Paradigm shift in the world of pacing
His Resynchronization Versus Biventricular Pacing in Patients With Heart Failure and Left Bundle Branch Block. DOI: 10.1016/j.jacc.2018.09.073
Transvenous cardiac pacing has been around for several decades and although life-saving in patients with no intrinsic heart rhythm, the adverse consequences of chronic pacing has been known for a long time. Placement of a ventricular lead in RV (right ventricular) apex leads to a dyssynchronous cardiac contraction with LBBB (left bundle branch block) on ECG which can lead to pacing-induced cardiomyopathy, atrial fibrillation and heart failure.
Cardiac resynchronisation therapy (CRT, biventricular pacing) overcomes these shortcomings of conventional bradycardic pacing, but it is a complex, cumbersome and more expensive procedure with a higher complication rate than simple RV pacing.
Fortunately, several groups looked into the concept of His bundle pacing, which restores the heart's normal physiological electrical activation, eliminating the need for another lead and potential for pacing-induced cardiomyopathy. The results of one of the registries are presented in the JACC.
The authors compared His bundle pacing and biventricular pacing in patients with heart failure and LBBB. His bundle pacing provided better resynchronisation than biventricular pacing, with a more significant reduction in QRS duration, LV activation time, and LV dyssynchrony and a better acute haemodynamic response.
His bundle pacing was therefore superior to biventricular pacing, and at the same time, it is less expensive and less complicated. His bundle pacing is a technically challenging procedure, but once the technique and material are optimised, it is poised to become a procedure of choice for most pacing indications.