Permanent His-bundle pacing using stylet-directed, active-fixation leads placed via coronary sinus sheaths compared
Michael V Orlov1, David Casavant2, Ioannis Koulouridis1
1Department of Medicine, Division of Cardiology, Section of Electrophysiology, Steward St. Elizabeth's Medical Center, Boston, Massachusetts; Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts.
Insights
His-bundle pacing (HBP) using stylet-driven leads (SDLs) delivered via coronary sinus (CS) sheaths is feasible and safe. This method showed comparable procedural success and lead performance to conventional techniques, offering a viable alternative for cardiac pacing.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- His-bundle pacing (HBP) traditionally uses stylet-less leads via custom catheters.
- The use of coronary sinus (CS) sheaths for delivering stylet-driven leads (SDLs) in HBP has not been previously described.
Purpose of the Study:
- To evaluate the feasibility and performance of HBP using SDLs delivered through CS sheaths.
- To compare this novel approach with the conventional method using stylet-less leads.
Main Methods:
- Delivery of Medtronic 4471 and 7742 SDLs was attempted in 27 patients using CS guide catheters and custom stylets.
- Procedural characteristics and lead performance were compared to 17 patients who received lumen-less leads (LLLs).
- Patients had diverse pacing indications.
Main Results:
- Successful HBP was achieved in 89% of patients with SDLs versus 88% with LLLs.
- Procedural and fluoroscopy times were similar between groups (P=NS).
- Acute HBP thresholds were higher with SDLs (2.6 ± 1.5 V vs 1.5 ± 1.2 V; P=.02), remaining stable at follow-up.
Conclusions:
- Permanent HBP with SDLs delivered via conventional CS sheaths is feasible.
- Procedural characteristics and lead performance are clinically acceptable.
- This technique provides a viable alternative for HBP.
Background:
The use of coronary sinus (CS) sheaths to deliver stylet-driven leads (SDLs) for His-bundle pacing (HBP) has not been described. Conventionally, HBP is achieved using a stylet-less lead delivered through a customized catheter.
Objective:
The purpose of this study was to characterize the acute and early-term HBP experience with stylet-driven, active-fixation leads delivered through CS sheaths compared to the conventional approach.
Methods:
Delivery of Medtronic 4471 and 7742 SDLs was attempted in 27 patients. Delivery was facilitated using CS guide catheters and custom-shaped stylets. Procedural characteristics and lead performance were compared to those of a group of 17 patients in whom delivery of 3830 lumen-less leads (LLLs) was attempted. Patients had heterogeneous pacing indications.
Results:
HBP with SDL was successful in 24 of 27 patients(89%) compared to 15 of 17 patients (88%) in the LLL group. Mean procedural and fluoroscopy times in the SDL and LLL groups were 129 ± 43 minutes vs 104 ± 43 minutes and 9.6 ± 5.2 minutes vs 8.3 ± 5.0 minutes, respectively (both P = NS). There was a significant difference in procedure and fluoroscopy times within the SDL group between the first and second halves of the series, probably secondary to a learning curve. Acute HBP thresholds were higher with SDL than with LLL (2.6 ± 1.5 V vs 1.5 ± 1.2 V; P = .02) and remained stable at 8.4 ± 5.3 months. Both SDLs exhibited similar pacing thresholds. Two crossovers between groups occurred (1 in each group). Four patients with SDL and 1 patient with LLL exhibited high thresholds during follow-up.
Conclusion:
Permanent HBP using stylet-driven, active-fixation leads delivered through conventional CS sheaths is feasible. Procedural characteristics and lead performance were clinically acceptable.
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