Conventional cardiac pacing involves right ventrical apical pacing (RVAP), which promotes dyssynchronous ventricular activation, has been shown to lead to heart failure and atrial arrhythmias. In comparison, conduction system pacing (CSP), through direct stimulation of the His-purkinje cardiac conduction system, aims to activate the ventricle physiologically and potentially reduce these adverse events. This can be achieved through His bundle pacing (HBP) and left bundle branch pacing (LBBP). HBP was first described in 2000 and has since become technically easier to deliver and widespread, with an increasing evidence base demonstrating its potential benefits in preventing pacing-induced heart failure. LBBP is a more contemporary method of CSP, which provides an alternative method of delivering physiological pacing with similar potential benefits. The ability of both methods of CSP to reverse bundle branch block (BBB) has also meant that CSP has a potential role in achieving more effective cardiac resynchronization in patients with heart failure with reduced ejection fraction and ventricular desynchrony, compared to more established epicardial LV pacing systems.
Cardiac resynchronization therapy (CRT) through epicardial biventricular (BiV) pacing, has traditionally been the cornerstone of advanced guideline driven heart failure with reduced ejection fraction (HFrEF) therapy for those with ventricular desynchrony as characterized by a broad QRS duration. However, up to 30%, do not derive a clinical or echocardiographic benefit. Anatomical limitations associated with LV lead implantation, alongside patient factors, often negate the potential positive impact of CRT. Several studies have utilized different electrical, imaging and mechanical metrics to improve outcomes, with mixed success. CSP could potentially provide an alternative and superior method of promoting more coordinated cardiac conduction, in a broader variety of patients with reduced ejection fraction. Whilst HBP is considered to be the most physiological pacing method, high lead capture thresholds, oversensing and a technical learning curve have been a barrier to its more widespread use. This Research Topic will focus on the important advances and new directions in which the field of physiological pacing is heading, with a focus on mechanistic insights, technological and feasibility advancements, and improving patient outcomes and selection.
Potential sub-topics include, but are not limited to:
- Mechanistic insights into different physiological pacing techniques and locations
- Innovations in technical delivery of cardiac resynchronization
- Potential pro-arrhythmogenic effects of CSP and its interaction with myocardial scar
- Prediction of which patients may benefit from different pacing locations
- Approaches in challenging cases
- Impact of physiological pacing on mechanical desynchrony and hemodynamics
- Novel cardiac resynchronization techniques and identification of new pacing sites
- Methods of improving of CRT delivery through BiV pacing
Topic Editor Frits Prinzen received financial support from Abbott and Biotronik. Topic Editor Aldo Rinaldi received financial support from Abbott, Medtronic, Boston Scientific, Spectranetics and MicroPort. Topic Editor Angelo Auricchio received financial support from Boston Scientific, Cairdac, Corvia, Medtronic, Microport CRM, EPD Philips and Radcliffe Publisher.
Conventional cardiac pacing involves right ventrical apical pacing (RVAP), which promotes dyssynchronous ventricular activation, has been shown to lead to heart failure and atrial arrhythmias. In comparison, conduction system pacing (CSP), through direct stimulation of the His-purkinje cardiac conduction system, aims to activate the ventricle physiologically and potentially reduce these adverse events. This can be achieved through His bundle pacing (HBP) and left bundle branch pacing (LBBP). HBP was first described in 2000 and has since become technically easier to deliver and widespread, with an increasing evidence base demonstrating its potential benefits in preventing pacing-induced heart failure. LBBP is a more contemporary method of CSP, which provides an alternative method of delivering physiological pacing with similar potential benefits. The ability of both methods of CSP to reverse bundle branch block (BBB) has also meant that CSP has a potential role in achieving more effective cardiac resynchronization in patients with heart failure with reduced ejection fraction and ventricular desynchrony, compared to more established epicardial LV pacing systems.
Cardiac resynchronization therapy (CRT) through epicardial biventricular (BiV) pacing, has traditionally been the cornerstone of advanced guideline driven heart failure with reduced ejection fraction (HFrEF) therapy for those with ventricular desynchrony as characterized by a broad QRS duration. However, up to 30%, do not derive a clinical or echocardiographic benefit. Anatomical limitations associated with LV lead implantation, alongside patient factors, often negate the potential positive impact of CRT. Several studies have utilized different electrical, imaging and mechanical metrics to improve outcomes, with mixed success. CSP could potentially provide an alternative and superior method of promoting more coordinated cardiac conduction, in a broader variety of patients with reduced ejection fraction. Whilst HBP is considered to be the most physiological pacing method, high lead capture thresholds, oversensing and a technical learning curve have been a barrier to its more widespread use. This Research Topic will focus on the important advances and new directions in which the field of physiological pacing is heading, with a focus on mechanistic insights, technological and feasibility advancements, and improving patient outcomes and selection.
Potential sub-topics include, but are not limited to:
- Mechanistic insights into different physiological pacing techniques and locations
- Innovations in technical delivery of cardiac resynchronization
- Potential pro-arrhythmogenic effects of CSP and its interaction with myocardial scar
- Prediction of which patients may benefit from different pacing locations
- Approaches in challenging cases
- Impact of physiological pacing on mechanical desynchrony and hemodynamics
- Novel cardiac resynchronization techniques and identification of new pacing sites
- Methods of improving of CRT delivery through BiV pacing
Topic Editor Frits Prinzen received financial support from Abbott and Biotronik. Topic Editor Aldo Rinaldi received financial support from Abbott, Medtronic, Boston Scientific, Spectranetics and MicroPort. Topic Editor Angelo Auricchio received financial support from Boston Scientific, Cairdac, Corvia, Medtronic, Microport CRM, EPD Philips and Radcliffe Publisher.
