His Bundle pacing (HBP) is no longer the latest thing in cardiac electrophysiology (EP).Now direct pacing of the left bundle branch seems to be.
HBP is increasing recognized as a safe and more physiological alternative to right ventricular apical pacing. HBP is now part of the latest AHA/ACC/HRA guidelines. (2018).
HBP has been shown to be capable of normalizing the QRS duration and the ejection fraction in as many as 80% of cases of nonischemic cardiomyopathy with left bundle branch block (LBBB). However, in 20% of cases HBP cannot correct the abnormal conduction pattern at a capture threshold suitable for long term pacing or is not effective because of distal His Purkinje disease.
There have been several case reports of successful pacing in the left bundle branch in such cases. More recently Dr. Pugazhendhi Vijayaraman from Geisinger Clinc discussed his experience with Left bundle branch area pacing(LBBAP) in 100 cases at the 2019 Heart Rhythm Society meeting. See here.
He reported early success but emphasized the many yet to be answered question and concerns with this new technique. The electrode screw is inserted much deeper ( a centimeter or more) into the heart than with typical HBP pacing and the long term consequences of that are yet to be determined. Early report are encouraging ( lower capture thresholds and good r wave sensing )and hopefully better implantation tools will be developed to improve the process and more long term followup will help define what role LBBAP will have.
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