Left ventricular activation time and pattern are preserved with both selective and nonselective His bundle pacing
Ahran D Arnold1, Matthew J Shun-Shin1, Nadine Ali1
1National Heart and Lung Institute, Imperial College London, London, United Kingdom.
Insights
Nonselective His bundle pacing (NS-HBP) causes early right ventricular activation and prolongs QRS duration compared to selective HBP (S-HBP). However, NS-HBP maintains left ventricular activation, suggesting dyssynchrony is not a major concern.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Pacing
Background:
- His bundle pacing (HBP) offers two methods: selective HBP (S-HBP) and nonselective HBP (NS-HBP).
- NS-HBP involves capturing local myocardium, leading to a pre-excited electrocardiogram appearance.
Purpose of the Study:
- To evaluate the impact of ventricular pre-excitation from NS-HBP on left and right ventricular dyssynchrony.
- To compare ventricular activation times and patterns between S-HBP and NS-HBP.
Main Methods:
- Recruited patients exhibiting both S-HBP and NS-HBP.
- Utilized noninvasive epicardial electrical mapping to assess left and right ventricular activation time (LVAT and RVAT) and patterns.
Main Results:
- NS-HBP resulted in a mean within-patient decrease in LVAT of -5.5 ms compared to S-HBP (P < .0001).
- NS-HBP did not significantly prolong RVAT (P = .296) but did prolong QRS duration by 22.1 ms (P = .0003).
- In patients with narrow intrinsic QRS, NS-HBP preserved LVAT but prolonged QRS duration and mean RVAT compared to S-HBP.
Conclusions:
- Local myocardial capture during NS-HBP causes basal right ventricular pre-excitation, prolonging QRS duration.
- NS-HBP effectively preserves the left ventricular activation time and pattern observed with S-HBP.
- Ventricular dyssynchrony is generally not a significant consideration when choosing between S-HBP and NS-HBP.
Background:
His bundle pacing (HBP) can be achieved in 2 ways: selective HBP (S-HBP), where the His bundle is captured alone, and nonselective HBP (NS-HBP), where local myocardium is also captured, resulting a pre-excited electrocardiogram appearance.
Objective:
We assessed the impact of this ventricular pre-excitation on left and right ventricular dyssynchrony.
Methods:
We recruited patients who displayed both S-HBP and NS-HBP. We performed noninvasive epicardial electrical mapping for left and right ventricular activation time (LVAT and RVAT) and pattern.
Results:
Twenty patients were recruited. In the primary analysis, the mean within-patient change in LVAT from S-HBP to NS-HBP was -5.5 ms (95% confidence interval: -0.6 to -10.4, noninferiority P < .0001). NS-HBP did not prolong RVAT (4.3 ms, -4.0 to 12.8, P = .296) but did prolong QRS duration (QRSd, 22.1 ms, 11.8 to 32.4, P = .0003). In patients with narrow intrinsic QRS (n = 6), NS-HBP preserved LVAT (-2.9 ms, -9.7 to 4.0, P = .331) but prolonged QRS duration (31.4 ms, 22.0 to 40.7, P = .0003) and mean RVAT (16.8 ms, -5.3 to 38.9, P = .108) compared to S-HBP. Activation pattern of the left ventricular surface was unchanged between S-HBP and NS-HBP, but NS-HBP produced early basal right ventricular activation that was not seen in S-HBP.
Conclusion:
Compared to S-HBP, local myocardial capture during NS-HBP produces pre-excitation of the basal right ventricle resulting in QRS duration prolongation. However, NS-HBP preserves the left ventricular activation time and pattern of S-HBP. Left ventricular dyssynchrony is not an important factor when choosing between S-HBP and NS-HBP in most patients.
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