A novel and practical technique to facilitate lead insertion at the His bundle region
Helbert Acosta1, Nathan Acosta2, Gerardo Viafara2
1Electrophysiology Division, UnityPoint Health Heart Center, Rock Island, IL, 61201, USA. Acosta@cvmedpc.com.
Insights
His bundle pacing is challenging. A right atrial septo-gram (RAS) effectively visualizes the His bundle (HB) region, improving His bundle pacing success rates and efficiency.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- His bundle (HB) pacing is technically demanding due to difficulties in precisely locating the HB.
- Existing methods for HB localization are often time-consuming and complex.
Purpose of the Study:
- To evaluate the efficacy and safety of a novel right atrial septo-gram (RAS) technique for His bundle (HB) localization.
- To improve the success rate of permanent His bundle pacing.
Main Methods:
- A right atrial septo-gram (RAS) using contrast injection was performed in 133 patients to visualize the HB region.
- The HB was identified at the apex of an angle formed by the tricuspid valve annulus and interatrial septum.
- Leads were advanced to the HB area and mapped using pace mapping and unipolar recordings.
Main Results:
- The RAS technique successfully localized the HB region in all patients.
- The overall acute success rate for lead insertion at the HB was 95%.
Conclusions:
- The RAS technique is a safe and efficient method for His bundle (HB) localization.
- This approach significantly enhances the success rate of permanent His bundle pacing compared to previous methods.
Background:
His bundle (HB) pacing techniques are challenging and time-consuming. This is primarily due to the limitations in locating the relatively small area of the HB body for pacing.
Methods:
Permanent HB pacing was performed in 133 consecutive patients with symptomatic bradycardia. A right atrial septo-gram (RAS) was performed in all patients to locate the HB. Briefly, 8-10 cc of contrast was injected through the Medtronic C315HIS delivery sheath while fluoroscopy cine runs were obtained in the RAO 15-20° projection. The images obtained provided the visualization of an approximately 90° angle composed by the medial aspect of the tricuspid valve annulus (TVA) anteriorly and the superior aspect of the interatrial septum superiorly. The apex of this angle coincides with the tip of the triangle of Koch (TK), where the HB body is usually located. A Medtronic SelectSecure™ MRI SureScan™ Model 3830 lead was then advanced and directed towards this area. The HB was mapped using pace mapping and unipolar recordings from the lead tip.
Results:
Localization of the apex of the TK/HB body with the RAS was successful in all patients. The overall acute success of inserting the lead at the HB was 95%.
Conclusion:
This study demonstrated that our method of utilizing a RAS to facilitate the localization the HB body proved to be safe and efficient in achieving permanent HB pacing with a success rate higher than previously reported.
