Replacing Ventricular Pacing with His Bundle Pacing: Why is it taking so long?
Main Article Content
Abstract
Introduction: As evidence of harm from ventricular pacing accumulated, the recommendation to replace ventricular pacing with His bundle pacing was first made nearly 50-years ago. Despite having better outcomes, a 2025 consensus statement suggested that His bundle pacing, while more physiological, has unresolvable challenges and therefore niche applicability. This is contrary to our experience. We report our success rates, all-cause mortality and challenges encountered with His bundle pacing in a large, unselected population requiring pacemakers or cardiac resynchronization therapy.
Methods: Over a six-year period, 1299 consecutive patients with wide-range of pacing indications including bradycardia, heart block and need for cardiac resynchronization therapy underwent His bundle pacing and were followed for 33±20 months.
Results: Using recording systems designed for intracardiac electrograms and in addition, when needed, specialized recording catheters instead of pacing lead, success was achieved 94%. The procedure times were 90±8 minutes. In patients with normal QRS the paced complex remained in normal range. In patients with conduction system disease, abnormal QRS axis and voltage were normalized, and a prolonged ventricular activation time was significantly decreased. Serious complications were rare, and 1-year and 3-year mortality was 7.2% and 13.5%.
Conclusion: Our study shows that His bundle pacing is safe and has a high success rate provided specialized methods for intracardiac recording are used instead of systems for routine pacemaker implants. The lower all-cause mortality of His bundle pacing makes it imperative that we adapt available recording methods, in use for electrophysiology studies, to simplify His bundle pacing and increase its adoption.
Article Details
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References
2. Scherlag, BJ, Lau, SH. Helfant, R.H. Catheter technique for recording His bundle activity in man Circulation. 1969; 39:13-18
3. Zottoli, SJ. The origins of the Grass foundation. Biol. Bull. 201:218-226 2001
4. Gott VL. Critical role of physiologist John A. Johnson in the origins of Minnesota's billion dollar pacemaker industry. Ann Thoracic Surg. 2007 Jan; 83(1):349-53. doi:10.1016/j.athoracsur.2006.10.070. PMID: 17184706
5. Hopps JA. The development of the pacemaker. Pacing Clin Electrophysiol. 1981 Jan;4(1):106-8.
doi: 10.1111/j.1540-8159.1981.tb03682.x. PMID: 6171784.
6. Gott VL, Weirich WL, Paneth M, Lillehei CW. Control of complete heart block by use of an artificial pacemaker and a myocardial electrode. Circ Res 1958;6:410-5.
7. Furman S, Robinson G. Stimulation of the ventricular endocardial surface in control of complete heart block. Ann Surg 1959; 150: 841–845
8. Fisher JD. Transvenous cardiac pacing. Heart Rhythm, Volume 21, Issue 10, 1765 – 1766
9. Kronborg MB, Varma N, Nielsen JC. How harmful is right ventricular pacing? The question revived by the BioPace trial. Europace. 2025 Mar 5;27(3):euaf005. doi: 10.1093/europace/euaf005. PMID: 40105784; PMCID: PMC11921416.
10. Funck RC, Müller HH, Lunati M, De Roy L, Klein N, Meisel E, Milasinovic G, Carlson MD, Wittenberg M, Hindricks G, Blanc JJ. Biventricular vs. right ventricular pacing devices in patients anticipated to require frequent ventricular pacing (BioPace). Europace. 2025 Mar 5;27(3):euaf029.
11. Ruschitzka F, Abraham WT, Singh JP, et al. Cardiac-resynchronization therapy in heart failure with a narrow QRS complex. N Engl J Med 2013; 369:1395-1405
12. Lamas GA, Lee KL, Sweeney MO, Silverman R, Leon A, Yee R et al. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. N Engl J Med 2002;346:1854–62.
13. Udo, Erik O. et al. Incidence and predictors of short- and long-term complications in pacemaker therapy: The FOLLOWPACE study. Heart Rhythm, Volume 9, Issue 5, 728–735
14. Botto GL, Ricci RP, Bénézet JM, et al. PreFER MVP Investigators Managed ventricular pacing compared with conventional dual chamber pacing for elective replacement in chronically paced patients: results of the Prefer for Elective Replacement Managed Ventricular Pacing randomized study Heart Rhythm, 11 (2014), pp. 992-1000
15. Stockburger M, Boveda S, Moreno J, et al. Long-term clinical effects of ventricular pacing reduction with a changeover mode to minimize ventricular pacing in a general pacemaker population Eur Heart J, 36 (2015), pp. 151-157
16. Boriani G, Tukkie R, Manolis AS, et al. Atrial antitachycardia pacing and managed ventricular pacing in bradycardia patients with paroxysmal or persistent atrial tachyarrhythmias: the MINERVA randomized multicenter international trial Eur Heart J, 35 (2014), pp. 2352-2362
17. Alanis J, Gonzalez H, Lopez E. Electrical activity of the bundle of His. J Physiol 142: 127, 1958
18. Deshmukh P, Casavant DA, Romanyshyn M, Anderson K. Permanent, direct His-bundle pacing: a novel approach to cardiac pacing in patients with normal His-Purkinje activation. Circulation. 2000 Feb 29;101(8):869-77. doi: 10.1161/01.cir.101.8.869. PMID: 10694526.
19. Abdelrahman M, Subzposh FA, Beer D, et al. Clinical outcomes of His bundle pacing compared to right ventricular pacing. J Am Coll Cardiol 2018; 71:2319–30.
20. Bhatt AG, Musat DL, Milstein N, et al. The efficacy of His bundle pacing: lessons learned from implementation for the first time at an experienced electrophysiology center. JACC Clin Electrophysiol 2018;4:1397–406.
21. Teng AE, Massoud L, Ajijola OA. Physiological mechanisms of QRS narrowing in bundle branch block patients undergoing permanent His bundle pacing. J Electrocardiol 2016;49:644–8.
22. Verma N, Knight BP. Permanent His-Bundle pacing in a patient with advanced conduction system disease: What is the mechanism of QRS narrowing? Clin Case Rep 2018;6:1236–40.
23. Upadhyay GA. Rozmino P, Tung R. Heart Rhythm O2, Volume 1, Issue 1, 68 - 75 His-bundle pacing is the best approach to physiological pacing
24. Glikson M, Burri H, Abdin A, Cano O. et al European Society of Cardiology (ESC) clinical consensus statement on indications for conduction system pacing. EP Europace: 27 2025, 10.1093/eur opace/euaf05 21099-5129
25. Mahmud R, Sternick EB, Sanchez-Quintana D, et al. Evidence for concealed fasciculoventricular connections as revealed by His bundle pacing. Europace. 2023;25:euad050.Issue 12, 2024, Pages 2563-2570, ISSN 1547-5271,
26. Mahmud R, Lee J, Lee D, Mohan A, Phillips B, Hakes S, Talaei, F Sternick EB. Outcomes with physiologic His bundle pacing in patients with narrow QRS complex, Heart Rhythm, Volume 21,
27. Mahmud R, Sanchez-Quintana D, Macias Y, De Almeida MC, Anderson RH, Sternick, EB. Correction of bundle branch block by so called nonselective His bundle pacing: The potential role of accessory connections in the ventricular crest. Heart Rhythm 2024. doi.org/10.1016/j.hrthm.2024.01.003
28. Mahmud R, Jamal S, Brenda H, Kukla S. Effect of Non-Selective His Bundle Pacing on Delayed Myocardial Activation in Left Axis Deviation and Left Bundle Branch Bloc. The Journal of Innovations in Cardiac Rhythm Management 2021,12:5 Doi: 10.19102/icrm.2021.121001
29. Mahmud R, Jamal S, Effect of His bundle pacing on right bundle branch block located distal to site of pacing. Journal of Electrocardiology. 2021;64: 58-65.
30. Macías, Y. Tretter, J.T. Sánchez-Quintana, D. Cabrera, JA. Spicer, DE. de Almeida, MC. Anderson, RH. The atrioventricular conduction axis and the aortic root—Inferences for transcatheter replacement of the aortic valve. Clin Anat. 2022, 35, 143–154.
31. Mahaim I. Kent’s fibers and the AV paraspecific conduction through the upper connection of the bundle of His-Tawara Am Heart J, 33 (1947), pp. 651-653
32. Macías Y, Tretter JT, Anderson RH, et al. Miniseries 1 – Part IV: how frequent are fasciculo-ventricular connections in the normal heart? Europace 2022;24:464–72
33. Sternick EB, Gerken LM, Vrandecic MO, Wellens HJ. Fasciculoventricular pathways: clinical and electrophysiologic characteristics of a variant of preexcitation. J Cardiovasc Electrophysiol. 2003 Oct;14(10):1057-63. doi: 10.1046/j.1540-8167.200 3.03206.x. PMID: 14521658.
34. Cappato R. What is concealed in concealed accessory pathways? Eur Heart J. 1999 Dec;20 (24):1766-7. doi: 10.1053/euhj.1999.1842. PMID: 10581131.
35. Upadhyay GA, QRS morphologies in V1 and V6 during left bundle branch area pacing: assessing the patterns, EP Europace, Volume 25, Issue 9, September 2023, euad284,
36. Briongos-Figuero S, Estévez-Paniagua Á, Sánchez-Hernández A, Muñoz-Aguilera R. Combination of current and new electrocardiographic-based criteria: a novel score for the discrimination of left bundle branch capture. Europace. 2023 Mar 30;25(3):1051-1059. doi: 10.1093/europace/euac276. PMID: 36691717; PMCID: PMC10062292.
37. Crichton, M, Aliens cause Global Warming, 17 January 2003 speech at the California Institute of Technology (http://s8int.com/crichton.html