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His Purkinje Conduction System Pacing Should be

First Line Therapy for AV Block with Preserved LV function

Pugazhendhi Vijayaraman MD

Professor of Medicine

Geisinger Commonwealth School of Medicine

Geisinger Heart Institute

Wilkes Barre, PA

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Disclosures

Advisory board - Boston Scientific

- Eaglepoint LLC

Speaker, Consultant, Research, - Medtronic

Fellowship support

Consultant - Abbott, Biotronik, Merritt Medical

His delivery tool - Patent pending

3Kusumoto F, et al. Circulation 2018Nov 6:CIR0000000000000627 4Kusumoto F, et al. Circulation 2018Nov 6:CIR0000000000000627

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5Kusumoto F, et al. Circulation 2018Nov 6:CIR0000000000000627 6Kusumoto F, et al. Circulation 2018Nov 6:CIR0000000000000627

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Pacing Concern is Not New

• “Pressure developed. . .after . . .contraction is far less in the artificially than in

the naturally elicited beats. [U]ndoubtedly its significance must be. . . carefully

considered”

Wiggers CJ, Am J Physiol 73: 346; 1925

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Right Ventricular Pacing

Longstanding EffectsAcute Changes

Sweeney MO. J Am Coll Cardiol 47:282-288; 2006

A Form of Desynchronization Therapy

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MOST – Freedom from first HFH

Fre

ed

om

fro

m fir

st

HF

H

HR 2.6

The DAVID Trial

Willkoff BL. JAMA 2002; 288:3115–3123

P=0.03

CHF admissions/mortality

Months to death or heart failure hospitalization

Cum

ula

tive p

robabili

ty Mean RV pacing

= 58.9±36.0%

Mean RV pacing

= 3.5±14.9%

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Heart Failure post RV pacing

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Time Course

|14

Acute Phase (0-6 months)

HR 1.62 (95% CI: 1.48-1.79, p<0.001)

Chronic Phase (6 months – 4 Years)

HR 1.16 (95% CI: 1.08-1.25, p<0.001)

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His bundle pacing- The new paradigm in pacing

• Replicates true physiology (what nature has selected over millions

of years of human evolution)

• The most efficient way to stimulate the ventricles (QRS duration

ranges from 50 ms to 110 ms in most humans over their lifespan)

• The ideal form of AV and VV (intra and interventricular) synchrony;

no other existing form of pacing can claim this as the ventricle is

non-physiologically activated

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19Ploux S,..Bordacher P. Heart Rhythm 2015;12:782–791

ECG Imaging

Vijayaraman et al. JACC 2018;72:927-47

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• First described by Scherlag et al in 1967 in dog

• Narula et al described temporary His bundle pacing in humans in 1976

• Deshmukh et al (2000) described permanent His bundle pacing in 18 pts

with

– Dilated CMP, chronic AF, normal QRS, AVN ablation

– Successful in 12 pts

– Pacing threshold 2.4 ± 1.0 V @0.5 ms, R wave 1-3.2 mV

– LVEF improved from 20 ± 9% to 31± 11%

– Lead dislodgement 2 pts

His Bundle Pacing

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61.2

37.4

60.7

44

30

35

40

45

50

55

60

65

EF > 45% EF ≤ 45%

BASELINE

POST-IMPLANT

P = 0.144

P < 0.001

ROVIGO EXPERIENCE

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HBP compared to RV pacing: Long-term performance

192

PPMs implanted 2011

94

HBP attempted

75 (80%) successful HBP

19 implanted in RV septum

98

RV pacing group

60 RV apex 38 RV septum

Vijayaraman P, et al. Heart Rhythm 2018;15:696-702 25

His Bundle Pacing (HBP) RV Pacing

Number of patients (n, %) 75, 80% 98, 100%

Baseline QRS duration (ms) 109±26 102±24

Paced QRS duration (ms) 124±22 168±21

Fluoroscopy times (min) - median 9.2 6.4

Pacing thresholds (V @ 0.5 ms) Mean ± SD Mean ± SD

Implant 1.35 ± 0.9 0.62±0.5

1 year 1.60± 0.9 0.80±0.3

2 year 1.50±0.8 0.80±0.4

5 year 1.62±1.0 0.84±0.4

Procedural Outcomes

124±22 168±21

1.35 ± 0.9 0.62±0.5

1.62±1.0 0.84±0.4

Vijayaraman P, et al. Heart Rhythm 2018;15:696-702

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Fre

ed

om

fro

m d

ea

th o

r H

FH

B

---- HBP (N=47)

---- RVP (N=60)

Follow-up (years)

Patients with >40% VP

Combined End-point of Death or Heart Failure Hospitalization

P=0.02

HR 2.1

On TreatmentFollow-up (years)

---- HBP (N=75)

---- RVP (N=98)

P=0.04

HR 1.7

All Patients

All Patients Patients with VP >40%

25

30

35

40

45

50

55

60

HBP RVP HBP RVP

Baseline

Follow-up

Eje

ction F

raction %

P=NS P=0.002 P=NS P<0.001

At 5 years

Vijayaraman P, et al. Heart Rhythm 2018;15:696-702

Death or HFH in pts with VP>40%

(INTENTION TO TREAT)

QRS duration (paced)

LV Ejection Fraction

Pacing Induced CMP

Device parameters

Pacing Threshold

Lead revisions

Generator changes

5-year follow-up data 192 pts

HBP

75/94 (80%) pts

1.62±1.0 (@0.5ms)

5 (6.7%)

7 (9%)

126±29 ms

57 ± 6 %

1 (2%)

19,32%

RV pacing

98 pts

0.84±0.4 (@0.5ms)

2 (3%)

1 (1%)

170±31 ms

52 ± 11 %

13 (22%)

32, 53%

P<0.01

P<0.01

P<0.001

P=0.04

Long-Term Lead Performance and Clinical Outcomes

P<0.01

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Clinical Outcomes

765

Patients

332

HBP attempted

304 (92%) successful HBP

28 (8%) RV septum

433

RV pacing

176 (41%) RV apex

257 (59%) Non-apical

➢ Mean Follow-up duration 725 ±423 days

➢ 220 reached the primary endpoint

Abdelrahman M,…Vijayaraman P. JACC 2018;71:2319-30

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Procedural

Characteristics His Bundle pacing (n=304) RV pacing (n=433) P-value

Procedure duration (min) 70.21±34 55.02±25 <0.01*

Fluoroscopy duration (min) 10.27±6.5 7.40±5.1 <0.01*

Implant Capture threshold (V @ ms) 1.30±0.85 @ 0.79±0.26 0.59±0.42 @ 0.5±0.03 <0.01*

Last follow up Capture threshold (V @ ms) 1.56±0.95 @ 0.78±0.30 0.76±0.29 @ 0.46±0.09 <0.01*

QRS duration (ms) 104.5±24.5 110.5±28.4 <0.01*

Paced QRS duration (ms) 128±27.7 166±21.8 <0.01*

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Primary Outcome (Death, HFH or upgrade to

biventricular pacing) All patients

83/332 (25%)

137/433

(32%)

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Primary Outcome (Death, HFH or upgrade to

biventricular pacing) Patients with VP >20%

49/194 (25%)

99/278 (36%)

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Heart Failure Hospitalizations

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All- Cause Mortality

477 consecutive patients who underwent PM implantation for complete/advanced AVB.

Ventricular pacing leads were located in the

HA 148

RVS 140

RVA 189

The first case report described LBB pacing that corrected LBBB with a low and stable threshold by pacing the LBB region immediately beyond the conduction block.

• By venous access; Trans and intraventricular septum; Deep septal pacing at Peri-LBB Area

• Demonstrate LBB potential and RBBB morphology of paced QRS complex

• with or without selective LBB pacing

AV nodalHB

LBB

https://doi.org/10.1016/j.cjca.2017.09.013

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HB

RB

B

LB

B

Narrow targetaccurate positioning needed

Wider conduction netEasy to find and fix

LBB pacing can be easily achieved?

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I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

HBP

RA

LBBH LB

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

LBBP

Bipolar Pacing

3.0V 1.0V 0.5V

NS-LBBP S-LBBPRV+LV+LBB

RAO 30° LAO 45°

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Sheath angiography

The depth of the lead tip in the ventricular septum by echo and CT scan

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Summary

• His Purkinje Conduction System Pacing is feasible and safe in all 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

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Conclusions“When the speed of rushing

water reaches the point

where it can move boulders,

this is the force of

momentum.”

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HBP Publications