High efficiency and workflow of His bundle pacing and atrioventricular node ablation guided by three-dimensional mapping system

Ablate and pace strategy for atrial fibrillation: pacing modalities, ablation approaches and impact on patient outcomes

INTRODUCTION

In patients with symptomatic, refractory atrial fibrillation the ablate and pace (A&P) strategy (pacemaker implantation followed by atrio-ventricular junction ablation (AVJA)) is superior to medical therapy in improving quality of life and prognosis. Despite its well-proven benefits, this invasive therapeutic option is still underutilized in clinical practice. The choice of pacing modality (right ventricular pacing, biventricular pacing, BVP, or conduction system pacing, CSP) is crucial and can have significant clinical implications. In particular, in recent years CSP is emerging as an alternative to BVP, showing a good effectiveness and safety profile. Other important aspects are the timing of ablation, the approach used for AVJA, and the correct device programming after AVJA.

AREAS COVERED

This article reviews the currently available evidence on this therapeutic strategy with a particular focus on its impact on patient outcome, recognized indications, technical considerations, and future perspectives.

EXPERT OPINION

With the availability of more robust evidence confirming the better effectiveness and safety profile of CSP compared to conventional pacing modalities, in the next few years CSP will become the standard pacing modality in candidates for A&P. The routine adoption of this pacing modality could lead to a wider use of A&P in clinical practice.

Review of Atrioventricular Node Ablation Combined with Permanent His-Purkinje Conduction System Pacing in Patients with Atrial Fibrillation with Heart Failure

With the advancement of pacing technologies, His-Purkinje conduction system pacing (HPCSP) has been increasingly recognized as superior to conventional right ventricular pacing (RVP) and biventricular pacing (BVP). This method is characterized by a series of strategies that either strengthen the native cardiac conduction system or fully preserve physical atrioventricular activation, ensuring optimal clinical outcomes. Treatment with HPCSP is divided into two pacing categories, His bundle pacing (HBP) and left bundle branch pacing (LBBP), and when combined with atrioventricular node ablation (AVNA), can significantly improve left ventricular (LV) function. It effectively prevents tachycardia and regulates ventricular rates, demonstrating its efficacy and safety across different QRS wave complex durations. Therefore, HPCSP combined with AVNA can alleviate symptoms and improve the quality of life in patients with persistent atrial fibrillation (AF) who are unresponsive to multiple radiofrequency ablation, particularly those with concomitant heart failure (HF) who are at risk of further deterioration. As a result, this "pace and ablate" strategy could become a first-line treatment for refractory AF. As a pacing modality, HBP faces challenges in achieving precise localization and tends to increase the pacing threshold. Thus, LBBP has emerged as a novel approach within HPCSP, offering lower thresholds, higher sensing amplitudes, and improved success rates, potentially making it a preferable alternative to HBP. Future large-scale, prospective, and randomized controlled studies are needed to evaluate patient selection and implantation technology, aiming to clarify the differential clinical outcomes between pacing modalities.

AV-node isolation as an alternative to AV-node ablation in patients undergoing pace & ablate strategy

INTRODUCTION

Atrioventricular (AV)-node ablation (AVNA) is a common therapy option for rate control strategy of permanent atrial fibrillation (AF). We hypothesized that isolation of the AV nodal isolation (AVNI) is associated with a more frequent preservation of an adequate escape rhythm compared to AVNA.

METHODS

This retrospective study included 20 patients with therapy-refractory AF being treated with AVNI and 40 historical AVNA-controls. In AVNI the AV-node region was mapped using a 3D mapping system. Ablation was performed around the previously mapped HIS-cloud regions isolating the atrium from the AV-node. In the AVNI group, ablation was performed with irrigated tip ablation catheter in all cases. The two approaches were compared regarding rate of escape rhythm, delta QRS, and procedural data.

RESULTS

The number of patients with adequate escape rhythm in AVNI was significantly superior to AVNA immediately postoperative (90% vs. 40%, p < 0.01) and during follow-up (77% vs. 36%, p < 0.05). The median change in QRS width was 0 ms in AVNI versus +26 ms in AVNA (p < 0.01). Thirty percent new bundle branch blocks in AVNA were observed compared to 0% in AVNI (p < 0.01). In the AVNI group, fluoroscopy time and total dose area product were significantly lower (p < 0.01).

CONCLUSION

The present study suggests that AV-node isolation using 3D navigation mapping system is a feasible and effective alternative to conventional AVNA. The precise application of radiofrequency lesions preserves a stable AV-junctional rhythm.

Three-dimensional mapping in cardiac implantable electronic device - a feasible and effective alternative to fluoroscopy

BACKGROUND

During the last decade, three-dimensional mapping technology has substantially aided the development of cardiac implanted electronic devices (CIEDs). This article intends to present an outline of the use and benefits of three-dimensional (3D) mapping systems in CIEDs.

RESULT

As an alternative to fluoroscopy, 3D mapping greatly minimizes radiation exposure and eliminates the need for contrast dye during the implantation of CIEDs. Based on the visualization of the pacing lead tip and accurate anatomic reconstruction of the chamber of interest and a specialized mapping technique, 3D mapping technology dramatically improves the efficacy and success of the advanced cardiac implantable devices' placement. Additionally, it provides a superior option for those with complex medical conditions.

CONCLUSION

The use of 3D mapping technology in CIEDs has been proven feasible and effective by accumulating evidence. It is fair to anticipate that it will be widely used in CIED implantation in the future.

Zero fluoroscopy atrioventricular node ablation and left bundle branch pacing guided by electroanatomic tridimensional mapping system

Recent publications have reported the feasibility of atrioventricular node ablation (AVNA) and concomitant His-bundle pacing guided by an electroanatomic tridimensional mapping system (ETMS). We report the case of a 65-year-old female patient in which zero fluoroscopy left bundle branch pacing and AVNA were performed guided just by ETMS. Optimal device functioning, electrical parameters stability, and correct lead location were observed 24 h and 30 days after the procedure. In selected cases, in which ionizing radiation is not recommended, this technique may represent an alternative for performing both interventions in the same procedure. <Learning objective: Left bundle branch pacing is a physiological form of ventricular pacing achievable with zero fluoroscopy, being a feasible alternative technique when fluoroscopy is not recommended.>.