1 9/14/2019 Selective His Bundle Pacing Histological 90 90 40 - - PDF document

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When and How to Perform His-Purkinje Conduction System Pacing

Pugazhendhi Vijayaraman, MD Professor Of Medicine Geisinger Commonwealth School of Medicine Geisinger Heart Institute, Wilkes-Barre, PA, USA

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Disclosures

Consultant

• Abbott

Advisory board

• Boston Scientific

Advisory board

• Eaglepoint LLC

Speaker, Consultant, Research

• Medtronic

Fellowship support

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His Purkinje Conduction System Pacing – Why?

• Most physiological form of ventricular pacing
• Conduction occurs through native His-Purkinje system
• No pacing induced dyssynchrony
• Lead tip and body potentially within the right atrium

– Prevents lead related issues such as tricuspid regurgitation

• Both AV and VV synchrony can be achieved at the same time
• Has significant clinical advantage over traditional RV pacing or even

biventricular pacing

LV-RV part of MS LV-RA part

• f MS

AV node HB Courtesy: K.Shivkumar, UCLA

Anatomy of His Bundle

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Histological

Correa de Sa,…, Lustgarten D. Circ AE 2012

Selective His Bundle Pacing

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40 S V 90 40 H V 90 HBP

Baseline HBP 1.2V 1.0V

120 160 HBP RA A H 150 250 V 40 A H V 40 80

Nonselective HBP

H 50 90 140 90

RA HBP

150 150

Baseline HBP 1.5V 1.0V

Nonselective HBP

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ECG IMAGING

Vijayaraman P, et al. His bundle pacing JACC 2018;72:927-47

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Patient Selection for HPCSP

• AV nodal block
• Infra-nodal AV block
• Sinus node dysfunction
• Atrial fibrillation with slow ventricular rate
• AV node ablation
• Cardiac Resynchronization Therapy

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Overview of Implantation

• Deflectable delivery sheath
• Medtronic SelectSite C304 - 8 Fr

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Overview of Implantation

• Fixed Curve Medtronic C315 His sheath

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• Deflectable Medtronic C304His sheath

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C315His C304His C304

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Overview of Implantation

• Electrophysiology mapping

catheter to locate the His

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Overview of Implantation

Unipolar mapping

A H A H V

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How to perform HBP

0.1 mV/mm

HBP 0.5V @ 0.5ms

18 19 20

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5 minutes

His bundle injury current

At implant 20 minutes

IC No IC

P value

Number of pts 60 (n, %) 22 (37%) 38 (63%) Fluoroscopy duration ( min) 8.9 ± 4 9.5 ± 3.5 NS R wave (mV) 4.1 ± 2.8 5.4 ± 3.2 NS Pacing Impedance (Ohms) 557 ± 97 639 ± 159 NS Pacing thresholds (V @ 0.5 ms) Mean ± SD Mean ± SD Implant 1.16±0.4 1.75±0.7 <0.05 2 weeks 1.18±0.5 1.82±0.8 <0.05 2 months 1.23±0.6 1.93±0.8 <0.05 1 yr (N =41) 1.31±0.6 1.98±0.9 <0.05

His bundle injury current

Vijayaraman P,Dandamudi G, Worsnick SA, et al. Acute His bundle injury…. PACE 2015:38:540-6 22 (37%) 38 (63%) 1.16±0.4 1.75±0.7 1.18±0.5 1.82±0.8 1.23±0.6 1.93±0.8 1.31±0.6 1.98±0.9

Complete AV nodal block

A A H A A H H A A

2:1 HV block

A H V A H A H A H V

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Mapping the His bundle

in the setting of

Intra-Hisian Block

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Complete AV Block Proximal His

A H H A

Distal His

A H A H H H

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Proximal His Bundle Distal His Bundle

His bundle Mapping

1.4V @ 1 ms 1.2V @ 1 ms 1.0V @ 1 ms

NS-HBP S-HBP S-LBP

Output Dependent His Capture

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His Bundle Pacing in Advanced AV block

Advanced AV block N = 100 AV nodal Block N = 46 Successful 43 (93%) Unsuccessful 3 (7%) Infra nodal Block N = 54 Successful 41 (76%) Unsuccessful 13 (24%)

Vijayaraman P, Naperkowski A, Ellenbogen KA et al. JACCEP 2015;1:571-81

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HBP and AV Node ablation

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HBP and AVNA

• HBP and AVNA were performed simultaneously in 30 patients (71%)
• AVNA in patients with prior HBP in 8 (19% - 1 to 15 months after)
• HBP in patients with previous AVNA in 4 (10% - infection 2, HF 2; 1-12

years after)

• HBP and AVNA was successful in 40/42 patients (95%)
• HBP lead placement was unsuccessful in one pt.
• HBP lead dislodged during failed attempt at AVN ablation on the right side →left sided

ablation

Vijayaraman P et al. Europace 2017;19:iv10-16 TV CS Os HBP lead * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

AV Node Ablation Site in Relation to HBP Electrodes

* T (near Tip) * TR (Tip to Ring) * R (at Ring) * BR (Below Ring) * L (Left sided) AORTA Vijayaraman P et al. Europace 2017;19:iv10-16

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10 20 30 40 50 60 LVEF (all) LVEF <40% LVEF >40% P = 0.01 P < 0.001 P = 0.5

Baseline Post-HBP

Left ventricular Ejection Fraction (%)

Vijayaraman P, Subzposh F, Naperkowski A. Europace 2017;19:iv10-16

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HBP for Cardiac Resynchronization Therapy

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HBP lead

LBBB

190

C

AV node

Selective His Bundle Pacing @ 2 V

HBP lead

95

B

AV node

Selective HBP @ 1.4 V

190

HBP lead

C

AV node

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Heart Rhythm 2018;15:413-420

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Methods

Permanent HBP was attempted in patients with cardiomyopathy, reduced LV function (EF <50%) and heart failure Group I (RESCUE HBP)

• LV lead placement was unsuccessful
• Prior CRT did not result in clinical response (non-responder)

Group II (PRIMARY HBP)

• AV block / AV node ablation
• High RV pacing burden
• Bundle branch block

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25 8 15 27 31 22 8 15 25 25 5 10 15 20 25 30 35 Rescue HBP in Failed BiV Rescue HBP in BiV Non-responders Primary HBP in AVB/AVJ Primary HBP in BBB Primary HBP in Ventricular Pacing Attempted Cases Successful Cases

Group 2

Group 1 95/106 (90%)

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QRS duration

157 163 177 103 118 116 125 108 20 40 60 80 100 120 140 160 180 200 Overall BBB Ventricular paced Narrow QRS Baseline QRSd HBP QRSd

p-value = 0.0001 p = 0.04

LV Ejection Fraction

30 25 44 44 40 55 10 20 30 40 50 60 Overall Baseline LVEF < 35% Baseline LVEF 35-50% Baseline Follow-up

* * *

* P < 0.001

Ahran D. Arnold et al. JACC 2018;72:3112-3122

HBP IN RBBB

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Sharma PS, Naperkowski A, Bauch T, Chan DSY , Whinnett Z, Arnold A, Ellenbogen KA, Vijayaraman P.

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Figure 2

1.5 V @ 1 ms

Selective HBP

5 V @ 1 ms

RV

Nonselective HBP

1.0 V @ 1 ms

Selective RBP Baseline RBBB

His bundle Intra-Hisian RBBB HBP lead Nonselective-HBP HBP lead Selective-HBP HBP lead Selective-RBP

ECG Imaging

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80 90 100 110 120 130 140 150 160 Baseline HBP

QRS duration

158 127

*

1 1.5 2 2.5 3 3.5 Baseline HBP

NYHA Class

2.8 2.0

*

20 25 30 35 40 Baseline HBP

Ejection Fraction

31 39

* * P <0.001

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Vijayaraman P, Herweg B, Ellenbogen KA, Gajek J. 2019;12:e006934

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83 yrs old man with ischemic CMP, LBBB, Class IV CHF

210

Selective HBP

146

His synchronus LV pacing (His-LV timing at 50 ms)

LV 110

His Optimized CRT

Baseline S-HBP His→LV 50 ms

210 146 110

Q-LV 160 ms 96 ms QRSd 210 ms 146 ms 110 ms 80 100 120 140 160 180 200 Baseline BVP HBP HOT-CRT

P < 0.001 * vs baseline * vs BVP * vs HBP

*** ** * QRS Duration

95% echocardiographic response

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 LBBP HBP H LB

LEFT BUNDLE BRANCH AREA PACING

AV node His bundle Left bundle Right bundle

Vijayaraman P et al. Heart Rhythm 2019

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HB RB B LB B Narrow target accurate positioning needed Wider conduction net Easy to find and fix

LBB pacing can be easily achieved?

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AV nodal HB LBB

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Case presentation

• 75-year-old man
• Prior CAD, s/p PCI
• Chronic LBBB x 20 years
• LVEF 40% on OMT x 20 years
• Syncope → intermittent CHB

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I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 LBBP HBP

H

Baseline NSHBP LBBP-Uni Bipolar 3V 0.6V 0.5V

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I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 LBBP RA

Baseline AVD 200 ms

HBP

170 ms 150 ms 130 ms 100 ms 80 ms

contrast LBB P HBP

LBBP lead LV

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BBB/IVCD AV block Complete BBB correction His lead only Incomplete BBB correction Consider addition

• f LV lead

HOT CRT No correction or no His capture Standard BIV pacing / CRT His bundle pacing

Left Bundle branch Pacing

BBB correction at <2V

yes ?Left Bundle branch Pacing

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Conclusions

➢Permanent HPCSP is feasible in all patients requiring permanent pacemakers. ➢HPCSP is effective in patients requiring AV node ablation ➢HPCSP may be considered as an alternative to biventricular pacing in patients requiring CRT

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Thank you for your attention

#DontDisTheHis