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"Pacing"
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Permanent His bundle pacing: shaping the future of physiological ventricular pacing
Conventional right ventricular (RV) pacing, particularly RV apical pacing, can have deleterious effects on cardiac function. Long-term RV apical pacing has been associated with increased risk of atrial fibrillation, hospitalization for heart failure, pacing-induced cardiomyopathy and associated death. His bundle pacing (HBP) results in physiological ventricular activation and has generated tremendous research interest and enthusiasm. By stimulating the His–Purkinje network directly, HBP results in synchronized ventricular activation, which might translate into improved clinical outcomes compared with dyssynchronous ventricular activation with RV apical pacing. HBP can also overcome bundle branch block patterns, and data are accumulating on the benefit of HBP for cardiac resynchronization therapy. In this Review, we summarize the anatomy of the His bundle and early clinical observations, implantation techniques and available outcome data associated with permanent HBP. We also highlight the challenges with HBP and the need for additional tools and more randomized data before widespread application of permanent HBP.
Journal Article
ECG and Pacing Criteria for Differentiating Conduction System Pacing from Myocardial Pacing
During His-Purkinje conduction system (HPS) pacing, it is crucial to confirm capture of the His bundle or left bundle branch versus myocardialonly capture. For this, several methods and criteria for differentiation between non-selective (ns) capture – capture of the HPS and the adjacent myocardium – and myocardial-only capture were developed. HPS capture results in faster and more homogenous depolarisation of the left ventricle than right ventricular septal (RVS) myocardial-only capture. Specifically, the depolarisation of the left ventricle (LV) does not require slow cell-to-cell spread of activation from the right side to the left side of the interventricular septum but begins simultaneously with QRS onset as in native depolarisation. These phenomena greatly influence QRS complex morphology and form the basis of electrocardiographic differentiation between HPS and myocardial paced QRS. Moreover, the HPS and the working myocardium are different tissues within the heart muscle that vary not only in conduction velocities but also in refractoriness and capture thresholds. These last two differences can be exploited for the diagnosis of HPS capture using dynamic pacing manoeuvres, namely differential output pacing, programmed stimulation and burst pacing. This review summarises current knowledge of this subject.
Journal Article
Immediate clinical outcomes of left bundle branch area pacing vs conventional right ventricular pacing
Background Left bundle branch area pacing (LBBaP) is a new physiological pacing strategy that produces comparable clinical effects to His bundle pacing (HBP). Objective The purpose of this study was to investigate the immediate clinical outcomes of LBBaP vs RVP. Methods and Results From April 2018 to September 2018, we included 44 patients under continuous pacemaker implantation. Patients were randomly divided into the LBBaP group and conventional RVP group. Compared to the RVP group, the LBBaP group displayed significantly increased operative (90.10 ± 19.68 minutes vs 61.57 ± 6.62 minutes, P < .001) and X‐ray exposure times (15.55 ± 5.62 minutes vs 4.67 ± 2.06 minutes, P < .001). The lead threshold of the LBBaP group was increased (0.68 ± 0.20 mV vs 0.51 ± 0.0 mV, P = .001), while the R‐wave amplitude and ventricular impedance did not significantly differ between the two groups. The conventional RVP procedure significantly widened the QRS complex (93.62 ± 8.28 ms vs 135.19 ± 12.21 ms, P = .001), whereas the LBBaP had no effect on QRS complex (130.13 ± 43.30 ms vs 112.63 ± 12.14 ms, P = .904). Furthermore, the LBBaP procedure significantly narrowed the QRS complex in patients with left bundle branch block (LBBB) (168.43 ± 38.870 ms vs 119.86 ± 6.69 ms, P = .019). Conclusion LBBaP is a new physiological, safe and effective pacing procedure with a high overall success rate. Compared to conventional RVP, LBBaP can correct LBBB, thereby improving cardiac electrical dyssynchrony.
Journal Article
His-Purkinje conduction system pacing for pacing-induced cardiomyopathy: a systematic literature review and meta-analysis
Background
Upgrading to His-Purkinje conduction system pacing (HPCSP) has been proven to reverse ventricular remodeling and improve cardiac function in patients with pacing-induced cardiomyopathy (PICM). This meta-analysis aimed to assess the efficacy and clinical benefit of upgrading to HPCSP in patients with PICM after chronic right ventricular pacing (RVP).
Methods
We systematically searched PubMed, Cochrane Library, and Embase for relevant articles from databases’ establishment to April 22, 2022. Clinical outcomes and pacing parameters included left ventricular ejection fraction (LVEF) pre-RVP, pre-HPCSP, and during follow-up, New York Heart Association (NYHA) functional class at baseline and follow-up, lead-related complications, heart failure hospitalization (HFH), all-cause mortality, pacing thresholds at implant and during follow-up, and QRS duration (QRSd) pre-RVP, pre-HPCSP, and during follow-up.
Results
A total of 6 articles including 144 patients were enrolled in this meta-analysis. QRSd increased from 127 ± 29 ms at baseline to 175 ± 19 ms (
P
< 0.001) during RVP and then significantly narrowed to 116 ± 18 ms (
P
< 0.001) after upgrading to HPCSP. During a mean follow-up of 17.9 ± 10.5 months, LVEF improved from 35 ± 8% pre-HPSCP to 48 ± 12% after upgrading to HPCSP (
P
< 0.001). The capture thresholds were 1.2 ± 0.9 V at baseline and increased slightly during follow-up. NYHA functional class improved significantly from 2.7 ± 0.8 to 1.9 ± 0.8 during follow-up (
P
< 0.001).
Conclusion
Our meta-analysis indicates that upgrading to HPCSP in patients with PICM is feasible and efficient, as it significantly improves electrical synchrony and cardiac function.
Journal Article
Success and complication rates of conduction system pacing: a meta-analytical observational comparison of left bundle branch area pacing and His bundle pacing
Background
Left bundle branch area pacing (LBBAP) and His bundle pacing (HBP) are the main strategies to achieve conduction system pacing (CSP), but only observational studies with few patients have compared the two pacing strategies, sometimes with unclear results given the different definitions of the feasibility and safety outcomes. Therefore, we conducted a meta-analysis aiming to compare the success and complications of LBBAP versus HBP.
Methods
We systematically searched the electronic databases for studies published from inception to March 22, 2023, and focusing on LBBAP versus HBP. The study endpoints were CSP success rate, device-related complications, CSP lead-related complications and non-CSP lead-related complications.
Results
Fifteen observational studies enrolling 2491 patients met the inclusion criteria. LBBAP led to a significant increase in procedural success [91.1% vs 80.9%; RR: 1.15 (95% CI: 1.08–1.22);
p
< 0.00001] with a significantly lower complication rate [1.8% vs 5.2%; RR: 0.48 (95% CI: 0.29–0.78);
p
= 0.003], lead-related complications [1.1% vs 4.3%; RR: 0.38 (95% CI: 0.21–0.72);
p
= 0.003] and lead failure/deactivation [0.2% vs 3.9%; RR: 0.16 (95% CI: 0.07–0.35);
p
< 0.00001] than HBP. No significant differences were found between CSP lead dislodgement and non-CSP lead-related complications.
Conclusion
This meta-analysis of observational studies showed a higher success rate of LBBAP compared to HBP with a lower incidence of complications.
Journal Article
Conduction System Pacing: Hope, Challenges, and the Journey Forward
Purpose of the review
Cardiac pacing has evolved in recent years currently culminating in the specific stimulation of the cardiac conduction system (conduction system pacing, CSP). This review aims to provide a comprehensive overview of the available literature on CSP, focusing on a critical classification of studies comparing CSP with standard treatment in the two fields of pacing for bradycardia and cardiac resynchronization therapy in patients with heart failure. The article will also elaborate specific benefits and limitations associated with CSP modalities of His bundle pacing (HBP) and left bundle branch area pacing (LBBAP).
Recent findings
Based on a growing number of observational studies for different indications of pacing therapy, both CSP modalities investigated are advantageous over standard treatment in terms of narrowing the paced QRS complex and preserving or improving left ventricular systolic function. Less consistent evidence exists with regard to the improvement of heart failure-related rehospitalization rates or mortality, and effect sizes vary between HBP and LBBAP. LBBAP is superior over HBP in terms of lead measurements and procedural duration. With regard to all reported outcomes, evidence from large scale randomized controlled clinical trials (RCT) is still scarce.
Summary
CSP has the potential to sustainably improve patient care in cardiac pacing therapy if patients are appropriately selected and limitations are considered. With this review, we offer not only a summary of existing data, but also an outlook on probable future developments in the field, as well as a detailed summary of upcoming RCTs that provide insights into how the journey of CSP continues.
Graphical Abstract
Journal Article
Single-Chamber versus Dual-Chamber Pacing for High-Grade Atrioventricular Block
Patients with high-grade atrioventricular block usually require the implantation of a permanent pacemaker. Retrospective studies have suggested that dual-chamber pacemakers reduce the risk of atrial fibrillation, stroke, heart failure, and death in this setting, as compared with single-chamber ventricular pacemakers. In a randomized trial comparing these two pacing methods, however, no significant advantage of dual-chamber pacing was demonstrated.
In a randomized trial comparing these two pacing methods, no significant advantage of dual-chamber pacing was demonstrated.
Cardiac pacing is the established treatment for high-grade atrioventricular block, but the appropriate pacing mode remains the subject of debate.
1
Single-chamber ventricular pacing prevents bradycardia and death from ventricular standstill, but dual-chamber pacing better emulates normal cardiac physiology by restoring atrioventricular synchrony and matching the ventricular pacing rate to the sinus rate. As a result, dual-chamber pacing, as compared with single-chamber ventricular pacing, improves hemodynamic function,
2
–
4
but the clinical benefit is uncertain.
Nonrandomized studies suggest that dual-chamber pacing is associated with a lower incidence of atrial fibrillation, stroke, and heart failure than is single-chamber pacing.
5
There is also evidence . . .
Journal Article
Biventricular Pacing in Patients with Bradycardia and Normal Ejection Fraction
In this comparative-effectiveness trial, biventricular pacing prevented the reduction in left ventricular ejection fraction that is seen with right ventricular pacing.
The deleterious effect of nonphysiologic right ventricular apical pacing on left ventricular systolic function has been recognized since the 1920s.
1
In the Dual Chamber and VVI Implantable Defibrillator (DAVID) trial, the unexpected increased rates of death and hospital admission for heart failure among patients who were randomly assigned to the dual-chamber, rate-adaptive (DDDR) mode were purportedly due to the adverse effect of right ventricular apical pacing on left ventricular structural remodeling.
2
Results of subsequent trials have supported the notion that right ventricular apical pacing might lead to adverse clinical outcomes in patients with standard pacing indications.
3
–
7
Nevertheless, right ventricular . . .
Journal Article