His bundle pacing

Electrophysiological demonstration of nonselective His-Purkinje system capture with para-Hisian pacing

BACKGROUND

The adverse effects of conventional right ventricular (RV) apical pacing prompted the search for more physiological pacing sites, such as selective and nonselective His bundle pacing (HBP), a variant of nonselective HBP (para-Hisian pacing), and mid-septal pacing. However, knowledge of their true benefit on the physiology of ventricular activation, lead stability, and pacing thresholds is limited.

METHODS AND RESULTS

We included 152 consecutive patients (mean age 61 ± 24, 63% men) in this retrospective study. Of these, 137 patients with different bradyarrhythmias underwent active fixation lead implantation at the RV apex (n = 54), para-Hisian region (n = 66), or mid interventricular septum (n = 17). Fifteen patients with ventricular preexcitation due to an accessory pathway not undergoing pacing were included as controls. A 12‑lead ECG was recorded in all patients, and cardiac electrical synchrony was assessed using the Synchromax® cross-correlation cardiac synchrony index (CSI).

RESULTS

QRS duration was prolonged in all pacing sites: from 114 ± 28 to 160 ± 29 (RV apex), from 110 ± 28 to 122 ± 29 (para-Hisian), and from 121 ± 24 to 154 ± 30 (mid interventricular septum). The CSI was significantly improved only in patients undergoing para-Hisian pacing, despite a slight widening of the QRS interval. There was no difference in pacing thresholds and sensed R-wave voltage between pacing sites. Only 1 lead, implanted at the para-Hisian region (1.5%), was dislodged towards the mid septum 48 h after implantation but did not require repositioning.

CONCLUSIONS

QRS duration was not associated with changes in CSI, meaning that QRS width does not significantly affect electrical synchrony.

Remembering the canonical discoverers of the core components of the mammalian cardiac conduction system: Keith and Flack, Aschoff and Tawara, His, and Purkinje

The mammalian cardiac conduction system (CCS) is a multifaceted continuum of electrically distinct, interconnected constructs within the myocardial mass. The key components are the sinus node (SAN), the atrioventricular node (AVN), the His bundle (HB), and the Purkinje fiber network (PF), the latter serendipitously discovered by Jan Evangelista Purkinje in 1839 in the sheep ventricle. In 1893, Wilhelm His, Jr. described a ventricular muscular tract conveying SAN-generated action potentials from the AVN (discovered by Sunao Tawara and Karl Albert Aschoff in 1906) to the PF. In 1906, Keith and Flack completed these explorations by localizing the SAN, the primum movens of CCS, which functions as a biologic oscillator emitting cadenced impulses that travel via the Bachmann bundle to the atrial myocytes and, via internodal pathways, to the AVN. Here these impulses are briefly delayed, enabling atrial systole before continuing via the AVN and the high-speed His-Purkinje conduction axis to signal ventricular contraction. The CCS canonical discoverers (Keith and Flack, Aschoff and Tawara, His, and Purkinje), historical controversies, fundamental notions of anatomy, physiology, and pathology, and therapeutic interventions pertaining to the CCS are the main themes of this review. Any scientist mentioned or unmentioned in this report who contributed directly or indirectly, with correct or inaccurate hypotheses, to the characterization of the CCS deserves our deepest gratitude for the long and painstaking hours spent microscopically scrutinizing heart specimens from multiple mammalian species, including humans.NEW & NOTEWORTHY This report presents the first comprehensive summary of the factors enabling the discovery of the cardiac conduction system (CCS). Biographical highlights and achievements of the CCS canonical discoverers, hypotheses concerning mechanisms underlying sinus node (SAN) automaticity, use of eponyms to denominate a discovery, famous controversies, possible reproachable behavior (e.g., intellectual support for eugenics in post-World War I Germany) by two of the discoverers, and examples of historical mentor-pupil relationships are discussed.