Nam Michael C Y, O'Sullivan Patricia, Tonchev Ivaylo, Moore Benjamin M, Watts Troy, Wynn Gareth, Lee Geoff, Joshi Subodh, Stevenson Irene
Department of Cardiology Royal Melbourne Hospital Parkville Victoria Australia.
J Arrhythm. 2022 Dec 13;39(1):27-33. doi: 10.1002/joa3.12800. eCollection 2023 Feb.
To mitigate the risk of dyssynchrony-induced cardiomyopathy, international guidelines advocate His bundle pacing (HBP) with a ventricular backup lead prior to atrioventricular node ablation in treatment-refractory atrial fibrillation and normal left ventricular ejection fraction. As a result of concerns with long-term pacing parameters associated with HBP, this case series reports an adopted strategy of HBP combined with deep septal left bundle branch area pacing (dsLBBAP) in this patient cohort, enabling intrapatient comparison of the two pacing methods.
Eight patients aged 72 ± 10 years (left ventricular ejection fraction 53 ± 4%) underwent successful combined HBP and dsLBBAP implant prior to AV node ablation. Intrinsic QRS duration was 118 ± 46 ms. When compared to dsLBBAP, HBP had lower sensed ventricular amplitude (2.4 ± 1.1 vs. 15 ± 5.3 V, = .001) and lower lead impedance (522 ± 57 vs. 814 ± 171ohms, = .02), but shorter paced QRS duration (101 ± 20 vs. 119 ± 17 ms, = .02). HBP pacing threshold was 1.0 ± 0.6 V at 1 ms pulse width, and dsLBBAP pacing threshold was 0.5 ± 0.2 V at 0.4 ms pulse width. Five patients underwent cardiac CT showing adequate dsLBBAP ventricular septal penetration (8.6 ± 1.3 mm depth, 2.4 ± 0.5 mm distance from left ventricular septal wall). No complications occurred during a mean follow-up duration of 121 ± 92 days.
Combined HBP and dsLBBAP pacing is a feasible approach as a pace and ablate strategy for atrial fibrillation refractory to medical therapy.
为降低不同步性心肌病的风险，国际指南提倡在治疗难治性心房颤动且左心室射血分数正常的患者中，在房室结消融术前采用带有心室备用导线的希氏束起搏（HBP）。由于对与HBP相关的长期起搏参数存在担忧，本病例系列报告了在该患者队列中采用的HBP联合深部间隔左束支区域起搏（dsLBBAP）策略，从而能够在患者体内比较两种起搏方法。
8例年龄72±10岁（左心室射血分数53±4%）的患者在房室结消融术前成功植入了联合HBP和dsLBBAP。固有QRS时限为118±46毫秒。与dsLBBAP相比，HBP的心室感知振幅较低（2.4±1.1对15±5.3伏，P = 0.001），导线阻抗较低（522±57对814±171欧姆，P = 0.02），但起搏QRS时限较短（101±20对119±17毫秒，P = 0.02）。HBP起搏阈值在脉宽1毫秒时为1.0±0.6伏，dsLBBAP起搏阈值在脉宽0.4毫秒时为0.5±0.2伏。5例患者接受了心脏CT检查，显示dsLBBAP对室间隔的穿透足够（深度8.6±1.3毫米，距左心室间隔壁的距离2.4±0.5毫米）。在平均121±92天的随访期间未发生并发症。
联合HBP和dsLBBAP起搏作为药物治疗难治性心房颤动的起搏和消融策略是一种可行的方法。
