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HIS BUNDLE PACING IN HFD.D MANOLATOS MD, PHD, FESC
ELECTROPHYSIOLOGY DEPARTMENT
ACCEPTANCE
30-40% NON responders to BiV-CRT
Only 34% of pts with HF have LBBB
TRULY LBBB
RBBB + QRSd 120-150 ms IIB
MADIT CRT/ PR interval
RV apical pacing
Non-physiological dyssynchronous ventricular activation
↓
Remodeling and impaired cardiac function
PM induced CM 12.8%
Fup= 4 yrs
His pacingHF post PM implantation
His Pacing
Circulation. 2000 Feb 29;101(8):869-77
Permanent DHBP is feasible in select patients who have chronic atrial fibrillation
and dilated cardiomyopathy. Long-term, DHBP results in a reduction of left
ventricular dimensions and improved cardiac function.
Implantation techniques and tools
A:V ratio: 1:3 or lower
:ACCEPTABLE THRESHOLDS:
AV nodal disease: up to 2V 1ms
His-Purkinjee disease: 3V 1ms
HIS BUNDLE PACING
Physiological cardiac activation is maintained when His‐bundle pacing is applied to people with a narrow QRS duration.
HBP: restores normal physiological activation in
patients with BBB
https://onlinelibrary.wiley.com/doi/full/10.1002/ehf2.12315
Pacing distal to the site of block
Site of block
https://files.radcliffecardiology.com/s3fs-public/figure4-mechanisms-for-left-bundle.png
Longitudinal dissociation of the HB
His Pacing for Cardiac Resynchronization
J Am Coll Cardiol 2018;72:927-47.
His pacing
Endpoints
Hard endpoints There are no long-term RCTsevaluating clinical outcomes and mortality that compare HBP and RV pacing
Soft endpoints
↑↑ O2 uptake
↑↑ Exercise duration
↓↓ Anaerobic threshold
↓↓ NYHA
↑↑ LVEF
↓↓ MR or TR
J Am Coll Cardiol 2017;69:3099–114.
Heart Rhythm 2018;15:413-420.
His pacingCardiac Resynchronization Therapy
retrospective, observational multicenter study
His-SYNC pilot study
His-SYNC pilot study
Primary outcomes:
change in QRS duration
improvement in LVEF
time to cardiovascular hospitalization or death
His-SYNC pilot study
Crossover :
His-CRT: 48%
QRS narrowing < 20%
High threshold (>5V)
BiV-CRT: 26%
LV lead could not be placed
LV lead delivery into the anterior interventricular or middle
cardiac veins was discouraged
HOPE HF study
His pacingHF, RBBB, HV 100ms, AV block
His pacingHF, RBBB, HV 100ms, AV block
His pacingHF, RBBB, HV 100ms, AV block
PHBP
Prevention PICM
CRT bail out strategy
Non-responders,
Failed Coronary Sinus Lead Placement,
Cardiomyopathies with Chronic Bundle Branch Blocks
LBBB induced cardiomyopathy
AV nodal ablation (AF and narrow QRS)
Pacing therapy in pts with HF and narrow QRS
Use of HBP in pts with IVCD is UNCERTAIN