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How to Choose Between His Bundle Pacing and Biventricular Pacing for Cardiac Resynchronization Therapy

  • Gaurav A. Upadhyay
  • Pugazhendhi VijayaramanEmail author
Arrhythmias (J. Bunch, Section Editor)
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Part of the following topical collections:
  1. Topical Collection on Arrythmias

Abstract

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.

Recent Findings

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.

Summary

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.

Keywords

Cardiac resynchronization therapy His bundle pacing Biventricular pacing Left bundle branch block 

Abbreviations

AF

Atrial fibrillation

AV

Atrioventricular

BBB

Bundle branch block

CCB

Complete conduction block

CRT

Cardiac resynchronization therapy

CSP

Conduction system pacing

CS

Coronary sinus

HBP

His bundle pacing

HF

Heart failure

HPCD

His-Purkinje conduction disease

IPA

Intact Purkinje activation

IVCD

Intraventricular conduction delay

LBBB

Left bundle branch block

LV

Left ventricle or left ventricular

LVEF

Left ventricular ejection fraction

MI

Myocardial infarction

NYHA

New York Heart Association

RCT

Randomized controlled trial

RBBB

Right bundle branch block

RV

Right ventricular

Notes

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.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 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. 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
  3. 3.
    Leclercq C, Cazeau S, Le Breton H, et al. Acute hemodynamic effects of biventricular DDD pacing in patients with end-stage heart failure. J Am Coll Cardiol. 1998;32(7):1825–31.CrossRefGoogle Scholar
  4. 4.
    Kass DA, Chen CH, Curry C, Talbot M, Berger R, Fetics B, et al. Improved left ventricular mechanics from acute VDD pacing in patients with dilated cardiomyopathy and ventricular conduction delay. Circulation. 1999;99(12):1567–73.CrossRefGoogle Scholar
  5. 5.
    McAlister FA, Ezekowitz J, Hooton N, et al. Cardiac resynchronization therapy for patients with left ventricular systolic dysfunction: a systematic review. JAMA. 2007;297(22):2502–14.CrossRefGoogle Scholar
  6. 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
  7. 7.
    Cheng YJ, Zhang J, Li WJ, Lin XX, Zeng WT, Tang K, et al. More favorable response to cardiac resynchronization therapy in women than in men. Circ Arrhythm Electrophysiol. 2014;7(5):807–15.CrossRefGoogle Scholar
  8. 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
  9. 9.
    Fornwalt BK, Sprague WW, BeDell P, Suever JD, Gerritse B, Merlino JD, et al. Agreement is poor among current criteria used to define response to cardiac resynchronization therapy. Circulation. 2010;121(18):1985–91.CrossRefGoogle Scholar
  10. 10.
    Daubert C, Behar N, Martins RP, Mabo P, Leclercq C. Avoiding non-responders to cardiac resynchronization therapy: a practical guide. Eur Heart J. 2017;38(19):1463–72.PubMedGoogle Scholar
  11. 11.
    European Heart Rhythm A, European Society of C, Heart Rhythm S, et al. 2012 EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management. Europace. 2012;14(9):1236–86.CrossRefGoogle Scholar
  12. 12.
    Auricchio A, Prinzen FW. Enhancing response in the cardiac resynchronization therapy patient: the 3B perspective-bench, bits, and bedside. JACC Clin Electrophysiol. 2017;3(11):1203–19.CrossRefGoogle Scholar
  13. 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. 14.
    Mower MM. Inventor. Method and apparatus for treating hemodynamic dysfunction. US patent 4,928,6881989.Google Scholar
  15. 15.
    Narula OS. Longitudinal dissociation in the His bundle. Bundle branch block due to asynchronous conduction within the His bundle in man. Circulation. 1977;56(6):996–1006.CrossRefGoogle Scholar
  16. 16.
    El-Sherif N, Amay YLF, Schonfield C, et al. Normalization of bundle branch block patterns by distal His bundle pacing. Clinical and experimental evidence of longitudinal dissociation in the pathologic his bundle. Circulation. 1978;57(3):473–83.CrossRefGoogle Scholar
  17. 17.
    Deshmukh P, Casavant DA, Romanyshyn M, Anderson K. Permanent, direct His-bundle pacing: a novel approach to cardiac pacing in patients with normal His-Purkinje activation. Circulation. 2000;101(8):869–77.CrossRefGoogle Scholar
  18. 18.
    Morina-Vazquez P, Barba-Pichardo R, Venegas-Gamero J, Herrera-Carranza M. Cardiac resynchronization through selective His bundle pacing in a patient with the so-called InfraHis atrioventricular block. Pacing Clin Electrophysiol. 2005;28(7):726–9.CrossRefGoogle Scholar
  19. 19.
    Dabrowski P, Kleinrok A, Kozluk E, Opolski G. Physiologic resynchronization therapy: a case of His bundle pacing reversing physiologic conduction in a patient with CHF and LBBB during 2 years of observation. J Cardiovasc Electrophysiol. 2011;22(7):813–7.CrossRefGoogle Scholar
  20. 20.
    Manovel A, Barba-Pichardo R, Tobaruela A. Electrical and mechanical cardiac resynchronisation by novel direct His-bundle pacing in a heart failure patient. Heart Lung Circ. 2011;20(12):769–72.CrossRefGoogle Scholar
  21. 21.
    Rehwinkel AE, Muller JG, Vanburen PC, Lustgarten DL. Ventricular resynchronization by implementation of direct his bundle pacing in a patient with congenital complete AV block and newly diagnosed cardiomyopathy. J Cardiovasc Electrophysiol. 2011;22(7):818–21.CrossRefGoogle Scholar
  22. 22.
    Wu G, Cai Y, Huang W, Su L. Hisian pacing restores cardiac function. J Electrocardiol. 2013;46(6):676–8.CrossRefGoogle Scholar
  23. 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
  24. 24.
    Ajijola OA, Romero J, Vorobiof G, Suh WM, Shivkumar K, Tung R. Hyper-response to cardiac resynchronization with permanent His bundle pacing: is parahisian pacing sufficient? HeartRhythm Case Rep. 2015;1(6):429–33.CrossRefGoogle Scholar
  25. 25.
    Boczar K, Slawuta A, Zabek A, et al. Cardiac resynchronization therapy with His bundle pacing as a method of treatment of chronic heart failure in patients with permanent atrial fibrillation and left bundle branch block. J Electrocardiol. 2018;51(3):405–8.CrossRefGoogle Scholar
  26. 26.
    Barba-Pichardo R, Manovel Sanchez A, Fernandez-Gomez JM, Morina-Vazquez P, Venegas-Gamero J, Herrera-Carranza M. Ventricular resynchronization therapy by direct His-bundle pacing using an internal cardioverter defibrillator. Europace. 2013;15(1):83–8.CrossRefGoogle Scholar
  27. 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
  28. 28.
    Su L, Xu L, Wu SJ, Huang WJ. Pacing and sensing optimization of permanent His-bundle pacing in cardiac resynchronization therapy/implantable cardioverter defibrillators patients: value of integrated bipolar configuration. Europace. 2016;18(9):1399–405.CrossRefGoogle Scholar
  29. 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. 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. 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. 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. 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
  34. 34.
    Sherf L, James TN. A new electrocardiographic concept: synchronized sinoventricular conduction. Dis Chest. 1969;55(2):127–40.CrossRefGoogle Scholar
  35. 35.
    Lazzara R, Yeh BK, Samet P. Functional transverse interconnections within the His bundle and the bundle branches. Circ Res. 1973;32(4):509–15.CrossRefGoogle Scholar
  36. 36.
    Bailey JC, Spear JF, Moore EN. Functional significance of transverse conducting pathways within the canine bundle of His. Am J Cardiol. 1974;34(7):790–5.CrossRefGoogle Scholar
  37. 37.
    Fabregas RA, Tse WW, Han J. Conduction disturbances of the bundle branches produced by lesions in the nonbranching portion of His bundle. Am Heart J. 1976;92(3):356–62.CrossRefGoogle Scholar
  38. 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. 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. 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. 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
  42. 42.
    Mafi-Rad M, Luermans JG, Blaauw Y, Janssen M, Crijns HJ, Prinzen FW, et al. Feasibility and acute hemodynamic effect of left ventricular septal pacing by transvenous approach through the interventricular septum. Circ Arrhythm Electrophysiol. 2016;9(3):e003344.CrossRefGoogle Scholar
  43. 43.
    Sugrue A, Bhatia S, Vaidya VR, Kucuk U, Mulpuru SK, Asirvatham SJ. His bundle (conduction system) pacing: a contemporary appraisal. Card Electrophysiol Clin. 2018;10(3):461–82.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.From the Center for Arrhythmia Care at the University of Chicago MedicineChicagoUSA
  2. 2.Geisinger Heart InstituteGeisinger Commonwealth School of MedicineWilkes-BarreUSA

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