Single-center experience with His bundle lead implantation: success rate, implantation method optimization, and lessons learned in 426 patients

Abstract

Abstract Background Conduction system pacing (CSP) is increasingly used to avoid the development of pacing-induced cardiomyopathy in patients who require a high amount of ventricular pacing. His bundle pacing (HBP) is considered as ideal to achieve the narrowest paced QRS and optimal synchronization in patients with intrinsic narrow QRS or right bundle branch block but also as difficult at implantation. Purpose We analyzed our experience with HBP in terms of time and effort, pacing and sensing results, success rate, and lessons learned for optimization over a time period of 7 years. Methods All consecutive patients in whom HBP was attempted between 6/2016 and 11/2023 were included in this analysis. Implantations were performed using a pacing system analyzer (PSA) with high-resolution electrograms (EGMs). Data on implantation success [selective or non-selective HBP, left bundle branch area pacing (LBBAP)], sensing and pacing parameters, achievement of His bundle current of injury (coi), duration of implantation and fluoroscopy were collected prospectively. These results were compared for the 1st, 2nd, 3rd and 4th quartile of implantations and reasons for improvement or deterioration were analyzed. Results HBP was attempted in 426 patients (78±11 years, 38% female, 90% AV block, left ventricular ejection fraction 54±10 %, 81 single-, 286 dual-, 46 triple-chamber pacemakers, 2 dual- and 11 triple-chamber ICDs) and was successful in 404 patients (95%): 182 non-selective HBP, 206 selective HBP, and 16 LBBAP. R wave amplitude was 4.5±3.5 mV, pacing threshold 1.1 ± 0.6V/1.0 ms. In 16% of patients, a ventricular back-up lead was implanted. A His bundle coi was achieved in 61% of patients. The implantation duration was 92±43 min, fluoroscopy duration 10±8 min. Success rate increased from 89% in the 1st to 99% in the 4th quartile. Improved implantation success was associated with using a stiff 3D steerable sheath, implantation site at the distal His bundle, and an increased number of screw-in turns until a His bundle coi was visible. Conclusions Establishing an implantation routine with 1) a PSA and high-resolution EGMs, 2) use of a stiff 3D steerable sheath, 3) implantation at the distal His bundle with myocardial capture (non-selective HBP) as a back-up, and 4) an increased number of screw-in turns of the lead tip until a His bundle coi is achieved, HBP implantation can be facilitated and results optimized to a highly acceptable implantation effort and a success rate >95%.