HIS BUNDLE PACING IN HFD.D MANOLATOS MD, PHD, FESC

ELECTROPHYSIOLOGY DEPARTMENT

ACCEPTANCE

30-40% NON responders to BiV-CRT

Only 34% of pts with HF have LBBB

TRULY LBBB

RBBB + QRSd 120-150 ms IIB

MADIT CRT/ PR interval

RV apical pacing

Non-physiological dyssynchronous ventricular activation

↓

Remodeling and impaired cardiac function

PM induced CM 12.8%

Fup= 4 yrs

His pacingHF post PM implantation

His Pacing

Circulation. 2000 Feb 29;101(8):869-77

Permanent DHBP is feasible in select patients who have chronic atrial fibrillation

and dilated cardiomyopathy. Long-term, DHBP results in a reduction of left

ventricular dimensions and improved cardiac function.

Implantation techniques and tools

A:V ratio: 1:3 or lower

:ACCEPTABLE THRESHOLDS:

AV nodal disease: up to 2V 1ms

His-Purkinjee disease: 3V 1ms

HIS BUNDLE PACING

Physiological cardiac activation is maintained when His‐bundle pacing is applied to people with a narrow QRS duration.

HBP: restores normal physiological activation in

patients with BBB

https://onlinelibrary.wiley.com/doi/full/10.1002/ehf2.12315

Pacing distal to the site of block

Site of block

https://files.radcliffecardiology.com/s3fs-public/figure4-mechanisms-for-left-bundle.png

Longitudinal dissociation of the HB

His Pacing for Cardiac Resynchronization

J Am Coll Cardiol 2018;72:927-47.

His pacing

Endpoints

Hard endpoints There are no long-term RCTsevaluating clinical outcomes and mortality that compare HBP and RV pacing

Soft endpoints

↑↑ O2 uptake

↑↑ Exercise duration

↓↓ Anaerobic threshold

↓↓ NYHA

↑↑ LVEF

↓↓ MR or TR

J Am Coll Cardiol 2017;69:3099–114.

Heart Rhythm 2018;15:413-420.

His pacingCardiac Resynchronization Therapy

retrospective, observational multicenter study

His-SYNC pilot study

His-SYNC pilot study

Primary outcomes:

change in QRS duration

improvement in LVEF

time to cardiovascular hospitalization or death

His-SYNC pilot study

Crossover :

His-CRT: 48%

QRS narrowing < 20%

High threshold (>5V)

BiV-CRT: 26%

LV lead could not be placed

LV lead delivery into the anterior interventricular or middle

cardiac veins was discouraged

HOPE HF study

His pacingHF, RBBB, HV 100ms, AV block

His pacingHF, RBBB, HV 100ms, AV block

His pacingHF, RBBB, HV 100ms, AV block

PHBP

Prevention PICM

CRT bail out strategy

Non-responders,

Failed Coronary Sinus Lead Placement,

Cardiomyopathies with Chronic Bundle Branch Blocks

LBBB induced cardiomyopathy

AV nodal ablation (AF and narrow QRS)

Pacing therapy in pts with HF and narrow QRS

Use of HBP in pts with IVCD is UNCERTAIN