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


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.


  1. 1.

    Tse, H. F. & Lau, C. P. Long-term effect of right ventricular pacing on myocardial perfusion and function. J. Am. Coll. Cardiol. 29, 744–749 (1997).

  2. 2.

    Sweeney, M. O. et al. 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, 2932–2937 (2003).

  3. 3.

    Khurshid, S. et al. Incidence and predictors of right ventricular pacing-induced cardiomyopathy. Heart Rhythm 11, 1619–1625 (2014).

  4. 4.

    Kiehl, E. L. et al. Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function. Heart Rhythm 13, 2272–2278 (2016).

  5. 5.

    Curtis, A. B. et al. Improvement in clinical outcomes with biventricular versus right ventricular pacing: the BLOCK HF study. J. Am. Coll. Cardiol. 67, 2148–2157 (2016).

  6. 6.

    Funck, R. C. et al. Characteristics of a large sample of candidates for permanent ventricular pacing included in the Biventricular Pacing for Atrio-ventricular Block to Prevent Cardiac Desynchronization Study (BioPace). Europace 16, 354–362 (2014).

  7. 7.

    Sharma, P. S. et al. Permanent His-bundle pacing is feasible, safe, and superior to right ventricular pacing in routine clinical practice. Heart Rhythm 12, 305–312 (2015).

  8. 8.

    Abdelrahman, M. et al. Clinical outcomes of his bundle pacing compared to right ventricular pacing. J. Am. Coll. Cardiol. 71, 2319–2330 (2018).

  9. 9.

    Brignole, M. et al. A randomized controlled trial of atrioventricular junction ablation and cardiac resynchronization therapy in patients with permanent atrial fibrillation and narrow QRS. Eur. Heart J 39, 3999–4008 (2018).

  10. 10.

    Tawara, S. Das Reizleitungssystem des Saugetierherzens. Eine Anatomisch-Histologische Studie fiber das Atrioventrikularbiindel und die Purkinjeschen Faden 135–138 (Jena Gustav Fischer, 1906).

  11. 11.

    Kawashima, T. & Sasaki, H. A macroscopic anatomical investigation of atrioventricular bundle locational variation relative to the membranous part of the ventricular septum in elderly human hearts. Surg. Radiol. Anat. 27, 206–213 (2005).

  12. 12.

    Scherlag, B. J., Kosowsky, B. D. & Damato, A. N. A technique for ventricular pacing from the His bundle of the intact heart. J. Appl. Physiol. 22, 584–587 (1967).

  13. 13.

    Narula, O. S., Scherlag, B. J. & Samet, P. Pervenous pacing of the specialized conducting system in man. His bundle and A-V nodal stimulation. Circulation 41, 77–87 (1970).

  14. 14.

    Kaufmann, R. & Rothberger, C. J. Beiträge zur entstehungsweise Extrasystolischer Allorhythmien [German]. Z. Gesamte Exp. Med. 9, 104–122 (1919).

  15. 15.

    James, T. N. & Sherf, L. Fine structure of the His bundle. Circulation 44, 9–28 (1971).

  16. 16.

    Narula, O. S. Longitudinal dissociation in the His bundle. Bundle branch block due to asynchronous conduction within the His bundle in man. Circulation 6, 996–1006 (1977).

  17. 17.

    Deshmukh, P., Casavant, D. A., Romanyshyn, M. & Anderson, K. Permanent, direct His-bundle pacing: a novel approach to cardiac pacing in patients with normal His-Purkinje activation. Circulation 101, 869–877 (2000).

  18. 18.

    Barba-Pichardo, R. et al. Permanent His-bundle pacing in patients with infra-Hisian atrioventricular block [Spanish]. Rev. Esp. Cardiol. 59, 553–558 (2006).

  19. 19.

    Occhetta, E. et al. 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. J. Am. Coll. Cardiol. 47, 1938–1945 (2006).

  20. 20.

    Dandamudi, G. & Vijayaraman, P. How to perform permanent His bundle pacing in routine clinical practice. Heart Rhythm 13, 1362–1366 (2016).

  21. 21.

    Vijayaraman, P. et al. Permanent His bundle pacing: recommendations from a Multicenter His Bundle Pacing Collaborative Working Group for standardization of definitions, implant measurements, and follow-up. Heart Rhythm 15, 460–468 (2018).

  22. 22.

    Vijayaraman, P., Dandamudi, G., Worsnick, S. & Ellenbogen, K. A. Acute His-bundle injury current during permanent His-bundle pacing predicts excellent pacing outcomes. Pacing Clin. Electrophysiol. 38, 540–546 (2015).

  23. 23.

    Vijayaraman, P. & Ellenbogen, K. A. Approach to permanent His bundle pacing in challenging implants. Heart Rhythm 15, 1428–1431 (2018).

  24. 24.

    Zanon, F. et al. Permanent His-bundle pacing: a systematic literature review and meta-analysis. Europace 20, 1819–1826 (2018).

  25. 25.

    Sharma, P. S., Subzposh, F. A., Ellenbogen, K. A. & Vijayaraman, P. Permanent His-bundle pacing in patients with prosthetic cardiac valves. Heart Rhythm 14, 59–64 (2017).

  26. 26.

    Zhang, J. et al. Comparison of the effects of selective and non-selective His bundle pacing on cardiac electrical and mechanical synchrony. Europace 20, 1010–1017 (2018).

  27. 27.

    Barba-Pichardo, R., Morina-Vazquez, P., Fernandez-Gomez, J. M., Venegas-Gamero, J. & Herrera-Carranza, M. Permanent His-bundle pacing: seeking physiological ventricular pacing. Europace 12, 527–533 (2010).

  28. 28.

    Zanon, F. et al. Safety and performance of a system specifically designed for selective site pacing. Pacing Clin. Electrophysiol. 34, 339–347 (2011).

  29. 29.

    Sharma, P. S. et al. Permanent His-bundle pacing as an alternative to biventricular pacing for cardiac resynchronization therapy: a multicenter experience. Heart Rhythm 15, 413–420 (2018).

  30. 30.

    Vijayaraman, P. et al. Permanent His-bundle pacing: long-term lead performance and clinical outcomes. Heart Rhythm 15, 696–702 (2018).

  31. 31.

    Worsnick, S. A. et al. Routine permanent His bundle pacing is feasible in unselected population: correlating procedural outcomes with experience [abstract]. Heart Rhythm 12, S158 (2015).

  32. 32.

    Kronborg, M. B. et al. His or para-His pacing preserves left ventricular function in atrioventricular block: a double-blind, randomized, crossover study. Europace 16, 1189–1196 (2014).

  33. 33.

    Pastore, G. et al. The risk of atrial fibrillation during right ventricular pacing. Europace 18, 353–358 (2016).

  34. 34.

    Lustgarten, D. L. et al. His-bundle pacing versus biventricular pacing in cardiac resynchronization therapy patients: a crossover design comparison. Heart Rhythm 12, 1548–1557 (2015).

  35. 35.

    Su, L., Xu, L., Wu, S. J. & Huang, W. J. Pacing and sensing optimization of permanent His-bundle pacing in cardiac resynchronization therapy/implantable cardioverter defibrillators patients: value of integrated bipolar configuration. Europace 18, 1399–1405 (2016).

  36. 36.

    Ajijola, O. A., Upadhyay, G. A., Macias, C., Shivkumar, K. & Tung, R. Permanent His-bundle pacing for cardiac resynchronization therapy: initial feasibility study in lieu of left ventricular lead. Heart Rhythm 14, 1353–1361 (2017).

  37. 37.

    Sharma, P. S. et al. Permanent His bundle pacing for cardiac resynchronization therapy in patients with heart failure and right bundle branch block. Circ. Arrhythm. Electrophysiol. 11, e006613 (2018).

  38. 38.

    Huang, W. et al. Long-term outcomes of His bundle pacing in patients with heart failure with left bundle branch block. Heart 105, 137–143 (2019).

  39. 39.

    Shan, P. et al. Beneficial effects of upgrading to His bundle pacing in chronically paced patients with left ventricular ejection fraction <50. Heart Rhythm 15, 405–412 (2018).

  40. 40.

    Barba-Pichardo, R. et al. Ventricular resynchronization therapy by direct His-bundle pacing using an internal cardioverter defibrillator. Europace 15, 83–88 (2013).

  41. 41.

    Sharma, P. S., Huizar, J., Ellenbogen, K. A. & Tan, A. Y. Recruitment of bundle branches with permanent His bundle pacing in a patient with advanced conduction system disease: what is the mechanism? Heart Rhythm 13, 623–625 (2016).

  42. 42.

    Boczar, K. et al. Cardiac resynchronization therapy with His bundle pacing. Pacing Clin. Electrophysiol. 42, 374–380 (2019).

  43. 43.

    Lustgarten, D. L. et al. Electrical resynchronization induced by direct His-bundle pacing. Heart Rhythm 7, 15–21 (2010).

  44. 44.

    Arnold, A. D. et al. His resynchronization versus biventricular pacing in patients with heart failure and left bundle branch block. J. Am. Coll. Cardiol. 72, 3112–3122 (2018).

  45. 45.

    Vijayaraman, P., Herweg, B., Ellenbogen, K. A. & Gajek, J. His-optimized cardiac resynchronization therapy to maximize electrical resynchronization. Circ. Arrhythm. Electrophysiol. 12, e006934 (2019).

  46. 46.

    Vijayaraman, P. et al. Outcomes of His bundle pacing upgrade after long-term right ventricular pacing and/or pacing-induced cardiomyopathy: insights into disease progression. Heart Rhythm (2019).

  47. 47.

    Deshmukh, P. M. & Romanyshyn, M. Direct His-bundle pacing: present and future. Pacing Clin. Electrophysiol. 27, 862–870 (2004).

  48. 48.

    Vijayaraman, P., Subzposh, F. A. & Naperkowski, A. Atrioventricular node ablation and His bundle pacing. Europace 19 (Suppl. 4), iv10–iv16 (2017).

  49. 49.

    Huang, W. et al. Benefits of permanent His bundle pacing combined with atrioventricular node ablation in atrial fibrillation patients with heart failure with both preserved and reduced left ventricular ejection fraction. J. Am. Heart Assoc. 6, e005309 (2017).

  50. 50.

    Zimberg, R. et al. Success rates, safety and short-term outcomes of His bundle pacing following AVJ ablations [abstract B-AB01-06]. Heart Rhythm 15, S1–S107 (2018).

  51. 51.

    Slawuta, A. et al. Dual chamber cardioverter-defibrillator used for His bundle pacing in patient with chronic atrial fibrillation. Int. J. Cardiol. 182, 395–398 (2015).

  52. 52.

    Daubert, C., Behar, N., Martins, R. P., Mabo, P. & Leclercq, C. Avoiding non-responders to cardiac resynchronization therapy: a practical guide. Eur. Heart J. 38, 1463–1472 (2017).

  53. 53.

    Bhatt, A. G. et al. The efficacy of His bundle pacing: lessons learned from implementation for the first time at an experienced electrophysiology center. JACC Clin. Electrophysiol. 4, 1397–1406 (2018).

  54. 54.

    Vijayaraman, P., Dandamudi, G., Lustgarten, D. & Ellenbogen, K. A. Permanent His bundle pacing: electrophysiological and echocardiographic observations from long-term follow-up. Pacing Clin. Electrophysiol. 40, 883–891 (2017).

  55. 55.

    Burri, H., Keene, D., Whinnett, Z., Zanon, F. & Vijayaraman, P. Device programming for His bundle pacing. Circ. Arrhythm. Electrophysiol. 12, e006816 (2019).

  56. 56.

    Lustgarten, D., Sharma, P. S. & Vijayaraman, P. Troubleshooting and programming considerations for His bundle pacing. Heart Rhythm 16, 654–662 (2019).

  57. 57.

    Saini, A. et al. Novel method for assessment of His bundle pacing morphology using near field and far field device electrograms. Circ. Arrhythm. Electrophysiol. 12, e006878 (2019).

  58. 58.

    Huang, W. et al. A novel pacing strategy with low and stable output: pacing the left bundle branch immediately beyond the conduction block. Can. J. Cardiol. 33, 1736.e1–1736.e3 (2017).

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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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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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