How to Choose Between His Bundle Pacing and Biventricular Pacing for Cardiac Resynchronization Therapy
- 1 Downloads
Purpose of Review
The goal of this critical appraisal is to evaluate the role for His bundle pacing (HBP) in cardiac resynchronization, examine early clinical and physiologic data, as well as offer recommendations for selecting patients for HBP versus biventricular pacing for CRT.
Biventricular pacing with a left ventricular (LV) coronary sinus lead has been the primary mode of delivering cardiac resynchronization therapy (CRT) for over two decades. By fusing multiple wavefronts of activation, biventricular pacing shortens and homogenizes ventricular activation, increases left ventricular ejection fraction (LVEF), reduces mitral regurgitation, and is also associated with improved clinical outcomes, including reduced heart failure (HF) hospitalization and mortality. Despite these myriad benefits, approximately one-third of patients do not derive benefit from traditional CRT. HBP is a means of delivering CRT which restores electromechanical synchrony by activating the His-Purkinje system distal to the site of proximal bundle branch block. Early clinical data suggest that CRT with HBP may be associated with comparable clinical benefits to biventricular pacing in CRT-eligible patients, although randomized data are not yet available.
The available data suggest that HBP is an alternative approach to biventricular pacing to achieve cardiac resynchronization by restoration of native Purkinje activation. The applicability is most clear in patients with typical BBB patterns. Further research and randomized studies are necessary to evaluate the role of HBP in CRT.
KeywordsCardiac resynchronization therapy His bundle pacing Biventricular pacing Left bundle branch block
Bundle branch block
Complete conduction block
Cardiac resynchronization therapy
Conduction system pacing
His bundle pacing
His-Purkinje conduction disease
Intact Purkinje activation
Intraventricular conduction delay
Left bundle branch block
Left ventricle or left ventricular
Left ventricular ejection fraction
New York Heart Association
Randomized controlled trial
Right bundle branch block
Compliance with Ethical Standards
Conflict of Interest
Pugazhendhi Vijayaraman reports grants and personal fees from Medtronic, personal fees from Boston Scientific, personal fees from Biotronik, personal fees from Abbott, outside the submitted work. In addition, Dr. Vijayaraman has a patent pending for a His bundle pacing delivery tool.
Gaurav Upadhyay declares that he has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Yancy CW, Jessup M, Bozkurt B, Butler J, Casey de Jr, Colvin MM, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70(6):776–803.CrossRefGoogle Scholar
- 2.Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–200.CrossRefGoogle Scholar
- 6.Hsu JC, Solomon SD, Bourgoun M, McNitt S, Goldenberg I, Klein H, et al. Predictors of super-response to cardiac resynchronization therapy and associated improvement in clinical outcome: the MADIT-CRT (multicenter automatic defibrillator implantation trial with cardiac resynchronization therapy) study. J Am Coll Cardiol. 2012;59(25):2366–73.CrossRefGoogle Scholar
- 8.Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2013;127(3):e283–352.CrossRefGoogle Scholar
- 13.•• Kusumoto FM, Schoenfeld MH, Barrett C, et al. ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Circulation. 2018;2018. https://doi.org/10.1161/CIR.0000000000000628 These updated guidelines provide new indications for cardiac resynchronization therapy for patients with bradycardia and reduced left ventricular function utilizing physiologic pacing.
- 14.Mower MM. Inventor. Method and apparatus for treating hemodynamic dysfunction. US patent 4,928,6881989.Google Scholar
- 23.Shan P, Su L, Chen X, Xu L, Ni X, Huang W. Direct His-bundle pacing improved left ventricular function and remodelling in a biventricular pacing nonresponder. Can J Cardiol 2016;32:1577.e1–1577.e4.Google Scholar
- 27.•• Lustgarten DL, Crespo EM, Arkhipova-Jenkins I, et al. His-bundle pacing versus biventricular pacing in cardiac resynchronization therapy patients: a crossover design comparison. Heart Rhythm. 2015;12(7):1548–57 This is the only randomized, crossover study comparing His bundle pacing with biventricular pacing in patients requiring cardiac resynchronization therapy. Both biventricular pacing and His bundle pacing resulted in equivalent but significant improvement in functional class and LV ejection fraction compared to baseline. CrossRefGoogle Scholar
- 29.•• Ajijola OA, Upadhyay GA, 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. 2017;14(9):1353–61 This is the first study to demonstrate the feasibility of His bundle pacing as first-line therapy in patients requiring cardiac resynchronization therapy in place of LV lead placement. CrossRefGoogle Scholar
- 30.•• Sharma PS, Dandamudi G, Herweg B, et al. Permanent His-bundle pacing as an alternative to biventricular pacing for cardiac resynchronization therapy: a multicenter experience. Heart Rhythm. 2018;15(3):413–20 This is the largest observational study of His bundle pacing in patients eligible for biventricular pacing. HBP was successful in 90% of patients with bundle branch block or AV conduction disease and cardiomyopathy with good response rates. CrossRefGoogle Scholar
- 31.•• Sharma PS, Naperkowski A, Bauch TD, et al. Permanent His bundle pacing for cardiac resynchronization therapy in patients with heart failure and right bundle branch block. Circ Arrhythm Electrophysiol. 2018;11(9):e006613 This study demonstrated modest benefits of improvement in LV function and functional class in patients with right bundle branch block utilizing permanent His bundle pacing . CrossRefGoogle Scholar
- 32.•• Huang W, Su L, Wu S, et al. Long-term outcomes of His bundle pacing in patients with heart failure with left bundle branch block. Heart 2019;105(2):137–143. This study demonstrated the role of His bundle pacing in improving long-term clinical outcomes in patients with cardiomyopathy and left bundle branch block . Majority of patients developed normalization of LV function uring three year follow-up . Google Scholar
- 33.•• Vijayaraman P, Dandamudi G, Zanon F, 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. 2018;15(3):460–8 This article discusses the nomenclature for permanent His bundle pacing in patients with normal His-Purkinje conduction and those with underlying His-Purkinje conduction disease . CrossRefGoogle Scholar
- 38.•• Upadhyay GA, Cherian T, Shatz D, et al. Intracardiac delination of left bundle branch block activation patterns: mechanistic evidence of left intra-Hisian block circumvented by His pacing. Heart Rhythm 2018;15:S641 This article presents evidence for discrete conduction block in the distal His bundle or proximal left bundle in the majority of patients with left bundle branch block and predicts response to His bundle pacing using intrinsic ventricular activation patterns . Google Scholar
- 39.• Vijayaraman P, Herweg B, Ellenbogen KA, Gazek J. His-optimized cardiac resynchronization therapy (HOT-CRT): a novel approach to enhance CRT response. Heart Rhythm 2018;15:supplement (abstract). This abstract presents a novel concept of combining His bundle pacing and left ventricular pacing in patients with advanced cardiomyopathy and severe left Purkinje conduction disease . Google Scholar
- 40.Padeletti L, Pieragnoli P, Ricciardi G, et al. Simultaneous His bundle and left ventricular pacing for optimal cardiac resynchronization therapy delivery: acute hemodynamic assessment by pressure-volume loops. Circ Arrhythm Electrophysiol. 2016;9(5).Google Scholar
- 41.• Huang W, Su L, Wu S, et al. A novel pacing strategy with low and stable output: pacing the left bundle branch immediately beyond the conduction block. Can J Cardiol. 2017;33(12):1736 e1731–3 This novel concept describes a innovative technique for pacing the left bundle branch beyond the site of block via transvenous, transseptal approach. CrossRefGoogle Scholar