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Jastrzębski M, Moskal P, Hołda MK, Strona M, Bednarek A, Kiełbasa G, Czarnecka D. Deep septal deployment of a thin, lumenless pacing lead: a translational cadaver simulation study. Europace 2021; 22:156-161. [PMID: 31722391 DOI: 10.1093/europace/euz270] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 09/11/2019] [Indexed: 11/13/2022] Open
Abstract
AIMS The recently introduced technique of direct transseptal pacing of the left bundle branch is poorly characterized with many questions with regard to the optimal implantation strategy and safety concerns largely left unanswered. We developed a cadaver model for deep septal lead deployment in order to investigate the depth of penetration in relation to lead behaviour, lead tip position, and the number of rotations. METHODS AND RESULTS Five fresh human hearts and five lumenless, 4.1-Fr pacing leads were used for deep septal deployment simulations. The leads were positioned with the use of a dedicated delivery sheath and screwed into the interventricular septum at several sites progressively more distal from the atrioventricular ring with a predetermined number of lead rotations. During each lead deployment, the depth of tip penetration was measured and the lead behaviour was noted. Four distinct lead behaviours were observed: (i) helix only penetration, no matter how many rotations were performed, due to the 'endocardial entanglement effect' (43.1% cases) or (ii) 'endocardial barrier effect' (19.6% cases), (iii) shallow/moderate penetration, with ensuing 'drill effect' when more rotations were added (9.8% cases), and (iv) deep progressive penetration with each additional rotation, occurring when the 'screwdriver effect' was present (27.4% cases, including three septal perforations). These different lead behaviours seemed to be determined by the lead position-mainly the strength of the initial endocardial layer-and the number of fully transmitted rotations. CONCLUSION New insights into deep septal lead deployment technique were gained with regard to safe and successful implantation.
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Affiliation(s)
- Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kopernika 17, 31-501 Kraków, Poland
| | - Paweł Moskal
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kopernika 17, 31-501 Kraków, Poland
| | - Mateusz K Hołda
- Department of Anatomy, HEART-Heart Embryology and Anatomy Research Team, Jagiellonian University Medical College, Kraków, Poland
| | - Marcin Strona
- Department of Forensic Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Bednarek
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kopernika 17, 31-501 Kraków, Poland
| | - Grzegorz Kiełbasa
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kopernika 17, 31-501 Kraków, Poland
| | - Danuta Czarnecka
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kopernika 17, 31-501 Kraków, Poland
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Jastrzębski M, Kiełbasa G, Moskal P, Bednarek A, Kusiak A, Sondej T, Bednarski A, Rajzer M, Vijayaraman P. Fixation beats: A novel marker for reaching the left bundle branch area during deep septal lead implantation. Heart Rhythm 2020; 18:562-569. [PMID: 33359876 DOI: 10.1016/j.hrthm.2020.12.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/04/2020] [Accepted: 12/17/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND One of the challenges of left bundle branch (LBB) pacing is placing the pacing lead deep enough in the septum to reach the LBB area, yet not too deep to avoid perforation. OBJECTIVE The purpose of this study was to investigate whether the occurrence of the ectopic beats with qR/rsR' morphology in lead V1 (fixation beats) during lead fixation would predict whether the desired intraseptal lead depth had been reached, whereas the lack of fixation beats would indicate a too-shallow position and the need for more lead rotations. METHODS Consecutive patients during LBB pacing device implantation were analyzed retrospectively and then prospectively with respect to the occurrence of fixation beats during each episode of lead rotation. We compared the presence of fixation beats during the lead rotation event directly before the LBB area depth was reached vs during the events before intermediate/unsuccessful positions. RESULTS A total of 339 patients and 1278 lead rotation events were analyzed. In the retrospective phase, fixation beats were observed in 327 of 339 final lead positions and in 9 of 939 intermediate lead positions (P <.001). Sensitivity, specificity, and positive and negative predictive values of the fixation beats as a marker for reaching the LBB area were 96.4%, 97.3%, 97.3%, and 96.5%, respectively. In the prospective, fixation beats-guided implantation phase, fixation beats were observed in all patients and only at the LBB capture depth. CONCLUSION Monitoring fixation beats during deep septal lead deployment can facilitate the procedure and possibly increase the safety of lead implantation.
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Affiliation(s)
- Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland.
| | - Grzegorz Kiełbasa
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Paweł Moskal
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Agnieszka Bednarek
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, 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
| | - Marek Rajzer
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Pugazhendhi Vijayaraman
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania
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Arnold AD, Whinnett ZI, Vijayaraman P. His-Purkinje Conduction System Pacing: State of the Art in 2020. Arrhythm Electrophysiol Rev 2020; 9:136-145. [PMID: 33240509 PMCID: PMC7675135 DOI: 10.15420/aer.2020.14] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/30/2020] [Indexed: 01/02/2023] Open
Abstract
Conduction system pacing involves directly stimulating the specialised His-Purkinje cardiac conduction system with the aim of activating the ventricles physiologically, in contrast to the dyssynchronous activation produced by conventional myocardial pacing. Since the first report of permanent His bundle pacing (HBP) in 2000, the stylet-driven technique of its earliest incarnation has been superseded by a more successful stylet-less approach. Widespread uptake has led to a much greater evidence base. Single-centre observational studies have now been supported by large multicentre, international registries, mechanistic studies and the first randomised controlled trials. New evidence has elucidated mechanisms of HBP and illustrated the nature and magnitude of its potential benefits for preventing pacing-induced cardiomyopathy and correcting bundle branch block. Left bundle branch pacing (LBBP) is a newer technique in which the lead is fixed deep into the left side of the intraventricular septum to allow capture of the left bundle, distal to the His bundle. LBBP holds promise as a method for physiological pacing that overcomes some of the fixation, threshold and sensing challenges of HBP. In this state-of-the-art review of His-Purkinje conduction system pacing, the authors assess recent evidence and current practice and explore emerging and future directions in this rapidly evolving field.
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Affiliation(s)
- Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Pugazhendhi Vijayaraman
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania, US
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Jastrzębski M, Moskal P, Bednarek A, Kiełbasa G, Kusiak A, Sondej T, Bednarski A, Vijayaraman P, Czarnecka D. Programmed deep septal stimulation: A novel maneuver for the diagnosis of left bundle branch capture during permanent pacing. J Cardiovasc Electrophysiol 2020; 31:485-493. [PMID: 31930753 DOI: 10.1111/jce.14352] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/13/2019] [Accepted: 12/23/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Permanent deep septal stimulation with capture of the left bundle branch (LBB) enables maintenance/restoration of the physiological activation of the left ventricle. However, it is almost always accompanied by the simultaneous engagement of the local septal myocardium, resulting in a fused (nonselective) QRS complex, therefore, confirmation of LBB capture remains difficult. METHODS We hypothesized that programmed extrastimulus technique can differentiate nonselective LBB capture from myocardial-only capture as the effective refractory period (ERP) of the myocardium is different from the ERP of the LBB. Consecutive patients undergoing pacemaker implantation underwent programmed stimulation delivered from the lead implanted in a deep septal position. Responses to programmed stimulation were categorized on the basis of sudden change in the QRS morphology of the extrastimuli, observed when ERP of LBB or myocardium was encroached upon, as: "myocardial," "selective LBB," or nondiagnostic (unequivocal change of QRS morphology). RESULTS Programmed deep septal stimulation was performed 269 times in 143 patients; in every patient with the use of a basic drive train of 600 milliseconds and in 126 patients also during intrinsic rhythm. The average septal-myocardial refractory period was shorter than the LBB refractory period: 263.0 ± 34.4 vs 318.0 ± 37.4 milliseconds. Responses diagnostic for LBB capture ("myocardial" or "selective LBB") were observed in 114 (79.7%) of patients. CONCLUSIONS A novel maneuver for the confirmation of LBB capture during deep septal stimulation was developed and found to enable definitive diagnosis by visualization of both components of the paced QRS complex: selective paced LBB QRS and myocardial-only paced QRS.
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Affiliation(s)
- Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
| | - Paweł Moskal
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Bednarek
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland.,Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania
| | - Grzegorz Kiełbasa
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
| | - Aleksander Kusiak
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland.,Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania
| | - Tomasz Sondej
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
| | - Adam Bednarski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
| | - Pugazhendhi Vijayaraman
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania
| | - Danuta Czarnecka
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
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Moskal P, Jastrzębski M, Krakowiak A, Su L, Huang W, Czarnecka D. Rate-related block during permanent His bundle pacing. J Cardiovasc Electrophysiol 2019; 31:240-242. [PMID: 31746053 DOI: 10.1111/jce.14261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/20/2019] [Accepted: 08/23/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Paweł Moskal
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | - Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Krakowiak
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, University Hospital, Krakow, Poland
| | - Lan Su
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Weijian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Danuta Czarnecka
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Krakow, Poland
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