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Taddeucci S, Mirizzi G, Santoro A. Lumenless and Stylet-Driven Leads for Left Bundle Branch Area Pacing: Materials, Techniques, Benefits, and Trade-Offs of the Two Approaches. J Clin Med 2024; 13:4758. [PMID: 39200900 PMCID: PMC11355410 DOI: 10.3390/jcm13164758] [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: 07/03/2024] [Revised: 08/06/2024] [Accepted: 08/07/2024] [Indexed: 09/02/2024] Open
Abstract
Left bundle branch area pacing (LBBPa) is an innovative technique for physiological pacing. Compared with His bundle pacing, LBBPa provides better pacing thresholds, lower rates of macrodislodgment, and a reliable strategy for cardiac resynchronization. LBBPa traditionally employs lumenless leads (LLL), which are characterized by small lead bodies and a fixed helix design. These features guarantee stability, avoid helix retraction, and facilitate easier septal penetration, all contributing to an advantageous learning curve. On the other hand, stylet-driven pacing leads (SDL) have shown comparable success rates related to lumenless pacing leads, although they carry risks of helix retraction and lead fracture. SDL have been increasingly employed with favorable results, as they provide good maneuverability and support during implantation with continuous monitoring of ECG-paced morphology. Different manufacturers are offering a variety of SDL, and new dedicated tools are being developed to simplify lead implantation. In this review, we examine the procedural techniques, advantages, and limitations of the most commonly used pacing leads and tools for LBBPa, and we summarize the complications associated with both lumenless leads (LLL) and stylet-driven leads (SDL).
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Affiliation(s)
- Simone Taddeucci
- Division of Biotechnology, University of Siena, Viale Bracci 1, 53100 Siena, Italy;
| | - Gianluca Mirizzi
- Division of Cardiology, Tuscany Foundation ‘Gabriele Monasterio’, Via Moruzzi, 1, 56100 Pisa, Italy;
| | - Amato Santoro
- Division of Interventional Cardiology, Azienda Ospedaliera Universitaria Senese, Viale Bracci 1, 53100 Siena, Italy
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2
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König S, Hilbert S, Bode K. Conduction System Pacing: Hope, Challenges, and the Journey Forward. Curr Cardiol Rep 2024; 26:801-814. [PMID: 38976199 DOI: 10.1007/s11886-024-02085-8] [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] [Accepted: 06/17/2024] [Indexed: 07/09/2024]
Abstract
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. 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.
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Affiliation(s)
- S König
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
- Helios Health Institute, Real World Evidence and Health Technology Assessment, Berlin, Germany.
| | - S Hilbert
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - K Bode
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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3
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Seow SC. A novel method to disengage trapped helix during left bundle branch pacing. Heart Rhythm 2024; 21:1412-1414. [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] [MESH Headings] [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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4
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Bressi E, Sedláček K, Čurila K, Cano Ó, Luermans JGLM, Rijks JHJ, Meiburg R, Smits KC, Nguyen UC, De Ruvo E, Calò L, Kron J, Ellenbogen KA, Prinzen F, Vernooy K, Grieco D. Clinical impact and predictors of periprocedural myocardial injury among patients undergoing left bundle branch area pacing. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01863-2. [PMID: 38969963 DOI: 10.1007/s10840-024-01863-2] [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: 06/02/2024] [Accepted: 06/26/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND The clinical impact of Periprocedural myocardial injury (PMI) in patients undergoing permanent pacemaker implantation with Left Bundle Branch Area Pacing (LBBAP) is unknown. METHODS 130 patients undergoing LBBAP from January 2020 to June 2021 and completing 12 months follow up were enrolled to assess the impact of PMI on composite clinical outcome (CCO) defined as any of the following: all-cause death, hospitalization for heart failure (HHF), hospitalization for acute coronary syndrome (ACS) and ventricular arrhythmias (VAs). High sensitivity Troponin T (HsTnT) was measured up to 24-h after intervention to identify the peak HsTnT values. PMI was defined as increased peak HsTnT values at least > 99th percentile of the upper reference limit (URL: 15 pg/ml) in patients with normal baseline values. RESULTS PMI occurred in 72 of 130 patients (55%). ROC analysis yielded a post-procedural peak HsTnT cutoff of fourfold the URL for predicting the CCO (AUC: 0.692; p = 0.023; sensitivity 73% and specificity 71%). Of the enrolled patients, 20% (n = 26) had peak HsTnT > fourfold the URL. Patients with peak HsTnT > fourfold the URL exhibited a higher incidence of the CCO than patients with peak HsTnT ≤ fourfold the URL (31% vs. 10%; p = 0.005), driven by more frequent hospitalizations for ACS (15% vs. 3%; p = 0.010). Multiple (> 2) lead repositions attempts, the use of septography and stylet-driven leads were independent predictors of higher risk of PMI with peak HsTnT > fourfold the URL. CONCLUSIONS PMI seems common among patients undergoing LBBAP and may be associated with an increased risk of clinical outcomes in case of more pronounced (peak HsTnT > fourfold the URL) myocardial damage occurring during the procedure.
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Affiliation(s)
- Edoardo Bressi
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169, Rome, Italy.
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Kamil Sedláček
- 1st Department of Internal Medicine - Cardiology and Angiology, Faculty of Medicine, University Hospital and Charles University, Hradec Králové, Czech Republic
| | - Karol Čurila
- Department of Cardiology, Cardiocenter, Third Faculty of Medicine, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Óscar Cano
- Electrophysiology Section, Cardiology Department, Hospital Universitari I Politècnic La Fe, Área de Enfermedades Cardiovasculares, Valencia, Spain
- Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Justin G L M Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jesse H J Rijks
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Roel Meiburg
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Karin C Smits
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Uyen Chau Nguyen
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ermenegildo De Ruvo
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169, Rome, Italy
| | - Leonardo Calò
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169, Rome, Italy
| | - Jordana Kron
- Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Kenneth A Ellenbogen
- Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Frits Prinzen
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Domenico Grieco
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169, Rome, Italy
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Chaumont C, Azincot M, Savouré A, Auquier N, Hamoud RA, Popescu E, Viart G, Mirolo A, Eltchaninoff H, Anselme F. His bundle pacing versus left bundle branch area pacing in patients undergoing atrioventricular node ablation: A prospective and comparative study. Arch Cardiovasc Dis 2024:S1875-2136(24)00216-X. [PMID: 38981841 DOI: 10.1016/j.acvd.2024.05.118] [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: 03/28/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Pacemaker implantation combined with atrioventricular node ablation (AVNA) is a well-established strategy for uncontrolled atrial arrhythmias. Limited data are available regarding His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) in this setting. AIM To compare the outcomes of HBP and LBBAP in patients undergoing pacemaker implantation combined with AVN in routine clinical practice. METHODS We prospectively included all patients who underwent AVNA after successful conduction system pacing (CSP) in two hospitals between September 2017 and May 2023. The primary outcome was the 1-year composite of first episode of heart failure hospitalization, symptomatic atrioventricular node reconduction requiring a second AVNA procedure, lead revision or death from any cause. RESULTS A total of 164 patients underwent AVNA following successful CSP (68 HBP and 96 LBBAP). Mean pacemaker implantation and AVNA procedure times were shorter in the LBBAP group than the HBP group (46±18 vs 59±23min; P<0.001 and 31±12 vs 43±22min, respectively; P<0.001). Complete atrioventricular block was more frequently obtained in the LBBAP group (88/96 patients [92%] vs 54/68 patients [79%]; P=0.04). One-year freedom from the composite outcome was more frequent in the LBBAP group (89.7% vs 72.9%; hazard ratio 0.32, 95% confidence interval 0.14-0.72; P=0.01). The strategy was similarly effective in both groups with a significant improvement in NYHA class and left ventricular ejection fraction. A secondary pacing threshold elevation >1V occurred only in the HBP group (11%). CONCLUSION In this prospective, comparative study, LBBAP provided better 1-year outcomes than HBP.
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Affiliation(s)
- Corentin Chaumont
- Department of Cardiology, CHU Rouen, 76000 Rouen, France; Inserm U1096, Université de Rouen Normandie, 76000 Rouen, France
| | - Maxime Azincot
- Department of Cardiology, CHU Rouen, 76000 Rouen, France
| | - Arnaud Savouré
- Department of Cardiology, CHU Rouen, 76000 Rouen, France
| | | | | | - Elena Popescu
- Department of Cardiology, Le Havre Hospital, 76620 Le Havre, France
| | | | - Adrian Mirolo
- Department of Cardiology, CHU Rouen, 76000 Rouen, France
| | - Hélène Eltchaninoff
- Department of Cardiology, CHU Rouen, 76000 Rouen, France; Inserm U1096, Université de Rouen Normandie, 76000 Rouen, France
| | - Frédéric Anselme
- Department of Cardiology, CHU Rouen, 76000 Rouen, France; Inserm U1096, Université de Rouen Normandie, 76000 Rouen, France.
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Özpak E, Van Heuverswyn F, Timmermans F, De Pooter J. Lead performance of stylet-driven leads in left bundle branch area pacing: Results from a large single-center cohort and insights from in vitro bench testing. Heart Rhythm 2024; 21:865-873. [PMID: 38307309 DOI: 10.1016/j.hrthm.2024.01.049] [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: 11/28/2023] [Revised: 01/08/2024] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) requires deep septal lead deployment for left-sided conduction stimulation. Advancing leads toward deep septal positions might add mechanical stress on these leads. Concerns about lead performance and reliability remain an unanswered question. OBJECTIVE The purpose of this study was to analyze lead performance and integrity of stylet-driven pacing leads (SDLs) for LBBAP. METHODS This study assessed lead fracture rates of SDL in a large single-center cohort of adult LBBAP patients. Fluoroscopic analysis of lead bending angulations at the septal insertion point and in vitro bench testing of lead preconditioning were performed to simulate clinical use conditions. Lead performance was compared between LBBAP and conventional right ventricular apical pacing (RVp) sites. RESULTS The study included 325 LBBAP patients (66% male; age 71±15 years). During median follow-up of 18 months, 2 patients (0.6%) experienced conductor fracture between tip housing and ring electrode, whereas no such fractures occurred with RVp patients (n = 149; P = .22). X-ray analysis revealed that high lead bending angulations occurred in 1.3% of the patients. Accelerated bench testing of excessive preconditioned leads showcased a higher probability of early conductor fracture compared to standard preconditioned leads. CONCLUSION The incidence of early conductor failure in LBBAP seems higher than with conventional RVp sites. The most vulnerable lead part seems to be the interelectrode space between the tip housing and ring electrode. Excessive angulation and preconditioning might contribute to early fatigue fracture.
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Affiliation(s)
- Emine Özpak
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium.
| | | | - Frank Timmermans
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Jan De Pooter
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
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7
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Ghosh A, Ka MA, Sriram CS, Pandurangi UM. Caveats related to conduction system pacing utilizing a proprietary deflectable mapping catheter with a stylet-driven lead. J Interv Card Electrophysiol 2024; 67:759-771. [PMID: 37840120 DOI: 10.1007/s10840-023-01637-2] [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: 06/20/2023] [Accepted: 09/01/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Hitherto, lumen less leads (LLLs) were routinely utilized for conduction system pacing (CSP). We report the largest experience using stylet-driven leads (SDLs) with a deflectable mapping catheter for CSP. METHODS Patients were prospectively and sequentially enrolled for CSP with SDL between June, 2021 and November, 2022 to (i) a novel deflectable mapping catheter (AgilisHisProTM, Abbott) (Group A) or (ii) a fixed curve sheath (Selectra3D, Biotronik) (Group B) in a 1:1 non-randomized fashion. The primary aim was to evaluate safety, feasibility, and efficacy of the CSP using SDL and deflectable mapping catheter (Group A) while reporting procedural success and intermediate-term follow-up. RESULTS Seventy-nine patients (59.4%M, mean age 67.2+/-10.6 years) were allocated to either (i) Group A (n = 40) or (ii) Group B (n = 39). In Group A (n = 40, 50% M, mean age 67.2+/-9.5 years, follow-up 210.7 + 25.1days), His bundle pacing (HBP) was the default strategy with left bundle branch area pacing (LBBaP) for bailout. Procedural success with HBP was feasible in 17/40 (42.5%) patients with remaining 23/40 (57.5%) needing LBBaP bailout. After initial learning curve, a manual septal curve was introduced to successfully aid LBBaP in 6/23 (26.1%) cases. Procedural and follow-up parameters did not differ significantly in HBP vs. LBBaP. Head-to-head comparison was not performed between the groups owing to different default protocols (HBP-Group A, Discretionary-Group B). CONCLUSIONS Use of SDL with single-curve deflectable mapping catheter was safe, feasible and yielded moderate procedural success with HBP and frequently needed a LBBaP bailout strategy. In approximately one-fourth of the latter, an out-of-plane manual septal curve was needed to optimize LBBaP.
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Affiliation(s)
- Anindya Ghosh
- Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure Academy, The Madras Medical Mission, 4-A, Dr. JJ Nagar, Mogappair, Chennai, Tamil Nadu, India
| | - Mohamed Akram Ka
- Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure Academy, The Madras Medical Mission, 4-A, Dr. JJ Nagar, Mogappair, Chennai, Tamil Nadu, India
| | - Chenni S Sriram
- Division of Cardiology, Sub-section of Electrophysiology, Children's Hospital of Michigan and Detroit Medical Center, Detroit, MI, USA
| | - Ulhas M Pandurangi
- Department of Cardiac Electrophysiology and Pacing, Arrhythmia Heart Failure Academy, The Madras Medical Mission, 4-A, Dr. JJ Nagar, Mogappair, Chennai, Tamil Nadu, India.
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8
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Liu CF, Prasad KV, Moretta A, Vijayaraman P, Zanon F, Gleva M, De Pooter J, Chinitz LA. Left bundle branch area pacing using a stylet-driven, retractable-helix lead: Short-term results from a prospective multicenter IDE trial (the BIO-CONDUCT study). Heart Rhythm 2024:S1547-5271(24)02547-5. [PMID: 38772432 DOI: 10.1016/j.hrthm.2024.05.007] [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: 04/16/2024] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) has swiftly emerged as a safe and effective alternative to right ventricular pacing. Limited data exist on the use of retractable-helix, stylet-driven leads for LBBAP. OBJECTIVE The objective of this study was to prospectively evaluate the performance and safety of a stylet-driven pacing lead in a rigorously controlled multicenter trial to support US market application. METHODS A multicenter, prospective, nonrandomized trial enrolled patients with standard pacing indications. Implant procedure and lead data, including threshold, sensing, impedance, and capture type, were collected through 3 months. Primary end points were freedom from LBBAP lead-related serious complications through 3 months and LBBAP implant success according to prespecified criteria. A blinded clinical events committee adjudicated all potential end point complications. RESULTS A total of 186 patients were included from 14 US sites. LBBAP implants were successful in 95.7% (178 of 186; 95% confidence interval 91.7%-98.1%; P < .0001 for comparison to the performance goal of 88%). Through the 3-month follow-up visit, 3 patients (1.7%) experienced a serious LBBAP complication (all lead dislodgments), resulting in a LBBAP lead-related complication-free rate of 98.3%. A total of 13 patients (7.8%) experienced any system- or procedure-related complication. The mean threshold was 0.89 V at 0.4 ms, the sensing value was 10.8 mV, and impedance was 608 Ω. CONCLUSION The short-term results from this prospective trial demonstrate both high implant success and freedom from LBBAP lead-related complications using this stylet-driven retractable helix lead. This trial supports the safety, use, and effectiveness of stylet-driven leads for performing contemporary physiologic pacing.
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Affiliation(s)
- Christopher F Liu
- New York-Presbyterian-Weill Cornell Medical Center, New York, New York
| | | | | | | | | | - Marye Gleva
- Washington University School of Medicine, St. Louis, Missouri
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9
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Prech M, Kaczmarzyk-Radka A, Gwizdek T, Szymkiewicz P. Conduction latency in left bundle branch pacing in heart failure patient. J Electrocardiol 2024; 84:161-164. [PMID: 38733733 DOI: 10.1016/j.jelectrocard.2024.04.011] [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: 02/17/2024] [Revised: 04/21/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024]
Abstract
Since the introduction of left bundle branch pacing (LBBP), a search for precise parameters confirming successful capture of conduction system was conducted. Most of the proposed electrocardiographic criteria refer to patients with narrow QRS complexes. We present a patient with heart failure in whom cardiac resynchronization was achieved using conduction system pacing. While measuring left ventricular activation time, an isoelectric interval of 74 ms between stimulus and R-wave appeared resulting in prolongation of V6 RWPT to 124 ms. Considering the immediate narrowing of QRS complexes following LBBP, the observed latency most probably reflects prolonged conduction time through the His-Purkinje system.
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Affiliation(s)
- Marek Prech
- Department of Cardiology, District Hospital, Leszno, Kiepury 45, 64-100 Leszno, Poland.
| | | | - Tomasz Gwizdek
- Department of Cardiology, District Hospital, Leszno, Kiepury 45, 64-100 Leszno, Poland
| | - Paweł Szymkiewicz
- Department of Cardiology, 4th Military Hospital, Wroclaw, Weigla 5, 50-981 Wroclaw, Poland
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10
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Scott M, Needleman JS, Kean AC. Conduction System Pacing in Pediatrics and Congenital Heart Disease: A Case Report and Literature Review. J Innov Card Rhythm Manag 2024; 15:5749-5755. [PMID: 38444449 PMCID: PMC10911636 DOI: 10.19102/icrm.2024.15021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/28/2023] [Indexed: 03/07/2024] Open
Abstract
Conduction system pacing involving either His bundle pacing (HBP) or left bundle branch pacing (LBBP) is a modality that has been introduced as a safe and effective alternative to right ventricular (RV) pacing to help prevent pacemaker-associated cardiomyopathy. While HBP has been employed in the pediatric and congenital populations, several small studies have shown LBBP to be safe and effective in the pediatric population. We present a patient with congenital atrioventricular block and postoperative ventricular septal defect repair cardiomyopathy with subsequent left ventricular function improvement following a transition from an RV epicardial pacemaker system to an LBBP system. This case report serves as a foundation for a review of the current state of LBBP in pediatrics and congenital heart disease.
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Affiliation(s)
- Michael Scott
- Division of Pediatric Cardiology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Joseph S. Needleman
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University, School of Medicine, Atlanta, GA, USA
| | - Adam C. Kean
- Division of Pediatric Cardiology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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11
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Skeete J, Huang HD, Mazur A, Sharma PS, Engelstein E, Trohman RG, Larsen TR. Evolving Concepts in Cardiac Physiologic Pacing in the Era of Conduction System Pacing. Am J Cardiol 2024; 212:51-66. [PMID: 38012990 DOI: 10.1016/j.amjcard.2023.11.023] [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: 09/25/2023] [Revised: 10/22/2023] [Accepted: 11/11/2023] [Indexed: 11/29/2023]
Abstract
Cardiac physiologic pacing (CPP) has become a well-established therapy for patients with cardiomyopathy (left ventricular ejection fraction <35%) in the presence of a left bundle branch block. In addition, CPP can be highly beneficial in patients with pacing-induced cardiomyopathy and patients with existing cardiomyopathy expected to have a right ventricular pacing burden of >40%. The benefits of CPP with traditional biventricular pacing are only realized if adequate resynchronization can be achieved. However, left ventricular lead implantation can be limited by individual anatomic variation within the coronary venous system and can be adversely affected by underlying abnormal myocardial substrate (i.e., scar tissue), especially if located within the basal lateral wall. In the last 7 years the investigation of conduction system pacing (CSP) and its potential salutary benefits are being realized and have led to a rapid evolution in the field of cardiac resynchronization pacing. However, supportive evidence for CSP for patients eligible for cardiac resynchronization remains limited compared with data available for biventricular cardiac resynchronization, mostly derived from leading CSP investigative centers. In this review, we perform an up-to-date comprehensive review of the available literature on CPP.
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Affiliation(s)
- Jamario Skeete
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Henry D Huang
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Alex Mazur
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Parikshit S Sharma
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Erica Engelstein
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Richard G Trohman
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Timothy R Larsen
- Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois.
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12
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Sdogkos E, Iliodromitis K, Xanthopoulos A, Triposkiadis F, Skoularigis J, Bogossian H, Vogiatzis I. Conduction system pacing: how far are we from the "electrical" bypass? Heart Fail Rev 2024; 29:45-63. [PMID: 37776404 DOI: 10.1007/s10741-023-10349-8] [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] [Accepted: 09/13/2023] [Indexed: 10/02/2023]
Abstract
Conduction system pacing is an alternative practice to conventional right ventricular apical pacing. It is a method that maintains physiologic ventricular activation, based on a correct pathophysiological basis, in which the pacing lead bypasses the lesion of the electrical fibers and the electrical impulse transmits through the intact adjacent conduction system. For this reason, it might be reasonably characterized by the term "electrical bypass" compared to the coronary artery bypass in revascularization therapy. In this review, reference is made to the sequence of events in which conventional right ventricular pacing may cause adverse outcomes. Furthermore, there is a reference to alternative strategies and pacing sites. Interest focuses on the modalities for which there are data from the literature, namely for the right ventricular (RV) septal pacing, the His bundle pacing (HBP), and the left bundle branch pacing (LBBP). A more extensive reference is about the HBP, for which there are the most updated data. We analyze the considerations that limit HBP-wide application in three axes, and we also present the data for the implantation and follow-up of these patients. The indications with their most important studies to date are then described in detail, not only in their undoubtedly positive findings but also in their weak aspects, because of which this pacing mode has not yet received a strong recommendation for implementation. Finally, there is a report on LBBP, focusing mainly on its points of differentiation from HBP.
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Affiliation(s)
- Evangelos Sdogkos
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece.
| | - Konstantinos Iliodromitis
- Klinik Für Kardiologie und Rhythmologie, Evangelisches Krankenhaus Hagen-Haspe, Brusebrinkstraße 20, 58135, Hagen, Germany
- School of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58455, Witten, Germany
| | | | | | - John Skoularigis
- Department of Cardiology, University Ηospital of Larissa, Larissa, Greece
| | - Harilaos Bogossian
- Klinik Für Kardiologie und Rhythmologie, Evangelisches Krankenhaus Hagen-Haspe, Brusebrinkstraße 20, 58135, Hagen, Germany
- School of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58455, Witten, Germany
| | - Ioannis Vogiatzis
- Department of Cardiology, General Hospital of Veroia, Veroia, Greece
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13
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François C, De Becker B, De Smet M, Knecht S, Duytschaever M, Tavernier R, le Polain de Waroux JB. Interaction between left bundle branch area pacing lead and defibrillator lead: A case report. HeartRhythm Case Rep 2024; 10:72-75. [PMID: 38264098 PMCID: PMC10801089 DOI: 10.1016/j.hrcr.2023.10.026] [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)
- Clara François
- Department of Cardiology, Sint-Jan Hospital, Bruges, Belgium
| | | | - Maarten De Smet
- Department of Cardiology, Sint-Jan Hospital, Bruges, Belgium
| | | | | | - René Tavernier
- Department of Cardiology, Sint-Jan Hospital, Bruges, Belgium
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Somani S, Rogers AJ. Advances in cardiac pacing with leadless pacemakers and conduction system pacing. Curr Opin Cardiol 2024; 39:1-5. [PMID: 37751365 DOI: 10.1097/hco.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW The field of cardiac pacing has undergone significant evolution with the introduction and adoption of conduction system pacing (CSP) and leadless pacemakers (LLPMs). These innovations provide benefits over conventional pacing methods including avoiding lead related complications and achieving more physiological cardiac activation. This review critically assesses the latest advancements in CSP and LLPMs, including their benefits, challenges, and potential for future growth. RECENT FINDINGS CSP, especially of the left bundle branch area, enhances ventricular depolarization and cardiac mechanics. Recent studies show CSP to be favorable over traditional pacing in various patient populations, with an increase in its global adoption. Nevertheless, challenges related to lead placement and long-term maintenance persist. Meanwhile, LLPMs have emerged in response to complications from conventional pacemaker leads. Two main types, Aveir and Micra, have demonstrated improved outcomes and adoption over time. The incorporation of new technologies allows LLPMs to cater to broader patient groups, and their integration with CSP techniques offers exciting potential. SUMMARY The advancements in CSP and LLPMs present a transformative shift in cardiac pacing, with evidence pointing towards enhanced clinical outcomes and reduced complications. Future innovations and research are likely to further elevate the clinical impact of these technologies, ensuring improved patient care for those with conduction system disorders.
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Affiliation(s)
- Sulaiman Somani
- Department of Medicine
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
| | - Albert J Rogers
- Department of Medicine
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
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15
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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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16
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Özpak E, Van Heuverswyn F, Timmermans F, De Pooter J. Feasibility and safety of left bundle branch area pacing in patients with septal hypertrophy. J Cardiovasc Electrophysiol 2023; 34:2255-2261. [PMID: 37717221 DOI: 10.1111/jce.16073] [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: 06/23/2023] [Revised: 08/29/2023] [Accepted: 09/08/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Left bundle branch area pacing (LBBAP) aims to provide physiological ventricular activation during pacing. Left ventricular septal hypertrophy (LVSH) might be challenging for LBBAP due to the thickness of the interventricular septum and potential presence of septal scar. This study assesses the feasibility, safety, and outcome of LBBAP in patients with LVSH using primarily stylet-driven leads (SDL). METHODS Adult patients with LVSH who underwent LBBAP between March 2019 and November 2022 were enrolled. Baseline patient characteristics, procedural data and postprocedural results were collected. The feasibility of LBBAP in LVSH patients was compared to a cohort of LBBAP patients with normal septal wall thickness (NST). RESULTS Seventeen LVSH and 133 NST patients underwent LBBAP with successful implantation achieved in 15 LVSH patients (88%). Mean implant depth was 17.2 ± 1.9 mm, with 53% proven left bundle branch (LBB) capture. Paced QRS duration (146 ± 14 ms) and V6 R-wave peak time (V6 RWPT; 79 ± 20 ms) were comparable between patients with and without septal hypertrophy, although patients with NST had higher rates of proven LBB capture (71% vs. 53%). In LVSH pacing thresholds (0.6 ± 0.3 V at 0.4 ms) and R-wave amplitude (13.9 ± 5.6 mV) were favorable and remained stable at follow-up. At 12 months, 87% of patients had stable or improved left ventricular ejection fraction. CONCLUSION The results of the study indicate that LBBAP in patients with LVSH is safe and feasible and no lead-related complications were observed despite a mean implant depth exceeding 15 mm. LBBAP using SDL results in favorable pacing and electrocardiographic characteristics in LVSH patients, comparable to patients with NST.
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Affiliation(s)
- Emine Özpak
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | | | - Frank Timmermans
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Jan De Pooter
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
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Saouma S, Di Meglio S, Guttenplan N. Atrioventricular node ablation and left bundle branch area pacing in a patient with dextrocardia and interruption of the inferior vena cava with azygos continuation. HeartRhythm Case Rep 2023; 9:693-697. [PMID: 38047197 PMCID: PMC10691952 DOI: 10.1016/j.hrcr.2023.07.006] [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: 12/05/2023] Open
Affiliation(s)
- Samer Saouma
- Albert Einstein College of Medicine at Montefiore Hospital, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, New York
| | - Salvatore Di Meglio
- Albert Einstein College of Medicine at Montefiore Hospital, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, New York
| | - Nils Guttenplan
- Albert Einstein College of Medicine at Montefiore Hospital, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, New York
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Suzuki K, Sato E, Yamashina Y, Ishida A, Yagi T. A case of retractable helix lead auto-retraction: A possible cause of deep septal lead dislodgement. J Arrhythm 2023; 39:630-633. [PMID: 37560287 PMCID: PMC10407186 DOI: 10.1002/joa3.12891] [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: 05/05/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 08/11/2023] Open
Abstract
This paper explains the phenomenon where the helix lead automatically retracts because of residual torque during deep septal pacing.
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Affiliation(s)
- Keisuke Suzuki
- Department of Cardiovascular MedicineSendai City HospitalSendaiJapan
| | - Eiji Sato
- Department of Cardiovascular MedicineSendai City HospitalSendaiJapan
| | | | - Akihiko Ishida
- Department of Cardiovascular MedicineSendai City HospitalSendaiJapan
| | - Tetsuo Yagi
- Department of Cardiovascular MedicineSendai City HospitalSendaiJapan
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Celentano E, Ignatiuk B, Cristiano E, Bia E, Lo Monaco M, de Groot NM. Are three-dimensional mapping systems useful for left bundle branch area pacing? HeartRhythm Case Rep 2023; 9:465-468. [PMID: 37492049 PMCID: PMC10363463 DOI: 10.1016/j.hrcr.2023.04.011] [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: 07/27/2023] Open
Affiliation(s)
- Eduardo Celentano
- Humanitas Gavazzeni, Bergamo, Italy
- Lowlands Institute for Bioelectric Medicine, Unit Translational Electrophysiology, Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | | | | | - Natasja M.S. de Groot
- Lowlands Institute for Bioelectric Medicine, Unit Translational Electrophysiology, Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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20
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Markson F, Orji R, Ayinde H. Acute Left Bundle Branch Injury During Deep Septal Lead Implantation. J Innov Card Rhythm Manag 2023; 14:5451-5454. [PMID: 37216084 PMCID: PMC10193870 DOI: 10.19102/icrm.2023.14053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/07/2022] [Indexed: 05/24/2023] Open
Abstract
Left bundle branch pacing (LBBP) is a novel technique that has emerged as an alternative method for conduction system pacing. As a new modality, this procedure may carry complications that are yet to be explored. This report describes a case of injury to the left bundle branch during deep septal lead implantation for LBBP.
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Affiliation(s)
- Favour Markson
- Department of Medicine, Lincoln Medical Center, New York, NY, USA
| | - Richard Orji
- Department of Medicine, Rosalind Franklin University, North Chicago, IL, USA
- Department of Medicine, Northwestern Medicine Hospital, McHenry, IL, USA
| | - Hakeem Ayinde
- Division of Cardiology, Cardiology Associates of Fredericksburg, Fredericksburg, VA, USA
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21
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Bressi E, Grieco D, Čurila K, Zanon F, Marcantoni L, Cabrera JA, De Ruvo E, Vernooy K, Calò L. Pacing of the specialized His-Purkinje conduction system: 'back to the future'. Eur Heart J Suppl 2023; 25:C234-C241. [PMID: 37125312 PMCID: PMC10132574 DOI: 10.1093/eurheartjsupp/suad047] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The conduction system of the human heart is composed of specialized cardiomyocytes that initiate and propagate the electric impulse with consequent rhythmic and synchronized contraction of the atria and ventricles, resulting in the normal cardiac cycle. Although the His-Purkinje system (HPS) was already described more than a century ago, there has been a recent resurgence of conduction system pacing (CSP), where pacing leads are positioned in the His bundle region and left bundle branch area to provide physiological cardiac activation as alternatives to the unnatural myocardial stimulation obtained with conventional right ventricular and biventricular pacing. In this review, we describe the fundamental anatomical and pathophysiological aspects of the specialized HPS along with the CSP technique's nuts and bolts to highlight its potential benefits in everyday clinical practice.
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Affiliation(s)
- Edoardo Bressi
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169 Rome, Italy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Domenico Grieco
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169 Rome, Italy
| | - Karol Čurila
- Department of Cardiology, Cardiocenter, Third Faculty of Medicine, Charles University, University Hospital Kralovske Vinohrady, Ruská 2411, 100 00 Prague 10-Vinohrady, Czech Republic
| | - Francesco Zanon
- Arrhythmia and Electrophysiology Unit, Department of Cardiology, Santa Maria della Misericordia General Hospital, Viale Tre Martiri, 140, 45100 Rovigo, Italy
| | - Lina Marcantoni
- Arrhythmia and Electrophysiology Unit, Department of Cardiology, Santa Maria della Misericordia General Hospital, Viale Tre Martiri, 140, 45100 Rovigo, Italy
| | - Jose Angel Cabrera
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Calle de Juan Bravo, 49, 28006 Madrid, Spain
| | - Ermenegildo De Ruvo
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169 Rome, Italy
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Leonardo Calò
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169 Rome, Italy
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Affiliation(s)
- Jan De Pooter
- Heart Center, Ghent University Hospital, Ghent, Belgium
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23
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Ponnusamy SS, Vijayaraman P. My preferred approach to left bundle branch pacing: Lumenless leads. Heart Rhythm O2 2023; 4:147-153. [PMID: 36873316 PMCID: PMC9974988 DOI: 10.1016/j.hroo.2022.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Bressi E, Grieco D, Luermans J, Burri H, Vernooy K. Conduction system pacing for cardiac resynchronization therapy: State of the art, current controversies, and future perspectives. Front Physiol 2023; 14:1124195. [PMID: 36711020 PMCID: PMC9880410 DOI: 10.3389/fphys.2023.1124195] [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: 12/14/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023] Open
Abstract
Biventricular pacing (BVP) is the established treatment to perform cardiac resynchronization therapy (CRT) in patients with heart failure (HF) and left bundle branch block (LBBB). However, BVP is an unnatural pacing modality still conditioned by the high percentage of non-responders and coronary sinus anatomy. Conduction system pacing (CSP)-His bundle pacing (HBP) and Left bundle branch area pacing (LBBAP)- upcomes as the physiological alternative to BVP in the quest for the optimal CRT. CSP showed promising results in terms of better electro-mechanical ventricular synchronization compared to BVP. However, only a few randomized control trials are currently available, and technical challenges, along with the lack of information on long-term clinical outcomes, limit the establishment of a primary role for CSP over conventional BVP in CRT candidates. This review provides a comprehensive literature revision of potential applications of CSP for CRT in diverse clinical scenarios, underlining the current controversies and prospects of this technique.
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Affiliation(s)
- Edoardo Bressi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, Netherlands,Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Rome, Italy,*Correspondence: Edoardo Bressi,
| | - Domenico Grieco
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Rome, Italy
| | - Justin Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, Netherlands
| | - Haran Burri
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, Netherlands
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Zhang J, Zhang Y, Sun Y, Chen M, Wang Z, Ma C. Success rates, challenges and troubleshooting of left bundle branch area pacing as a cardiac resynchronization therapy for treating patients with heart failure. Front Cardiovasc Med 2023; 9:1062372. [PMID: 36704478 PMCID: PMC9872722 DOI: 10.3389/fcvm.2022.1062372] [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: 10/05/2022] [Accepted: 11/28/2022] [Indexed: 01/11/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) is an important treatment of heart failure patients with reduced left ventricular ejection fraction (LVEF) and asynchrony of cardiac electromechanical activity. Left bundle branch area pacing (LBBaP) is a novel physiological pacing modality that appears to be an effective method for CRT. LBBaP has several advantages over the traditional biventricular-CRT (BiV-CRT), including a low and stable pacing capture threshold, a high success rate of implantation, a short learning curve, and high economic feasibility. However, LBBaP is not suitable for all heart failure patients needing a CRT and the success rates of LBBaP in heart failure patients is lower because of myocardial fibrosis, non-specific intraventricular conduction disturbance (IVCD), enlargement of the right atrium or right ventricle, etc. In this literature review, we summarize the success rates, challenges, and troubleshooting of LBBaP in heart failure patients needing a CRT.
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Affiliation(s)
- Junmeng Zhang
- Department of Cardiology, Beijing Huaxin Hospital, Tsinghua University, Beijing, China
| | - Yimin Zhang
- Department of Cardiology, Beijing Huaxin Hospital, Tsinghua University, Beijing, China
| | - Yaxun Sun
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mengna Chen
- Department of Cardiology, Beijing Huaxin Hospital, Tsinghua University, Beijing, China
| | - Zefeng Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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26
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Orlov MV, Nikolaychuk M, Koulouridis I, Goldman A, Natan S, Armstrong J, Bhattacharya A, Hicks A, King M, Wylie J. Left bundle area pacing: Guiding implant depth by ring measurements. Heart Rhythm 2023; 20:55-60. [PMID: 36152975 DOI: 10.1016/j.hrthm.2022.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/11/2022] [Accepted: 09/16/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Criteria for successful left bundle area pacing (LBAP) are in flux and currently guided by lead tip measurements. Lead ring measurements during LBAP have not been well studied. OBJECTIVE The purpose of this study was to investigate dynamics in pacing parameters during successful and unsuccessful lead implant attempts. METHODS SelectSecure 3830 pacing leads (Medtronic, Inc) guided by C315 sheaths for LBAP were placed for standard pacing indications in 73 patients. Retrospective review of procedural, echocardiographic, and standard pacing data were performed. Depth and lead-septal angle of implanted electrodes were determined from fluoroscopy with septal contrast delineation. Depth was graded in 4 categories according to the degree of ring penetration into the septum. Successful implant was defined by the ability to advance the lead deep into the septum and achieve LBAP criteria (ventricular activation time, QRS width/shape). RESULTS Ring impedance increased stepwise during successful attempts as opposed to unsuccessful attempts (P = .039). A wider lead-septal angle at implant position correlated with higher ring impedance (P = .036), whereas no association was found with tip impedance. Unipolar ring threshold correlated with depth of lead implant (P = .029). Tip impedance measurements at implant position were less predictive of lead depth and did not correlate with septal thickness. CONCLUSION Ring pacing parameters are more predictive of lead progress than tip measurements. Lead depth and lead-septal angle can be determined from ring impedance measurements. These measurements may provide determination of lead depth and could obviate the need for contrast injection.
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Affiliation(s)
- Michael V Orlov
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Steward St. Elizabeth's Medical Center/Tufts University School of Medicine, Boston, Massachusetts.
| | - Marianna Nikolaychuk
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Steward St. Elizabeth's Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - Ioannis Koulouridis
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Steward St. Elizabeth's Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - Alena Goldman
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Steward St. Elizabeth's Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - Shaw Natan
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Steward St. Elizabeth's Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - James Armstrong
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Steward St. Elizabeth's Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - Adhiraj Bhattacharya
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Steward St. Elizabeth's Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - Amy Hicks
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Steward St. Elizabeth's Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - Michael King
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Steward St. Elizabeth's Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - John Wylie
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Steward St. Elizabeth's Medical Center/Tufts University School of Medicine, Boston, Massachusetts
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Conduction System Pacing Today and Tomorrow. J Clin Med 2022; 11:jcm11247258. [PMID: 36555877 PMCID: PMC9780948 DOI: 10.3390/jcm11247258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
Conduction system pacing (CSP) encompassing His bundle (HBP) and left bundle branch area pacing (LBBAP) is gaining increasing attention in the electrophysiology community. These relatively novel physiological pacing modalities have the potential to outperform conventional pacing approaches with respect to clinical endpoints, although data are currently still limited. While HBP represents the most physiological form of cardiac stimulation, success rates, bundle branch correction, and electrical lead performance over time remain a concern. LBBAP systems may overcome these limitations. In this review article, we provide a comprehensive overview of the current evidence, implantation technique, device programming, and follow-up considerations concerning CSP systems. Moreover, we discuss ongoing technical developments and future perspectives of CSP.
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28
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Hua W, Gu M, Niu H, Gold MR. Advances of Implantation Techniques for Conduction System Pacing. JACC Clin Electrophysiol 2022; 8:1587-1598. [PMID: 36543514 DOI: 10.1016/j.jacep.2022.09.022] [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: 08/12/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 12/05/2022]
Abstract
Conduction system pacing (CSP), including His bundle and left bundle branch pacing are physiological pacing modalities, but lead deployment is often difficult mainly due to a lack of anatomical landmark for lead tip location. Several implantation techniques for CSP implantation have been developed including 3-dimensional electroanatomical mapping, placing a second lead as a reference (dual-lead method technique), and using fluoroscopic imaging (9-partition and visualization techniques). In this review, the authors summarize the implantation techniques for CSP and compare the different methods.
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Affiliation(s)
- Wei Hua
- Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Min Gu
- Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongxia Niu
- Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA.
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Fu Y, Liu P, Jin L, Li Y, Zhang Y, Qin X, Zheng Q. Left bundle branch area pacing: A promising modality for cardiac resynchronization therapy. Front Cardiovasc Med 2022; 9:901046. [PMID: 36465440 PMCID: PMC9715961 DOI: 10.3389/fcvm.2022.901046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/31/2022] [Indexed: 12/19/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) is recognized as the first-line management for patients with heart failure (HF) and conduction disorders. As a conventional mode for delivering CRT, biventricular pacing (BVP) improves cardiac function and reduces HF hospitalizations and mortality, but there are still limitations given the high incidence of a lack of response rates. Alternative pacing methods are needed either for primary or rescue therapy. In recent years, conduction system pacing (CSP) has emerged as a more physiological pacing modality for simultaneous stimulation of the ventricles, including His bundle pacing (HBP) and left bundle branch pacing (LBBP). CSP activates the His-Purkinje system, allowing normal ventricular stimulation. However, HBP is technically challenging with a relatively low success rate, high pacing threshold, and failure to correct distal conduction abnormalities. Therefore, LBBP stands out as a novel ideal physiological pacing modality for CRT. Several non-randomized studies compared the feasibility and safety of LBBP with BVP and concluded that LBBP is superior to BVP for delivering CRT with a narrower QRS and greater improvements in left ventricular ejection fraction (LVEF) and New York Heart Association (NYHA) functional class. Concurrently, some studies showed lower and stable pacing thresholds and greater improvement of B-type natriuretic peptide (BNP) levels, as well as better mechanical synchronization and efficiency. LBBP ensures better ventricular electromechanical resynchronization than BVP. In this review, we discuss current knowledge of LBBP, compare LBBP with BVP, and explore the potential of LBBP to serve as an alternative primary therapy to realize cardiac resynchronization.
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Affiliation(s)
- Yuping Fu
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Peng Liu
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Lingyan Jin
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yingqi Li
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yudi Zhang
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Xinghua Qin
- School of Life Sciences, Northwestern Polytechnical University, Xi’an, Shaanxi, China
| | - Qiangsun Zheng
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
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Hua J, Kong Q, Chen Q. Alternative pacing strategies for optimal cardiac resynchronization therapy. Front Cardiovasc Med 2022; 9:923394. [PMID: 36237907 PMCID: PMC9551024 DOI: 10.3389/fcvm.2022.923394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/06/2022] [Indexed: 12/02/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) via biventricular pacing (BVP) improves morbidity, mortality, and quality of life, especially in subsets of patients with impaired cardiac function and wide QRS. However, the rate of unsuccessful or complicated left ventricular (LV) lead placement through coronary sinus is 5-7%, and the rate of "CRT non-response" is approximately 30%. These reasons have pushed physicians and engineers to collaborate to overcome the challenges of LV lead implantation. Thus, various alternatives to BVP have been proposed to improve CRT effectiveness. His bundle pacing (HBP) has been increasingly used by activating the His-Purkinje system but is constrained by challenging implantation, low success rates, high and often unstable thresholds, and low perception. Therefore, the concept of pacing a specialized conduction system distal to the His bundle to bypass the block region was proposed. Multiple clinical studies have demonstrated that left bundle branch area pacing (LBBAP) has comparable electrical resynchronization with HBP but is superior in terms of simpler operation, higher success rates, lower and stable capture thresholds, and higher perception. Despite their well-demonstrated effectiveness, the transvenous lead-related complications remain major limitations. Recently, leadless LV pacing has been developed and demonstrated effective for these challenging patient cohorts. This article focuses on the current state and latest progress in HBP, LBBAP, and leadless LV pacing as alternatives for failed or non-responsive conventional CRT as well as their limits and prospects.
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Affiliation(s)
| | | | - Qi Chen
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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