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Kuschyk J, Sattler K, Fastenrath F, Rudic B, Akin I. [Treatment with cardiac electronic implantable devices]. Herz 2024; 49:233-246. [PMID: 38709278 DOI: 10.1007/s00059-024-05246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 05/07/2024]
Abstract
Cardiac device therapy provides not only treatment options for bradyarrhythmia but also advanced treatment for heart failure and preventive measures against sudden cardiac death. In heart failure treatment it enables synergistic reverse remodelling and reduces pharmacological side effects. Cardiac resynchronization therapy (CRT) has revolutionized the treatment of reduced left ventricular ejection fraction (LVEF) and left bundle branch block by decreasing the mortality and morbidity with improvement of the quality of life and resilience. Conduction system pacing (CSP) as an alternative method of physiological stimulation can improve heart function and reduce the risk of pacemaker-induced cardiomyopathy. Leadless pacers and subcutaneous/extravascular defibrillators offer less invasive options with lower complication rates. The prevention of infections through preoperative and postoperative strategies enhances the safety of these therapies.
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Affiliation(s)
- Jürgen Kuschyk
- I. Medizinische Klinik, Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Katherine Sattler
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Fabian Fastenrath
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Boris Rudic
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Ibrahim Akin
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
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Kiełbasa G, Jastrzębski M, Bednarek A, Kusiak A, Sondej T, Bednarski A, Ostrowska A, Żydzik Ł, Rajzer M, Vijayaraman P, Moskal P. The strength-duration curves for left bundle branch area pacing. Heart Rhythm 2024:S1547-5271(24)02568-2. [PMID: 38759916 DOI: 10.1016/j.hrthm.2024.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Despite growing clinical use of left bundle branch pacing (LBBP) there is scarcity of data regarding fundamentals of this pacing modality including chronaxie and rheobase. OBJECTIVE The aims of this study were to calculate strength-duration curves with chronaxie, rheobase values for LBBP and left ventricular septal myocardial pacing (LVSP), to analyse battery current drain and presence of selective LBBP at very short pulse duration (PD). METHODS The group of 141 patients with permanent LBBP were studied. The LBBP and LVSP capture thresholds were assessed at 6 different PDs to calculate the strength-duration curves. Battery current drain at these PDs and presence of selective LBBP were determined. For comparison of strength-duration curves between His bundle pacing (HBP) and LBBP, source data from our previous work based on 127 patients with HBP were obtained. RESULTS The chronaxies for LBBP and LVSP were very similar (0.38 ms vs. 0.39 ms) and the rheobases were identical (0.27V). The chronaxie for LBBP was lower than for HBP (0.38ms vs. 0.53 ms, p < 0.001), whereas rheobases were similar (0.27V vs. 0.26V). A narrow zone of selective capture was present in 19% and 41% of patients at PD of 0.06 ms and 0.03 ms, respectively. When pacing with the safety margin of +1 V, the lowest battery current drain was achieved with PD of 0.2 ms. CONCLUSION The obtained strength-duration curves for LBBP and LVSP provide insights for optimal programming of LBBAP devices with regard to pulse duration, voltage amplitude, battery longevity and selective capture.
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Affiliation(s)
- Grzegorz Kiełbasa
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; First Department of Cardiology, Interventional Electrocardiology and Hypertension University Hospital in Krakow, Krakow, Poland.
| | - Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; Electrophysiology Laboratory, University Hospital in Krakow, Krakow, Poland
| | - Agnieszka Bednarek
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; First Department of Cardiology, Interventional Electrocardiology and Hypertension University Hospital in Krakow, Krakow, Poland
| | - Aleksander Kusiak
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Tomasz Sondej
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Adam Bednarski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Aleksandra Ostrowska
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Łukasz Żydzik
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Marek Rajzer
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; First Department of Cardiology, Interventional Electrocardiology and Hypertension University Hospital in Krakow, Krakow, Poland
| | - Pugazhendhi Vijayaraman
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland; Geisinger Heart Institute, Wilkes-Barre, Pennsylvania, USA
| | - Paweł Moskal
- Electrophysiology Laboratory, University Hospital in Krakow, Krakow, Poland
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Batta A, Hatwal J. Left bundle branch pacing set to outshine biventricular pacing for cardiac resynchronization therapy? World J Cardiol 2024; 16:186-190. [PMID: 38690215 PMCID: PMC11056871 DOI: 10.4330/wjc.v16.i4.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/09/2024] [Accepted: 03/18/2024] [Indexed: 04/23/2024] Open
Abstract
The deleterious effects of long-term right ventricular pacing necessitated the search for alternative pacing sites which could prevent or alleviate pacing-induced cardiomyopathy. Until recently, biventricular pacing (BiVP) was the only modality which could mitigate or prevent pacing induced dysfunction. Further, BiVP could resynchronize the baseline electromechanical dssynchrony in heart failure and improve outcomes. However, the high non-response rate of around 20%-30% remains a major limitation. This non-response has been largely attributable to the direct non-physiological stimulation of the left ventricular myocardium bypassing the conduction system. To overcome this limitation, the concept of conduction system pacing (CSP) came up. Despite initial success of the first CSP via His bundle pacing (HBP), certain drawbacks including lead instability and dislodgements, steep learning curve and rapid battery depletion on many occasions prevented its widespread use for cardiac resynchronization therapy (CRT). Subsequently, CSP via left bundle branch-area pacing (LBBP) was developed in 2018, which over the last few years has shown efficacy comparable to BiVP-CRT in small observational studies. Further, its safety has also been well established and is largely free of the pitfalls of the HBP-CRT. In the recent metanalysis by Yasmin et al, comprising of 6 studies with 389 participants, LBBP-CRT was superior to BiVP-CRT in terms of QRS duration, left ventricular ejection fraction, cardiac chamber dimensions, lead thresholds, and functional status amongst heart failure patients with left bundle branch block. However, there are important limitations of the study including the small overall numbers, inclusion of only a single small randomized controlled trial (RCT) and a small follow-up duration. Further, the entire study population analyzed was from China which makes generalizability a concern. Despite the concerns, the meta-analysis adds to the growing body of evidence demonstrating the efficacy of LBBP-CRT. At this stage, one must acknowledge that the fact that still our opinions on this technique are largely based on observational data and there is a dire need for larger RCTs to ascertain the position of LBBP-CRT in management of heart failure patients with left bundle branch block.
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Affiliation(s)
- Akash Batta
- Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana 141001, India.
| | - Juniali Hatwal
- Department of Internal Medicine, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
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Alfieri M, Bruscoli F, Di Vito L, Di Giusto F, Scalone G, Marchese P, Delfino D, Silenzi S, Martoni M, Guerra F, Grossi P. Novel Medical Treatments and Devices for the Management of Heart Failure with Reduced Ejection Fraction. J Cardiovasc Dev Dis 2024; 11:125. [PMID: 38667743 PMCID: PMC11050600 DOI: 10.3390/jcdd11040125] [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: 03/25/2024] [Revised: 04/13/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Heart failure (HF) is a growing issue in developed countries; it is often the result of underlying processes such as ischemia, hypertension, infiltrative diseases or even genetic abnormalities. The great majority of the affected patients present a reduced ejection fraction (≤40%), thereby falling under the name of "heart failure with reduced ejection fraction" (HFrEF). This condition represents a major threat for patients: it significantly affects life quality and carries an enormous burden on the whole healthcare system due to its high management costs. In the last decade, new medical treatments and devices have been developed in order to reduce HF hospitalizations and improve prognosis while reducing the overall mortality rate. Pharmacological therapy has significantly changed our perspective of this disease thanks to its ability of restoring ventricular function and reducing symptom severity, even in some dramatic contexts with an extensively diseased myocardium. Notably, medical therapy can sometimes be ineffective, and a tailored integration with device technologies is of pivotal importance. Not by chance, in recent years, cardiac implantable devices witnessed a significant improvement, thereby providing an irreplaceable resource for the management of HF. Some devices have the ability of assessing (CardioMEMS) or treating (ultrafiltration) fluid retention, while others recognize and treat life-threatening arrhythmias, even for a limited time frame (wearable cardioverter defibrillator). The present review article gives a comprehensive overview of the most recent and important findings that need to be considered in patients affected by HFrEF. Both novel medical treatments and devices are presented and discussed.
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Affiliation(s)
- Michele Alfieri
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I-Lancisi-Salesi”, 60121 Ancona, Italy; (M.A.); (F.G.)
| | - Filippo Bruscoli
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Luca Di Vito
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Federico Di Giusto
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Giancarla Scalone
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Procolo Marchese
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Domenico Delfino
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Simona Silenzi
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Milena Martoni
- Medical School, Università degli Studi “G. d’Annunzio”, 66100 Chieti, Italy;
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I-Lancisi-Salesi”, 60121 Ancona, Italy; (M.A.); (F.G.)
| | - Pierfrancesco Grossi
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
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Kono H, Kuramitsu S, Fukunaga M, Korai K, Nagashima M, Hiroshima K, Ando K. Outcomes of left bundle branch area pacing compared to His bundle pacing and right ventricular apical pacing in Japanese patients with bradycardia. J Arrhythm 2024; 40:333-341. [PMID: 38586856 PMCID: PMC10995588 DOI: 10.1002/joa3.12997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 04/09/2024] Open
Abstract
Background His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) emerge as better alternatives to right ventricular apical pacing (RVAP) in patients with bradycardia requiring permanent cardiac pacing. We aimed to compare the clinical outcomes of LBBAP, HBP, and RVAP in Japanese patients with bradycardia. Methods A total of 424 patients who underwent successful pacemaker implantation (HBP, n = 53; LBBAP, n = 75; and RVAP, n = 296) were retrospectively enrolled in this study. The primary study endpoint was the cumulative incidence of heart failure hospitalization (HFH) during the follow-up. Results The success rate for implantation was higher in the LBBAP group than in the HBP group (94.9% and 81.5%, respectively). Capture threshold increase >1V during the follow-up occurred in the HBP and RVAP groups (9.4% and 5.1%, respectively), while it did not in the LBBAP group. The cumulative incidence of HFH was significantly lower in the LBBAP group than the RVAP (adjusted hazard ratio, 0.12 [95% confidence interval: 0.02-0.86]; p = .034); it did not differ between the HBP and RVAP groups (adjusted hazard ratio, 0.48 [95% confidence interval: 0.17-1.34]; p = .16). Advanced age, mean percent right ventricular pacing (per 10% increase), left ventricular ejection fraction <50%, and RVAP were associated with HFH. Conclusions Compared to RVAP and HBP, LBBAP appeared more feasible and effective in patients with bradycardia requiring permanent cardiac pacing.
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Affiliation(s)
- Hiroyuki Kono
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | - Shoichi Kuramitsu
- Department of Cardiovascular MedicineSapporo Cardiovascular Clinic, Sapporo Heart CenterSapporoJapan
| | - Masato Fukunaga
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | - Kengo Korai
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | | | | | - Kenji Ando
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
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Tan ESJ, Soh R, Lee JY, Boey E, Chan SP, Lim TW, Yeo WT, Leong KMW, Seow SC, Kojodjojo P. Prognostic benefits of His-Purkinje capture in physiological pacemakers for bradycardia. J Cardiovasc Electrophysiol 2024; 35:727-736. [PMID: 38351331 DOI: 10.1111/jce.16211] [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: 07/19/2023] [Revised: 10/11/2023] [Accepted: 01/29/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Clinical outcomes of long-term ventricular septal pacing (VSP) without His-Purkinje capture remain unknown. This study evaluated the differences in clinical outcomes between conduction system pacing (CSP), VSP, and right ventricular pacing (RVP). METHODS Consecutive patients with bradycardia indicated for pacing from 2016 to 2022 were prospectively followed for the clinical endpoints of heart failure (HF)-hospitalizations and all-cause mortality at 2 years. VSP was defined as septal pacing due to unsuccessful CSP implant or successful CSP followed by loss of His-Purkinje capture within 90 days. RESULTS Among 1016 patients (age 73.9 ± 11.2 years, 47% female, 48% atrioventricular block), 612 received RVP, 335 received CSP and 69 received VSP. Paced QRS duration was similar between VSP and RVP, but both significantly longer than CSP (p < .05). HF-hospitalizations occurred in 130 (13%) patients (CSP 7% vs. RVP 16% vs. VSP 13%, p = .001), and all-cause mortality in 143 (14%) patients (CSP 7% vs. RVP 19% vs. VSP 9%, p < .001). The association of pacing modality with clinical events was limited to those with ventricular pacing (Vp) > 20% (pinteraction < .05). Adjusting for clinical risk factors among patients with Vp > 20%, VSP (adjusted hazard ratio [AHR]: 4.74, 95% confidence interval [CI]: 1.57-14.36) and RVP (AHR: 3.08, 95% CI: 1.44-6.60) were associated with increased hazard of HF-hospitalizations, and RVP (2.52, 95% CI: 1.19-5.35) with increased mortality, compared to CSP. Clinical endpoints did not differ between VSP and RVP with Vp > 20%, or amongst groups with Vp < 20%. CONCLUSION Conduction system capture is associated with improved clinical outcomes. CSP should be preferred over VSP or RVP during pacing for bradycardia.
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Affiliation(s)
- Eugene S J Tan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Rodney Soh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Jie-Ying Lee
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Elaine Boey
- Department of Cardiology, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Siew-Pang Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Toon Wei Lim
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Wee Tiong Yeo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Kevin M W Leong
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Swee-Chong Seow
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Pipin Kojodjojo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
- Department of Cardiology, Ng Teng Fong General Hospital, Singapore, Singapore
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Seow SC. A novel method to disengage trapped helix during left bundle branch pacing. Heart Rhythm 2024:S1547-5271(24)00283-2. [PMID: 38508298 DOI: 10.1016/j.hrthm.2024.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Swee-Chong Seow
- Department of Cardiology, National University Hospital, Singapore.
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Sánchez-Quintana D, Cabrera JA, Anderson RH. The clinical anatomy of the atrioventricular conduction axis. Europace 2024; 26:euae048. [PMID: 38364795 PMCID: PMC10911402 DOI: 10.1093/europace/euae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/12/2024] [Indexed: 02/18/2024] Open
Abstract
It is axiomatic that the chances of achieving accurate capture of the conduction axis and its fascicles will be optimized by equally accurate knowledge of the relationship of the components to the recognizable cardiac landmarks, and we find it surprising that acknowledged experts should continue to use drawings that fall short in terms of anatomical accuracy. The accuracy achieved by Sunao Tawara (1906) in showing the location of the atrioventricular conduction axis is little short of astounding. Our purpose in bringing this to current attention is to question the need of the experts to have produced such inaccurate representations, since the findings of Tawara have been extensively endorsed in very recent years. The recent studies do no more than point to the amazing accuracy of the initial account of Tawara. At the same time, we draw attention to the findings described in the middle of the 20th century by Ivan Mahaim (1947). These observations have tended to be ignored in recent accounts. They are, perhaps, of equal significance to those seeking specifically to pace the left fascicles of the branching atrioventricular bundle.
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Affiliation(s)
- Damián Sánchez-Quintana
- Departamento de Anatomía Humana y Biología Celular, Facultad de Medicina, Universidad de Extremadura, Elvas Avenue, Badajoz 06006, Spain
| | - Jose-Angel Cabrera
- Departamento de Cardiología, Unidad de Arritmias, Hospital Universitario Quirón-Salud Madrid and complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Burri H. Maintaining mechanical synchrony with left bundle branch area pacing. Eur Heart J Cardiovasc Imaging 2024; 25:337-338. [PMID: 37966280 DOI: 10.1093/ehjci/jead310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/16/2023] Open
Affiliation(s)
- Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Rue Gabrielle Perret Gentil 4, Geneva 1211, Switzerland
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Burri H. Perforation of the interventricular septum with left bundle branch area pacing: Diagnosis and management. HeartRhythm Case Rep 2024; 10:117-118. [PMID: 38404975 PMCID: PMC10885709 DOI: 10.1016/j.hrcr.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Affiliation(s)
- Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
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Ghosh A, Sekar A, Sriram CS, Pandurangi UM. A case of exaggerated exuberance: Iatrogenic atrioventricular block/intra-Hisian Wenckebach during conduction system pacing. J Arrhythm 2024; 40:156-159. [PMID: 38333381 PMCID: PMC10848609 DOI: 10.1002/joa3.12968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/01/2023] [Accepted: 11/19/2023] [Indexed: 02/10/2024] Open
Abstract
Isolated sinus node dysfunction with its pursuant long-term risk for atrioventricular (AV) conduction disease poses a unique dilemma for proponents of CSP due to paucity of imprimatur guidelines. In such scenarios, the risk and prognosis of iatrogenic AV block is not well elucidated but is a valid concern. We report a case where CSP was complicated by iatrogenic AV block and peculiarly the rare phenomenon of intra-Hisian Wenckebach.
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Affiliation(s)
- Anindya Ghosh
- Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure AcademyThe Madras Medical MissionChennaiIndia
| | - Anbarasan Sekar
- Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure AcademyThe Madras Medical MissionChennaiIndia
| | - Chenni S. Sriram
- Division of Cardiology, Sub‐Section of ElectrophysiologyChildren's Hospital of Michigan and Detroit Medical CenterDetroitMichiganUSA
| | - Ulhas M. Pandurangi
- Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure AcademyThe Madras Medical MissionChennaiIndia
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Taddeucci S, Marallo C, Merello G, Santoro A. Cardiac resynchronization therapy with conduction system pacing in a long-term heart transplant recipient: A case report. Indian Pacing Electrophysiol J 2024:S0972-6292(24)00003-2. [PMID: 38199455 DOI: 10.1016/j.ipej.2024.01.003] [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: 08/17/2023] [Revised: 11/01/2023] [Accepted: 01/08/2024] [Indexed: 01/12/2024] Open
Abstract
We performed cardiac resynchronization therapy by means of conduction system pacing in a heart transplant patient suffering from heart failure with reduced ejection fraction and atrial fibrillation with conduction disturbance (bifascicular block and QRS >160 ms). ECG monitoring showed paroxysmal atrioventricular block. Biventricular pacing was not feasible due to the absence of a suitable coronary sinus branch for pacing. His bundle pacing was performed, and an implantable cardioverter-defibrillator was implanted due to severe left ventricular dysfunction. Cardiac allograft vasculopathy was excluded. During follow-up, the patient's left ventricular function improved, and symptoms alleviated with a high percentage of ventricular stimulation.
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Affiliation(s)
| | | | | | - Amato Santoro
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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Kosztin A, Maass A, Diemberger I. Editorial: Response to cardiac resynchronization therapy. Front Cardiovasc Med 2024; 10:1297343. [PMID: 38250031 PMCID: PMC10797118 DOI: 10.3389/fcvm.2023.1297343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/12/2023] [Indexed: 01/23/2024] Open
Affiliation(s)
- Annamaria Kosztin
- Department of Cardiology, Heart and Vascular Center, Semmelweis Univeristy, Budapest, Hungary
| | - Alexander Maass
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherland
| | - Igor Diemberger
- Institute of Cardiology, Department of Medical and Surgical Sciences, University of Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
- UOC di Cardiologia, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Dipartimento Cardio-toraco-vascolare, Bologna, Italy
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Van Puyvelde T, Rosseel T, Pluijmert N, Van Casteren L, Willems R, Vörös G. A case report of far-field P-wave oversensing in left bundle branch area pacing. HeartRhythm Case Rep 2024; 10:76-80. [PMID: 38264105 PMCID: PMC10801066 DOI: 10.1016/j.hrcr.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Affiliation(s)
- Tim Van Puyvelde
- Division of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium
| | - Thomas Rosseel
- Division of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium
| | - Niek Pluijmert
- Division of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium
- Division of Cardiology, General Hospital Diest, Diest, Belgium
| | | | - Rik Willems
- Division of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Catholic University of Leuven, Leuven, Belgium
| | - Gábor Vörös
- Division of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Catholic University of Leuven, Leuven, Belgium
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15
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Yang Z, Liang J, Chen R, Pang N, Zhang N, Guo M, Gao J, Wang R. Clinical outcomes of left bundle branch area pacing: Prognosis and specific applications. Pacing Clin Electrophysiol 2024; 47:80-87. [PMID: 38112026 DOI: 10.1111/pace.14907] [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: 07/23/2023] [Revised: 11/02/2023] [Accepted: 12/05/2023] [Indexed: 12/20/2023]
Abstract
Cardiac pacing has become a widely accepted treatment strategy for bradyarrhythmia and heart failure. However, conventional right ventricular pacing (RVP) has been associated with electrical dyssynchrony, which may result in atrial fibrillation and heart failure. To achieve physiological pacing, Deshmukh et al. reported the first case of His bundle pacing (HBP) in 2000. This strategy was reported to have preserved ventricular synchronization by activating the conventional conduction system. Nonetheless, due to the anatomical location of the His bundle (HB), several issues such as high pacing thresholds, lead fixation, and early battery depletion may pose a challenge. Recently, left bundle branch area pacing (LBBAP) has emerged as a novel physiological pacing strategy to achieve conduction system pacing by capturing the left bundle branch through the deep septum. Additionally, several studies have investigated the clinical outcomes of LBBAP. In this paper, we describe the pacing parameters, QRS duration (QRSd), cardiac function, complications, and specific applications of LBBAP in recent years.
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Affiliation(s)
- Zhen Yang
- The First Clinical Medical College, Shanxi Medical University, Shanxi, China
- Department of Cardiology, First Hospital of Shanxi Medical University, Shanxi, China
| | - Jiadong Liang
- The First Clinical Medical College, Shanxi Medical University, Shanxi, China
- Department of Cardiology, First Hospital of Shanxi Medical University, Shanxi, China
| | - Ruizhe Chen
- The First Clinical Medical College, Shanxi Medical University, Shanxi, China
- Department of Cardiology, First Hospital of Shanxi Medical University, Shanxi, China
| | - Naidong Pang
- The First Clinical Medical College, Shanxi Medical University, Shanxi, China
- Department of Cardiology, First Hospital of Shanxi Medical University, Shanxi, China
| | - Nan Zhang
- Department of Cardiology, First Hospital of Shanxi Medical University, Shanxi, China
| | - Min Guo
- Department of Cardiology, First Hospital of Shanxi Medical University, Shanxi, China
| | - Jia Gao
- Department of Cardiology, First Hospital of Shanxi Medical University, Shanxi, China
| | - Rui Wang
- Department of Cardiology, First Hospital of Shanxi Medical University, Shanxi, China
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16
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Sola-García E, Molina-Lerma M, Jiménez-Jáimez J, Macías-Ruiz R, Sánchez-Millán PJ, Tercedor L, Álvarez M. Autothreshold algorithm feasibility and safety in left bundle branch pacing. Europace 2023; 26:euad359. [PMID: 38042980 PMCID: PMC10766140 DOI: 10.1093/europace/euad359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 11/25/2023] [Indexed: 12/04/2023] Open
Abstract
AIMS Autothreshold algorithms enable remote monitoring of patients with conventional pacing, but there is limited information on their performance in left bundle branch pacing (LBBP). Our objective was to analyse the behaviour of the autothreshold algorithm in LBBP and compare it with conventional pacing and manual thresholds during initial device programming (acute phase), after 1-7 days (subacute), and 1-3 months later (chronic). METHODS AND RESULTS A prospective, non-randomized, single-centre comparative study was conducted. Consecutive patients with indication for cardiac pacing were enrolled. Implants were performed in the left bundle branch area or the right ventricle endocardium at the discretion of the operator. Left bundle branch pacing was determined according to published criteria. Autothreshold algorithm was activated in both groups whenever allowed by the device. Seventy-five patients were included, with 50 undergoing LBBP and 25 receiving conventional pacing. Activation of the autothreshold algorithm was more feasible in later phases, showing a favourable trend towards bipolar pacing. Failures in algorithm activation were primarily due to insufficient safety margins (82.8% in LBBP and 90% in conventional pacing). The remainder was attributed to atrial tachyarrhythmias (10.3% and 10%, respectively) and electrical noise (the remaining 6.9% in the LBBP group). In the LBBP group, there were not statistically significant differences between manual and automatic thresholds, and both remained stable during follow-up (mean increase of 0.50 V). CONCLUSION The autothreshold algorithm is feasible in LBBP, with a favourable trend towards bipolar pacing. Automatic thresholds are similar to manual in patients with LBBP, and they remain stable during follow-up.
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Affiliation(s)
- Elena Sola-García
- Cardiology Department, Virgen de las Nieves University Hospital, Avenida de las Fuerzas Armadas n° 2, Granada 18014, Spain
- Instituto de investigación biosanitaria de Granada (FIBAO), Edificio Licinio de la Fuente, Calle Dr. Azpitarte nº 4, Planta 5ª, Granada 18012, Spain
| | - Manuel Molina-Lerma
- Instituto de investigación biosanitaria de Granada (FIBAO), Edificio Licinio de la Fuente, Calle Dr. Azpitarte nº 4, Planta 5ª, Granada 18012, Spain
- Arrhythmia Unit, Cardiology Department, Virgen de las Nieves University Hospital, Avenida de las Fuerzas Armadas n° 2, Granada 18014, Spain
| | - Juan Jiménez-Jáimez
- Instituto de investigación biosanitaria de Granada (FIBAO), Edificio Licinio de la Fuente, Calle Dr. Azpitarte nº 4, Planta 5ª, Granada 18012, Spain
- Arrhythmia Unit, Cardiology Department, Virgen de las Nieves University Hospital, Avenida de las Fuerzas Armadas n° 2, Granada 18014, Spain
| | - Rosa Macías-Ruiz
- Instituto de investigación biosanitaria de Granada (FIBAO), Edificio Licinio de la Fuente, Calle Dr. Azpitarte nº 4, Planta 5ª, Granada 18012, Spain
- Arrhythmia Unit, Cardiology Department, Virgen de las Nieves University Hospital, Avenida de las Fuerzas Armadas n° 2, Granada 18014, Spain
| | - Pablo J Sánchez-Millán
- Instituto de investigación biosanitaria de Granada (FIBAO), Edificio Licinio de la Fuente, Calle Dr. Azpitarte nº 4, Planta 5ª, Granada 18012, Spain
- Arrhythmia Unit, Cardiology Department, Virgen de las Nieves University Hospital, Avenida de las Fuerzas Armadas n° 2, Granada 18014, Spain
| | - Luis Tercedor
- Instituto de investigación biosanitaria de Granada (FIBAO), Edificio Licinio de la Fuente, Calle Dr. Azpitarte nº 4, Planta 5ª, Granada 18012, Spain
- Arrhythmia Unit, Cardiology Department, Virgen de las Nieves University Hospital, Avenida de las Fuerzas Armadas n° 2, Granada 18014, Spain
| | - Miguel Álvarez
- Instituto de investigación biosanitaria de Granada (FIBAO), Edificio Licinio de la Fuente, Calle Dr. Azpitarte nº 4, Planta 5ª, Granada 18012, Spain
- Arrhythmia Unit, Cardiology Department, Virgen de las Nieves University Hospital, Avenida de las Fuerzas Armadas n° 2, Granada 18014, Spain
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17
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Glikson M, Jastrzebski M, Gold MR, Ellenbogen K, Burri H. Conventional biventricular pacing is still preferred to conduction system pacing for atrioventricular block in patients with reduced ejection fraction and narrow QRS. Europace 2023; 26:euad337. [PMID: 38153385 PMCID: PMC10754179 DOI: 10.1093/europace/euad337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 11/05/2023] [Indexed: 12/29/2023] Open
Abstract
It is well established that right ventricular pacing is detrimental in patients with reduced cardiac function who require ventricular pacing (VP), and alternatives nowadays are comprised of biventricular pacing (BiVP) and conduction system pacing (CSP). The latter modality is of particular interest in patients with a narrow baseline QRS as it completely avoids, or minimizes, ventricular desynchronization associated with VP. In this article, experts debate whether BiVP or CSP should be used to treat these patients.
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Affiliation(s)
- Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Marek Jastrzebski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Jakubowskiego 2, 30-688 Krakow, Poland
| | - Michael R Gold
- Virginia Commonwealth University, VCU Medical Center Gateway Building, 1200 E. Marshall Street, Richmond, VA 23219, USA
| | - Kenneth Ellenbogen
- MUSC Division of Cardiology, Medical University of South Carolina, 25 Courtenay Dr, MS-592, Charleston, SC 29425, USA
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Rue Gabrielle Perret Gentil 4, 1211, Geneva, Switzerland
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18
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Stankovic I, Voigt JU, Burri H, Muraru D, Sade LE, Haugaa KH, Lumens J, Biffi M, Dacher JN, Marsan NA, Bakelants E, Manisty C, Dweck MR, Smiseth OA, Donal E. Imaging in patients with cardiovascular implantable electronic devices: part 2-imaging after device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J Cardiovasc Imaging 2023; 25:e33-e54. [PMID: 37861420 DOI: 10.1093/ehjci/jead273] [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: 10/14/2023] [Revised: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 10/21/2023] Open
Abstract
Cardiac implantable electronic devices (CIEDs) improve quality of life and prolong survival, but there are additional considerations for cardiovascular imaging after implantation-both for standard indications and for diagnosing and guiding management of device-related complications. This clinical consensus statement (part 2) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients after implantation of conventional pacemakers, cardioverter defibrillators, and cardiac resynchronization therapy (CRT) devices. The document summarizes the existing evidence regarding the role and optimal use of various cardiac imaging modalities in patients with suspected CIED-related complications and also discusses CRT optimization, the safety of magnetic resonance imaging in CIED carriers, and describes the role of chest radiography in assessing CIED type, position, and complications. The role of imaging before and during CIED implantation is discussed in a companion document (part 1).
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Affiliation(s)
- Ivan Stankovic
- Clinical Hospital Centre Zemun, Department of Cardiology, Faculty of Medicine, University of Belgrade, Vukova 9, 11080 Belgrade, Serbia
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven/Department of Cardiovascular Sciences, Catholic University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Leyla Elif Sade
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, PA, USA
- University of Baskent, Department of Cardiology, Ankara, Turkey
| | - Kristina Hermann Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
- Faculty of Medicine, Karolinska Institutet and Cardiovascular Division, Karolinska University Hospital, Stockholm, Sweden
| | - Joost Lumens
- Cardiovascular Research Center Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Mauro Biffi
- Department of Cardiology, IRCCS, Azienda Ospedaliero Universitaria Di Bologna, Policlinico Di S.Orsola, Bologna, Italy
| | - Jean-Nicolas Dacher
- Department of Radiology, Normandie University, UNIROUEN, INSERM U1096-Rouen University Hospital, F 76000 Rouen, France
| | - Nina Ajmone Marsan
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, The Netherlands
| | - Elise Bakelants
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Charlotte Manisty
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Otto A Smiseth
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Rennes, France
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19
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Hopman LHGA, Beunder KP, Borodzicz-Jazdzyk S, Götte MJW, van Halm VP. Loss of capture of conduction system pacemaker caused by fibrosis surrounding the lead: a case report. BMC Cardiovasc Disord 2023; 23:621. [PMID: 38114911 PMCID: PMC10729341 DOI: 10.1186/s12872-023-03656-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Conduction system pacing (CSP) is a novel technique that involves pacing the His-Purkinje system instead of the traditional right ventricular (RV) apex. This technique aims to avoid the adverse effects of RV apical pacing, which can lead to ventricular dyssynchrony and heart failure over time. CSP is gaining popularity but its long-term efficacy and challenges remain uncertain. This report discusses a case where CSP was initially successful but faced complications due to an increasing pacing threshold. CASE PRESENTATION A 65-year-old female with total atrioventricular block was referred for brady-pacing. Due to the potential for chronic RV pacing, CSP was chosen. The CSP implantation involved subcutaneous device placement, with a CSP lead in the left bundle branch area (LBBA) and an RV backup lead. A year after successful implantation, the LBBA pacing threshold progressively increased. Subsequent efforts to correct it led to anodal capture and battery depletion. Cardiac magnetic resonance imaging (CMR) revealed mid-septal fibrosis at the area of LBBA lead placement and suggested cardiac sarcoidosis as a possible cause. CONCLUSION CSP is a promising technique for treating bradyarrhythmias, but this case underscores the need for vigilance in monitoring pacing thresholds. Increasing thresholds can render CSP ineffective, necessitating alternative pacing methods. The CMR findings of mid-septal fibrosis and the potential diagnosis of cardiac sarcoidosis emphasize the importance of pre-implantation assessment, as CSP may be compromised by underlying structural abnormalities. This report highlights the complexities of pacing strategy selection and the significance of comprehensive evaluation before adopting CSP.
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Affiliation(s)
- Luuk H G A Hopman
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Kyle P Beunder
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Sonia Borodzicz-Jazdzyk
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marco J W Götte
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Vokko P van Halm
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
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20
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Wijesuriya N, Mehta V, Vere FD, Howell S, Behar JM, Shute A, Lee M, Bosco P, Niederer SA, Rinaldi CA. Cost-effectiveness analysis of leadless cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2023; 34:2590-2598. [PMID: 37814470 PMCID: PMC10946454 DOI: 10.1111/jce.16102] [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: 07/14/2023] [Revised: 09/11/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND The Wireless Stimulation Endocardially for CRT (WiSE-CRT) system is a novel technology used to treat patients with dyssynchronous heart failure (HF) by providing leadless cardiac resynchronization therapy (CRT). Observational studies have demonstrated its safety and efficacy profile, however, the treatment cost-effectiveness has not previously been examined. METHODS A cost-effectiveness evaluation of the WiSE-CRT System was performed using a cohort-based economic model adopting a "proportion in state" structure. In addition to the primary analysis, scenario analyses and sensitivity analyses were performed to test for uncertainty in input parameters. Outcomes were quantified in terms of quality-adjusted life year (QALY) differences. RESULTS The primary analysis demonstrated that treatment with the WiSE-CRT system is likely to be cost-effective over a lifetime horizon at a QALY reimbursement threshold of £20 000, with a net monetary benefit (NMB) of £3781 per QALY. Cost-effectiveness declines at time horizons shorter than 10 years. Sensitivity analyses demonstrated that average system battery life had the largest impact on potential cost-effectiveness. CONCLUSION Within the model limitations, these findings support the use of WiSE-CRT in indicated patients from an economic standpoint. However, improving battery technology should be prioritized to maximize cost-effectiveness in times when health services are under significant financial pressures.
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Affiliation(s)
- Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Felicity De Vere
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Sandra Howell
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Jonathan M. Behar
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | | | | | - Paolo Bosco
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- National Heart and Lung InstituteImperial CollegeLondonUK
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging SciencesKing's College LondonLondonUK
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
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21
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Moreira GR, Villacorta H. A Personalized Approach to the Management of Congestion in Acute Heart Failure. Heart Int 2023; 17:35-42. [PMID: 38455673 PMCID: PMC10919353 DOI: 10.17925/hi.2023.17.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/18/2023] [Indexed: 03/09/2024] Open
Abstract
Heart failure (HF) is the common final pathway of several conditions and is characterized by hyperactivation of numerous neurohumoral pathways. Cardiorenal interaction plays an essential role in the progression of the disease, and the use of diuretics is a cornerstone in the treatment of hypervolemic patients, especially in acute decompensated HF (ADHF). The management of congestion is complex and, to avoid misinterpretations and errors, one must understand the interface between the heart and the kidneys in ADHF. Congestion itself may impair renal function and must be treated aggressively. Transitory elevations in serum creatinine during decongestion is not associated with worse outcomes and diuretics should be maintained in patients with clear hypervolemia. Monitoring urinary sodium after diuretic administration seems to improve the response to diuretics as it allows for adjustments in doses and a personalized approach. Adequate assessment of volemia and the introduction and titration of guideline-directed medical therapy are mandatory before discharge. An early visit after discharge is highly recommended, to assess for residual congestion and thus avoid readmissions.
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Affiliation(s)
- Gustavo R Moreira
- Cardiology Division, Fluminense Federal University, Niterói, Rio de Janeiro State, Brazil
| | - Humberto Villacorta
- Cardiology Division, Fluminense Federal University, Niterói, Rio de Janeiro State, Brazil
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22
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Liu Z, Liu X. Feasibility and Safety Study of Concomitant Left Bundle Branch Area Pacing and Atrioventricular Node Ablation with Same-Day Hospital Dismissal. J Clin Med 2023; 12:7002. [PMID: 38002617 PMCID: PMC10672577 DOI: 10.3390/jcm12227002] [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: 09/26/2023] [Revised: 10/30/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) has rapidly emerged as a promising modality of physiologic pacing and has demonstrated excellent lead stability. In this retrospective study, we evaluate whether this pacing modality can allow concomitant atrioventricular node (AVN) ablation and same-day dismissal. METHODS Twenty-four consecutive patients (female 63%, male 37%) with an average age of 78 ± 5 years were admitted for pacemaker (75%)/defibrillator (25%) implantations and concomitant AVN ablation. Device implantation with LBBAP was performed first, followed by concomitant AVN ablation through left axillary vein access to allow for quicker post-procedure ambulation. The patients were discharged on the same day after satisfactory post-ambulation device checks. RESULTS LBBAP was successful in 22 patients (92% in total, 20 patients had an LBBP and two patients had a likely LBBP), followed by AVN ablation from left axillary vein access (21/24, 88%). All patients had successful post-op chest x-rays, post-ambulation device checks, and were discharged on the same day. After a mean follow up of three months, no major complications occurred, such as LBBA lead dislodgement requiring a lead revision. The LBBA lead pacing parameters immediately after implantation vs. three-month follow up were a capture threshold of 0.8 ± 0.3 V@0.4 ms vs. 0.6 ± 0.3 V@0.4 ms, sensing 9.9 ± 3.9 mV vs. 10.4 ± 4.1 mV, and impedance of 710 ± 216 ohm vs. 544 ± 110 ohm. The QRS duration before and after AVN ablation was 117 ± 32 ms vs. 123 ± 14 ms. Mean LVEF before and three months after the implantation was 44 ± 14% vs. 46 ± 12%. CONCLUSION LBBA pacing not only offers physiologic pacing, but also allows for a concomitant AVN ablation approach from the left axillary vein and safe same-day hospital dismissal.
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Affiliation(s)
- Zhigang Liu
- Department of Cardiology, Ascension Borgess Hospital, Kalamazoo, MI 49048, USA
| | - Xiaoke Liu
- Department of Cardiovascular Medicine, Mayo Clinic Health System, La Crosse, WI 54601, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55901, USA
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23
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Ghosh A, Sriram CS, Pandurangi UM. The curious case of conduction system pacing: Electrophysiology in situ. J Cardiovasc Electrophysiol 2023; 34:2364-2367. [PMID: 37855605 DOI: 10.1111/jce.16106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/18/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Anindya Ghosh
- Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure Academy, The Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Chenni S Sriram
- Children's Hospital of Michigan and Detroit Medical Center, Division of Cardiology, Sub-Section of Electrophysiology, Detroit, Michigan, USA
| | - Ulhas M Pandurangi
- Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure Academy, The Madras Medical Mission, Chennai, Tamil Nadu, India
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24
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Cano Ó, Navarrete-Navarro J, Jover P, Osca J, Izquierdo M, Navarro J, Ayala HD, Martínez-Dolz L. Conduction System Pacing for Cardiac Resynchronization Therapy. J Cardiovasc Dev Dis 2023; 10:448. [PMID: 37998506 PMCID: PMC10672305 DOI: 10.3390/jcdd10110448] [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: 09/13/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 11/25/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) via biventricular pacing (BiVP-CRT) is considered a mainstay treatment for symptomatic heart failure patients with reduced ejection fraction and wide QRS. However, up to one-third of patients receiving BiVP-CRT are considered non-responders to the therapy. Multiple strategies have been proposed to maximize the percentage of CRT responders including two new physiological pacing modalities that have emerged in recent years: His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). Both pacing techniques aim at restoring the normal electrical activation of the ventricles through the native conduction system in opposition to the cell-to-cell activation of conventional right ventricular myocardial pacing. Conduction system pacing (CSP), including both HBP and LBBAP, appears to be a promising pacing modality for delivering CRT and has proven to be safe and feasible in this particular setting. This article will review the current state of the art of CSP-based CRT, its limitations, and future directions.
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Affiliation(s)
- Óscar Cano
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Área de Enfermedades Cardiovasculares, Planta 4-Torre F. Av, Fernando Abril Martorell, 106, 46026 Valencia, Spain (H.D.A.)
- Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Javier Navarrete-Navarro
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Área de Enfermedades Cardiovasculares, Planta 4-Torre F. Av, Fernando Abril Martorell, 106, 46026 Valencia, Spain (H.D.A.)
- Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Pablo Jover
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Área de Enfermedades Cardiovasculares, Planta 4-Torre F. Av, Fernando Abril Martorell, 106, 46026 Valencia, Spain (H.D.A.)
- Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Joaquín Osca
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Área de Enfermedades Cardiovasculares, Planta 4-Torre F. Av, Fernando Abril Martorell, 106, 46026 Valencia, Spain (H.D.A.)
- Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Maite Izquierdo
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Área de Enfermedades Cardiovasculares, Planta 4-Torre F. Av, Fernando Abril Martorell, 106, 46026 Valencia, Spain (H.D.A.)
- Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Josep Navarro
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Área de Enfermedades Cardiovasculares, Planta 4-Torre F. Av, Fernando Abril Martorell, 106, 46026 Valencia, Spain (H.D.A.)
| | - Hebert D. Ayala
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Área de Enfermedades Cardiovasculares, Planta 4-Torre F. Av, Fernando Abril Martorell, 106, 46026 Valencia, Spain (H.D.A.)
- Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
| | - Luis Martínez-Dolz
- Electrophysiology Section, Cardiology Department, Hospital Universitari i Politècnic La Fe, Área de Enfermedades Cardiovasculares, Planta 4-Torre F. Av, Fernando Abril Martorell, 106, 46026 Valencia, Spain (H.D.A.)
- Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain
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25
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Sritharan A, Kozhuharov N, Masson N, Bakelants E, Valiton V, Burri H. Procedural outcome and follow-up of stylet-driven leads compared with lumenless leads for left bundle branch area pacing. Europace 2023; 25:euad295. [PMID: 37766468 PMCID: PMC10563653 DOI: 10.1093/europace/euad295] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 09/21/2023] [Indexed: 09/29/2023] Open
Abstract
AIMS Left bundle branch area pacing (LBBAP) is most often delivered using lumenless leads (LLLs), but may also be performed using stylet-driven leads (SDLs). There are limited reports on the comparison of these tools, mainly limited to reports describing initial operator experience or without detailed procedural data. Our aim was to perform an in-depth comparison of SDLs and LLLs for LBBAP at implantation and follow-up in a larger cohort of patients with experience that extends beyond that of the initial learning curve. METHODS AND RESULTS A total of 306 consecutive patients (age 77 ± 11 years, 183 males) undergoing LBBAP implantation at a single centre were prospectively included. The population was split into two groups of 153 patients based on the initial use of an SDL (from 4 manufacturers) or an LLL. After having discounted the initial learning curve of 50 patients, there was no difference in the success rate between the initial use of lead type (96.0% with SDL vs. 94.3% with LLL, P = 0.56). There were no significant differences in success between lead models. Electrocardiogram and electrical parameters were comparable between the groups. Post-operative macro-dislodgement occurred in 4.3% of patients (essentially within the first day following implantation) and presumed micro-dislodgement with loss of conduction system capture or rise in threshold (occurring mostly during the first month) was observed in 4.7% of patients, without differences between groups. CONCLUSION Left bundle branch area pacing may be safely and effectively performed using either LLLs or SDLs, which provides implanters with alternatives for delivering this therapy.
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Affiliation(s)
- Aarthiga Sritharan
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève, Switzerland
| | - Nikola Kozhuharov
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève, Switzerland
| | - Nicolas Masson
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève, Switzerland
| | - Elise Bakelants
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève, Switzerland
| | - Valérian Valiton
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève, Switzerland
| | - Haran Burri
- Cardiac Pacing Unit, Department of Cardiology, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Genève, Switzerland
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Kato H, Sato T, Shimeno K, Mito S, Nishida T, Soejima K. Predictors of implantation failure in left bundle branch area pacing using a lumenless lead in patients with bradycardia. J Arrhythm 2023; 39:766-775. [PMID: 37799795 PMCID: PMC10549844 DOI: 10.1002/joa3.12906] [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: 06/14/2023] [Revised: 07/12/2023] [Accepted: 07/23/2023] [Indexed: 10/07/2023] Open
Abstract
Background Left bundle branch area pacing (LBBAP) is a novel conduction system pacing technique. In this multicenter study, we aimed to evaluate the procedural success, safety, and preoperative predictors of procedural failure of LBBAP. Methods LBBAP was attempted in 285 patients with pacemaker indications for bradyarrhythmia, which were mainly atrioventricular block (AVB) (68.1%) and sick sinus syndrome (26.7%). Procedural success and electrophysiological and echocardiographic parameters were evaluated. Results LBBAP was successful in 247 (86.7%) patients. Left bundle branch (LBB) capture was confirmed in 54.7% of the population. The primary reasons for procedural failure were the inability of the pacemaker lead to penetrate deep into the septum (76.3%) and failure to achieve shortening of stimulus to left ventricular (LV) activation time in lead V6 (18.4%). Thickened interventricular septum (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.15-5.35), severe tricuspid regurgitation (OR, 8.84; 95% CI, 1.22-64.06), and intraventricular conduction delay (OR, 8.16; 95% CI, 2.32-28.75) were preoperative predictors of procedural failure. The capture threshold and ventricular amplitude remained stable, and no major complications occurred throughout the 2-year follow-up. In patients with ventricular pacing burden >40%, the LV ejection fraction remained high regardless of LBB capture. Conclusions Successful LBBAP was affected by abnormal cardiac anatomy and intraventricular conduction. LBBAP is feasible and safe as a primary strategy for patients with AVB, depending on ventricular pacing.
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Affiliation(s)
- Hiroyuki Kato
- Department of Cardiology, Japan Community Healthcare Organization Chukyo HospitalNagoyaJapan
| | - Toshiaki Sato
- Division of Advanced Arrhythmia ManagementKyorin University School of MedicineMitakaJapan
| | - Kenji Shimeno
- Department of Cardiology, Osaka City General HospitalOsakaJapan
| | - Shinji Mito
- Department of Cardiology, Chikamori HospitalKochiJapan
| | - Taku Nishida
- Department of Cardiovascular MedicineNara Medical UniversityKashiharaJapan
| | - Kyoko Soejima
- Department of Cardiovascular MedicineKyorin University School of MedicineMitakaJapan
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Katritsis DG, Calkins H. Septal and Conduction System Pacing. Arrhythm Electrophysiol Rev 2023; 12:e25. [PMID: 37860698 PMCID: PMC10583155 DOI: 10.15420/aer.2023.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/18/2023] [Indexed: 10/21/2023] Open
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Curila K, Burri H. Left ventricular septal pacing - can we trust the ECG? Indian Pacing Electrophysiol J 2023; 23:155-157. [PMID: 37429526 PMCID: PMC10491966 DOI: 10.1016/j.ipej.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/28/2023] [Accepted: 07/07/2023] [Indexed: 07/12/2023] Open
Abstract
In contrast to left bundle branch pacing, the criteria for left ventricular septal pacing (LVSP) were never validated. LVSP is usually defined as deep septal deployment of the pacing lead with a pseudo-right bundle branch morphology in V1. The case report describes an implant procedure during which this definition of LVSP was fulfilled in four of five pacing locations within the septum, with the shallowest of them present in less than 50% of the septal thickness. The case highlights the need for a more precise definition of LVSP.
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Affiliation(s)
- Karol Curila
- Department of Cardiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
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Sato T, Togashi I, Ikewaki H, Mohri T, Katsume Y, Tashiro M, Nonoguchi N, Hoshida K, Ueda A, Matsuo S, Soejima K. Diverse QRS morphology reflecting variations in lead placement for left bundle branch area pacing. Europace 2023; 25:euad241. [PMID: 37748089 PMCID: PMC10519621 DOI: 10.1093/europace/euad241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/26/2023] [Indexed: 09/27/2023] Open
Abstract
AIMS Left bundle branch area pacing (LBBAP) is a potential alternative to His bundle pacing. This study aimed to investigate the impact of different septal locations of pacing leads on the diversity of QRS morphology during non-selective LBBAP. METHODS AND RESULTS Non-selective LBBAP and left ventricular septal pacing (LVSP) were achieved in 50 and 21 patients with atrioventricular block, respectively. The electrophysiological properties of LBBAP and their relationship with the lead location were investigated. QRS morphology and axis showed broad variations during LBBAP. Echocardiography demonstrated a widespread distribution of LBBAP leads in the septum. During non-selective LBBAP, the qR-wave in lead V1 indicated that the primary location for pacing lead was the inferior septum (93%). The non-selective LBBAP lead was deployed deeper than the LVSP lead in the inferior septum. The Qr-wave in lead V1 with the inferior axis in aVF suggested pacing lead placement in the anterior septum. The penetration depth of the non-selective LBBAP lead in the anterior septum was significantly shallower than that in the inferior septum (72 ± 11 and 87 ± 8%, respectively). In lead V6, the deep S-wave indicated the time lag between the R-wave peak and the latest ventricular activation in the coronary sinus trunk, with pacemaker leads deployed closer to the left ventricular apex. CONCLUSION Different QRS morphologies and axes were linked to the location of the non-selective LBBAP lead in the septum. Various lead deployments are feasible for LBBAP, allowing diversity in the conduction system capture in patients with atrioventricular block.
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Affiliation(s)
- Toshiaki Sato
- Division of Advanced Arrhythmia Management, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan
| | - Ikuko Togashi
- Division of Advanced Arrhythmia Management, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan
| | - Hirotsugu Ikewaki
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Takato Mohri
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Yumi Katsume
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Mika Tashiro
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Noriko Nonoguchi
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Kyoko Hoshida
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Akiko Ueda
- Division of Advanced Arrhythmia Management, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan
| | - Seiichiro Matsuo
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Mitaka, Japan
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30
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Upadhyay GA. QRS morphologies in V1 and V6 during left bundle branch area pacing: assessing the patterns. Europace 2023; 25:euad284. [PMID: 37713733 PMCID: PMC10519663 DOI: 10.1093/europace/euad284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 09/17/2023] Open
Affiliation(s)
- Gaurav A Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, 5841 S. Maryland Avenue, MC 9024, Chicago, IL 60637, USA
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