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Conduction System Pacing

Raja Selvaraj
Cardiac Electrophysiologist
Professor of Cardiology
JIPMER

Evolution of pacing therapy

  • From life saving therapy to optimal, physiologic pacing
  • AV synchrony
  • Reduce intra- and inter- ventricular dyssynchrony
  • Multisite pacing
  • Conduction system pacing

Anatomy

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Deshmukh P, Casavant DA, Romanyshyn M, Anderson K. Permanent, direct His-bundle pacing: a novel approach to cardiac pacing in patients with normal His-Purkinje activation. Circulation. 2000 Feb 29;101(8):869-77.

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Questions

  • LBAP versus HBP
  • Fixed helix (lumenless) versus retractable helix (stylet driven)
  • LVSP versus non-selective LBAP versus selective LBAP

Primary areas of application

  • Cardiac resynchronization - Alternative to BiV pacing
  • Cardiac resynchronization - Adjunct to BiV pacing
  • Bradycardia - high risk of PICM
  • Bradycardia, low to no risk of PICM

Cardiac resynchronization - Alternative to BiV CRT

  • HBP equivalent to biventricular pacing (1, 2)
  • Conduction system pacing may be superior (3, 4)
  1. Lustgarten DL et al. His-bundle pacing versus biventricular pacing in cardiac resynchronization therapy patients: A crossover design comparison. Heart Rhythm. 2015 Jul;12(7):1548-57. doi: 10.1016/j.hrthm.2015.03.048.
  2. Upadhyay GA et al. His corrective pacing or biventricular pacing for cardiac resynchronization in heart failure. J Am Coll Cardiol 2019;74:157–9.
  3. Wang Y et al. His-Purkinje system pacing versus biventricular pacing in clinical efficacy: a systematic review and meta-analysis. BMC Cardiovasc Disord. 2023 Jun 3;23(1):285.
  4. Wang Y et al; LBBP-RESYNC Investigators. Randomized Trial of Left Bundle Branch vs Biventricular Pacing for Cardiac Resynchronization Therapy. J Am Coll Cardiol. 2022 Sep 27;80(13):1205-1216.

Cardiac resynchronization - Adjunct to BiV CRT

  • HOT-CRT superior to BiV CRT or His-CRT when His-CRT suboptimal (1)
  • LOT-CRT could be an alternative to BiV-CRT (2)
  • LOT-CRT provides better resynchronization when LBBP-CRT suboptimal (3)
  1. Vijayaraman et al. His-optimized cardiac resynchronization therapy to maximize electrical resynchronization. Circ Arrhythm Electrophysiol. 2019;12:e006934
  2. Jastrzębski M et al. Left bundle branch-optimized cardiac resynchronization therapy (LOT-CRT): Results from an international LBBAP collaborative study group. Heart Rhythm. 2022 Jan;19(1):13-21.
  3. Chinmay Parale… Raja Selvaraj. Comparison of Electrocardiographic parameters between LOT-CRT and LBBP-CRT. PACE 2023 (Accepted for publication)

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2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm 2023. 20(9);E17-E91

Bradycardia pacing - Risk of PICM

  • LVEF < 40%, pacing requirement > 40%

Bradycardia pacing - Low risk of PICM ?

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2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm 2023. 20(9);E17-E91

Future

Better understanding

  • Non-selective versus selective capture
  • LV septal pacing versus LBB pacing
  • Best approach in RBBB / IVCD
  • Long term outcomes - stability, extractability

Hardware improvements

  • Stylet driven versus lumen-less
  • Specially designed leads
  • Sheaths - Effective and economical

Combine with other devices

  • Leadless pacemaker
  • ICD

Summary

  • Conduction system pacing is a revolutionary shift in pacing therapy
  • Conduction system pacing is here to stay and to dominate pacing therapy
  • Clearly non-inferior, possibly superior to traditional BiV pacing for CRT
  • May be preferred in patients at risk of PICM
  • Unclear if it will replace traditional pacing for all bradycardia indications