Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary...
Transcript of Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary...
![Page 1: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/1.jpg)
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
![Page 2: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/2.jpg)
Disclosures
Speaker, Consultant, Research, - MedtronicFellowship support
Consultant - Abbott, Biotronik- Boston Scientific - Eaglepoint LLC
![Page 3: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/3.jpg)
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
![Page 4: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/4.jpg)
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
![Page 5: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/5.jpg)
His Bundle Pacing
• Sensing Challenges
• Smaller R waves (1-3 mV)
• Ventricular undersensing
• Atrial oversensing
• Atrial capture
![Page 6: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/6.jpg)
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
![Page 7: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/7.jpg)
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
![Page 8: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/8.jpg)
Tawara S. Das Reizleitungssystem des Säugetierhezens. Verlag von Gustav Fischer, Jena 1906.
Courtesy:
K Shivkumar, UCLA
![Page 9: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/9.jpg)
![Page 10: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/10.jpg)
![Page 11: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/11.jpg)
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
![Page 12: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/12.jpg)
12
AV nodalHB
LBB
![Page 13: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/13.jpg)
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)
![Page 14: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/14.jpg)
How to choose the initial site for LBB pacing
H: His area; L: LBB area; A: Apex
RAO
![Page 15: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/15.jpg)
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
![Page 16: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/16.jpg)
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
![Page 17: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/17.jpg)
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
![Page 18: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/18.jpg)
RA
LBBLB
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
HBPH
Vijayaraman P, Huang W. Heart Rhythm Case Report 2019
![Page 19: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/19.jpg)
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
![Page 20: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/20.jpg)
RAO 30° LAO 45°
Vijayaraman P, Huang W. Heart Rhythm Case Report 2019
![Page 21: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/21.jpg)
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
![Page 22: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/22.jpg)
![Page 23: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/23.jpg)
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
![Page 24: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/24.jpg)
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
![Page 25: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/25.jpg)
contrast
LBBP
HBP
LBBP lead
LV
![Page 26: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/26.jpg)
26
Baseline Dyssynchrony Post LBBP
![Page 27: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/27.jpg)
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
![Page 28: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/28.jpg)
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
![Page 29: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/29.jpg)
Thank you
![Page 30: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/30.jpg)
![Page 31: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/31.jpg)
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
![Page 32: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/32.jpg)
AP HBP RAO LBBP LAO LBBP
contrast
![Page 33: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/33.jpg)
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
LBBP
2V 1V 0.5VLBBP
![Page 34: Left Bundle Branch Area Pacing - SOBRAC · HV block, LBBB, RBBB Geisinger Pacing Protocol. Summary • His Purkinje Conduction System Pacing is feasible and safe in patients requiring](https://reader034.fdocuments.us/reader034/viewer/2022042510/5f7c6eea1ef7355efd014e3d/html5/thumbnails/34.jpg)
Final