Results of Using Various Conduction System Pacing Options in Patients with Bradyarrhythmia

Keywords: pacemaker-induced cardiomyopathy, left bundle branch area pacing, selective His bundle pacing, atrioventricular block, bradycardia

Abstract

Chronic right ventricular myocardial pacing causes an asynchronous pattern of left ventricular activation, reduces left ventricular ejection fraction (LVEF), and may be associated with worsening of clinical outcomes in the long term. Although with the emergence of algorithms that minimize ventricular pacing it became possible to reduce the percentage of paced complexes in patients with sinus node dysfunction, permanent ventricular pacing is still inevitable in patients with high-degree atrioventricular (AV) block. The use of permanent conduction system pacing is a promising method for preserving the physiological activation of the ventricular myocardium and preventing the development of heart failure due to ventricular dyssynchrony.

The aim. To analyze the immediate and long-term results of the use of conduction system pacing in patients with indications for permanent ventricular pacing.

Materials and methods. This study included 18 patients with indications for permanentventricular pacing who were operated at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine in the period from 01/01/2013 to 12/31/2022, in whom permanent conduction system pacing was used. There were 17 patients with bradyarrhythmias, of these 16 (88%) suffered from high-degree AV block (including 1 patient with Frederick’s syndrome and 1 (5%) patient with atrial ϐibrillation with slow ventricular response) and 1 (5%) patient with ischemic cardiomyopathy with left bundle branch block and ϐirstdegree AV block with indications for cardiac resynchronization therapy. The mean age of the patients was 55 ± 16 years (8 men, 10 women), LVEF at the time of the intervention was 56.42 ± 9.13 %, end diastolic volume 130.2 ± 23.8 ml, end systolic volume 55.1 ± 17.7 ml, diameter of the left atrium 4.01 ± 0.6 cm. The average QRS width before implantation was 116.5 ± 27.7 ms. In 6 (33%) patients, a special delivery system (С304-L69, Medtronic in 1 patient [5%], C315HIS in 5 [27%] patients) and 4.1F active ϐixation lead Medtronic 3830 Select Secure (69 or 74 cm) were used; in other cases (66%) standard 6F leads with active ϐixation and a lumen for a stylet without a delivery system were used.

Results. The average follow-up period after implantation of pacemaker was 36.35 ± 29.65 months. During the observation period, LVEF was 57.07 ± 5.38 %, end diastolic volume111.5 ± 18.09 ml, end systolic volume 49.5 ± 13.4 ml, diameter of the left ventricle 3.9 ± 0.5 cm. The mean duration of paced QRS was 119.1 ± 10.09 ms. In 6 patients (33%), it was possible to demonstrate a change in the QRS width when the amplitude of ventricular stimulation was reduced, with 2 variants of transitions: 1) 4 (22%) patients with a transition from non-selective His bundle pacing (NSHBP) to selective His bundle pacing (SHBP), in 2 (11%) of these patients with a transition from SHBP with correction of right bundle branch block (RBBB) to SHBP without correction of RBBB, and then loss of capture of the myocardium of the ventricles; 2) 2 patients (11%) with a transition from NSHBP to myocardial septal ventricular pacing and further with a decrease in amplitude to the loss of capture of the myocardium of the ventricles. One (5%) patient with complete heart block had permanent non-selective left bundle branch area pacing. The other 11 (61%) patients met the criteria for parahisian pacing without visible transitions with a change in the amplitude of ventricular pacing. The average global longitudinal strain was -17.6 ± 2.7 %. The average interval from the stimulus to the peak of the R-wave in lead V6, which indicated the time of left ventricular activation, was 73.2 ± 8.7 ms. Pacing parameters were standardly set according to the primary indications, but with correction of the amplitude of ventricular stimulation relative to the thresholds of pacing of the conduction system. AV delay was corrected for the latency from the stimulus to the onset of the QRS in SHBP or for the duration of the “pseudodelta” wave in NSHBP which in both cases was the duration of the H-V interval. There were no complications in the acute or long-term postoperative period.

Conclusions. Conduction system pacing is a challenge in the practice of cardiologist for treating life-threatening bradyarrhythmias and heart failure, but at the same time it is a safe method that provides physiological electrical and mechanical activation of the myocardium of the ventricles, that allows to effectively avoid the consequences of dyssynchrony due to permanent myocardial ventricular pacing.

References

  1. Tops LF, Schalij MJ, Bax JJ. The Effects of Right Ventricular Apical Pacing on Ventricular Function and Dyssynchrony: Implications for Therapy. J Am Coll Cardiol. 2009;54(9):764-76. https://doi.org/10.1016/j.jacc.2009.06.006
  2. Sweeney MO, Hellkamp AS, Ellenbogen KA, Greenspon AJ, Freedman RA, Lee KL, et al.; MOde Selection Trial Investigators. Adverse Effect of Ventricular Pacing on Heart Failure and Atrial Fibrillation Among Patients With Normal Baseline QRS Duration in a Clinical Trial of Pacemaker Therapy for Sinus Node Dysfunction. Circulation. 2003;107(23):2932-7. https://doi.org/10.1161/01.CIR.0000072769.17295.B1
  3. Wilkoff BL, Cook JR, Epstein AE, Greene HL, Hallstrom AP, Hsia H, et al.; Dual Chamber and VVI Implantable Defibrillator Trial Investigators. Dual-Chamber Pacing or Ventricular Backup Pacing in Patients With an Implantable Defibrillator: The Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. JAMA. 2002;288(24):3115-23. https://doi.org/10.1001/jama.288.24.3115
  4. Nielsen JC, Kristensen L, Andersen HR, Mortensen PT, Pedersen OL, Pedersen AK. A randomized comparison of atrial and dual-chamber pacing in 177 consecutive patients with sick sinus syndrome: Echocardiographic and clinical outcome. J Am Coll Cardiol. 2003;42(4):614-23. https://doi.org/10.1016/s0735-1097(03)00757-5
  5. Kaye GC, Linker NJ, Marwick TH, Pollock L, Graham L, Pouliot E, et al.; Protect-Pace trial investigators. Effect of right ventricular pacing lead site on left ventricular functionin patients with high-grade atrioventricular block: results of the Protect-Pace study. Eur Heart J. 2015;36(14):856-62. https://doi.org/10.1093/eurheartj/ehu304
  6. Leclercq C, Sadoul N, Mont L, Defaye P, Osca J, Mouton E, et al.; SEPTAL CRT Study Investigators. Comparison of right ventricular septal pacing and right ventricular apical pacing in patients receiving cardiac resynchronization therapy defibrillators: the SEPTAL CRT Study. Eur Heart J. 2016;37(5):473-83. https://doi.org/10.1093/eurheartj/ehv422
  7. Hussain MA, Furuya-Kanamori L, Kaye G, Clark J, Doi SA. The Effect of Right Ventricular Apical and Nonapical Pacing on the Short- and Long-Term Changes in Left Ventricular Ejection Fraction: A Systematic Review and Meta-Analysis of Randomized-Controlled Trials. Pacing Clin Electrophysiol. 2015;38(9):1121-36. https://doi.org/10.1111/pace.12681
  8. Cho SW, Gwag HB, Hwang JK, Chun KJ, Park KM, On YK, et al. Clinical features, predictors, and long-term prognosis of pacing-induced cardiomyopathy. Eur J Heart Fail. 2019;21(5):643-51. https://doi.org/10.1002/ejhf.1427
  9. Curtis AB, Worley SJ, Adamson PB, Chung ES, Niazi I, Sherfesee L, et al.; Biventricular versus Right Ventricular Pacing in Heart Failure Patients with Atrioventricular Block (BLOCK HF) Trial Investigators. Biventricular Pacing for Atrioventricular Block and Systolic Dysfunction. N Engl J Med. 2013;368(17):1585-93. https://doi.org/10.1056/NEJMoa1210356
  10. Ruschitzka F, Abraham WT, Singh JP, Bax JJ, Borer JS, Brugada J, et al.; EchoCRT Study Group. Cardiac-Resynchronization Therapy in Heart Failure with a Narrow QRS Complex. N Engl J Med. 2013;369(15):1395-405. https://doi.org/10.1056/NEJMoa1306687
  11. Sweeney MO, Bank AJ, Nsah E, Koullick M, Zeng QC, Hettrick D, et al.; Search AV Extension and Managed Ventricular Pacing for Promoting Atrioventricular Conduction (SAVE PACe) Trial. Minimizing Ventricular Pacing to Reduce Atrial Fibrillation in Sinus-Node Disease. N Engl J Med. 2007;357(10):1000-8. https://doi.org/10.1056/NEJMoa071880
  12. Jastrzębski M, Moskal P, Curila K, Fijorek K, Kukla P, Bednarek A, et al. Electrocardiographic characterization of non-selective His-bundle pacing: validation of novel diagnostic criteria. Europace. 2019;21(12):1857-64. https://doi.org/10.1093/europace/euz275
  13. Burri H, Jastrzebski M, Vijayaraman P. ElectrocardiographicAnalysis for His Bundle Pacing at Implantation and Follow-Up. JACC Clin Electrophysiol. 2020;6(7):883-900. https://doi.org/10.1016/j.jacep.2020.03.005
  14. Huang W, Chen X, Su L, Wu S, Xia X, Vijayaraman P. A beginner’s guide to permanent left bundle branch pacing. Heart Rhythm. 2019;16(12):1791-6. https://doi.org/10.1016/j.hrthm.2019.06.016
  15. Jastrzębski M, Burri H, Kiełbasa G, Curila K, Moskal P, Bednarek A, et al. The V6-V1 interpeak interval: a novel criterion for the diagnosis of left bundle branch capture. Europace. 2022;24(1):40-7. https://doi.org/10.1093/europace/euab164
  16. Vijayaraman P, Subzposh FA, Naperkowski A. Extraction of the permanent His bundle pacing lead: Safety outcomes and feasibility of reimplantation. Heart Rhythm. 2019;16(8):1196-203. https://doi.org/10.1016/j.hrthm.2019.06.005
  17. Occhetta E, Bortnik M, Magnani A, Francalacci G, Piccinino C, Plebani L, et al. Prevention of Ventricular Desynchronization by Permanent Para-Hisian Pacing After Atrioventricular Node Ablation in Chronic Atrial Fibrillation: A Crossover, Blinded, Randomized Study Versus Apical Right Ventricular Pacing. J Am Coll Cardiol. 2006;47(10):1938-45. https://doi.org/10.1016/j.jacc.2006.01.056
  18. Abdelrahman M, Subzposh FA, Beer D, Durr B, Naperkowski A, Sun H, et al. Clinical Outcomes of His Bundle Pacing Compared to Right Ventricular Pacing. J Am Coll Cardiol. 2018;71(20):2319-30. https://doi.org/10.1016/j.jacc.2018.02.048
  19. Sharma PS, Patel NR, Ravi V, Zalavadia DV, Dommaraju S, Garg V, et al. Clinical outcomes of left bundle branch area pacing compared to right ventricular pacing: Results from the Geisinger-Rush Conduction System Pacing Registry. Heart Rhythm. 2022;19(1):3-11. https://doi.org/10.1016/j.hrthm.2021.08.033
  20. Upadhyay GA, Vijayaraman P, Nayak HM, Verma N, Dandamudi G, Sharma PS, et al.; His-SYNC Investigators. On-treatment comparison between corrective His bundle pacing and biventricular pacing for cardiac resynchronization: A secondary analysis of the His-SYNC Pilot Trial. Heart Rhythm. 2019;16(12):1797-807. https://doi.org/10.1016/j.hrthm.2019.05.009
  21. Vijayaraman P, Ponnusamy S, Cano Ó, Sharma PS, Naperkowski A, Subsposh FA, et al. Left Bundle Branch Area Pacing for Cardiac Resynchronization Therapy: Results From the International LBBAP Collaborative Study Group. JACC Clin Electrophysiol. 2021;7(2):135-47. https://doi.org/10.1016/j.jacep.2020.08.015
  22. Jastrzębski M, Moskal P, Huybrechts W, Curila K, Sreekumar P, Rademakers LM, et al. Left bundle branch-optimized cardiac resynchronization therapy (LOT-CRT): Results from an international LBBAP collaborative study group. Heart Rhythm. 2022;19(1):13-21. https://doi.org/10.1016/j.hrthm.2021.07.057
  23. Vijayaraman P, Herweg B, Ellenbogen KA, Gajek J. His-Optimized Cardiac Resynchronization Therapy to Maximize Electrical Resynchronization: A Feasibility Study. Circ Arrhythm Electrophysiol. 2019;12(2):e006934. https://doi.org/10.1161/CIRCEP.118.006934
  24. Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, et al.; ESC Scientific Document Group. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021;42(35):3427-520. https://doi.org/10.1093/eurheartj/ehab364
  25. Yuan Z, Cheng L, Wu Y. Meta-Analysis Comparing Safety and Efficacy of Left Bundle Branch Area Pacing Versus His Bundle Pacing. Am J Cardiol. 2022;164:64-72. https://doi.org/10.1016/j.amjcard.2021.10.025
  26. Zanon F, Ellenbogen KA, Dandamudi G, Sharma PS, Huang W, Lustgarten DL, et al. Permanent His-bundle pacing: a systematic literature review and meta-analysis. Europace. 2018;20(11):1819-26. https://doi.org/10.1093/europace/euy058
Published
2022-12-26
How to Cite
Perepeka, E. O., & Kravchuk, B. B. (2022). Results of Using Various Conduction System Pacing Options in Patients with Bradyarrhythmia. Ukrainian Journal of Cardiovascular Surgery, 30(4), 94-103. https://doi.org/10.30702/ujcvs/22.30(04)/PK064-94103

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