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Zupan Mežnar A, Mrak M, Mullens W, Štublar J, Ivanovski M, Žižek D. AV-optimized conduction system pacing for treatment of AV dromotropathy: A randomized, cross-over study. J Cardiovasc Electrophysiol 2024; 35:1340-1350. [PMID: 38686618 DOI: 10.1111/jce.16268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 02/04/2024] [Accepted: 03/19/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Severe first-degree atrioventricular (AV) block may produce symptoms similar to heart failure due to AV dyssynchrony, a syndrome termed AV dromotropathy. According to guidelines, it should be considered for permanent pacemaker implantation, yet evidence supporting this treatment is scarce. OBJECTIVES This study aimed to determine the impact of AV-optimized conduction system pacing (CSP) in patients with symptomatic severe first-degree AV block and echocardiographic signs of AV dyssynchrony. METHODS Patients with symptomatic first-degree AV block (PR > 250 ms), preserved left ventricular ejection fraction, narrow QRS, and AV dyssynchrony were included in the study. In a single-blind cross-over design, patients were randomized to AV sequential CSP or backup VVI pacing with a base rate of 40 bpm. We compared exercise capacity, echocardiographic parameters, and symptom occurrence at the end of 3 months of each period. RESULTS Fourteen patients completed the study. During the AV-optimized CSP compared to the backup pacing period, patients achieved a higher workload on exercise test (147.2 ± 50.9 vs. 140.7 ± 55.8 W; p = .032), with a trend towards higher peak VO2 (23.3 ± 7.1 vs. 22.8 ± 7.1 mL/min/kg; p = .224), and higher left ventricular stroke volume (LVSV 74.5 ± 13.8 vs. 66.4 ± 12.5 mL; p < .001). Symptomatic improvement was recorded, with fewer patients reporting general tiredness and 71% of patients preferring the AV-optimized CSP (p = .008). CONCLUSIONS AV-optimized CSP could improve symptoms, exercise capacity and LVSV in patients with severe first-degree AV block.
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Affiliation(s)
- Anja Zupan Mežnar
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Mrak
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Hasselt, Belgium
| | - Jernej Štublar
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Department of Cardiovascular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Maja Ivanovski
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - David Žižek
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Beer D, Vijayaraman P. Current role of Conduction System Pacing in Patients Requiring Permanent Pacing. Korean Circ J 2024; 54:54.e52. [PMID: 38859643 DOI: 10.4070/kcj.2024.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 04/11/2024] [Indexed: 06/12/2024] Open
Abstract
His bundle pacing (HBP) and left bundle branch pacing (LBBP) are novel methods of pacing directly pacing the cardiac conduction system. HBP while developed more than two decades ago, only recently moved into the clinical mainstream. In contrast to conventional cardiac pacing, conduction system pacing including HBP and LBBP utilizes the native electrical system of the heart to rapidly disseminate the electrical impulse and generate a more synchronous ventricular contraction. Widespread adoption of conduction system pacing has resulted in a wealth of observational data, registries, and some early randomized controlled clinical trials. While much remains to be learned about conduction system pacing and its role in electrophysiology, data available thus far is very promising. In this review of conduction system pacing, the authors review the emergence of conduction system pacing and its contemporary role in patients requiring permanent cardiac pacing.
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Vijayaraman P, Chelu MG, Curila K, Dandamudi G, Herweg B, Mori S, Jastrzebski M, Sharma PS, Shivkumar K, Tung R, Upadhyay G, Vernooy K, Welter-Frost A, Whinnett Z, Zanon F, Ellenbogen KA. Cardiac Conduction System Pacing: A Comprehensive Update. JACC Clin Electrophysiol 2023; 9:2358-2387. [PMID: 37589646 DOI: 10.1016/j.jacep.2023.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/10/2023] [Accepted: 06/02/2023] [Indexed: 08/18/2023]
Abstract
The field of cardiac pacing has changed rapidly in the last several years. Since the initial description of His bundle pacing targeting the conduction system, recent advances in pacing the left bundle branch and its fascicles have evolved. The field and investigators' knowledge of conduction system pacing including relevant anatomy and physiology has advanced significantly. The aim of this review is to provide a comprehensive update on recent advances in conduction system pacing.
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Affiliation(s)
- Pugazhendhi Vijayaraman
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania, USA.
| | - Mihal G Chelu
- Division of Cardiology, Baylor College of Medicine and Baylor St. Luke's Medical Center and Texas Heart Institute, Houston, Texas, USA
| | - Karol Curila
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Gopi Dandamudi
- Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Bengt Herweg
- University of South Florida Morsani College of Medicine, Department of Cardiovascular Sciences, Tampa, Florida, USA
| | - Shumpei Mori
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Marek Jastrzebski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Parikshit S Sharma
- Department of Cardiology, Rush University School of Medicine, Chicago, Illinois, USA
| | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Roderick Tung
- Division of Cardiology, University of Arizona College of Medicine-Phoenix, Banner-University Medical Center, Phoenix, Arizona, USA
| | - Gaurav Upadhyay
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Kevin Vernooy
- Center for Arrhythmia Care, Heart and Vascular Center, University of Chicago, Chicago, Illinois, USA
| | - Allan Welter-Frost
- Cleveland Clinic Indian River Hospital, Heart Vascular and Thoracic Institute, Vero Beach, Florida, USA
| | - Zachary Whinnett
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Kenneth A Ellenbogen
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Whinnett ZI, Shun‐Shin MJ, Tanner M, Foley P, Chandrasekaran B, Moore P, Adhya S, Qureshi N, Muthumala A, Lane R, Rinaldi A, Agarwal S, Leyva F, Behar J, Bassi S, Ng A, Scott P, Prasad R, Swinburn J, Tomson J, Sethi A, Shah J, Lim PB, Kyriacou A, Thomas D, Chuen J, Kamdar R, Kanagaratnam P, Mariveles M, Burden L, March K, Howard JP, Arnold A, Vijayaraman P, Stegemann B, Johnson N, Falaschetti E, Francis DP, Cleland JG, Keene D. Effects of haemodynamically atrio-ventricular optimized His bundle pacing on heart failure symptoms and exercise capacity: the His Optimized Pacing Evaluated for Heart Failure (HOPE-HF) randomized, double-blind, cross-over trial. Eur J Heart Fail 2023; 25:274-283. [PMID: 36404397 PMCID: PMC10946926 DOI: 10.1002/ejhf.2736] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/22/2022] Open
Abstract
AIMS Excessive prolongation of PR interval impairs coupling of atrio-ventricular (AV) contraction, which reduces left ventricular pre-load and stroke volume, and worsens symptoms. His bundle pacing allows AV delay shortening while maintaining normal ventricular activation. HOPE-HF evaluated whether AV optimized His pacing is preferable to no-pacing, in a double-blind cross-over fashion, in patients with heart failure, left ventricular ejection fraction (LVEF) ≤40%, PR interval ≥200 ms and either QRS ≤140 ms or right bundle branch block. METHODS AND RESULTS Patients had atrial and His bundle leads implanted (and an implantable cardioverter-defibrillator lead if clinically indicated) and were randomized to 6 months of pacing and 6 months of no-pacing utilizing a cross-over design. The primary outcome was peak oxygen uptake during symptom-limited exercise. Quality of life, LVEF and patients' holistic symptomatic preference between arms were secondary outcomes. Overall, 167 patients were randomized: 90% men, 69 ± 10 years, QRS duration 124 ± 26 ms, PR interval 249 ± 59 ms, LVEF 33 ± 9%. Neither peak oxygen uptake (+0.25 ml/kg/min, 95% confidence interval [CI] -0.23 to +0.73, p = 0.3) nor LVEF (+0.5%, 95% CI -0.7 to 1.6, p = 0.4) changed with pacing but Minnesota Living with Heart Failure quality of life improved significantly (-3.7, 95% CI -7.1 to -0.3, p = 0.03). Seventy-six percent of patients preferred His bundle pacing-on and 24% pacing-off (p < 0.0001). CONCLUSION His bundle pacing did not increase peak oxygen uptake but, under double-blind conditions, significantly improved quality of life and was symptomatically preferred by the clear majority of patients. Ventricular pacing delivered via the His bundle did not adversely impact ventricular function during the 6 months.
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Affiliation(s)
- Zachary I. Whinnett
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
| | - Matthew J. Shun‐Shin
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
| | - Mark Tanner
- West Sussex Hospitals NHS TrustWest SussexUK
| | - Paul Foley
- Great Western Hospitals NHS Foundation TrustSwindonUK
| | | | - Philip Moore
- West Hertfordshire Hospitals NHS TrustHertfordshireUK
- Barts Health NHS TrustLondonUK
| | | | | | - Amal Muthumala
- Barts Health NHS TrustLondonUK
- North Middlesex University HospitalLondonUK
| | | | - Aldo Rinaldi
- Guy's and St. Thomas's NHS Foundation TrustLondonUK
| | | | | | | | - Sukh Bassi
- Sherwood Forest Hospitals NHS Foundation TrustUK
| | - Andre Ng
- Department of Cardiovascular SciencesUniversity of LeicesterLeicesterUK
| | | | | | | | | | - Amarjit Sethi
- London North West University Healthcare NHS TrustLondonUK
| | - Jaymin Shah
- London North West University Healthcare NHS TrustLondonUK
| | - Phang Boon Lim
- National Heart and Lung InstituteImperial College LondonLondonUK
| | | | - Dewi Thomas
- Morriston Hospital Regional Cardiac CentreWalesUK
| | - Jenny Chuen
- Nottingham University Hospitals NHS TrustNottinghamUK
| | | | | | | | - Leah Burden
- Imperial College Healthcare NHS TrustLondonUK
| | | | - James P. Howard
- National Heart and Lung InstituteImperial College LondonLondonUK
| | - Ahran Arnold
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
| | | | | | | | | | | | | | - Daniel Keene
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
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Galand V, Martins RM, Daubert C. Pacing for long PR: who, why, and how? Europace 2021; 24:703-705. [PMID: 34907440 DOI: 10.1093/europace/euab302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Vincent Galand
- Faculté de Médecine-Université de Rennes 1, Rennes, F-35043, France.,Département de Cardiologie, CHU Rennes, Rennes, F-35033, France.,LTSI-UMR1099, Rennes, F-35000, France
| | - Raphael M Martins
- Faculté de Médecine-Université de Rennes 1, Rennes, F-35043, France.,Département de Cardiologie, CHU Rennes, Rennes, F-35033, France.,LTSI-UMR1099, Rennes, F-35000, France
| | - Claude Daubert
- Faculté de Médecine-Université de Rennes 1, Rennes, F-35043, France.,LTSI-UMR1099, Rennes, F-35000, France
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