CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 3, July/August 2023 AFRICA 193 Key points • The Biotronik Solia lead and delivery guide were feasible and reliable in the three cases observed here. • The second patient highlighted the importance of appropriate programming when implanting HBP. The shortening of the AV delay is paramount to optimise biventricular resynchronisation. • The third patient showed the importance of assessing the conduction system to predict patients who might benefit from HBP and additional LV lead implant, as per HOT-CRT evidence. Conclusion This is the first reported cases series from Africa. The importance of HBP in resource-limited countries cannot be over-emphasised. In the cases of CRT, the dual-chamber box is often used for HBP, and one fewer lead is needed. In our three-case series, HBP using the Biotronik extendable/retractable active fixation lead supported by a luminal stylet was achievable without limitations or complications. The stylet-based HBP afforded good lead stability and tissue contact, as shown by the observable current of injury. The Biotronik conduction system pacing tools were used with good acute outcomes in patients with different pacing indications. References 1. Ajijola OA, Upadhyay GA, Macias C, et al. Permanent His bundle pacing for cardiac resynchronization therapy: initial feasibility study in lieu of left ventricular lead. Heart Rhythm 2017; 14(9): 1353–1361. 2. Lustgarten DL, Crespo EM, Arkhipova-Jenkins I, et al. His-bundle pacing versus biventricular pacing in cardiac resynchronization therapy patients: A crossover design comparison. Heart Rhythm 2015; 12(7): 1548–1557. 3. Sharma AD, Rizo-Patron C, Hallstrom AP, et al. Percent right ventricular pacing predicts outcomes in the DAVID trial. Heart Rhythm 2005; 2(8): 830–834. 4. El-Sherif N, Amay-Y-Leon F, Schonfield C, et al. Normalization of bundle branch block patterns by distal His bundle pacing. Clinical and experimental evidence of longitudinal dissociation in the pathologic His bundle. Circulation 1978; 57(3): 473–483. 5. Vijayaraman P, Dandamudi G, Zanon F, et al. Permanent His bundle pacing: recommendations from a multicenter His bundle pacing collaborative working group for standardization of definitions, implant measurements, and follow-up. Heart Rhythm 2017; 15(3): 460–468. 6. Deshmukh P, Casavant DA, Romanyshyn M, et al. Permanent, direct His-bundle pacing: a novel approach to cardiac pacing in patients with normal His-Purkinje activation. Circulation 2000; 101(8): 869–877. 7. Zanon F, Marcantoni L, Pastore G, et al. Left bundle branch pacing by standard stylet-driven lead: Preliminary experience of two case reports. Heart Rhythm Case Rep 2020; 6(9): 614–617. 8. Zingarini G, Notaristefano F, Sphigi L, et al. Permanent His bundle pacing using a new tridimensional delivery sheath and a standard active fixation pacing lead: The telescopic technique. J Cardiovasc Electrophysiol 2021; 32(2): 449–457. 9. James Kneller. His bundle pacing: new approach using stylet-supported pacing leads. EP Lab Digest 2018; 18(8): 1. 10. Vijayaraman P, Herweg B, Ellenbogen KA, et al. His-optimized cardiac resynchronization therapy to maximize electrical resynchronization: a feasibility study. Circ Arrhythm Electrophysiol 2019; 12(2): e006934. …continued from page 188 exceptions. Wright said that for example, weightlifters consume unusually high amounts of protein, so high levels of serum creatinine in their urine do not necessarily signify kidney dysfunction. He added there was some discussion in the heart failure community regarding older patients who typically have little muscle mass. ‘Creatinine may not be as good a reflection of their kidney function because the creatinine is a derivative of broken-down protein. And if you don’t eat a lot of protein or have a lot of protein in your body, then the creatinine clearance may be misleading,’ he said. If the loss of renal function is tied to heart failure as more than a symptom, can the loss be reversed? ‘Not really. Renal function declines steadily with age,’ said Morgan. While this loss is inevitable with time, it was possible to slow it down by about half with appropriate medicines, including ACE inhibitors. Does this mean new therapies for heart failure? ‘This study continues to connect the kidney and heart in a cardiorenal loop,’ said Morgan. ‘Early albumin excretion is an opportunity to be alerted to not only developing kidney disease but heart failure risk as well.’ She felt that the study’s findings might affect medications prescribed and medical follow up, ‘providing the opportunity for preventative cardiac care, as opposed to interventional cardiac care’. Dr Andrew Clark, chair of clinical cardiology and head of the department of Academic Cardiology at Hull YorkMedical School, who was also not involved in the study, cautioned against basing all patient care on these new findings. ‘The study looks at associations between abnormalities in renal function and outcomes and cannot prove a causative link,’ he said, pointing out a limitation of an observational study. ‘In more-or-less any clinical scenario, worsening renal function is associated with worse outcomes, but that doesn’t mean it is the renal dysfunction causing the problem. Any causative association might be the other way round: heart failure potentially causes proteinuria, (abnormal amounts of protein in the urine),’ he said. He also noted the link the researchers found between these substances and heart failure ‘might simply arise from the fact that the same precursors cause both outcomes. So, for example, high blood pressure and diabetes both cause renal and heart damage.’ Wright suggested including a simple urine test measuring UAE and serum creatinine during check-ups, a test he suspects few doctors prescribe. ‘It’s an inexpensive, easy-to-do test, and carries a lot of prognostic information.’ Source: European Journal of Heart Failure 7 June 2023
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