Physiologic Ventricular Pacing with Conventional Pacing Leads: A Preferred Approach?

His bundle pacing (HBP) is increasingly preferred for ventricular pacing.¹ Despite the surging popularity among electrophysiologists, available tools dedicated to HBP remain limited. In this report, we discuss how HBP is feasible without specialized tools,² and that conventional implanting tools may even be preferable.

Case Description

A 72-year-old male with a remote history of CABG and ischemic cardiomyopathy (LVEF 45%) developed tachy-brady syndrome with profound chronotropic incompetence. The patient underwent implantation of a dual-chamber pacemaker in June 2019. A pacing system was selected for the option of rate-responsive pacing using Closed Loop Stimulation (BIOTRONIK). An atrial pacing strategy was planned, with an additional lead in the His bundle position should the need arise for ventricular pacing.^2,3

A Solia extendable/retractable pacing lead (BIOTRONIK) was advanced to the His position (Figure 1A) using a custom-curved stylet (Figure 1B), without the need for an outer guide sheath for lead support. An annular position was obtained upon lead withdrawal from the RVOT, with prominent His potential recorded in unipolar through the BIOTRONIK pacing system analyzer (PSA) prior to extension of the fixation screw (Figure 1C). The curved stylet was subsequently withdrawn, and a second Solia lead was implanted in the atrial position (Figure 2B). Post-op chest x-ray (Figure 3) and ECG demonstrating the onset of physiologic pacing are shown (Figure 2A).

DISCUSSION

Consistent with recommendations,⁴ our lab has performed HBP for all pacemaker cases since 2016. Only the SelectSecure MRI SureScan Model 3830 cardiac pacing lead (Medtronic) is presently approved for HBP. When availability of the approved system is limited, it remains desirable to perform HBP. In this setting, we began to pursue HBP using stylet-supported leads. This has become our preferred approach with >50 consecutive cases to date. Advantages include the ability to adapt stylet shape for unique patient anatomy and the convenience of an extendable/retractable fixation mechanism, without the need to slit an outer guide sheath. This approach has gained much traction worldwide, and motivated implanters can adopt these techniques with confidence. Our approach to shaping the lead stylet (Figure 1A), and engagement of the His position during lead withdrawal from the RVOT can be viewed in our patient education video on YouTube titled “Getting a Pacemaker? Watch an Implant Procedure!”

Disclosure: The author has no conflicts of interest to report regarding the content herein.

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2. Kneller J. His bundle pacing: new approach using stylet-supported pacing leads. EP Lab Digest. 2018;18(7):1,10-12.
3. Kneller J. Closed loop stimulation for rate-responsive pacing: single-center experience. EP Lab Digest. 2018;18(2):30-34.
4. Dandamudi G, Vijayaraman P. How to perform permanent His bundle pacing in routine clinical practice. Heart Rhythm. 2016;13:1362-1366.