HeartRhythm Case Reports

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HeartRhythm Case Reports Overcoming left bundle branch block by permanent His bundle pacing: Evidence of longitudinal dissociation in the His via recordings from a permanent pacing lead Parikshit S. Sharma, MD, MPH, FACC, Kristin Ellison, MD, Hena N. Patel, MD, Richard G. Trohman, MD, MBA HeartRhythm Case Reports DOI: 10.1016/j.hrcr.2017.08.002 Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 1 Unipolar recordings from the lead tip at different sites the His bundle region. Top panel with unipolar recordings (filtered and unfiltered electrograms) from the His bundle pacing lead using alligator cables. As noted, mid and distal His electrograms reveal a split His electrogram. The bottom panel represents paced QRS morphologies at the respective mapped sites. HeartRhythm Case Reports DOI: (10.1016/j.hrcr.2017.08.002) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 2 Unipolar recordings and pacing from the lead tip at different sites in the His bundle (HB) region. Proximal HB electrograms demonstrate a split HB (H1-H2 of 150 ms). Right anterior oblique fluoroscopic view demonstrates location of the tip electrode. Pacing at this site demonstrates a similar QRS with left bundle branch (LBB) delay. Moving from proximal to distal HB position results in a distal site that in 0.5 ms more distal fluoroscopically, with a larger distal HB electrogram. Pacing at this site results in narrowing of the QRS and loss of LBB delay. There is no local ventricular capture, suggesting selective HB capture and LBB recruitment. HeartRhythm Case Reports DOI: (10.1016/j.hrcr.2017.08.002) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 3 AAI pacing at incremental rates with progressive intra-His and left bundle branch (LBB) delay. Similar to Figure 2, there is progressive prolongation in LBB (140 ms to 170 ms). Note the prolongation in H1-H2 intervals (from 150 ms to 180 ms) suggestive of intra-Hisian LBB delay. HeartRhythm Case Reports DOI: (10.1016/j.hrcr.2017.08.002) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Supplemental Figure 1 Pacing the atrial lead to unmask left bundle branch (LBB) delay. AAI pacing in the atrial lead from 50 to 70 beats per minute demonstrates progressive prolongation of A-V interval (250 ms to 280 ms) and corresponding prolongation in LBB delay (108 ms to 140 ms). HeartRhythm Case Reports DOI: (10.1016/j.hrcr.2017.08.002) Copyright © 2017 Heart Rhythm Society Terms and Conditions