His bundle capture proximal to the site of bundle branch block: A novel pitfall of the para-Hisian pacing maneuver Marek Jastrzebski, MD, PhD, Piotr.

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His bundle capture proximal to the site of bundle branch block: A novel pitfall of the para-Hisian pacing maneuver Marek Jastrzebski, MD, PhD, Piotr Kukla, MD, PhD, Danuta Czarnecka, MD, PhD HeartRhythm Case Reports Volume 4, Issue 1, Pages 22-25 (January 2018) DOI: 10.1016/j.hrcr.2017.09.002 Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 1 The decrease in pacing output was accompanied by QRS complex prolongation, suggestive of loss of His bundle capture. However, there was no corresponding prolongation of the ventriculoatrial (VA) interval, indicating an extranodal response. CS1 to CS5 represent proximal to distal coronary sinus electrodes. HeartRhythm Case Reports 2018 4, 22-25DOI: (10.1016/j.hrcr.2017.09.002) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 2 Para-Hisian pacing with increase in pacing output. The first 2 QRS complexes of left bundle branch block morphology result from pure right ventricular myocardial capture. Subsequent narrower QRS complexes of right bundle branch block morphology represent His bundle capture proximal to the site of block in the right bundle. Narrowing of the QRS complex with His bundle capture corresponds to shortening of the ventriculoatrial (VA) interval from 128 to 85 ms. CS1 to CS5 represent proximal to distal coronary sinus electrodes. HeartRhythm Case Reports 2018 4, 22-25DOI: (10.1016/j.hrcr.2017.09.002) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 3 Schematic explanation of the 3 observed responses to para-Hisian pacing. A: High-output pacing with capture of the RV myocardium and distal His bundle capture (beyond the area of blockage in the right bundle fibers), resulting in a narrow QRS duration of 114 ms and a short VA interval of 85 ms. B: Intermediate-output pacing with capture of the RV myocardium and proximal His bundle capture (proximal to the area of blockage in the right bundle fibers), resulting in an intermediate QRS duration (140 ms) of right bundle branch block morphology and a short VA interval of 85 ms. C: Low-output pacing with capture of the RV myocardium only, resulting in a still longer QRS duration (160 ms) of left bundle branch block morphology and a longer VA interval of 128 ms. Retrograde conduction most likely occurred via right bundle (unidirectional block) since conduction via left bundle would result in much larger prolongation of VA conduction (by additional 50 ms). CS prox = proximal coronary sinus; RV = right ventricular; VA = ventriculoatrial. HeartRhythm Case Reports 2018 4, 22-25DOI: (10.1016/j.hrcr.2017.09.002) Copyright © 2017 Heart Rhythm Society Terms and Conditions