Emerging Technologies in Cardiac Pacing

Abstract

Cardiac pacing to treat bradyarrhythmias has evolved in recent decades. Recognition that a substantial proportion of pacemaker-dependent patients can develop heart failure due to electrical and mechanical dyssynchrony from traditional right ventricular apical pacing has led to development of more physiologic pacing methods that better mimic normal cardiac conduction and provide synchronized ventricular contraction. Conventional biventricular pacing has been shown to benefit patients with heart failure and conduction system disease but can be limited by scarring and fibrosis. His bundle pacing and left bundle branch area pacing are novel techniques that can provide more physiologic ventricular activation as an alternative to conventional or biventricular pacing. Leadless pacing has emerged as another alternative pacing technique to overcome limitations in conventional transvenous pacemaker systems. Our objective is to review the evolution of cardiac pacing and explore these new advances in pacing strategies.

Keywords: His bundle pacing; cardiac resynchronization therapy; conduction system pacing; leadless pacing; left bundle pacing; pacemaker.

Figure 1

Types of cardiac pacing: (a) CRT-P device, (b) His bundle lead, (c) left bundle branch area pacing, (d) leadless pacing. Abbreviations: AV, atrioventricular; CRT-P, cardiac resynchronization therapy pacing; SA, sinoatrial. Figure reprinted with permission, Cleveland Clinic Foundation ©2023. All rights reserved.

Figure 2

Cardiac physiologic pacing strategies for patients with pacing indications. Adapted from Reference 1 with permission. Abbreviations: CM, cardiomyopathy; CRT, cardiac resynchronization therapy; HBP, His bundle pacing; LBBAP, left bundle branch area pacing; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; V, ventricular.

Figure 3

Cardiac physiologic pacing strategies for patients with heart failure indications. Adapted from Reference 1 with permission. Abbreviations: CRT, cardiac resynchronization therapy; HBP, His bundle pacing; LBBAP, left bundle branch area pacing; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association functional class.