Ventricular Lead Placement

Hello everyone there has been some great discussion from our experienced members on the pros and cons of where the ventricular lead is placed: RV Apex, septal, HIS bundle, para Hisian, LBB, possibly more. Let's assemble a knowledge base and make an easily searchable thread for the future by simply looking for "ventricular lead placement". Please, everyone with something to share, please add your great insights into the pros and cons of the several sites of V lead placement and your own experiences which are invaluable. There have been many already but they are scattered about. Maybe, and you know who you are, you could simply copy and paste what you've already said to this thread so that you don't need to make a whole new statement. Thanks to all of you wonderful people. What a great resource is Pacemaker Club.


8 Comments

What an excellent idea

by Gemita - 2022-08-13 12:30:23

I will do what I can for you FG when it cools down a bit.  I will try to find past links on this subject and links from members who have successfully received HIS Bundle placement or more recently, Left Bundle Branch area placement and present them to you in a new comment from me.

In the meantime, give us your thoughts too?

Based upon what I know

by Good Dog - 2022-08-13 12:47:37

Based upon what I know, which is very little: The RV Apex (apial) placement of the lead is least desireable due to a greater liklihood of problems (HF) over time. Septal placement is preferred, but not much better. I have no doubt that His bundle lead placement is by-far the most desireable. It has been proven to actually reverse HF in many patients. It does not cause dyssynchrony and remodeling that can result in PM induced cardiomyopathy. Also, one of the side benefits of the the placement of the leads is that the His bundle usually resides on the atrial aspect of the tricuspid valve, at the septal leaflet of the valve, so the His pacing lead usually should not pass through the valve. That means that dangers presented by the lead through the valve like regurgitation over time is avoided. If His Bundle placement is not an option, there is also the possibility of left bundle branch placement for 3 lead CRT PM's. It was conveyed to me by someone that I respect:  “It’s not how narrow you make the QRS, it’s how you make it narrow,” referring to cardiac conduction system management. Now that just makes sense to me.

A late edit: My personal experience is that I have an RV lead placement at the Apex and after 30+ years I now have PM induced cardiomyopathy which I can attribute to that lead placement.

I honestly do not know much and certainly do not claim to. So my disclaimer is that those are just my opinions based upon my very limited knowledge, and so please take them with a grain of salt.

Sincerely,

Dave

Hi Gemita

by FG - 2022-08-13 19:24:50

Thank you for your comments you are certainly one of the knowledgeable ones! Well, I have been digging and digging as I have said. It seems the goal would be to place the ventricular lead at the most accessible, practical and physiological position. This would seem to be at or near the AV node or bundle of His. However there are technical difficulties so the ventricular septum apprears chosen more often by most EPs. There are articles reporting on experience with His bundle, para Hissian, or LBB placement. They are recent with no long-term experience as there is with RV apex. So who knows, there could be unforeseen problems with the newer supposedly more physiologic sites. I will discuss all this at my EP appointment coming up next week and report back.

Good Dog thank you for your most courteous reply. No apologies needed, you have plenty of great insight. Keep us informed as to what your next step is.

Hope this helps

by Gemita - 2022-08-13 20:45:47

FG, I have found the following Pacemaker Club links specifically on the subject of HIS bundle pacing and left bundle branch pacing which I hope you and other members will find of interest.  I also attach some general links giving more information about both modes of pacing, as well as right ventricular septal pacing, although I realise you have your own excellent resources to hand.    

We all know that standard right ventricular pacing may increase the risk of heart failure in the future and can also lead to atrial fibrillation (AF) or worsening AF, especially if the right ventricle is paced more than 40% of the time.  This can be avoided with a more natural means of pacing like LBB or HIS Bundle pacing.

As you know I have RV septal wall pacing (since 2018), so does my husband.  This may be a good alternative to HIS Bundle at the moment and would certainly be easier to perform, is well tested and is a safer option than pacing in the RV apical area which over time could lead to LV remodelling and heart failure symptoms.  However, as I have said in your earlier post, many patients who are 100% paced in their right ventricle fortunately never go on to develop heart failure.  Indeed according to my EP, if it is going to happen it will probably do so in the first year of pacing. If it doesn't, it probably never will.

Looking to the future should I require a pacemaker upgrade, my preference from what I have read would be LBB pacing which I believe is superior to either CRT or HIS Bundle pacing.  In any event CRT in the UK is usually only indicated if our Ejection Fraction is lower than 35%, or when we develop heart failure symptoms, not usually before.   LBB pacing on the other hand doesn’t have to meet CRT criteria for it to be offered.   I have no concerns about heavy RV pacing at the moment since my pacing is almost always 100% in the Right Atrium with minimum Right Ventricular pacing.  Over to you:-

https://www.pacemakerclub.com/message/36404/total-heart-block-5-years

https://www.pacemakerclub.com/message/41984/falling-ejection-fraction-is-it-pacemaker-induced

https://www.pacemakerclub.com/message/42193/left-bundle-branch-area-pacing

https://www.pacemakerclub.com/message/34870/his-bundle-pacing-hiting-mainstream

https://www.pacemakerclub.com/message/42204/his-bundle-vs-rv-apical-vs-biventricular-pacing

https://www.pacemakerclub.com/message/36687/bundle-of-his-pacing-lifting-weights

LBB pacing links:-

https://www.ahajournals.org/doi/10.1161/CIRCEP.120.008874

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021709/

HIS Bundle pacing:-

https://www.ahajournals.org/doi/10.1161/JAHA.118.010972

https://www.sciencedirect.com/science/article/pii/S110996662100186X

RV Septal pacing:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252807/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6204444/

 

FG - HIS Bundle

by Good Dog - 2022-08-13 20:52:23

Actually, His bundle placement of the leads for DDD pacing has been performed for quite a long time. I am unsure exactly how long, but Dr. Pugazhendhi Vijayaraman (most just call him Dr. V) has been performing, teaching, and promoting the procedure long before most others even knew or considered utilizing it. He is with the Geisinger Medical Group out in Eastern Pa. Here is a link to one of the many studies that he published back in July of 2017:

https://pubmed.ncbi.nlm.nih.gov/28569391/

Back in 2013 when I was sent to the Cleveland Clinic for a consult, I tried to discuss the possibility of utilizing the HIS Bundle procedure as an alternative to a CRT in the event that I needed a new lead. I had held the belief that it could provide me with the most benefit in the long-term and prevent the PM induced cardiomyopathy that I have eventually ended-up with. Unfortunately, they were not performing this procedure back then and were unwilling to even entertain that possibility. Instead, they held the belief that a CRT would provide at the least, an equal or greater benefit. So the attitude seemed to be; why bother.

I have to tell you that there are now plenty of studies out there that confirm the benefit of Bundle pacing with little or no downside. On the contrary. It has served to improve cardiac function more naturally (with only two leads). Yes, in a small percentage of cases it is not a viable solution. However, there are much better tools now that the docs can utilize for more efficient lead placement, so the procedure frequency is actually expanding quite considerably from the early days. They are now performing it at the clinic.

BTW: Gemita, my Doc has already informed me that he will utilize LBB placement of the third lead if I am eventually upgraded to a CRT.

Anyway, I think that the effort you are making is really worthwhile. I appreciate it. I am very interested and will be following along in the hope that I can learn more!

Sincerely,

Dave

Excellent new article

by FG - 2022-08-18 23:00:20

https://www.aerjournal.com/articles/his-purkinje-conduction-system-pacing-state-art-2020

Gemita/Lavender/Good dog/agent x86 and others what do you guys think of this article? What a fine diagram see below!

https://assets.radcliffecardiology.com/s3fs-public/article/2020-12/figure1-conduction-system-pacing.png

Good dog I think this is the same guy you mentioned. 

FG

by Gemita - 2022-08-19 08:28:39

I will read the additional link you posted and give you my thoughts later.  As you will have noted from my own links, my preference is for the Left Bundle Branch area pacing too which seems to be an improvement on HIS pacing.  Even so we are perhaps still some way off to receiving important feedback on this alternative pacing area.  In the meantime I am happy with right septal ventricle pacing.

Just a tip, you might get new responses if you repost your message (start a new message) to bump it to the top of the message board.  Your new comment may be missed otherwise as your message drops down the first page.  Not ideal since i appreciate you want to keep all the posts on this subject "together" but this is not possible the way this site works.

Excellent suggestion Gemita

by FG - 2022-08-19 20:05:31

Done!

And thank you for all your links. I am dutifully reading them all. BTW I had an EP appt yesterday and he was puzzled by my heart rate range from 40-140 from rest to peak exercise from a junctional pacemaker source. I have a junctional escape rhythm of 40 with narrow QRS. His EKG showed the same as the last 2 months - NSR at 72, 3rd degree AV block w AV dissociation and regular junctional ventricular rate of 40. So he said you look stable enough to do a few more tests first and ordered cardiac CT and MRI as well as treadmill. I am interested in the combination of physiological ventricular pacing as well as a reasonable expectation of lead longevity without risk of pacing induced heart failure. By the grace of God I'd like to live long enough to enjoy the retirement funds my wife and I have saved. Thanks again for the great knowledge you share. I'll keep you informed. 

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