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Novel approach to diagnosis of His bundle capture using individualized left ventricular lateral wall activation time
Marek Jastrzębski1, Paweł Moskal1, Piotr Kukla2
1First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland.
Insights
Confirming His bundle (HB) capture is crucial. A new ECG criterion using V6 R-wave peak time (RWPT) reliably distinguishes HB capture from right ventricular septal capture, improving pacing accuracy.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Diagnostics
Background:
- Distinguishing His bundle (HB) capture from right ventricular septal (RVS) capture during pacing is clinically significant.
- Left ventricular lateral wall activation time, assessed by V6 R-wave peak time (RWPT), is a key indicator.
Purpose of the Study:
- To validate a hypothesis that during HB capture, V6 RWPT does not exceed native conduction activation time.
- To establish a reliable electrocardiogram (ECG)-based criterion for confirming HB capture.
Main Methods:
- Compared stimulus-V6 RWPT and native HB potential-V6 RWPT in patients with permanent HB pacing.
- Utilized receiver operating characteristic (ROC) curve analysis to identify delta V6 RWPT as diagnostic for lack of HB capture.
- Excluded patients with abnormal His-ventricle interval or left bundle branch block.
Main Results:
- Analyzed 723 ECGs from 219 patients, including native rhythm, selective HB, nonselective HB, and RVS capture.
- Found RVS capture resulted in a significantly longer V6 RWPT (32.0 ±9.5 ms) compared to HB capture.
- Delta V6 RWPT > 12 ms demonstrated high diagnostic accuracy (99.1% specificity, 100% sensitivity) for lack of HB capture.
Conclusions:
- Validated a novel criterion for HB capture based on individualized left ventricular activation time.
- Paced V6 RWPT not exceeding native conduction by >12 ms confirms HB capture.
- Longer paced V6 RWPT suggests RVS capture, enabling accurate diagnosis.
Background:
During nonselective His bundle (HB) pacing, it is clinically important to confirm His bundle capture versus right ventricular septal (RVS) capture. The present study aimed to validate the hypothesis that during HB capture, left ventricular lateral wall activation time, approximated by the V6 R-wave peak time (V6 RWPT), will not be longer than the corresponding activation time during native conduction.
Methods:
Consecutive patients with permanent HB pacing were recruited; cases with abnormal His-ventricle interval or left bundle branch block were excluded. Two corresponding intervals were compared: stimulus-V6 RWPT and native HB potential-V6 RWPT. The difference between these two intervals (delta V6 RWPT), which was diagnostic of lack of HB capture, was identified using receiver operating characteristic (ROC) curve analysis.
Results:
A total of 723 electrocardiograms (ECGs) (219 with native rhythm, 172 with selective HB, 215 with nonselective HB, and 117 with RVS capture) were obtained from 219 patients. The native HB-V6 RWPT, nonselective-, and selective-HB paced V6 RWPT were nearly equal, while RVS V6 RWPT was 32.0 (±9.5) ms longer. The ROC curve analysis indicated delta V6 RWPT > 12 ms as diagnostic of lack of HB capture (specificity of 99.1% and sensitivity of 100%). A blinded observer correctly diagnosed 96.7% (321/332) of ECGs using this criterion.
Conclusions:
We validated a novel criterion for HB capture that is based on the physiological left ventricular activation time as an individualized reference. HB capture can be diagnosed when paced V6 RWPT does not exceed the value obtained during native conduction by more than 12 ms, while longer paced V6 RWPT indicates RVS capture.
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