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.
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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The authors declare no competing interests.
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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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Sharma, P.S., Vijayaraman, P. & Ellenbogen, K.A. Permanent His bundle pacing: shaping the future of physiological ventricular pacing. Nat Rev Cardiol 17, 22–36 (2020). https://doi.org/10.1038/s41569-019-0224-z
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