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Published on: April 21, 2013
Conduction-guided intervention: A first-in-human study of computed tomography angiography-guided targeting of
Óscar Cano1, Justin T Tretter2, Tarikh Asyraf3
1Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe, Valencia, Spain; Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Department of Cardiology, Ascires Hospital, Valencia, Spain.
Insights
Computed tomography angiography (CTA)-guided conduction system pacing (CSP) successfully targeted proximal conduction structures in 90% of patients. This novel workflow integrates cardiac CTA with patient-specific anatomy for improved His bundle and left bundle branch pacing.
Area of Science:
- Cardiology
- Medical Imaging
- Electrophysiology
Background:
- Conduction system pacing (CSP) implantation is challenging due to difficulties in precisely targeting proximal His bundle and left bundle branch (LBB) structures.
- Current techniques often struggle with accurate anatomical targeting, impacting procedural success.
Purpose of the Study:
- To evaluate a novel computed tomography angiography (CTA)-guided workflow for precise, patient-specific targeting of proximal conduction system structures.
- To assess the feasibility and efficacy of this CTA-guided approach in facilitating His bundle and LBB pacing.
Main Methods:
- A prospective, first-in-human study enrolled 40 patients undergoing CSP.
- The Conduction Guided Intervention (CGI) workflow integrated pre-procedural cardiac CTA, patient-specific conduction system reconstruction, and real-time fluoroscopic overlay.
- Procedural success was defined by implantation at a target proximal conduction site, while clinical success required effective pacing with QRS correction.
Main Results:
- Procedural success was achieved in 95% of patients (38/40).
- Significant inter-individual anatomical variability in the proximal conduction system was observed via CTA.
- Final pacing sites included distal His pacing (35%) and proximal LBB trunk pacing (55%), achieving clinical success in 90% of patients.
Conclusions:
- CTA-guided conduction system mapping is a feasible technique for intentional targeting of proximal conduction structures during CSP.
- Integrating patient-specific anatomical data from CTA complements traditional fluoroscopic and electrophysiological guidance.
- This approach shows promise for improving the accuracy and success rates of conduction system pacing.
Background:
Conduction system pacing (CSP) remains technically challenging because intentional targeting of proximal conduction structures, such as the distal His bundle and proximal left bundle branch (LBB) trunk, is difficult using current implantation techniques.
Objective:
We evaluated a novel computed tomography angiography (CTA)-guided workflow designed to facilitate patient-specific targeting of these structures.
Methods:
Conduction-guided intervention (CGI) integrates preprocedural cardiac CTA with patient-specific conduction system reconstruction and real-time fluoroscopic overlay. In this first-in-human prospective study, 40 consecutive patients undergoing CSP were enrolled. Procedural success was defined as implantation at a proximal conduction system target according to predefined anatomical and electrophysiological criteria. Clinical success required proximal conduction system capture with QRS correction at working output.
Results:
Procedural success was achieved in 38/40 patients (95%). CTA analysis demonstrated substantial inter-individual variability in proximal conduction system anatomy, with marked differences in distances and trajectories along the AVN-His axis between patients. Distal His pacing according to predefined procedural criteria was initially achieved in 26 patients (65%). However, transition to proximal LBB trunk pacing was required in 12 patients because of inadequate QRS correction and/or unfavorable pacing thresholds. Final adjudicated pacing sites included distal His pacing in 14 patients (35%) and proximal LBB trunk pacing in 22 patients (55%), resulting in proximal conduction system pacing in 36/40 patients (clinical success 90%).
Conclusion:
CTA-guided conduction system mapping was feasible and enabled intentional targeting of proximal conduction structures in most patients. Integration of patient-specific anatomical information may complement conventional fluoroscopic and electrophysiological guidance during CSP implantation.
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