Abstract
His-Purkinje conduction system pacing (HPCSP) in the form of His bundle pacing and left bundle branch pacing allows normal ventricular activation, thereby preventing the adverse consequences of right ventricular pacing. One potential area where HPCSP could be used is in the field of atrioventricular (AV) node ablation in patients with atrial fibrillation refractory to medical therapy and/or catheter ablation. His bundle pacing has been established for several years, with centres from North America, Europe and China publishing their experience. The differing patterns of His bundle capture are clearly described with established guidance as to how to implant such systems. Left bundle branch pacing has only recently been reported, but there are several advantages with better pacing parameters and lower risk of threshold change after AV node ablation. Six studies have been identified in the literature which describe the experience of His bundle pacing in patients requiring AV node ablation. Overall the results are positive and favour this new technique; however, they are limited by low numbers of patients and non-randomised study design. An observational study was recently published demonstrating better outcomes with left bundle branch pacing in a small number of patients with left ventricular dysfunction and atrial fibrillation that underwent AV node ablation. HPCSP has the potential to be the primary pacing modality in patients with atrial fibrillation requiring AV node ablation. However, it is essential that this is confirmed in large randomised clinical trials.
Zusammenfassung
Die Stimulation des His-Purkinje-Systems (HPCSP) in Form einer His-Bündel- oder Linksschenkelstimulation ermöglicht eine normale ventrikuläre Aktivierung und verhindert hierdurch negative Auswirkungen der rechtsventrikulären Stimulation. Eine mögliche Anwendung der HPCSP betrifft die Stimulation nach Ablation des atrioventrikulären (AV) Knotens bei Patienten mit therapierefraktärem Vorhofflimmern (nach medikamentöser Therapie und/oder Katheterablation). Die His-Bündel-Stimulation ist seit einigen Jahren etabliert; nordamerikanische, europäische und chinesische Zentren haben ihre Ergebnisse publiziert. Die verschiedenen Muster des His-Bündel-Capture sind genau beschrieben und es existieren Anleitungen, wie eine His-Bündel-Elektrode implantiert wird. Die Linksschenkelstimulation wurde erst kürzlich beschrieben, scheint jedoch mehrere Vorteile zu bieten, einschließlich besserer Stimulationsparameter und eines geringeren Risikos des Reizschwellenanstiegs nach AV-Knoten-Ablation. In der Literatur finden sich 6 Studien, die über Erfahrungen mit der His-Bündel-Stimulation bei Patienten nach AV-Knoten-Ablation berichten. Die Ergebnisse sind insgesamt positiv und zeigen Vorteile dieser neuen Technik, sind jedoch limitiert durch eine geringe Patientenzahl und das nichtrandomisierte Design der Studien. Kürzlich wurde eine Beobachtungsstudie mit einer kleinen Zahl von Patienten publiziert, die bei Vorhofflimmern und AV-Knoten-Ablation im Kontext einer eingeschränkten linksventrikulären Funktion bessere Ergebnisse unter Linksschenkelstimulation zeigte. Die HPCSP hat das Potenzial, sich bei Patienten mit Vorhofflimmern und erforderlicher AV-Knoten-Ablation als primäre Stimulationsform zu etablieren. Dies muss aber in großen randomisierten Studien bestätigt werden.
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P. Vijayaraman: Speaker, Consultant, Fellowship support, Research (Medtronic), Consultant (Boston Scientific, Abbott, Biotronik), patent pending for His delivery tool. A. Muthumala declares that he has no competing interests.
For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.
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Muthumala, A., Vijayaraman, P. His-Purkinje conduction system pacing and atrioventricular node ablation. Herzschr Elektrophys 31, 117–123 (2020). https://doi.org/10.1007/s00399-020-00679-7
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DOI: https://doi.org/10.1007/s00399-020-00679-7