Introduction
Right ventricular (RV) apical pacing has remained the standard approach
to ventricular pacing despite evidence that it causes electrical
dyssynchrony associated with an increased risk of developing atrial
fibrillation and left ventricular systolic
dysfunction.1-4 The current popularity of RV apical
pacing as the preferred pacing site is driven primarily by the ease of
placing pacing leads into the apex, as well as the stability of pacing
parameters at this location. In recent years, “physiological”
approaches to pacing have attracted significant interest as
electrophysiologists seek to maintain left ventricular synchrony and
mitigate the adverse effects of RV apical pacing. Though His-bundle
pacing (HBP) had emerged as a promising approach to physiologic pacing,
HBP can be technically challenging to perform using current
tools.5-10 Furthermore, HBP has been associated with a
high incidence of rising pacing thresholds and low sensing values.
Indeed, unacceptable pacing parameters over time can mandate lead
revision and/or generator replacement for pre-mature battery depletion.
Together, these serve as major deterrents to the adoption of physiologic
pacing when compared to traditional RV apical
pacing.11-14
More recently, left bundle branch area pacing (LBBAP) has emerged as an
attractive alternative to achieving physiologic pacing – particularly
since initial studies have not reported rising pacing thresholds or
reduced sensing values.15-19 As operators begin to
explore physiologic pacing strategies in their practice, it is unclear
whether one should pursue HBP, LBBAP or a combination of the two
strategies. In this study, we compared procedural outcomes and
intermediate follow-up for the first 50 patients at our institution
undergoing either HBP or LBBP. By sharing this early experience with
both approaches to physiological pacing, we aim to highlight the
challenges one may experience with the adoption of physiological pacing.