Permanent direct his bundle pacing does not induce ventricular dyssynchrony unlike conventional right ventricular apical pacing

An intrapatient acute comparison study
  • Domenico Catanzariti
  • Massimiliano Maines
  • Claudio Cemin
  • Gianpaolo Broso
  • Tiziana Marotta
  • Giuseppe Vergara



Benefits of A-V synchrony during right ventricular apical pacing are neutralized by induction of ventricular dyssynchrony. Only a few data are reported about direct His bundle pacing influence on ventricular synchronism.


Was to assess the capability of direct His bundle pacing to prevent pacing-induced ventricular dyssynchrony comparing DDD- (or VVI- in case of Atrial Fibrillation) right ventricular apical pacing with DDD- (or VVI-) direct His bundle pacing in the same patients cohort.


23 of 24 patients (mean age 75.1 ± 6.4 years) with narrow QRS (HV < 65 ms) underwent permanent direct His bundle pacing for “brady–tachy syndrome” (11) or supra-Hisian II/III-degree AV Block (permanent atrial fibrillation 7, AV Node ablation 1). A 4.1 F screw-in lead was fixed in His position, guided by endocardial pacemapping and unipolar recordings. Additional permanent (13 patients) or temporary right ventricular apical pacing leads were also positioned. Inter- and left intra-ventricular dyssynchrony, mitral regurgitation and left systolic ventricular function Tei index were assessed during either direct His bundle pacing or right ventricular apical pacing.


Permanent direct His bundle pacing was obtained in 23 of 24 patients. Indexes of ventricular dyssynchrony were drastically reduced, mitral regurgitation decreased and left systolic ventricular function Tei index improved during direct His bundle pacing (or His bundle and septum pacing) in comparison to apical pacing (p < 0.05). No statistically significant differences were observed between direct His bundle pacing and combined His bundle and septum pacing.


Direct His bundle pacing (also fused with adjacent septum capture) prevents pacing-induced ventricular dyssynchrony.


His bundle pacing His bundle Brady Tachy sick sinus syndrome SupraHisian AV block Cardiac pacing Ventricular dyssynchrony 


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  1. 1.
    Andersen, H. R., Nielsen, J. C., Thomsen, P. E., et al. (1997). Long-term follow-up of patients from a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome. Lancet, 350(9086), 1210–1216.CrossRefPubMedGoogle Scholar
  2. 2.
    Connolly, S. J., Kerr, C. R., Gent, M., et al. (2000). Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death due to cardiovascular causes. Canadian trial of physiologic pacing investigators. New England Journal of Medicine, 342(19), 1385–1391.CrossRefPubMedGoogle Scholar
  3. 3.
    Lamas, G. A., Lee, K. L., Sweeney, M. O., et al. (2002). Mode selection trial in sinus-node dysfunction. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. New England Journal of Medicine, 346(24), 1854–1862.CrossRefPubMedGoogle Scholar
  4. 4.
    Nielsen, J. C., Kristensen, L., Andersen, H. R., Mortensen, P. T., Pedersen, O. L., & Pedersen, A. K. (2003). A randomized comparison of atrial and dual-chamber pacing in 177 consecutive patients with sick sinus syndrome: Echocardiographic and clinical outcome. Journal of the American College of Cardiology, 42(4), 614–623.CrossRefPubMedGoogle Scholar
  5. 5.
    Sweeney, M. O., Hellkamp, A. S., Ellenbogen, K. A., et al. (2003). Mode selection trial investigators. Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction. Circulation, 107(23), 2932–2937.CrossRefPubMedGoogle Scholar
  6. 6.
    Kerr, C. R., Connolly, S. J., Abdollah, H., et al. (2004). Canadian trial of physiological pacing: Effects of physiological pacing during long-term follow-up. Circulation, 109(3), 357–362, 27.CrossRefPubMedGoogle Scholar
  7. 7.
    Sharma, A. D., Rizo-Patron, C., Hallstrom, A. P., et al. (2005). Percent right ventricular pacing predicts outcomes in the DAVID trial. Heart Rhythm, 2(8), 830–834.CrossRefPubMedGoogle Scholar
  8. 8.
    van Oosterhout, M. F., Prinzen, F. W., & Arts, T., et al. (1998). Asynchronous electrical activation induces asymmetrical hypertrophy of the left ventricular wall. Circulation, 98, 588–595.PubMedGoogle Scholar
  9. 9.
    Rosenqvist, M., Isaaz, K., Botvinick, E. H., et al. (1991). The importance of activation sequence compared to atrioventricular synchrony in left ventricular function. American Journal of Cardiology, 67, 148–156.CrossRefPubMedGoogle Scholar
  10. 10.
    Tse, H. F., Yu, C., Wong, K. K., et al. (2002). Functional abnormalities in patients with permanent right ventricular pacing: The effect of sites of electrical stimulation. Journal of the American College of Cardiology, 40, 1451–1458.CrossRefPubMedGoogle Scholar
  11. 11.
    Barold, S. S., & Ovsyshcher, I. E. (2005). Pacemaker-induced mitral regurgitation. Pacing and Clinical Electrophysiology, 28, 357–359.CrossRefPubMedGoogle Scholar
  12. 12.
    Nahlawi, M., Waligora, M., Spies, S. M., Bonow, R. O., Kadish, A. H., & Goldberger, J. J. (2004). Left ventricular function during and after right ventricular pacing. Journal of the American College of Cardiology, 44(9), 1883–1888.CrossRefPubMedGoogle Scholar
  13. 13.
    Barold, S. S., & Herweg, B. (2005). Right ventricular outflow tract pacing: Not ready for prime-time. Journal of Interventional Cardiac Electrophysiology, 13, 39–46.CrossRefPubMedGoogle Scholar
  14. 14.
    Deshmukh, P., Casavant, D., Romanyshyn, M., et al. (2000). Permanent, direct His-bundle pacing. A novel approach to cardiac pacing in patients with normal His–Purkinje activation. Circulation, 101, 869–877.PubMedGoogle Scholar
  15. 15.
    Deshmukh, P. M., & Romanyshyn, M. (2004). Direct His-bundle pacing: Present and future. Pacing and Clinical Electrophysiology, 27(6 Pt 2), 862–870.CrossRefPubMedGoogle Scholar
  16. 16.
    Zanon, F., Baracca, E., Aggio, S., et al. (2006). A feasible approach for direct His-bundle pacing using a new steerable catheter to facilitate precise lead placement. Journal of Cardiovascular Electrophysiology, 17(1), 29–33.PubMedGoogle Scholar
  17. 17.
    Gregoratos, G., Abrams, J., Epstein, A. E., et al. (2002). ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: Summary article. A report of the ACC/AHA task force on practice guidelines. Circulation, 106, 2145–2161.CrossRefPubMedGoogle Scholar
  18. 18.
    Hunt, S. A., Abraham, W. T., Chin, M. H., et al. (2005). ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the adult. Circulation, 112(12), e154–e235.CrossRefPubMedGoogle Scholar
  19. 19.
    Hirao, K., Otano, K., Wang, X., et al. (1996). Para Hisian pacing. Circulation, 94, 1027–1035.PubMedGoogle Scholar
  20. 20.
    Dubin, J., Wallerson, D. C., Cody, R. J., et al. (1990). Comparative accuracy of Doppler echocardiography methods for clinical stroke volume determination. American Heart Journal, 120, 116–123.CrossRefPubMedGoogle Scholar
  21. 21.
    Schiller, N. B., Shah, P. M., Crawford, M., et al. (1989). Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. Journal of American Society of Echocardiography, 2, 358–367.Google Scholar
  22. 22.
    Bordachar, P., Lafitte, S., Reuter, S., et al. (2004). Echocardiographic parameters of ventricular dyssynchrony validation in patients with heart failure using sequential biventricular pacing. Journal of the American College of Cardiology, 44, 2157–2165.CrossRefPubMedGoogle Scholar
  23. 23.
    Pitzalis, M. V., Iacoviello, M., Romito, R., et al. (2002). Cardiac resynchronization therapy tailored by echocardiographic evaluation of ventricular asynchrony. Journal of the American College of Cardiology, 40, 1615–1622.CrossRefPubMedGoogle Scholar
  24. 24.
    Bax, J. J., Bleeker, G. B., Marwick, T. H., et al. (2004). Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. Journal of the American College of Cardiology, 44, 1834–1840.CrossRefPubMedGoogle Scholar
  25. 25.
    Bader, H., Garrigue, S., Lafitte, S., et al. (2004). Intra-left ventricular electromechanical asynchrony. A new independent predictor of severe cardiac events in heart failure patients. Journal of the American College of Cardiology, 43, 248–256.CrossRefPubMedGoogle Scholar
  26. 26.
    Enriquez-Sarano, M., Seward, J. B., Bailey, K. R., et al. (1994). Effective regurgitant orifice area: A non invasive Doppler development of an old hemodynamic concept. Journal of the American College of Cardiology, 23, 443–451.PubMedCrossRefGoogle Scholar
  27. 27.
    Tei, C., Nishimura, R. A., Seward, J. B., & Tajik, A. J. (1997). Noninvasive doppler-derived myocardial performance index: Correlation with simultaneous measurements of cardiac catheterisation measurements. Journal of the American Society of Echocardiography, 10(2), 169–178.CrossRefPubMedGoogle Scholar
  28. 28.
    Sweeney, M. O., Ellenbogen, K. A., Casavant, D., et al. (2005). Multicenter, prospective, randomized safety and efficacy study of a new atrial-based managed ventricular pacing mode (MVP) in dual chamber ICDs. Journal of Cardiovascular Electrophysiology, 16, 1–7.CrossRefGoogle Scholar
  29. 29.
    Vassallo, J. A., Cassidy, D. M., Miller, J. M., Buxton, A. E., Marchlinski, F. E., & Josephson, M. E. (1986). Left ventricular endocardial activation during right ventricular pacing: Effect of underlying heart disease. Journal of the American College of Cardiology, 7(6), 1228–1233.PubMedGoogle Scholar
  30. 30.
    Karpawich, P., Gates, J., & Stokes, P. (1992). Septal His–Purkinje ventricular pacing in canines: A new endocardial electrode approach. Pacing and Clinical Electrophysiology, 5, 2011–2015.CrossRefPubMedGoogle Scholar
  31. 31.
    Yu, C. C., Lin, L. C., Lu, Y. B., Lin, M. S., Wang, J. Y., & Lin, J. L. (2005). Preservation of left ventricular contractile synchronism and diastolic function by right ventricular septal pacing: Implications from tissue Doppler imaging analysis. Circulation, 112(17), II-594 (abstr 2812).Google Scholar
  32. 32.
    Occhetta, E., Bortnik, M., Magnani, A., et al. (2006). Prevention of ventricular desynchronization by permanent para-Hisian pacing after atrioventricular node ablation in chronic atrial fibrillation. A crossover, blinded, randomized study versus apical right ventricular pacing. Journal of the American College of Cardiology, 47, 1938–1945.CrossRefPubMedGoogle Scholar
  33. 33.
    Saleh, S., Liakopoulos, O. J., & Buckberg, G. D. (2006). The septal motor of biventricular function. European Journal of Cardio-thoracic Surgery, 29S, S126–S138.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2006

Authors and Affiliations

  • Domenico Catanzariti
    • 1
  • Massimiliano Maines
    • 1
  • Claudio Cemin
    • 1
  • Gianpaolo Broso
    • 1
  • Tiziana Marotta
    • 2
  • Giuseppe Vergara
    • 1
  1. 1.Divisione di CardiologiaOspedale S. Maria del CarmineRoveretoItaly
  2. 2.Medtronic Italy, Inc.MilanItaly

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