Feasibility and Efficacy of His Bundle Pacing or Left Bundle Pacing Combined With Atrioventricular Node Ablation in Patients With Persistent Atrial Fibrillation and Implantable Cardioverter-Defibrillator Therapy

Songjie Wang, Shengjie Wu, Lei Xu, Fangyi Xiao, Zachary I Whinnett, Pugazhendhi Vijayaraman, Lan Su, Weijian Huang, Songjie Wang, Shengjie Wu, Lei Xu, Fangyi Xiao, Zachary I Whinnett, Pugazhendhi Vijayaraman, Lan Su, Weijian Huang

Abstract

Background Persistent atrial fibrillation may lead to a higher probability of inappropriate shocks in heart failure patients with an implantable cardioverter-defibrillator (ICD). The aim of this study was to evaluate the impact of His-Purkinje conduction system pacing combined with atrioventricular node ablation in improving heart function and preventing inappropriate shock therapy in these patients. Methods and Results A total of 86 consecutive patients with persistent atrial fibrillation and heart failure who had indications for ICD implantation were enrolled from January 2010 to March 2018. His-Purkinje conduction system pacing with ICD and atrioventricular node ablation was attempted in 55 patients, and the remaining patients underwent ICD implantation only. Left ventricular (LV) ejection fraction, LV end-systolic volume, New York Heart Association (NYHA) classification, shock therapies, and drug therapy were assessed during follow-up. Overall, 31 patients received ICD implantation with optimal drug therapy (group 1). atrioventricular node ablation combined with His-Purkinje conduction system pacing was successfully achieved in 52 patients (group 2). During follow-up, patients in group 2 had lower incidence of inappropriate shock (15.6% versus 0%, P<0.01) and adverse events (P=0.011). Meanwhile, improvement in LV ejection fraction and reduction in LV end-systolic volume were significantly higher in group 2 than in group 1 (15% versus 3%, P<0.001; and 40 versus 2 mL, P<0.01, respectively). NYHA functional class improved in both groups from a baseline 2.57±0.68 to 1.73±0.74 in group 1 and 2.73±0.59 to 1.42±0.53 in group 2 (P<0.01). Conclusions His-Purkinje conduction system pacing combined with atrioventricular node ablation is feasible and safe with a high success rate in persistent atrial fibrillation patients with heart failure and ICD indication. It can significantly reduce the incidence of inappropriate shocks and improve LV function.

Keywords: His bundle pacing; atrial fibrillation; atrioventricular node ablation; inappropriate shock; left bundle branch pacing.

Figures

Figure 1
Figure 1
Schematic summary of study and patient flow. AF indicates atrial fibrillation; AVN, atrioventricular node; HF, heart failure; HPSP, His‐Purkinje conduction system pacing; ICD, implantable cardioverter‐defibrillator; IS, inappropriate shock.
Figure 2
Figure 2
Kaplan–Meier curves showing probability of inappropriate shocks and event‐free survival. A, The cumulative proportion of patients who experienced a first inappropriate therapy is plotted against time. B, Kaplan–Meier survival curves for adverse outcomes (death or heart failure hospitalization). The number of patients at risk at a given time point of follow‐up is indicated below the x‐axis.
Figure 3
Figure 3
Paired LVEF/LVESV at baseline and during follow‐up. A and B, LVEF (A) and LVESV (B) of all patients in groups 1 and 2 at baseline and during follow‐up. LVEF (C) and LVESV (D) of patients with baseline ejection fraction ≤40% in groups 1 and 2 at baseline and during follow‐up. LVEF indicates left ventricular ejection fraction; LVESV, left ventricular end‐systolic volume.
Figure 4
Figure 4
Electrical parameters of His‐Purkinje conduction system pacing at implant (BL) and during the follow‐up period (1 mo, 6 mo, and 1 y). A, Pacing threshold. B, Sensed R‐wave amplitude. BL indicates baseline; HBP, His bundle pacing; LBBP, left bundle‐branch pacing.
Figure 5
Figure 5
Case example of atrioventricular node (AVN) ablation combined with His bundle pacing (HBP) in a patient with persistent atrial fibrillation with heart failure and cardiac resynchronization therapy defibrillator implantation. A, Native ECG. B, Electrogram after ablation. C, His bundle pacing. Radiograph before (D) and 2 years after (E) AVN ablation and HBP.
Figure 6
Figure 6
Case example of atrioventricular node (AVN) ablation combined with left bundle‐branch pacing (LBBP) in a persistent atrial fibrillation (AF) patient with heart failure and previous inappropriate implantable cardioverter‐defibrillator shocks. A, Native ECG. B, Inappropriate shock caused by AF. C, LBBP. Radiograph before (D) and 6 months after (E) AVN ablation and LBBP.

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