Programmed His Bundle Pacing: A Novel Maneuver for the Diagnosis of His Bundle Capture
Marek Jastrzębski1, Paweł Moskal1, Agnieszka Bednarek1
1First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland (M.J., P.M., A.B., G.K., D.C.).
Insights
Programmed His bundle (HB) pacing can differentiate between true HB capture and right ventricular (RV) myocardial pacing by analyzing effective refractory periods (ERPs). This novel technique accurately diagnoses His bundle pacing, distinguishing it from RV myocardial pacing.
Area of Science:
- Electrophysiology
- Cardiology
- Medical Device Technology
Background:
- Distinguishing nonselective His bundle (ns-HB) pacing from right ventricular (RV) myocardial pacing is critical during permanent His bundle pacing implantation.
- Differences in effective refractory periods (ERPs) between the His bundle (HB) and working myocardium suggest a method for differentiation.
Purpose of the Study:
- To hypothesize and test the ability of programmed extrastimulus technique to differentiate ns-HB capture from RV myocardial capture.
- To assess a novel maneuver for diagnosing HB capture based on ERP differences.
Main Methods:
- Programmed His bundle pacing was delivered using a screwed-in HB pacing lead in patients undergoing implantation.
- Premature beats were introduced in 10-ms steps during intrinsic rhythm and after a 600 ms drive train.
- The longest coupling interval causing an abrupt QRS morphology change identified the ERP of the HB or RV myocardium.
Main Results:
- In 34 of 36 ns-HB pacing cases, RV myocardial ERP was shorter than HB ERP (271.8±38 ms vs. 353.0±30 ms; P<0.0001).
- Programmed pacing revealed abrupt QRS morphology changes, transitioning from ns-HB to RV myocardial pacing in 34 cases and to selective HB pacing in 2 cases.
- The method correctly diagnosed all ns-HB and RV myocardial pacing cases, with stable QRS morphology in RV myocardial-only pacing.
Conclusions:
- A novel maneuver utilizing ERP differences between HB and myocardium was developed and validated for diagnosing HB capture.
- This technique is valuable for visualizing selective HB QRS in patients with otherwise obligatory ns-HB pacing.
- The method accurately differentiates true His bundle pacing from right ventricular myocardial pacing.
Background:
During permanent nonselective His bundle (ns-HB) pacing, it is crucial to confirm HB capture/exclude that only right ventricle (RV) myocardial septal pacing is present. Because the effective refractory period (ERP) of the working myocardium is different than the ERP of the HB, we hypothesized that it should be possible to differentiate ns-HB capture from RV myocardial capture using programmed extrastimulus technique.
Methods:
In consecutive patients during HB pacemaker implantation, programmed HB pacing was delivered from the screwed-in HB pacing lead. Premature beats were introduced at 10-ms steps during intrinsic rhythm and also after a drive train of 600 ms. The longest coupling interval that resulted in an abrupt change of QRS morphology was considered equal to ERP of HB or RV myocardium.
Results:
Programmed HB pacing was performed from 50 different sites in 32 patients. In 34 of 36 cases of ns-HB pacing, the RV myocardial ERP was shorter than HB ERP (271.8±38 versus 353.0±30 ms; P<0.0001). Programmed HB pacing using a drive train resulted in a typical abrupt change of paced QRS morphology: from ns-HB to RV myocardial QRS (34 of 36 cases) or to selective HB QRS (2 of 36 cases). Programmed HB pacing delivered during native conduction resulted in obtaining selective HB QRS in 20 of 34 and RV myocardial QRS in 14 of 34 of the ns-HB cases. In RV myocardial-only pacing cases (false ns-HB pacing, n=14), such responses were not observed-the QRS morphology remained stable. Therefore, the programmed HB pacing correctly diagnosed all ns-HB cases and all RV myocardial pacing cases.
Conclusions:
A novel maneuver for the diagnosis of HB capture, based on the differences in ERP between HB and myocardium, was formulated, assessed, and found as diagnostically valuable. This method is unique in enabling to visualize selective HB QRS in patients with otherwise obligatory ns-HB pacing (RV myocardial capture threshold
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