and echocardiographic features. Europace 2022; 25:526-535. [PMID: 36480437 PMCID: PMC9935006 DOI: 10.1093/europace/euac223] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 11/11/2022] [Indexed: 12/13/2022] Open
Abstract
AIMS Left bundle branch area pacing (LBBAP) is a recent technique aiming at preservation of physiological ventricular electrical activation. Our goal was to assess mechanical synchrony parameters in relation to electrocardiographic features during LBBAP performed in routine practice. METHODS AND RESULTS From June 2020 to August 2021, all patients of our institution with permanent pacemaker implantation indication were eligible for LBBAP. A 'qR' pattern in V1 and a delay from pacing spike to the peak of the R-wave in V6 < 80 ms defined a successful LBBAP. Electrocardiogram and echocardiography were performed during spontaneous rhythm and LBBAP: left ventricular mechanical synchrony (LVMS) parameters using 2D Speckle tracking and interventricular mechanical delay (IVMD) were collected. LBBAP was attempted with success in 134/163 patients (82.2%). During LBBAP, the mean QRS width was 104 ± 12 ms. In patients with left bundle branch block (n = 47), LBBAP provided a significant decrease of QRS width from 139 ± 16 to 105 ± 12 ms (P < 0.001) with reduction of LVMS (53 ± 21 vs. 90 ± 46 ms, P = 0.009), and IVMD (14 ± 13 vs. 49 ± 18 ms, P < 0.001). In patients with right bundle branch block (n = 38), LBBAP led to a significant decrease of QRS width from 134 ± 14 to 106 ± 13 ms (P < 0.001) with no effect on LVMS and a reduction of IVMD (17 ± 14 vs. 50 ± 16 ms, P < 0.001). CONCLUSION LBBAP in routine practice preserved intra-ventricular mechanical synchrony in patients with narrow and RBBB QRS and improved asynchrony parameters in patients with LBBB.
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Affiliation(s)
- Adrian Mirolo
- Department of cardiology, Rouen University Hospital, CHU—Hôpitaux de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Corentin Chaumont
- Department of cardiology, Rouen University Hospital, CHU—Hôpitaux de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Nathanael Auquier
- Department of cardiology, Jacques Monod Hospital, 29 Av. Pierre Mendès France, 76290 Montivilliers, France
| | - Arnaud Savoure
- Department of cardiology, Rouen University Hospital, CHU—Hôpitaux de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Benedicte Godin
- Department of cardiology, Rouen University Hospital, CHU—Hôpitaux de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Florence Vandevelde
- Department of cardiology, Jacques Monod Hospital, 29 Av. Pierre Mendès France, 76290 Montivilliers, France
| | - Helene Eltchaninoff
- Department of cardiology, Rouen University Hospital, CHU—Hôpitaux de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Frederic Anselme
- Corresponding author. Tel: +33 2 32 88 81 11; Fax: +33 2 32 88 81 23. E-mail address:
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Manolis AS, Manolis AA, Manolis TA, Melita H. Electrocardiography of cardiac resynchronization therapy: Pitfalls and practical tips. J Cardiovasc Electrophysiol 2021; 32:3228-3244. [PMID: 34664758 DOI: 10.1111/jce.15267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/11/2021] [Accepted: 09/29/2021] [Indexed: 12/25/2022]
Abstract
Cardiac resynchronization therapy (CRT) has been established as an effective mode of therapy in patients with heart failure and concurrent cardiac dyssynchrony, principally in the form of left bundle branch block (LBBB). The widespread use of CRT has ushered in a new landscape in 12-lead electrocardiography (ECG). ECG readings in these patients are most important to guide troubleshooting and also appropriate device programming, as well as discerning and managing nonresponders. A set of four ECG recordings need to accompany each patient with a CRT device, including a baseline ECG and recordings from monochamber (right and left ventricular) and biventricular pacing, which can be compared against a new recording to facilitate the evaluation of proper versus problematic biventricular pacing. Precordial ECG leads V1/2 acquired at the fourth intercostal space and limb leads, I and III, together with a quick assessment of perpendicular leads I and aVF to determine the quadrant of the QRS axis in the hexaxial diagram, may provide the framework for proper ECG interpretation in these patients. This important issue of 12-lead ECG in CRT patients is herein reviewed, pitfalls are pointed out and practical tips are provided for ECG reading to help recognize and manage problems with CRT device function. Furthermore, several pertinent ECG recordings and tabulated data are provided, and an algorithm is suggested that integrates prior algorithms and relevant information from current literature.
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Affiliation(s)
- Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | | | | | - Helen Melita
- Central Laboratories, Onassis Cardiac Surgery Center, Athens, Greece
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