HIS Bundle vs. RV apical vs. Biventricular pacing

As mentioned on other threads I'm trying to learn everything I can. I've read that the most often used RV apical pacing site for the ventricular lead can over time in some people lead to a condition called asynchronous heart failure since the QRS becomes widened, because this point of activation of the ventricles is not natural for the heart. So some centers have started using HIS bundle pacing in patients with intact left and right bundle branches to get the more physiologically natural simultaneous beat of both ventricles. Do any of you have HIS bundle pacing? If so how well is it working? And for those with long-term PMs have you had consequences from pacing at the traditional RV apex pacing site? Just wondering if I should be pushy about getting HIS bundle pacing versus RV apex. And of course there is biventricular pacing where three wires are used. I think this does almost the same as HIS bundle pacing.  Thanks to all you knowledgeable people.

3 Comments

I have dual chamber septal

by PacedNRunning - 2022-08-11 04:35:40

Most doctors don't place the RV lead in the apex any longer. Most do high septal wall. Mine is septal wall. I pace all the time and so far my EF went from 65-55%. Having it on the septal is suppose to be better than apex. If I knew I would eventually be 100% paced my doctor would have placed the HIS bundle. He kept thinking he would and talked himself out of it thinking I wouldn't pace much. So I would say go for the HIS. CRT too much hardware in the body and leads with future surgeries. Plus the CRT device is bigger. If you don't have AV Block then septal wall would be best. HIS is for
those with AV block. 

Which implant site is best

by Gemita - 2022-08-11 06:07:22

FG, your heart condition and doctor's ability and preference will probably determine the site chosen and pacemaker choice.  

I have seen recently a couple of members mention the Left Bundle Branch Area as an alternative pacing site to HIS bundle.  (Scroll down and see member Caratacus' message who has recently received this).  Although it is still in its infancy, left bundle branch area pacing would appear to guarantee electrical synchrony of the left ventricle with a low pacing threshold.  This appears better than His bundle pacing because of the challenges associated with HIS bundle placement, high pacing capture threshold and early battery depletion, see link below:-

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021709/

Like PacedNRunning, my implant site for RV lead is Septum area.  My implant was in 2018.  I have dual chamber pacing.  My husband is also paced in the RV septum area and has a single lead to his RV only.  I am mainly atrial paced, so no real worries, but my husband is paced mainly in his RV now (his implant was in 2018 too), so we are keeping a close eye on his ejection fraction.  He has right sided heart failure because of pulmonary hypertension.  His EP did say that if RV pacing is going to be a problem, it would show up pretty quickly (say in the first year following implantation).  If it doesn't happen quickly, it most likely won't happen.  After all, how many of us are paced 100% in the RV with heart block and lead normal lives for years?  We shouldn't "always" assume that RV pacing leads to heart failure and is bad for us, although clearly a more natural means of pacing should always be sought.  Hope that helps

Right questions

by dogtired - 2022-08-11 13:30:10

I'm amazed that the issues with RV pacing aren't discussed more frequently, especially when the EP outlines the risks.  One EP I saw actually refered me to another EP that specialized in HIS pacement and I was  scheduled but cancelled due to Covid.  The benefits are clear, but the big negative is the shortened battery life estimated at 5-6 yrs, which is something I just couldn't accept.  My EP I'm scheduled with is doing Left Bundle Branch pacing, which I'm surprised you didn't mention.  The lead is placed below the HIS in the LBB and results in a narrow QRS the same as with the HIS placement.  The big benefit is a battery life the same as RV pacing.  I believe in the near future this will become the prefered method.

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