Benefits of Permanent His Bundle Pacing Combined With Atrioventricular Node Ablation in Atrial Fibrillation Patients With Heart Failure With Both Preserved and Reduced Left Ventricular Ejection Fraction

Weijian Huang, Lan Su, Shengjie Wu, Lei Xu, Fangyi Xiao, Xiaohong Zhou, Kenneth A Ellenbogen, Weijian Huang, Lan Su, Shengjie Wu, Lei Xu, Fangyi Xiao, Xiaohong Zhou, Kenneth A Ellenbogen

Abstract

Background: Clinical benefits from His bundle pacing (HBP) in heart failure patients with preserved and reduced left ventricular ejection fraction are still inconclusive. This study evaluated clinical outcomes of permanent HBP in atrial fibrillation patients with narrow QRS who underwent atrioventricular node ablation for heart failure symptoms despite rate control by medication.

Methods and results: The study enrolled 52 consecutive heart failure patients who underwent attempted atrioventricular node ablation and HBP for symptomatic atrial fibrillation. Echocardiographic left ventricular ejection fraction and left ventricular end-diastolic dimension, New York Heart Association classification and use of diuretics for heart failure were assessed during follow-up visits after permanent HBP. Of 52 patients, 42 patients (80.8%) received permanent HBP and atrioventricular node ablation with a median 20-month follow-up. There was no significant change between native and paced QRS duration (107.1±25.8 versus 105.3±23.9 milliseconds, P=0.07). Left ventricular end-diastolic dimension decreased from the baseline (P<0.001), and left ventricular ejection fraction increased from baseline (P<0.001) in patients with a greater improvement in heart failure with reduced ejection fraction patients (N=20) than in heart failure with preserved ejection fraction patients (N=22). New York Heart Association classification improved from a baseline 2.9±0.6 to 1.4±0.4 after HBP in heart failure with reduced ejection fraction patients and from a baseline 2.7±0.6 to 1.4±0.5 after HBP in heart failure with preserved ejection fraction patients. After 1 year of HBP, the numbers of patients who used diuretics for heart failure decreased significantly (P<0.001) when compared to the baseline diuretics use.

Conclusions: Permanent HBP post-atrioventricular node ablation significantly improved echocardiographic measurements and New York Heart Association classification and reduced diuretics use for heart failure management in atrial fibrillation patients with narrow QRS who suffered from heart failure with preserved or reduced ejection fraction.

Keywords: His bundle pacing; atrial fibrillation; atrioventricular node ablation; heart failure.

© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Figures

Figure 1
Figure 1
Right (A) and left (B) anterior oblique fluoroscopic projections showing location of His bundle pacing lead and ablation catheter.
Figure 2
Figure 2
Schematic summary of study and patient flow.
Figure 3
Figure 3
Twelve‐lead body surface ECG (top 12 channels) and cardiac EGM with His bundle potential recording (bottom channel) in a patient. A, Recording of His bundle potential during atrial fibrillation. B, Recording of His bundle potential during escape rhythm after AVN ablation. C, His bundle pacing at 1.2 V and 0.5‐millisecond pulse width after AVN ablation. AVN indicates atrioventricular node; EGM, electrogram.
Figure 4
Figure 4
The Pearson product‐moment correlation between echocardiographic changes in LVEDd and LVEF after HBP vs the baseline values. A, The correlation between the percentage change (ordinate, %) in LVEF after HBP over the baseline vs the baseline LVEF (abscissa). B, The percentage change (ordinate, %) in LVEDd after HBP over the baseline vs the baseline LVEDd (abscissa). HBP indicates His bundle pacing; LVEDd, left ventricular end‐diastolic dimension; LVEF, left ventricular ejection fraction.
Figure 5
Figure 5
Acute and long‐term improvement in LVEDd (left) and LVEF (right) after His bundle pacing in patients with HFrEF. BL, baseline; 1M, 1 month after HBP; 3M, 3 months after HBP; 1Y, 1 year after HBP. Inserted P values were obtained by post hoc tests with least‐significant difference. HBP indicates His bundle pacing; HFrEF, heart failure with reduced left ventricular ejection fraction; LVEDd, left ventricular end‐diastolic dimension; LVEF, left ventricular ejection fraction.
Figure 6
Figure 6
Electrical parameters of HBP and the percentage of HBP during the follow‐up period. A, HBP threshold; (B) sensed R‐wave amplitude; and (C) the percentage of HBP. BL indicates baseline value; W1, 1‐week follow‐up visit; M1, 1‐month follow‐up visit; M3, 3‐month follow‐up visit; M6, 6‐month follow‐up visit; Y1, 1‐year follow‐up visit; LFU, last follow‐up visit. No significance (P>0.05) among different time points was detected by repeated‐measures analysis of variance. HBP indicates His bundle pacing.

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