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Review
. 2022 Dec 7;11(24):7258.
doi: 10.3390/jcm11247258.

Conduction System Pacing Today and Tomorrow

Andreas Haeberlin  1   2   3 , Siro Canello  1   2   3 , Andreas Kummer  1   2   3 , Jens Seiler  1 , Samuel H Baldinger  1 , Antonio Madaffari  1 , Gregor Thalmann  1 , Adrian Ryser  1   2   3 , Christoph Gräni  1 , Hildegard Tanner  1 , Laurent Roten  1 , Tobias Reichlin  1 , Fabian Noti  1
Affiliations
Review

Conduction System Pacing Today and Tomorrow

Andreas Haeberlin et al. J Clin Med. .

Abstract

Conduction system pacing (CSP) encompassing His bundle (HBP) and left bundle branch area pacing (LBBAP) is gaining increasing attention in the electrophysiology community. These relatively novel physiological pacing modalities have the potential to outperform conventional pacing approaches with respect to clinical endpoints, although data are currently still limited. While HBP represents the most physiological form of cardiac stimulation, success rates, bundle branch correction, and electrical lead performance over time remain a concern. LBBAP systems may overcome these limitations. In this review article, we provide a comprehensive overview of the current evidence, implantation technique, device programming, and follow-up considerations concerning CSP systems. Moreover, we discuss ongoing technical developments and future perspectives of CSP.

Keywords: conduction system pacing; leadless pacing; left bundle branch area pacing; left bundle branch pacing.

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Conflict of interest statement

A.H. has received travel/educational grants from Medtronic and Philips/Spectranetics. He is a consultant/advisor for DiNAQOR and Biotronik and a proctor for Medtronic. He is co-founder and head of Act-Inno, a cardiovascular device testing company. He has received research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, the Swiss Heart Rhythm Foundation, the Swiss Pacemaker Foundation, the Hasler Foundation, the Velux Foundation, and Novartis. F.N. has received travel/educational grants from Medtronic, Abbott, and Boston Scientific and Philips/Spectranetics. The spouse of J.S. is an employee and stock owner of Boston Scientific. C.G. received funding from the Swiss National Science Foundation, InnoSuisse, Center for Artificial Intelligence University Bern and the GAMBIT foundation, outside of the submitted work. L.R. has received speaker/consulting honoraria from Abbott and Medtronic and research grants from Medtronic. T.R. has received research grants from the Goldschmidt-Jacobson Foundation, the Swiss National Science Foundation, the Swiss Heart Foundation, and the sitem insel support fund, all for work outside the submitted study. He has received speaker/consulting honoraria or travel support from Abbott/SJM, Bayer, Biosense-Webster, Biotronik, Boston-Scientific, Daiichi Sankyo, Farapulse, Medtronic, and Pfizer-BMS, all for work outside the submitted study. He has received support for his institution’s fellowship program from Abbott/SJM, Biosense-Webster, Biotronik, Boston-Scientific, and Medtronic for work outside the submitted study. The other authors have nothing to disclose relevant to this manuscript.

Figures

Figure 1
Figure 1
Paced QRS morphology in a patient with a dual-chamber PM and an LBBAP lead. V1 exhibits an R’, R-wave peak time in V6 is ~70 ms, the V1–V6 interpeak interval is ~35 ms and paced QRS duration is ~120 ms.
Figure 2
Figure 2
Computed tomography (CT) images of a patient with AV block after transcatheter aortic valve replacement and consecutive dual-chamber PM implantation with a ventricular lead in LBBAP position. (A) The deep septal implantation site of the CSP lead in a short-axis projection. (B) The basal implantation site in the proximal left bundle in a reconstruction. The resulting ECG is shown in Figure 1.
Figure 3
Figure 3
ECG leads V1 and V6 during LBBAP lead implantation. Continuous unipolar pacing is performed from the lead’s tip. ① A wide QRS reflecting right ventricular septal pacing with a notch near the nadir of the QRS (one of the criteria for a suitable starting position for lead drilling). ② During the drilling process, this notch starts to move towards the end of the QRS in V1 and the QRS duration is shortened (deep septal pacing). ③ Finally, an r’ appears in V1 and the QRS suddenly shortens again significantly, indicating CSP capture.
Figure 4
Figure 4
12-lead ECG from a patient, who underwent LBBAP lead implantation. The unipolar electrogram (CSPuni) shows a left bundle branch potential during intrinsic rhythm, which is indicative of successful positioning of the lead in the specific conduction system (arrow).
Figure 5
Figure 5
Implantation of a leadless CSP PM in a domestic pig. The steerable implantation catheter (asterisk) allows positioning the stimulation electrode towards the interventricular septum (solid arrow). The main body of the leadless PM is implanted in an apical position (dotted arrow). The corresponding ECG with a simulated QRS duration of <100 ms is shown on the right.
See this image and copyright information in PMC

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