His bundle pacing procedure with limited radiation exposure

Introduction His bundle pacing (HBP) is a physiological alternative to right ventricular pacing. Observational studies have demonstrated the feasibility of this technique. However, it is associated with longer procedure time and higher fluoroscopy exposure compared to standard pacemaker implantation. Objective We evaluated the possibility to guide the His Bundle (HB) lead placement using HB unipolar mapping only, in an attempt to reduce radiation exposure. Method From October to November 2019, all consecutive patients candidates for HBP in our institution underwent pacemaker implantation using mainly unipolar mapping of the His bundle for lead placement. All procedures were performed by a single trained operator. His bundle electrogram was mapped with the pacing lead and directly recorded on both EP recording system and Medtronic pacing analyzer. Results Fourteen patients were implanted according to this new approach. Seven patients had a dual chamber pacemaker implantation. Indication for pacemaker implantation was sinus node dysfunction in 2 patients, AV nodal ablation for non-controlled atrial arrhythmias in 5 patients and atrioventricular conduction disease in 7 patients. HBP was successful in all patients. His Bundle signal was detected with the SelectSecure pacing lead during all procedures. Selective HBP was obtained in 9 patients (64%) while non selective HBP occurred in 5 patients. The mean procedure duration was 44 ± 8 min. The overall procedure fluoroscopy duration, including the atrial lead implantation, was 30 ± 13 sec. The mean radiation exposure was 0.22 ± 0.12 Gy.cm2. The baseline QRS duration was 102 ± 16ms and the paced QRS duration was 103 ± 14ms. The mean HBP threshold at implant was 1.31 ± 0.4 V. There was no pericardial effusion and no pneumothorax. Conclusion His Bundle lead placement mainly using HB unipolar mapping was feasible and effective and was associated with very limited radiation exposure without compromising procedure duration.