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Current Treatment Options in Cardiovascular Medicine Arrhythmia Section From the His Bundle to the Left Bundle: Clinical Applications of Conduction System Pacing

  • Arrhythmia (R Kabra, Section Editor)
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Abstract

Purpose of review

Conduction system pacing (CSP) has emerged as a new pacing strategy for patients with bradyarrhythmia as well as for applications to deliver cardiac resynchronization therapy (CRT) in patients with heart failure. The primary modes to achieve CSP include His bundle pacing (HBP), pacing at the proximal left conduction system (LCS) with left bundle branch area pacing (LBBAP), and left ventricular septal pacing (LVSP).

Studies involving conduction system pacing

This review summarizes pertinent, prospective data currently available regarding CSP. Currently, the majority of published data analyze outcomes after HBP and are composed primarily of single-center prospective cohort studies. The studies reviewed evaluated use of HBP in treatment of bradyarrhythmia, post atrioventricular (AV) node ablation, and for CRT applications with follow-up ranging from 12 to 24 months. Fewer studies currently exist in reference to LBBAP or LCS pacing with no randomized data presently available. Three LVSP prospective studies were reviewed with 6–24 months of follow-up.

Conclusion

CSP seeks to engage the His-Purkinje system either at the His bundle or the proximal fascicular system. Available data support a role for CSP in patients with bradyarrhythmia indications, and with growing experience in CRT applications. Present data best supports HBP, but LBBAP and LVSP may serve as alternative routes for CSP going forward.

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Authors and Affiliations

  1. Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Medicine, The University of Chicago Pritzker School of Medicine, Chicago, IL, USA

    Andrew Y. Chen MD & Gaurav A. Upadhyay MD

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Correspondence to Gaurav A. Upadhyay MD.

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Gaurav A. Upadhyay reports consulting and speaking fees from Abbott, BioTel, Biotronik, Medtronic, and Zoll Medical. Andrew Y. Chen declares that he has no conflict of interest.

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Key Points

• Conduction system pacing results in the capture or restoration of His-Purkinje activation, with three methods primarily used in clinical practice: HBP, LBBAP, LVSP

• The most robust data currently supports HBP with data suggesting benefit in patients with left ventricular dysfunction relative to right ventricular pacing, although with increased pacing thresholds in some patients

• LBBAP has emerged as an attractive alternative to HBP given lower pacing thresholds and ease of procedure; however, capture of the conduction system may be difficult to ascertain at implant, particularly in patients with bundle branch block

• LVSP may be simpler to achieve than HBP and LBBAP, although more data are needed regarding clinical outcomes

This article is part of the Topical Collection on Arrhythmia

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Chen, A.Y., Upadhyay, G.A. Current Treatment Options in Cardiovascular Medicine Arrhythmia Section From the His Bundle to the Left Bundle: Clinical Applications of Conduction System Pacing. Curr Treat Options Cardio Med 23, 7 (2021). https://doi.org/10.1007/s11936-020-00880-4

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