CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 3, July/August 2023 190 AFRICA Case Report Permanent His bundle pacing using a Biotronik styletdriven lead: feasibility and early outcomes from a single centre Brian Vezi, Ajijola Olujimi, Marcus Ngatcha, Aime Bonny, Justin Ragadu Abstract His bundle pacing (HBP) has been shown to be a good alternative to conventional cardiac resynchronisation therapy (CRT) and may theoretically provide an additional benefit where CRT has a response deficit of at least 30%. HBP requires mapping and identification of the His bundle, and to this purpose the lead delivery is challenging. This first-reported case series from Africa shares early experience with different pacing indications (complete heart block and pre-existing right ventricular pacing; heart failure with left bundle branch block) for using a standard 5.6F, Solia S 60, IS-1, ProMRI bipolar pacing lead and an 8.7F Selectra 3D introducer guide, 32–39-cm working length with 40/55/65-mm proximal radii (Biotronik). These cases highlighted the importance of appropriate programming when implanting HBP and of assessing the conduction system to predict patients who might benefit from HBP and additional left ventricular lead implant. The Biotronik Solia lead and delivery guide were found to be feasible and reliable in these cases. The Biotronik conduction system pacing tools were used with good acute outcomes in patients with different pacing indications. Keywords: His bundle pacing, selective, non-selective Submitted 5/11/21, accepted 28/5/22 Published online 12/10/22 Cardiovasc J Afr 2023; 34: 190–194 www.cvja.co.za DOI: 10.5830/CVJA-2022-026 His bundle pacing (HBP) has been shown to be a good alternative to conventional cardiac resynchronisation therapy (CRT).1,2 Right ventricular-only pacing (RVOP) in patients with bradycardia may be deleterious, especially with a high right ventricular (RV) pacing burden, which is expected in complete heart block (CHB).3 HBP may theoretically provide an additional benefit where CRT has a response deficit of at least 30%, by maintaining normal antegrade conduction via the His–Purkinje system rather than the sustained electropathy observed in CRT.1,2,4 CRT using HBP in lieu of the left ventricular (LV) lead has no need for coronary sinus cannulation. HBP may correct distal left bundle branch block (LBBB) if pacing is distal to the lesion site.1,4 RVOP has been shown to result in cardiomyopathy (CM), heart failure (HF) and atrial fibrillation (AF).2 There are two electrocardiogram (ECG) morphologies in HBP, selective (S-HBP) and non-selective (NS-HBP).5 In CHB or post-atrioventricular (AV) node ablation, NS-HBP may be preferred as a back-up as the local RV myocardium remains captured in case of loss of HBP. HBP requires mapping and identification of the His bundle. The lead delivery is challenging and may result in dislodgment.6 Until recently, only Medtronic supplied a screw-in lumenless lead (SelectSecure 3830) and two delivery guides (Preshaped catheter C315HIS and SelectSite catheter C304-L69).7 The small diameter and floppy design of the exposed screw in the Medtronic system make it easier to screw in the lead, even when the sheath is not perpendicular to the target site. However, this can represent a significant limitation since the lead can be screwed in a target site only if it can be accessed by the delivery sheath, and when the target site is in the intraventricular portion of the membranous septum, the anterior and septal leaflet of the tricuspid valve can make the His bundle inaccessible to these sheaths.8 Furthermore, the lead requires active fixation by manual turning of the lead and this may result in low acceptance in inexperienced hands. In Africa, where resources are strained, the cost of the Medtronic HBP guide and lead may be prohibitive. The Biotronik HBP lead is the same as the conventional lead used for right atrial and ventricular pacing and has been used recently without an outer sheath or guide.9 The combination of the stylet-driven Solia S 60 lead with the Selectra 3D can enable the lead to reach almost all desired regions (Fig. 1).7,8 Case reports Lead stylets expedite tissue contact and stability during implant and are familiar to cardiac pacing physicians. We report on three Busamed Gateway Private Hospital, Umhlanga, South Africa Brian Vezi, MB CHB, FCP (SA), Cert Cardio (SA), MPharm Med Pretoria, Electrophysiology (Ottawa, Canada), brian.vezi@gmail.com Cardiac Arrhythmia Center, University of California, Los Angeles, USA Ajijola Olujimi, MD, PhD Homeland Heart Center, Douala and District Hospital of Bonassama, University of Douala, Douala, Cameroon Marcus Ngatcha, MD Aime Bonny, MD Durban University of Technology, Durban, South Africa Justin Ragadu, N Diploma, B Tech
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