Why conduction system pacing is the most synchronized physiological pacing modality of the future?

11th February 2021

In a nutshell:

Patients with a bradycardia (slow heart rate) or conduction system disease, can now be paced more effectively with a procedure referred to as His Bundle Pacing (HBP). The conduction system is stimulated directly, allowing both ventricles to contract simultaneously. This leads to better patient outcomes, and bypasses the risk of developing left bundle block, often the result of long-term traditional pacing. HBP is hailed as the ‘pacing of the future’.

The procedure can generally only be performed by an electrophysiologist. It requires a steep learning curve and often success rates may vary depending on patient anatomy and substrate. The technique is a very suitable alternative or adjunct to CRT (cardiac resynchronize therapy). However, the results of randomized controlled studies are pending.

Quick notes

Fig 1: Diagram – Implant procedure tips

His‐Purkinje conduction system pacing (HPCSP) in the form of His bundle pacing (HBP) and left bundle branch pacing (LBBP) allows normal left ventricular activation, thereby preventing the adverse consequences of right ventricular pacing.

HBP has been established for several years with centers from China, Europe, and North America reporting their experience. There is international guidance as to how to implant such systems with the differing patterns of His bundle capture clearly described.

LBBP is a more recent innovation with potential advantages including improved pacing parameters.

HPCSP has been extensively studied in a variety of indications including cardiac resynchronization therapy, atrioventricular node ablation, and bradycardia pacing.

His bundle (HB) pacing is an established modality for achieving physiological pacing with a low risk of long‐term lead‐related complications. The development of specially designed lead and delivery tools has improved the feasibility and safety of HB pacing (HBP).

Knowledge of the anatomy of HB region and the variations is essential for successful implantation.

Newer delivery systems have further improved procedural outcomes. Challenging implant cases can be successfully performed by reshaping the current sheaths, using “sheath in sheath” technique or “two‐lead implantation technique.”

Special attention to the lead parameters at implant, programming, and follow‐up is necessary for successful long‐term outcomes with HBP.

Widespread use of HBP by electrophysiologists and further advances in dedicated delivery systems and leads are essential to further improve the effectiveness of the implantation.

HIS Bundle Pacing Summary Slides