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His bundle pacing: troubleshooting during follow-up

His-Bündel-Stimulation: Troubleshooting in der Nachsorge

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Abstract

Follow-up of pacemaker systems for His bundle pacing (HBP) requires electrocardiogram (ECG) knowledge and creative thinking. This relates to ventricular threshold measurement in which it can be difficult to distinguish between selective HBP and loss of capture with pseudofusion since, by definition, intrinsic QRS complexes and those selectively paced via the His bundle look identical. Threshold testing in HBP is best performed in unipolar pacing mode, recording of a 12-lead ECG and pacing in VVI mode significantly above the intrinsic rate. Peculiarities of HBP relate to oversensing by the His bundle lead of atrial activity or the His bundle potential itself, leading to ventricular asystole or incorrect measurements during sensing testing. Ventricular undersensing and the use of His bundle plus additional right ventricular leads may lead to complex ECGs. However, other daily pacemaker problems (such as tachycardia above the upper rate limit or premature beats) and specific phenomena (such as paradoxical cardiac memory) may also be demanding in ECG troubleshooting of HBP.

Zusammenfassung

Die Nachsorge von Schrittmachersystemen zur His-Bündel-Stimulation (HBS) erfordert elektrokardiographische Kenntnisse und kreatives Denken. Dies gilt zunächst für die Messung der ventrikulären Reizschwelle, bei der allein die Unterscheidung zwischen selektiver HBS und Verlust der Stimulation mit Pseudofusion schwierig sein kann, da intrinsische und selektiv via His-Bündel stimulierte QRS-Komplexe per definitionem identisch aussehen. Wichtig sind hier die Programmierung der His-Bündel-Stimulation auf unipolar, die Ableitung eines 12-Kanal-Elektrokardiogramms (EKG) und die Stimulation im VVI-Modus deutlich über der Eigenfrequenz. Weitere Besonderheiten betreffen die Möglichkeit, dass die His-Bündel-Elektrode atriale Aktionen oder das His-Bündel-Potenzial selbst sieht (Oversensing), was zu falschen Messwerten im Sensing-Test oder zu Asystolie führen kann. Ventrikuläres Undersensing kann ebenso wie die Verwendung einer His-Bündel- und zusätzlichen rechtsventrikulären Elektrode zu komplexen EKGs führen. Daneben können ganz alltägliche Schrittmacherprobleme (z. B. Tachykardien oberhalb der oberen Grenzfrequenz, Extrasystolie) und spezielle Phänomene (z. B. paradoxes Cardiac Memory) Herausforderungen beim EKG-Troubleshooting von HBS darstellen.

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Authors and Affiliations

  1. Klinik für Innere Medizin – Kardiologie, Diabetologie & Nephrologie, Evangelisches Klinikum Bethel, Burgsteig 13, 33617, Bielefeld, Germany

    Carsten W. Israel & Sona Tribunyan

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  1. Carsten W. Israel
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  2. Sona Tribunyan
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Correspondence to Carsten W. Israel.

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Conflict of interest

C.W. Israel: Medtronic (advisory board, honoraria for presentations, reimbursement for congress and travel costs). S. Tribunyan declares that she 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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Israel, C.W., Tribunyan, S. His bundle pacing: troubleshooting during follow-up. Herzschr Elektrophys 31, 183–209 (2020). https://doi.org/10.1007/s00399-020-00693-9

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  • DOI: https://doi.org/10.1007/s00399-020-00693-9

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