Permanent His bundle pacing: shaping the future of physiological ventricular pacing

Abstract

Conventional right ventricular (RV) pacing, particularly RV apical pacing, can have deleterious effects on cardiac function. Long-term RV apical pacing has been associated with increased risk of atrial fibrillation, hospitalization for heart failure, pacing-induced cardiomyopathy and associated death. His bundle pacing (HBP) results in physiological ventricular activation and has generated tremendous research interest and enthusiasm. By stimulating the His–Purkinje network directly, HBP results in synchronized ventricular activation, which might translate into improved clinical outcomes compared with dyssynchronous ventricular activation with RV apical pacing. HBP can also overcome bundle branch block patterns, and data are accumulating on the benefit of HBP for cardiac resynchronization therapy. In this Review, we summarize the anatomy of the His bundle and early clinical observations, implantation techniques and available outcome data associated with permanent HBP. We also highlight the challenges with HBP and the need for additional tools and more randomized data before widespread application of permanent HBP.

Key points

  • Conventional right ventricular apical pacing has been associated with adverse clinical outcomes, including atrial fibrillation, heart failure and death.

  • His bundle pacing (HBP) is a physiological form of pacing and has been shown to improve clinical outcomes compared with conventional right ventricular pacing.

  • HBP can potentially correct bundle branch block in patients with proximal bundle branch disease.

  • Early data suggest that His cardiac resynchronization therapy (CRT) might be at least as effective as biventricular CRT (among patients with a low left ventricular ejection fraction), but large randomized trials are needed to assess its true clinical benefit.

  • A continued need exists for improvement in lead design, delivery tools and devices to increase the success rates of HBP.

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Fig. 1: Anatomy of the His bundle.
Fig. 2: Longitudinal dissociation within the His bundle.
Fig. 3: Standard implantation tools and set-up.
Fig. 4: Algorithm for His bundle pacing.
Fig. 5: Selective and non-selective His bundle pacing.
Fig. 6: His Bundle pacing in left bundle branch block.
Fig. 7: His bundle pacing and atrioventricular nodal ablation.

Change history

  • 11 July 2019

    An amendment to this paper has been published and can be accessed via a link at the top of the paper.

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Author information

P.S.S. researched data for the article, and all the authors discussed its content. P.S.S. and P.V. wrote the manuscript, and all the authors reviewed and edited it before submission.

Correspondence to Parikshit S. Sharma.

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Nature Reviews Cardiology thanks F. Prinzen, D. J. Lustgarten and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Ventricular pacing burden

The amount of time (represented as a percentage) for which ventricular pacing is noted.

Biventricular-pacing cardiac resynchronization therapy

Resynchronization of ventricular activation by timed pacing of the right ventricular endocardium and left ventricular epicardium (via the coronary sinus).

His–Purkinje system

The portion of the atrioventricular conduction system distal to the atrioventricular node.

His bundle pacing

Placement of a permanent pacing lead at the bundle of His, distal to the suspected site of disease.

Bundle branch block

Specific electrocardiogram pattern that can occur as a result of conduction disease within the distal His bundle or bundle branches.

Longitudinal dissociation

Dissociation of predestined fibres in a longitudinal fashion.

Capture threshold

The minimum amount of energy required to capture targeted tissue.

Correction threshold

The minimum amount of energy required to capture and correct or overcome the wide QRS complex.

H–V interval

The duration from the His electrogram to the ventricular electrogram.

Pacing wavefronts

The electrical activation fronts created by a pacing impulse.

Blanking periods

The amount of time (in milliseconds) during which no impulses are sensed by a particular lead channel.

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