Abstract
Chronic right ventricular (RV) pacing has been associated with significant electrical and mechanical dyssynchrony leading to increased risk for recurrent heart failure hospitalizations and atrial arrhythmias. His bundle pacing (HBP) is an effective alternative to RV pacing as it is physiological and provides synchronized contraction of both ventricles. But there are limitations to HBP, which include lead stability, rise in threshold, early battery depletion and longer learning curve. Huang et al. recently reported a novel technique to directly capture the left bundle branch (LBB) by deep septal pacing. Subsequently, many studies have demonstrated the feasibility, safety and efficacy of left bundle branch pacing (LBBP). This has the potential to overcome the limitations of HBP and provide a safe technique to capture the conduction system in patients with distal His bundle and proximal bundle branch disease. The criteria for LBB capture and the methodology to perform LBBP are discussed in detail in this review. The Medtronic SelectSecure®3830 pacing lead is used along with a fixed-curve C315His® or a deflectable C304His® sheath. LBBP provides safe and low threshold compared to HBP. Left bundle potential should be demonstrable in all patients except in those with infrahisian complete heart block (CHB) and complete left bundle branch block (LBBB), wherein antegrade activation of the left bundle will not occur. LBBP has the potential to be an effective alternative to biventricular pacing or HBP in patients with left ventricular dysfunction, LBBB and recurrent heart failure. Long-term safety and clinical outcomes compared to traditional pacing need to be carefully studied in randomized clinical trials.
Zusammenfassung
Die dauerhafte rechtsventrikuläre (RV) Stimulation ist mit einer signifikanten elektrischen und mechanischen Dyssynchronie assoziiert, die zu einem erhöhten Risiko rezidivierender herzinsuffizienzbedingter Hospitalisationen und atrialer Tachyarrhythmien führt. Die His-Bündel-Stimulation stellt eine effektive Alternative zur RV-Stimulation dar, da sie physiologisch ist und eine synchronisierte Kontraktion beider Ventrikel gewährleistet. Es bestehen jedoch Limitationen der His-Bündel-Stimulation in Bezug auf stabile Elektrodenlage, Reizschwellenanstieg, frühe Batterieerschöpfung und längere Lernkurve bei der Implantation. Kürzlich haben Huang et al. eine neue Technik zur direkten Erregung des linken Schenkels (LS) durch tief septale Stimulation vorgestellt. Nachfolgend haben mehrere Studien die Machbarkeit, Sicherheit und Effektivität der LS-Stimulation bestätigt. Die LS-Stimulation besitzt das Potenzial, die Limitationen der His-Bündel-Stimulation zu überwinden und sich als eine sichere Technik zur Stimulation des Reizleitungssystems bei Patienten mit distaler His-Bündel- oder proximaler Schenkelblockierung zu erweisen. In der vorliegenden Übersicht werden die Kriterien für die LS-Erregung und die Implantationstechnik im Rahmen der LS-Stimulation im Detail diskutiert. Hierbei wird die SelectSecure®-3830-Schrittmacherelektrode zusammen mit einer fixierten C315His®- oder steuerbaren C304His®-Schleuse (alle Produkte von Medtronic) verwendet. Die LS-Stimulation liefert sichere und im Vergleich zur His-Bündel-Stimulation niedrigere Reizschwellen. Ein LS-Potenzial sollte bei allen Patienten sichtbar sein, außer es besteht ein infrahisärer oder ein kompletter LS-Block, bei denen keine antegrade Aktivierung des LS möglich ist. Die LS-Stimulation könnte sich als effektive Alternative zur biventrikulären oder His-Bündel-Stimulation bei Patienten mit linksventrikulärer Dysfunktion, LS-Block und rezidivierender Herzinsuffizienz erweisen. Langzeitsicherheit und klinisches Outcome müssen noch in randomisierten klinischen Studien mit der herkömmlichen Stimulation verglichen werden.
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P. Vijayaraman: Speaker, Consultant, Fellowship support, Research (Medtronic), Consultant (Boston Scientific, Abbott, Biotronik), patent pending for His delivery tool. S. Sundaram declares that he has no competing interests.
For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.
Caption Electronic Supplementary Material
Video 1: Advancement of the lead deep in the septum in left anterior oblique view
Video 2: Angiography demonstrating the depth of the lead in the ventricular septum
Video 3: Uncoiling the excessive lead loop
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Sundaram, S., Vijayaraman, P. Left bundle branch pacing. Herzschr Elektrophys 31, 124–134 (2020). https://doi.org/10.1007/s00399-020-00694-8
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DOI: https://doi.org/10.1007/s00399-020-00694-8