His bundle pacing, learning curve, procedure characteristics, safety, and feasibility: Insights from a large international observational study

Daniel Keene, Ahran D Arnold, Marek Jastrzębski, Haran Burri, Steven Zweibel, Eric Crespo, Badrinathan Chandrasekaran, Sukhbinder Bassi, Nader Joghetaei, Matthew Swift, Pawel Moskal, Darrel P Francis, Paul Foley, Matthew J Shun-Shin, Zachary I Whinnett, Daniel Keene, Ahran D Arnold, Marek Jastrzębski, Haran Burri, Steven Zweibel, Eric Crespo, Badrinathan Chandrasekaran, Sukhbinder Bassi, Nader Joghetaei, Matthew Swift, Pawel Moskal, Darrel P Francis, Paul Foley, Matthew J Shun-Shin, Zachary I Whinnett

Abstract

Background: His-bundle pacing (HBP) provides physiological ventricular activation. Observational studies have demonstrated the techniques' feasibility; however, data have come from a limited number of centers.

Objectives: We set out to explore the contemporary global practice in HBP focusing on the learning curve, procedural characteristics, and outcomes.

Methods: This is a retrospective, multicenter observational study of patients undergoing attempted HBP at seven centers. Pacing indication, fluoroscopy time, HBP thresholds, and lead reintervention and deactivation rates were recorded. Where centers had systematically recorded implant success rates from the outset, these were collated.

Results: A total of 529 patients underwent attempted HBP during the study period (2014-19) with a mean follow-up of 217 ± 303 days. Most implants were for bradycardia indications. In the three centers with the systematic collation of all attempts, the overall implant success rate was 81%, which improved to 87% after completion of 40 cases. All seven centers reported data on successful implants. The mean fluoroscopy time was 11.7 ± 12.0 minutes, the His-bundle capture threshold at implant was 1.4 ± 0.9 V at 0.8 ± 0.3 ms, and it was 1.3 ± 1.2 V at 0.9 ± 0.2 ms at last device check. HBP lead reintervention or deactivation (for lead displacement or rise in threshold) occurred in 7.5% of successful implants. There was evidence of a learning curve: fluoroscopy time and HBP capture threshold reduced with greater experience, plateauing after approximately 30-50 cases.

Conclusion: We found that it is feasible to establish a successful HBP program, using the currently available implantation tools. For physicians who are experienced at pacemaker implantation, the steepest part of the learning curve appears to be over the first 30-50 cases.

Keywords: His bundle pacing; His bundle pacing characteristics; His bundle pacing feasibility; His bundle pacing learning curve; physiological pacing.

© 2019 The Authors Journal of Cardiovascular Electrophysiology Published by Wiley Periodicals, Inc.

Figures

Figure 1
Figure 1
Learning curve metrics A, shows the relationship between fluoroscopy time and center experience (P = .15). B, shows the relationship between pacing threshold and center experience (P = .04). C, shows the log odds of receiving a back‐up pacing lead in the ventricle (P = .0018). Overall successful implantation rate was 81% which increased to 87% after 40 cases. As number of cases per center increased, fluoroscopy time and His capture threshold decreased until plateauing after 30 and 50 cases
Figure 2
Figure 2
Within patient change in thresholds for different pacing responses seen with His bundle pacing. Cartoon illustrations are shown above depicting what may be occurring with a change in voltage amplitude
Figure 3
Figure 3
Summary of QRS duration changes for all patients receiving His bundle pacing and then stratified according to intrinsic QRS duration either less than or more than 120 ms. (Error bars are standard error of the mean)

References

    1. 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;101(8):869‐877.
    1. Abdelrahman M, Subzposh FA, Beer D, et al. Clinical outcomes of his bundle pacing compared to right ventricular pacing. J Am Coll Cardiol. 2018;71(20):2319‐2330.
    1. Arnold AD, Shun‐Shin MJ, Keene D, et al. His resynchronization versus biventricular pacing in patients with heart failure and left bundle branch block. J Am Coll Cardiol. 2018;72(24):3112‐3122.
    1. Zanon F, Ellenbogen KA, Dandamudi G, et al. Permanent His‐bundle pacing: a systematic literature review and meta‐analysis. Europace. 2018;20(11):1819‐1826.
    1. Vijayaraman P, Naperkowski A, Subzposh FA, et al. Permanent His‐bundle pacing: long‐term lead performance and clinical outcomes. Heart Rhythm. 2017;15:696‐702.
    1. Jastrzębski M, Moskal P, Bednarek A, Kiełbasa G, Czarnecka D. His‐bundle pacing as a standard approach in patients with permanent atrial fibrillation and bradycardia. Pacing Clin Electrophysiol. 2018;41(11):1508‐1512.
    1. Keene D, Arnold A, Shun‐Shin MJ, et al. Rationale and design of the randomized multicentre His Optimized Pacing Evaluated for Heart Failure (HOPE‐HF) trial. ESC Heart Fail. 2018;5(5):965‐976.
    1. Sharma PS, Dandamudi G, Naperkowski A, et al. Permanent His‐bundle pacing is feasible, safe, and superior to right ventricular pacing in routine clinical practice. Heart Rhythm. 2015;12(2):305‐312.
    1. Zanon F, Baracca E, Aggio S, et al. A feasible approach for direct his‐bundle pacing using a new steerable catheter to facilitate precise lead placement. J Cardiovasc Electrophysiol. 2006;17(1):29‐33.
    1. Doshi RN, Daoud EG, Fellows C, et al. Left ventricular‐based cardiac stimulation post AV nodal ablation evaluation (the PAVE study). J Cardiovasc Electrophysiol. 2005;16(11):1160‐1165.
    1. Leclercq C, Cazeau S, Lellouche D, et al. Upgrading from single chamber right ventricular to biventricular pacing in permanently paced patients with worsening heart failure: The RD‐CHF Study. Pacing Clin Electrophysiol. 2007;30(Suppl 1):S23‐S30.
    1. Huang W, Su L, Wu S, et al. A novel pacing strategy with low and stable output: pacing the left bundle branch immediately beyond the conduction block. Can J Cardiol. 2017;33(12):1736.e1‐1736.e3.
    1. Gamble JHP, Herring N, Ginks M, Rajappan K, Bashir Y, Betts TR. Procedural success of left ventricular lead placement for cardiac resynchronization therapy. JACC: Clinical Electrophysiology. 2016;2(1):69‐77.
    1. Curtis AB, Worley SJ, Adamson PB, et al. Biventricular pacing for atrioventricular block and systolic dysfunction. N Engl J Med. 2013;368(17):1585‐1593.
    1. Sharma PS, Naperkowski A, Bauch TD, et al. Permanent his bundle pacing for cardiac resynchronization therapy in patients with heart failure and right bundle branch block. Circ Arrhythm Electrophysiol. 2018;11(9):e006613.
    1. Kirkfeldt RE, Johansen JB, Nohr EA, Jørgensen OD, Nielsen JC. Complications after cardiac implantable electronic device implantations: an analysis of a complete, nationwide cohort in Denmark. Eur Heart J. 2014;35(18):1186‐1194.
    1. Vijayaraman P, Dandamudi G, Zanon F, et al. Permanent His bundle pacing: Recommendations from a Multicenter His Bundle Pacing Collaborative Working Group for standardization of definitions, implant measurements, and follow‐up. Heart Rhythm. 2017;15(3):460‐468.

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