Permanent His bundle pacing in patients with right atriomegaly: The value of different dedicated delivery sheaths

BACKGROUND

An enlarged right atrium (RA) is a challenging anatomy that can limit the successful use of His bundle pacing (HBP). It is unknown whether new implantation tools could help overcome these challenges.

METHODS

Consecutive patients with RA volume index >25 mL/m² in men and >21 mL/m² in women underwent permanent HBP. We used a stylet-driven lead (SDL) with an extendable helix delivered via a dedicated delivery sheath (Selectra 3D, Biotronik) as a first attempt. In case of failure, a second attempt was performed with the same lead but with a different delivery curve. Finally, a lumen-less lead (LLL) was also available as a third attempt.

RESULTS

The study cohort included 24 patients (median age 75.7 years [interquartile range, 70.9-79.0], 88% men) with a RA volume of 49 mL/m² (45-54). Using SDL, HBP was achieved with a single sheath curve in 17 patients (71%). The second attempt with the same lead but a different sheath was successful in four more patients (SDL success 87%). The fluoroscopy time increased significantly when the second attempt was necessary (8 min [6-11] vs. 15 min [13-17], p < .001). In the remaining three patients, HBP was further attempted with a LLL leading to a final procedural success of 96%. No lead dislodgment nor significant increase in pacing threshold was observed at 1-month (1.2 [0.7-1.7] V@1.0 ms vs. 1.1 [0.8-1.7] V@1.0 ms, p = .939).

CONCLUSION

The availability of different dedicated delivery systems for HBP can improve procedural outcomes even in challenging circumstances, such as in patients with right atriomegaly.

His bundle pacing: Tips and tricks

His bundle (HB) pacing is an established modality for achieving physiological pacing with a low risk of long-term lead-related complications. The development of specially designed lead and delivery tools has improved the feasibility and safety of HB pacing (HBP). Knowledge of the anatomy of HB region and the variations is essential for successful implantation. Newer delivery systems have further improved procedural outcomes. Challenging implant cases can be successfully performed by reshaping the current sheaths, using "sheath in sheath" technique or "two-lead implantation technique." Special attention to the lead parameters at implant, programming, and follow-up is necessary for successful long-term outcomes with HBP. Widespread use of HBP by electrophysiologists and further advances in dedicated delivery systems and leads are essential to further improve the effectiveness of the implantation.