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Indikationen zur His-Bündel- und Linksschenkelstimulation

Indications for His bundle and left bundle branch pacing

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Zusammenfassung

Die His-Bündel-Stimulation (HBS) ermöglicht eine ventrikuläre Erregung durch das gesamte Reizleitungssystem, was im Vergleich zur myokardialen Stimulation zu einer besseren Synchronizität und damit Effektivität der ventrikulären Kontraktion führt. Sie hat sich aufgrund verbesserter Materialien und exakten Implantationsanleitungen zu einer Stimulationsform entwickelt, die mit vertretbarem zeitlichem Aufwand bei >90 % der Patienten erfolgreich angewandt werden kann. Auch die Rate an Elektrodendislokationen und Reizschwellenanstiegen hat sich an konventionelle Systeme angenähert. Auch wenn die Datenlage noch relativ dünn ist und randomisierte Studien weitgehend fehlen, scheint die HBS bei folgenden Indikationen eine Alternative zur konventionellen rechts- oder biventrikulären Stimulation darzustellen: (1) höhergradiger atrioventrikulärer (AV) Block mit erwartet >20 % ventrikulärer Stimulation, (2) AV-Block I° mit langem PQ-Intervall (allein oder in Kombination mit intermittierend höhergradigen AV-Blockierungen oder Sick-Sinus-Syndrom), (3) AV-Knoten-Ablation aufgrund von Vorhofflimmern und (4) Upgrade bei schrittmacherinduzierter Kardiomyopathie. Daneben kann eine HBS hilfreich im Kontext mit einer kardialen Resynchronisationstherapie (CRT) sein. Limitierend für die HBS sind Linksschenkelblockierungen distal des His-Bündels. In jüngster Zeit ist daher zusätzlich die Linksschenkelstimulation (LSS) entwickelt worden, um auch einen Linksschenkelblock gezielt zu korrigieren. Die LSS scheint einfacher implantierbar zu sein, erfordert jedoch ein aktives tiefes Einschrauben der Elektrode ins Ventrikelseptum. Zu diesem Vorgehen liegen noch wenige Erfahrungen vor, insbesondere zum Langzeitverlauf fehlen entsprechende Daten.

Abstract

His bundle pacing (HBP) allows ventricular excitation through the entire cardiac conduction system, resulting in a better synchronicity and efficacy of contraction compared to myocardial pacing. Due to better, dedicated implantation tools and exact practical implantation recommendations, HBP has developed into a form of stimulation that can be successfully applied with reasonable time and effort in >90% of patients. The rate of lead dislodgement and threshold increase is similar to conventional pacemaker systems. Despite a rather weak data base and a paucity of randomized trials, HBS represents an alternative to conventional right or biventricular pacing in the following conditions: (1) high-degree atrioventricular (AV) block with expected ventricular pacing >20% of the time, (2) AV block 1st degree with long PQ (alone or in combination with intermittent 2nd to 3rd degree AV block or sick sinus syndrome), (3) AV node ablation due to refractory atrial fibrillation, and (4) upgrade in pacing-induced cardiomyopathy. Moreover, HBP may be useful in context with cardiac resynchronization therapy (CRT). Left bundle branch block below the level of His represents a limitation of HBP. Therefore, more recently left bundle branch pacing (LBBP) has been introduced to correct left bundle branch block. LBBP seems to be possible in a wider anatomic area and may be easier to implant. However, LBBP requires active screw-in of the lead deep into the ventricular septum. Experience with this new technique is limited, particularly regarding long-term performance.

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Authors and Affiliations

  1. Klinik für Innere Medizin – Kardiologie, Diabetologie & Nephrologie, Evangelisches Klinikum Bethel, Burgsteig 13, 33617, Bielefeld, Deutschland

    Carsten W. Israel & Sona Tribunyan

  2. Abteilung für Elektrophysiologie, Herzzentrum Leipzig und Universität Leipzig, Leipzig, Deutschland

    Sergio Richter

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  1. Carsten W. Israel
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Correspondence to Carsten W. Israel.

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Interessenkonflikt

C.W. Israel weist auf folgende Beziehungen hin: Medtronic (Advisory Board, Honorare für Vorträge, Erstattung von Kongress- und Reisekosten). S. Richter weist auf folgende Beziehungen hin: Biotronik (Advisory Board). S. Tribunyan gibt an, dass kein Interessenskonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Israel, C.W., Tribunyan, S. & Richter, S. Indikationen zur His-Bündel- und Linksschenkelstimulation. Herzschr Elektrophys 31, 135–143 (2020). https://doi.org/10.1007/s00399-020-00689-5

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