9/14/2019 Disclosures His Purkinje Conduction System Pacing Should - - PDF document

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9/14/2019 Disclosures His Purkinje Conduction System Pacing Should - - PDF document

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9/14/2019 Disclosures His Purkinje Conduction System Pacing Should be First Line Therapy for AV Block with Preserved LV function Advisory board - Boston Scientific - Eaglepoint LLC Speaker, Consultant, Research, - Medtronic Fellowship

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His Purkinje Conduction System Pacing Should be First Line Therapy for AV Block with Preserved LV function

Pugazhendhi Vijayaraman MD

Professor of Medicine Geisinger Commonwealth School of Medicine Geisinger Heart Institute Wilkes Barre, PA

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Disclosures

Advisory board

  • Boston Scientific
  • Eaglepoint LLC

Speaker, Consultant, Research,

  • Medtronic

Fellowship support Consultant

  • Abbott, Biotronik, Merritt Medical

His delivery tool

  • Patent pending

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Kusumoto F, et al. Circulation 2018Nov 6:CIR0000000000000627

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Kusumoto F, et al. Circulation 2018Nov 6:CIR0000000000000627

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Kusumoto F, et al. Circulation 2018Nov 6:CIR0000000000000627

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Kusumoto F, et al. Circulation 2018Nov 6:CIR0000000000000627

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Pacing acing Concer Concern n is Not is Not New New

  • “Pressure developed. . .after . . .contraction is far less in the artificially than in

the naturally elicited beats. [U]ndoubtedly its significance must be. . . carefully considered”

Wiggers CJ, Am J Physiol 73: 346; 1925

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Right t Ventri tricular r Pacing Longstanding Effects Acute Changes

Sweeney MO. J Am Coll Cardiol 47:282-288; 2006

A Form of Desynchronization Therapy

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MOST – Freedom from first HFH

Freedom from first HFH

HR 2.6

The DAVID Trial

Willkoff BL. JAMA 2002; 288:3115–3123

P=0.03

CHF admissions/mortality

Months to death or heart failure hospitalization Cumulative probability Mean RV pacing = 58.9±36.0% Mean RV pacing = 3.5±14.9%

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Heart Failure post RV pacing

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Time Course

|

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Acute Phase (0-6 months) HR 1.62 (95% CI: 1.48-1.79, p<0.001) Chronic Phase (6 months – 4 Years) HR 1.16 (95% CI: 1.08-1.25, p<0.001) |

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|

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His bundle pacing- The new paradigm in pacing

  • Replicates true physiology (what nature has selected over millions
  • f years of human evolution)
  • The most efficient way to stimulate the ventricles (QRS duration

ranges from 50 ms to 110 ms in most humans over their lifespan)

  • The ideal form of AV and VV (intra and interventricular) synchrony;

no other existing form of pacing can claim this as the ventricle is non-physiologically activated

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Ploux S,..Bordacher P. Heart Rhythm 2015;12:782–791

ECG Imaging

Vijayaraman et al. JACC 2018;72:927-47 20

  • First described by Scherlag et al in 1967 in dog
  • Narula et al described temporary His bundle pacing in humans in 1976
  • Deshmukh et al (2000) described permanent His bundle pacing in 18 pts

with

– Dilated CMP, chronic AF, normal QRS, AVN ablation – Successful in 12 pts – Pacing threshold 2.4 ± 1.0 V @0.5 ms, R wave 1-3.2 mV – LVEF improved from 20 ± 9% to 31± 11% – Lead dislodgement 2 pts

His Bundle Pacing

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61.2 37.4 60.7 44

30 35 40 45 50 55 60 65

EF > 45% EF ≤ 45% BASELINE POST- IMPLANT

P = 0.144 P < 0.001

ROVIGO EXPERIENCE

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HBP compared to RV pacing:

Long-term performance

192 PPMs implanted 2011 94 HBP attempted 75 (80%) successful HBP 19 implanted in RV septum 98 RV pacing group 60 RV apex 38 RV septum Vijayaraman P, et al. Heart Rhythm 2018;15:696-702 25

His Bundle Pacing (HBP) RV Pacing

Number of patients (n, %) 75, 80% 98, 100% Baseline QRS duration (ms) 109±26 102±24 Paced QRS duration (ms) 124±22 168±21 Fluoroscopy times (min) - median 9.2 6.4 Pacing thresholds (V @ 0.5 ms) Mean ± SD Mean ± SD Implant 1.35 ± 0.9 0.62±0.5 1 year 1.60± 0.9 0.80±0.3 2 year 1.50±0.8 0.80±0.4 5 year 1.62±1.0 0.84±0.4

Procedural Outcomes

124±22 168±21 1.35 ± 0.9 0.62±0.5 1.62±1.0 0.84±0.4

Vijayaraman P, et al. Heart Rhythm 2018;15:696-702

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Freedom from death or HFH

B

  • --- HBP (N=47)
  • --- RVP (N=60)

Follow-up (years)

Patients with >40% VP

Combined End-point of Death or Heart Failure Hospitalization

P=0.02 HR 2.1

On Treatment

Follow-up (years)

  • --- HBP (N=75)
  • --- RVP (N=98)

P=0.04 HR 1.7

All Patients All Patients Patients with VP >40%

25 30 35 40 45 50 55 60

HBP RVP HBP RVP

Baseline Follow-up

Ejection Fraction %

P=NS P=0.002 P=NS P<0.001

At 5 years

Vijayaraman P, et al. Heart Rhythm 2018;15:696-702

Death or HFH in pts with VP>40% (INTENTION TO TREAT) QRS duration (paced) LV Ejection Fraction Pacing Induced CMP Device parameters Pacing Threshold Lead revisions Generator changes

5-year follow-up data 192 pts

HBP 75/94 (80%) pts 1.62±1.0 (@0.5ms) 5 (6.7%) 7 (9%) 126±29 ms 57 ± 6 % 1 (2%) 19,32% RV pacing 98 pts 0.84±0.4 (@0.5ms) 2 (3%) 1 (1%) 170±31 ms 52 ± 11 % 13 (22%) 32, 53%

P<0.01 P<0.01 P<0.001 P=0.04

Long-Term Lead Performance and Clinical Outcomes

P<0.01 29

Clinical Outcomes

765 Patients 332 HBP attempted 304 (92%) successful HBP 28 (8%) RV septum 433 RV pacing 176 (41%) RV apex 257 (59%) Non-apical

➢ Mean Follow-up duration 725 ±423 days ➢ 220 reached the primary endpoint

Abdelrahman M,…Vijayaraman P. JACC 2018;71:2319-30

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Procedural Characteristics

His Bundle pacing (n=304) RV pacing (n=433)

P-value

Procedure duration (min) 70.21±34 55.02±25 <0.01* Fluoroscopy duration (min) 10.27±6.5 7.40±5.1 <0.01* Implant Capture threshold (V @ ms) 1.30±0.85 @ 0.79±0.26 0.59±0.42 @ 0.5±0.03 <0.01* Last follow up Capture threshold (V @ ms) 1.56±0.95 @ 0.78±0.30 0.76±0.29 @ 0.46±0.09 <0.01* QRS duration (ms) 104.5±24.5 110.5±28.4 <0.01* Paced QRS duration (ms) 128±27.7 166±21.8 <0.01* 31

Primary Outcome (Death, HFH or upgrade to biventricular pacing) All patients

83/332 (25%) 137/433 (32%)

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Primary Outcome (Death, HFH or upgrade to biventricular pacing) Patients with VP >20%

49/194 (25%) 99/278 (36%)

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Heart Failure Hospitalizations

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All- Cause Mortality

477 consecutive patients who underwent PM implantation for complete/advanced AVB. Ventricular pacing leads were located in the HA 148 RVS 140 RVA 189

The he first t case re repor portdescrib ribedLBB pacingtha hat cor

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; Tra rans and nd intr ntraventric ricular r sept ptum; ; Deep sept ptal pacing at t Peri ri-LBB Area

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th or witho thout t selecti tive LBB pacing

AV nodalHB LBB

https://doi.org/10.1016/j.cjca.2017.09.013

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

H LB

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

Bipolar Pacing

3.0V 1.0V 0.5V

NS-LBBP S-LBBP RV+LV+LBB

RAO 30° LAO 45°

41 Sheath angiography

The depth of the lead tip in the ventricular septum by echo and CT scan

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Summary

  • His Purkinje Conduction System Pacing is feasible and safe in all

patients requiring ventricular pacing

  • HPCSP should be the first line therapy in patients requiring

ventricular pacing.

  • It is elegant in its simplicity and it is trying to “repair” existing

conduction problems rather than “replace” it with a new artificial and suboptimal conduction pattern

  • Reinstate “Physiology” in Electrophysiology

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Conclusions

“When the speed of rushing water reaches the point where it can move boulders, this is the force of momentum.”

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