A Case Report of Permanent his Bundle Pacing in A Patient with LVEF Worsened after CRT View PDF

*Leonardo Marinaccio
Presidio Ospedaliero Di Piove Di Sacco, Piove Di Sacco , Italy

*Corresponding Author:
Leonardo Marinaccio
Presidio Ospedaliero Di Piove Di Sacco, Piove Di Sacco , Italy
Email:leonardo.marinaccio@aulss6.veneto.it

Published on: 2020-10-26

Abstract

Deleterious effects from chronic RV pacing have been well documented. Physiologic pacing-induced by cardiac resynchronization therapy (CRT) and His bundle pacing (HBP) appears to mitigate the deleterious structural and functional effects of RV pacing. Based on the above-mentioned evidence, in patients with atrioventricular block who have an indication for permanent pacing with a left ventricular ejection fraction (LVEF) between 36% and 50% and are expected to require ventricular pacing more than 40% of the time, it is reasonable to choose pacing methods that maintain physiologic ventricular activation (e.g., CRT or HBP) over right ventricular pacing according to current guidelines; however, it is not clear when to prefer CRT over HBP and vice versa. We report a case of a patient with ischemic dilated cardiomyopathy, low ejection fraction, and narrow QRS who had a further worsening of LVEF after CRT-D therapy for advanced atrioventricular block and sudden death prevention, in whom His bundle pacing was a reasonable solution.

Keywords

His bundle pacing; CRT; Pacing-induced cardiomyopathy; Physiologic ventricular activation

Introduction

Right ventricular (RV) apical pacing has been routinely used for the treatment of patients with atrioventricular (AV) block; however, deleterious effects from chronic RV pacing have been well documented. RV apical pacing may have adverse effects on myocardial metabolism and perfusion, remodeling, hemodynamics, and mechanical function through electrical and mechanical dyssynchrony [1,2]; moreover, the incidence of these effects is higher if preimplant ejection fraction (EF) is reduced [3]. Current evidence against RV apical pacing has led to a vigorous search for a more physiological pacing mode that might avoid the adverse consequences delineated above. Physiologic pacing-induced by cardiac resynchronization therapy (CRT) and His bundle pacing (HBP) appears to mitigate the deleterious structural and functional effects of RV pacing, also it seems to improve left ventricular remodeling and function in patients affected by pacing-induced cardiomyopathy (PICM) [4-13]. Based on the above-mentioned evidence, in patients with atrioventricular block who have an indication for permanent pacing with a left ventricular ejection fraction (LVEF) between 36% and 50% and are expected to require ventricular pacing more than 40% of the time, it is reasonable to choose pacing methods that maintain physiologic ventricular activation (e.g., CRT or HBP) over right ventricular pacing regardless of the QRS complex width, according to current guidelines [14]; however, it is not clear when to prefer CRT over HBP and vice versa. We report a case of a patient with ischemic dilated cardiomyopathy, low ejection fraction, and narrow QRS who had a further worsening of LVEF after CRT-D therapy for advanced atrioventricular block and sudden death prevention, in whom His bundle pacing was a reasonable solution.

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