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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 14-19

The feasibility and efficacy of His-Purkinje conduction system pacing in patients with permanent atrial fibrillation and chronic heart failure indicated for cardiac resynchronization therapy


1 Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
2 Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China

Date of Web Publication25-Nov-2019

Correspondence Address:
Prof. Yangang Su
Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJHR.IJHR_7_19

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  Abstract 

Background: The aim is to study the feasibility and efficacy of His-Purkinje conduction system pacing (HPCSP) in cardiac resynchronization therapy (CRT) candidates of chronic heart failure with permanent atrial fibrillation (AF). Subjects and Methods: Patients with chronic heart failure and permanent AF (n = 16) were enrolled from the Department of Cardiology, Zhongshan Hospital of Fudan University, from September 2017 to April 2019 in this observational case study. The patients with chronic heart failure (left ventricular ejection fraction [LVEF] <40%) and permanent AF with low ventricular rate were indicated for CRT implantation. The study was approved by the Institutional Ethical Committee of Zhongshan Hospital of Fudan University, China. At baseline, 13 cases had narrow QRS duration (<120 ms) and 3 cases had left bundle branch block with QRS duration >120 ms. HPCSP lead connected to the RA port of the generator was implanted together with conventional biventricular pacing (BVP) and was programmed as HPCSP postprocedure. QRS durations were measured and compared during intrinsic, BVP, and HPCSP. Pacing parameters were measured and compared during postimplantation immediately and 6 months postimplantation. Echocardiogram parameters, New York Heart Association (NYHA) class, and 6-min walking distance (6MWD) were collected and compared between baseline and 6 months postimplantation. Results: QRS durations were significantly different during HPCSP compared with BVP (P < 0.0001). Pacing parameters including threshold and R wave amplitude were not significantly different during postimplantation immediately and 6 months postimplantation, whereas impedance was significantly different (P = 0.028). LVEF, left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, mitral regurgitation, tricuspid annular plane systolic excursion, pulmonary artery systolic pressure, and the percentages of moderate-to-severe mitral regurgitation and tricuspid regurgitation were not significantly different between baseline and 6 months postimplantation, whereas NYHA class and 6MWD were significantly different (P < 0.0001). Conclusion: HPCSP was feasible and effective in CRT candidates of chronic heart failure with permanent AF and low ventricular rate. It could significantly reduce QRS duration as compared to BVP. Moreover, although LVEF was not obviously improved, the pacing parameters were stable and NYHA class and 6MWD were improved during HPCSP at 6-month follow-up.

Keywords: Cardiac resynchronization therapy, chronic heart failure, His-Purkinje conduction system pacing, permanent atrial fibrillation


How to cite this article:
Chen X, Wang J, Qin S, Wang W, Bai J, Chen H, Liang Y, Su Y, Ge J. The feasibility and efficacy of His-Purkinje conduction system pacing in patients with permanent atrial fibrillation and chronic heart failure indicated for cardiac resynchronization therapy. Int J Heart Rhythm 2019;4:14-9

How to cite this URL:
Chen X, Wang J, Qin S, Wang W, Bai J, Chen H, Liang Y, Su Y, Ge J. The feasibility and efficacy of His-Purkinje conduction system pacing in patients with permanent atrial fibrillation and chronic heart failure indicated for cardiac resynchronization therapy. Int J Heart Rhythm [serial online] 2019 [cited 2019 Dec 16];4:14-9. Available from: http://www.ijhronline.org/text.asp?2019/4/1/14/271667


  Introduction Top


In 2000, Deshmukh et al.[1] first performed permanent His bundle pacing (HBP) in clinical practice. Nowadays, HBP has been used in patients with pacing dependence, especially those with decreased systolic function.[2] However, since the pacing threshold of HBP is usually high, it will be raised or even lost capture in a certain proportion of patients in the long-term.[3],[4] Left bundle branch pacing (LBBP) is gradually carried out in clinical practice.[5] Its advantages include stable pacing parameters and the maximum electrical synchrony of the left ventricle.[6],[7],[8],[9],[10]

His-Purkinje conduction system pacing (HPCSP), including HBP and LBBP, has been utilized in more and more cases to maintain or improve cardiac electrical synchrony. However, previous studies focusing on HPCSP were retrospective and rather small scale. In the present study, cardiac resynchronization therapy (CRT) patients with chronic heart failure and permanent atrial fibrillation (AF) were enrolled on the basis of biventricular pacing (BVP). HPCSP lead was connected to atrial port, and the feasibility and efficacy of HPCSP were evaluated.


  Subjects and Methods Top


Subjects

Patients with chronic heart failure and permanent AF (n = 16) were enrolled from the Department of Cardiology, Zhongshan Hospital of Fudan University, from September 2017 to April 2019. All the cases with low ventricular heart rate and left ventricular ejection fraction (LVEF) <40% were indicated for CRT implantation. At baseline, 13 cases had narrow QRS duration (<120 ms) and 3 cases had left bundle branch block (LBBB) with QRS duration >120 ms. All the patients were CRT candidates and received a CRT pacemaker (n = 6) or CRT defibrillator (n = 10) implantation. The baseline characteristics of the participants are shown in [Table 1]. This observational case study was ethically approved by the Institutional Ethical Committee of Zhongshan Hospital of Fudan University, China, and performed in line with the 2013 Revision of the Declaration of Helsinki, and patients or their family members signed an informed consent form.
Table 1: Baseline characteristics of the included patients with chronic heart failure and permanent atrial fibrillation

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Device implantation

Procedure: (1) Temporary pacing through axillary vein access was used before HPCSP implement. (2) The left ventricular lead was inserted into the lateral vein or posterior vein of the heart through the left ventricular lead delivery system. (3) HPCSP was performed using Select Secure pacing lead (model 3830, 69 cm, Medtronic Inc., Minneapolis, MN, USA) delivered through a fixed curve sheath (C315 HIS, Medtronic Inc.). The delivery sheath with the lead tip just beyond the distal part of the sheath under right anterior oblique 30° was first inserted into the His bundle region where the His bundle potential was recorded. The intracardiac echocardiography from the lead tip and a 12-lead surface electrocardiogram were simultaneously recorded by an EP system (CardioLab, GE MAC, USA). Once His electrogram is identified, the pacing lead is slowly rotated approximately five clockwise rotations. Pacing parameters were tested then. HBP lead would be reserved if His bundle capture threshold or LBBB correction threshold (for patients with LBBB) was <1.5 V/0.4 ms. Otherwise, the pacing lead will be further advanced across the tricuspid valve toward the ventricular septum to perform LBBP.[11],[12] At right anterior oblique 30°, with the HBP location as a reference image, the initial site for LBBP is approximately 1.5 cm distal to the His bundle region along the line between His bundle location and right ventricular (RV) apex. At this site, the paced QRS morphology before fixation usually demonstrates a “w” pattern with a notch at the nadir of the QRS in lead V1. The pacing lead was then screwed toward the left side of the septum. Once the paced electrocardiogram QRS morphology shows right bundle branch block pattern with or without the left bundle branch (LBB) potential recorded and left ventricular apical thrombus is shortened abruptly with increasing output, or remains shortest and constant both at low and high outputs, it suggests LBB capture.[10],[12] After sheath removal, HPCSP pacing lead was connected to the RA port of the generator, and the pacing threshold, R wave amplitude, and impedance were measured and recorded.

Programming and follow-up

Postoperative programming was HPCSP before BVP, and the latter was used as a backup (DDD, AV interval 150 ms) [Figure 1]. QRS durations were measured and compared during intrinsic rhythm, BVP, and HPCSP. Pacing parameters (R wave amplitude, threshold, and impedance), New York Heart Association (NYHA) class, 6-minute walking distance (6MWD), and echocardiogram parameters were measured 6 months postimplantation, including LVEF, left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, mitral regurgitation, tricuspid annular plane systolic excursion, and pulmonary artery systolic pressure.
Figure 1: Electrocardiograms of a HPCSP case. (a) Intrinsic, AF and III°AVB, LBBB, QRS duration 115 ms. (b) BVP: QRS duration 155 ms. (c) HPCSP (LBBP): QRS duration 120 ms. HPCSP = His-Purkinje conduction system pacing, AF = Atrial fibrillation, AVB = Atrioventricular block, BVP = Biventricular pacing, LBBB = Left bundle branch block, LBBP = Left bundle branch pacing

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Statistical analysis

All the analyses were performed by SPSS 19.0 (IBM, Armonk, NY, USA). Continuous variables were expressed as the mean ± standard deviation and compared between groups using Student's t-test or one-way analysis of variance with the least significant difference post hoc test as appropriate. Categorical variables were expressed as numbers and percentage (%), and Chi-square test was used to compare the differences. A two-tailed P < 0.05 indicated that the difference was statistically significant.


  Results Top


Comparison of QRS duration and pacing parameters

The intrinsic average QRS duration was 116.5 ± 26.4 ms. The average QRS duration of postprocedure BVP was 151.6 ± 10.6 ms (P< 0.0001; BVP vs. intrinsic). The average QRS duration of HPCSP was 118.1 ± 9.9 ms (P = 0.793; HPCSP vs. intrinsic), but there was a significant difference between HPCSP and BVP (P< 0.0001) [Figure 2].
Figure 2: QRS durations during intrinsic, BVP, and HPCSP. P <0.0001 among three groups; *P < 0.0001, vs. BVP. BVP = Biventricular pacing, HPCSP = His-Purkinje system pacing

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There were 6 of 16 patients receiving HBP (37.5%). In terms of pacemaker parameters, there was no significant difference in threshold and R wave amplitude during postimplantation immediately and 6 months postimplantation [Table 2].
Table 2: Comparison of pacing parameters immediately and 6 months postimplantation in His-Purkinje system pacing group

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Comparison of echocardiogram parameters and cardiac function

After 6 months of follow-up, the average values of LVEF during HPCSP were higher than those before implantation, but the difference was not statistically significant. Left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, tricuspid annular plane systolic excursion, pulmonary artery systolic pressure, and the percentages of moderate-to-severe mitral regurgitation and tricuspid regurgitation were also not significantly different between baseline and 6 months postimplantation (P > 0.05). NYHA class and the average 6MWD were significantly improved than those before implantation (P< 0.0001) [Table 3].
Table 3: Comparison of echocardiogram parameters, New York Heart Association class, and 6-minute walking distance immediately and 6 months postimplantation in His-Purkinje system pacing group

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  Discussion Top


The present study preliminarily demonstrates that HPCSP was feasible and effective in CRT candidates of chronic heart failure with permanent AF and low ventricular rate. It could significantly reduce QRS duration as compared with BVP. Moreover, the pacing parameters were stable. Although LVEF was not significantly improved, NYHA class and 6MWD were significantly improved after 6 months of follow-up.

CRT is a classical therapy for chronic heart failure patients which can reduce heart failure hospitalization and decrease all-cause mortality. However, the response rate is only about 70% for all patients with indications. Besides heart failure patients with wide QRS wave (>130 ms), BVP rather than RV pacing (RVP) was also recommended regardless of QRS duration for patients with pacing dependence and LVEF <40% (Class I and IIa).[13] However, theoretically, for patients with narrow QRS, BVP deteriorates left ventricular electrical synchrony when comparing with intrinsic, though it is better than RVP. Our study also found that QRS duration after HPCSP decreased significantly than that in BVP.

HPCSP is recognized as the most physiological pacing mode at present. For patients with narrow QRS, HPCSP can maintain electrical synchrony as much as possible, and for ventricular pacing-dependent patients, it can reduce the incidence of long-term heart failure caused by nonphysiological pacing.[14] For patients with wide QRS duration and bundle branch block, most of the typical LBBB can be completely corrected by HPCSP.[5],[15],[16],[17],[18] LBBP has more stable and reliable parameters than HBP.[5] For patients with nonspecific intraventricular block that cannot be completely corrected by HPCSP, HPCSP fusion with BVP would be a feasible choice.[19] Compared with conventional BVP, HPCSP could reduce QRS duration. Moreover, the difference was statistically significant, which fully indicated that HPCSP was superior to conventional BVP in maintaining cardiac electrical synchrony, which was consistent with the previous literature.[15],[16],[17],[18],[19]

This study also found that pacing parameters of HPCSP were stable at 6 months postimplantation. The immediate and 6-month follow-up showed that pacing threshold and R wave amplitude were not significantly different during postimplantation immediately and 6 months postimplantation. Impedance was significantly different, which may be related to the higher proportion of LBBP. Since the lead was implanted trans-septally to reach the subendocardium of the left ventricular septum for LBBP, the myocardial injury in the acute stage of the operation was obvious. Then, the impedance would significantly decrease after the recovery of the injury.

In addition, the improvement of cardiac function at 6 months postimplantation showed that the NYHA class and 6MWD were improved significantly. While for echocardiogram parameters, although LVEF, pulmonary artery systolic pressure and the percentages of moderate-to-severe mitral regurgitation and tricuspid regurgitation were improved from baseline to 6 months postimplantation, there was no significant difference, which suggested that the improvement in electrical synchrony was not equivalent to the improvement in mechanical synchrony even the reverse of heart remodeling. The inconsistency between them may be related to the various pathogenies of heart failure, short follow-up time, and small scale of the study. In addition, many patients had a long history of heart failure and persistent AF, which indicates that myocardial fibrosis and scars might be severe and it was difficult to reverse the cardiac function by simply improving electrical synchrony.

Limitations

There were some limitations in this study. First of all, this study was a small-scale, single-center, observational study. The pathogeny of heart failure is various. Narrow QRS and LBBB were included, which may lead to the inhomogeneity of the results. Second, the follow-up time was not long enough, and the reverse cardiac remodeling might not be fully achieved within 6 months. Moreover, echocardiogram parameters were compared during HPCSP and intrinsic rhythm, rather than BVP because of the sample size. The subjects of this study were patients with ventricular pacing dependence (AF patients with slow ventricular rate). The results would be more persuasive if compared with BVP.


  Conclusion Top


HPCSP was feasible and effective in CRT candidates of chronic heart failure with permanent AF and low ventricular rate. It could markedly reduce QRS duration compared with BVP. Moreover, although LVEF was not obviously improved, the pacing parameters were stable and NYHA class and 6MWD were improved during HPCSP at 6-month follow-up.

Acknowledgments

The study received assistance from Professor Weijian Huang (First Affiliated Hospital of Wenzhou Medical University, China).

Financial support and sponsorship

This study was financially supported by Shanghai Municipal Planning Commission of Science and Research, No. 20164Y0006.

Conflicts of interest

There are no conflicts of interest.

Institutional review board statement

The study was approved by the Institutional Ethical Committee of Zhongshan Hospital of Fudan University, China.

Declaration of patient consent

The authors certify that they have obtained all appropriate consent from patients or their family members. In the forms, the patients or their family members have given their consent for the patients' images and other clinical information to be reported in the journal. The patients or their family members understand that the patients' names and initials will not be published and due efforts will be made to conceal their identity forms.

 
  References Top

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;101:869-77.  Back to cited text no. 1
    
2.
Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the heart rhythm society. Circulation 2019;140:e382-e482.  Back to cited text no. 2
    
3.
Vijayaraman P, Naperkowski A, Subzposh FA, Abdelrahman M, Sharma PS, Oren JW, et al. Permanent his-bundle pacing: Long-term lead performance and clinical outcomes. Heart Rhythm 2018;15:696-702.  Back to cited text no. 3
    
4.
Zanon F, Abdelrahman M, Marcantoni L, Naperkowski A, Subzposh FA, Pastore G, et al. Long term performance and safety of his bundle pacing: A multicenter experience. J Cardiovasc Electrophysiol 2019;30:1594-601.  Back to cited text no. 4
    
5.
Huang W, Su L, Wu S, Xu L, Xiao F, Zhou X, et al. Anovel pacing strategy with low and stable output: Pacing the left bundle branch immediately beyond the conduction block. Can J Cardiol 2017;33:1736.e1-00.  Back to cited text no. 5
    
6.
Wu S, Su L, Wang S, Vijayaraman P, Ellenbogen KA, Huang W. Peri-left bundle branch pacing in a patient with right ventricular pacing-induced cardiomyopathy and atrioventricular infra-Hisian block. Europace 2019;21:1038.  Back to cited text no. 6
    
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Vijayaraman P, Huang W. Atrioventricular block at the distal his bundle: Electrophysiological insights from left bundle branch pacing. HeartRhythm Case Rep 2019;5:233-6.  Back to cited text no. 7
    
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Chan JYS, Huang WJ, Yan B. Non-invasive electrocardiographic imaging of his-bundle and peri-left bundle pacing in left bundle branch block. Europace 2019;21:837.  Back to cited text no. 8
    
9.
Chen K, Li Y, Dai Y, Sun Q, Luo B, Li C, et al. Comparison of electrocardiogram characteristics and pacing parameters between left bundle branch pacing and right ventricular pacing in patients receiving pacemaker therapy. Europace 2019;21:673-80.  Back to cited text no. 9
    
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Chen X, Wu S, Su L, Su Y, Huang W. The characteristics of the electrocardiogram and the intracardiac electrogram in left bundle branch pacing. J Cardiovasc Electrophysiol 2019;30:1096-101.  Back to cited text no. 10
    
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Dandamudi G, Vijayaraman P. How to perform permanent his bundle pacing in routine clinical practice. Heart Rhythm 2016;13:1362-6.  Back to cited text no. 11
    
12.
Huang W, Chen X, Su L, Wu S, Xia X, Vijayaraman P. A beginner's guide to permanent left bundle branch pacing. Heart Rhythm 2019. pii: S1547-5271 (19) 30573-9.  Back to cited text no. 12
    
13.
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: The task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the heart failure association (HFA) of the ESC. Eur Heart J 2016;37:2129-200.  Back to cited text no. 13
    
14.
Abdelrahman M, Subzposh FA, Beer D, Durr B, Naperkowski A, Sun H, et al. Clinical outcomes of his bundle pacing compared to right ventricular pacing. J Am Coll Cardiol 2018;71:2319-30.  Back to cited text no. 14
    
15.
Lustgarten DL, Crespo EM, Arkhipova-Jenkins I, Lobel R, Winget J, Koehler J, et al. His-bundle pacing versus biventricular pacing in cardiac resynchronization therapy patients: A crossover design comparison. Heart Rhythm 2015;12:1548-57.  Back to cited text no. 15
    
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Ajijola OA, Upadhyay GA, Macias C, Shivkumar K, Tung R. Permanent his-bundle pacing for cardiac resynchronization therapy: Initial feasibility study in lieu of left ventricular lead. Heart Rhythm 2017;14:1353-61.  Back to cited text no. 16
    
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Sharma PS, Dandamudi G, Herweg B, Wilson D, Singh R, Naperkowski A, et al. Permanent his-bundle pacing as an alternative to biventricular pacing for cardiac resynchronization therapy: A multicenter experience. Heart Rhythm 2018;15:413-20.  Back to cited text no. 17
    
18.
Huang W, Su L, Wu S, Xu L, Xiao F, Zhou X, et al. Long-term outcomes of his bundle pacing in patients with heart failure with left bundle branch block. Heart 2019;105:137-43.  Back to cited text no. 18
    
19.
Vijayaraman P, Herweg B, Ellenbogen KA, Gajek J. His-optimized cardiac resynchronization therapy to maximize electrical resynchronization. Circ Arrhythm Electrophysiol 2019;12:e006934.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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