Pugazhendhi Vijayaraman, MD

Professor Of Medicine

Geisinger Commonwealth School of Medicine

Geisinger Heart Institute,

Wilkes-Barre, PA, USA

Left Bundle Branch Area PacingEvolution of Conduction System Pacing

Disclosures

Speaker, Consultant, Research, - MedtronicFellowship support

Consultant - Abbott, Biotronik- Boston Scientific - Eaglepoint LLC

His Bundle Pacing

• Procedural Challenges

• Success rates vary from 70-92%

• Difficulty in fixation in 10%

• Small target – requires precision

• Limited tool set

• Lower success in infranodal, HV block

• 1% transient AV block, 2.5% persistent RBBB

His Bundle Pacing

• Threshold Challenges

• High pacing thresholds in ~10% at implant

• Unpredictable threshold increase in 10% at follow-up

• Lead revision ~5%

• Higher BBB correction thresholds

His Bundle Pacing

• Sensing Challenges

• Smaller R waves (1-3 mV)

• Ventricular undersensing

• Atrial oversensing

• Atrial capture

AVN

Proximal HB

Distal HB

Bundle Branch

Septum

RV

LV

Distal His or Left Bundle Branch Pacing

• Stable, low thresholds

• Pacing beyond the site of block

• Large R waves, no oversensing

• Left Septal myocardial capture

Choices for HP Conduction System Pacing

HB

RB

B

LB

B

Narrow target

accurate positioning

needed

Wider conduction net

Easy to find and fix

LBB pacing can be easily achieved?

Elizari M et al. J Electrocardiol 2017

Tawara S. Das Reizleitungssystem des Säugetierhezens. Verlag von Gustav Fischer, Jena 1906.

Courtesy:

K Shivkumar, UCLA

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

LBBP

HBPH

LB

LEFT BUNDLE BRANCH AREA PACING

AV node

His bundle

Left bundle

Right bundle

12

AV nodalHB

LBB

Left axillary vein access with C315His Sheath

Remove the sheath

Check Pacing parameters

**** The back-up ventricular pacing should be available to ensure safety for patient with CLBBB before implantation of LBBP lead

Steps for LBBP Lead Implantation – Dr. Huang

Technique

Notch moves towards the end of QRS in V1 with deep fixation

Confirm LBB Capture

Advance to the right depth in the septum

Observe for LBB Potential

Turn the leadwhile keeping the sheath perpendicular to the septum

Monitor unipolar impedance during fixation

Locate distal His bundle

Place the catheter 1-1.5 cm from HB towards RV apex

Find the location where paced QRS morphology has“W” pattern with notch closer to nadir in V1 or V2

One or both

Usually in RAO

Huang W, Vijayaraman P, et al. Heart Rhythm 2019: (in press)

How to choose the initial site for LBB pacing

H: His area; L: LBB area; A: Apex

RAO

I

II

III

LBB

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

420Ω 760Ω 720Ω500Ω 640Ω

Dynamic changes of paced QRS morphology during fixation

Monitor:

• Impedance (Tip)

• Paced QRS morphology

• Potential

• Threshold to capture LB (low

and high output)

• LV peak time

• Lead depth

Demonstration of LBB potential with deeper fixation

I

II

III

LBB

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

PP

P

0.84mv

P

0.5mv

HB

LBB

RBB

4V

HB

LBB

RBB

0.5V

HB

LBB

RBB

5V

HB

LBB

RBB

1V

I

II

III

LBB

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

RA

LBBLB

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

HBPH

Vijayaraman P, Huang W. Heart Rhythm Case Report 2019

Unipolar Tip Pacing

NS-LBBP S-LBBP

0.7V 0.5V

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

LBBP1.0V 0.5V

NS-LBBP S-LBBP

3.0V

RV+LV+LBB

Bipolar Pacing

RAO 30° LAO 45°

Vijayaraman P, Huang W. Heart Rhythm Case Report 2019

Case presentation

• 75-year-old man

• Prior CAD, s/p PCI

• Chronic LBBB x 20 years

• LVEF 40% on OMT x 20 years

• Syncope intermittent CHB

21

H

Baseline NSHBP LBBP-Uni Bipolar 3V 0.6V 0.5V

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

LBBP

HBPH

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

LBBP

RA

Baseline AVD 200 ms

HBP

170 ms 150 ms 130 ms 100 ms 80 ms

contrast

LBBP

HBP

LBBP lead

LV

26

Baseline Dyssynchrony Post LBBP

27

Indication for RV pacing

His Bundle Pacing

Left Bundle Branch Pacing

Left Bundle Branch Pacing

Reduced LVEF / Heart Failure

RV septal pacing Biventricular pacing

Unsuccessful

Normal His-Purkinje Conduction

His threshold >1.5V

No Yes

HV block, LBBB, RBBB

Geisinger Pacing Protocol

Summary

• His Purkinje Conduction System Pacing is feasible and safe in patients requiring ventricular pacing

• HPCSP should be the first line therapy in patients requiring ventricular pacing.

• It is elegant in its simplicity and it is trying to “repair” existing conduction problems rather than “replace” it with a new artificial and suboptimal conduction pattern

• Reinstate “Physiology” in Electrophysiology

28

Thank you

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

HBPH H 5V 4V

LBBB at baseline NSHBP with LBBB correction No LBBB correction

AP HBP RAO LBBP LAO LBBP

contrast

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

LBBP

2V 1V 0.5VLBBP

Final