Permanent His Bundle Pacing Implantation Facilitated by Visualization of the Tricuspid Valve Annulus.

Gu, Min; Niu, Hongxia; Hu, Yiran; Liu, Xi; Zhang, Nixiao; Cai, Minsi; Chen, Xuhua; Zhou, Xiaohong; Gold, Michael R; Hua, Wei; Zhang, Shu

Background - His bundle pacing (HBP) is the most physiologic pacing modality. However, HBP has longer procedure times with frequent high capture thresholds, which likely contributes to the low adoption of this approach. The aim of this study is to compare HBP implantation with a novel imaging technique versus the standard implantation technique. Methods - This study included 50 patients with standard pacing indications randomized to HBP with visualization of the tricuspid valve annulus (TVA, N=25, the visualization group) or with the standard method (N=25, the control group). In the visualization group, the TVA was imaged by contrast injection in the right ventricle during fluoroscopy. The site for HBP was identified in relationship to the tricuspid septal leaflet and interventricular septum. Results - Permanent HBP was successful in 92% in the visualization group and 88% in the control group. The fluoroscopic time for HBP lead placement was significantly shorter in the visualization group (7.1±3.3min) compared with the control group (10.1±5.6min, P=0.03). Total procedural and fluoroscopic times were also significantly shorter in the visualization group (91.0±15.7min and 9.6±3.8min) than the control group (104.4±17.8min and 12.7±6.2min, P=0.01 and 0.04, respectively). There was no significant difference in capture threshold between groups. In the visualization group, there was a quantitative association between the HBP site and the TVA. Conclusions - The visualization technique shortens the procedural and fluoroscopic times for HBP implantation. Moreover, anatomic localization of HBP sites is strongly associated with physiologic characteristics of pacing, which can help guide optimal lead placement.