218 His Bundle Pacing for Cardiac Resynchronisation Following Coronary Sinus Left Ventricular Lead Failure

Abstract

Cardiac Resynchronisation Therapy (CRT) has been well established to provide both symptomatic and prognostic benefit in patients with heart failure with reduced ejection fraction (HFREF) and ventricular dyssynchrony, however coronary sinus (CS) lead placement is unsuccessful in between 2 and 5% of patients due to unsuitable cardiac vein anatomy or phrenic nerve stimulation. His-bundle pacing (HBP) is a strategy which may be capable of providing the benefits of CRT in patients where CS lead placement is unsuccessful. We reviewed outcomes in patients from a single centre where HBP was employed as a salvage therapy following failed CS lead placement. 5 cases were identified where CS lead placement was unsuccessful. All patients had Class I indications for CRT as recommended by the 2013 ESC guidelines. In 3 patients cardiac branch vein anatomy was unsuitable and in 2 patients unacceptable phrenic nerve stimulation was present at threshold voltages. All 5 patients underwent successful HBP without procedural complications. Median threshold for selective His-bundle capture was 0.8 V (IQR 0.5–2.5V). Median QRS duration was significantly reduced from 160msec (IQR 137.5 – 183msec) to 120msec (IQR 105–142msec) with HBP (mean of differences -37.2msec, p=0.0004). Median LVEF significantly improved from 25% (IQR 24–32) to 37.5% (IQR 35–45%, mean of differences 12.25, p=0.004). All 5 patients reported subjective improvement in heart failure symptoms. This case series illustrates the utility of HBP as an alternative method of CRT in patients who have failed CS lead implantation, reinforcing HBP as an essential tool in the armamentarium of the modern electrophysiologist.