His bundle combined with deep septal left bundle branch area pacing for atrial fibrillation prior to atrioventricular
Michael C Y Nam1, Patricia O'Sullivan1, Ivaylo Tonchev1
1Department of Cardiology Royal Melbourne Hospital Parkville Victoria Australia.
Insights
This study introduces a combined His bundle pacing (HBP) and deep septal left bundle branch area pacing (dsLBBAP) strategy for atrial fibrillation. This novel approach offers a feasible alternative for patients refractory to medical therapy, showing promising results.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- International guidelines recommend His bundle pacing (HBP) before AV node ablation for treatment-refractory atrial fibrillation to prevent cardiomyopathy.
- Concerns regarding long-term pacing parameters of HBP have prompted exploration of alternative strategies.
Purpose of the Study:
- To evaluate the feasibility and efficacy of a combined HBP and deep septal left bundle branch area pacing (dsLBBAP) strategy.
- To enable intrapatient comparison of HBP and dsLBBAP pacing parameters in patients undergoing AV node ablation for atrial fibrillation.
Main Methods:
- Eight patients with treatment-refractory atrial fibrillation and normal left ventricular ejection fraction underwent combined HBP and dsLBBAP implantation.
- Pacing parameters including sensed ventricular amplitude, lead impedance, paced QRS duration, and pacing thresholds were compared between HBP and dsLBBAP.
- Cardiac CT was used to assess dsLBBAP septal penetration depth and proximity to the left ventricular septal wall.
Main Results:
- Combined HBP and dsLBBAP implantation was technically successful in all patients.
- HBP demonstrated lower sensed ventricular amplitude and lead impedance compared to dsLBBAP.
- dsLBBAP showed a trend towards wider paced QRS duration but required lower pacing output.
- Adequate septal penetration for dsLBBAP was confirmed by CT, with no procedural complications during follow-up.
Conclusions:
- Combined HBP and dsLBBAP pacing is a feasible and safe approach for patients with refractory atrial fibrillation.
- This strategy provides an alternative to standard HBP, potentially offering improved long-term pacing characteristics.
- Further research is warranted to fully elucidate the long-term benefits of this combined pacing technique.
Background:
To mitigate the risk of dyssynchrony-induced cardiomyopathy, international guidelines advocate His bundle pacing (HBP) with a ventricular backup lead prior to atrioventricular node ablation in treatment-refractory atrial fibrillation and normal left ventricular ejection fraction. As a result of concerns with long-term pacing parameters associated with HBP, this case series reports an adopted strategy of HBP combined with deep septal left bundle branch area pacing (dsLBBAP) in this patient cohort, enabling intrapatient comparison of the two pacing methods.
Methods And Results:
Eight patients aged 72 ± 10 years (left ventricular ejection fraction 53 ± 4%) underwent successful combined HBP and dsLBBAP implant prior to AV node ablation. Intrinsic QRS duration was 118 ± 46 ms. When compared to dsLBBAP, HBP had lower sensed ventricular amplitude (2.4 ± 1.1 vs. 15 ± 5.3 V, p = .001) and lower lead impedance (522 ± 57 vs. 814 ± 171ohms, p = .02), but shorter paced QRS duration (101 ± 20 vs. 119 ± 17 ms, p = .02). HBP pacing threshold was 1.0 ± 0.6 V at 1 ms pulse width, and dsLBBAP pacing threshold was 0.5 ± 0.2 V at 0.4 ms pulse width. Five patients underwent cardiac CT showing adequate dsLBBAP ventricular septal penetration (8.6 ± 1.3 mm depth, 2.4 ± 0.5 mm distance from left ventricular septal wall). No complications occurred during a mean follow-up duration of 121 ± 92 days.
Conclusions:
Combined HBP and dsLBBAP pacing is a feasible approach as a pace and ablate strategy for atrial fibrillation refractory to medical therapy.
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