An Interesting Case of Permanent His-Bundle Pacing and a Review of the Current Literature

Figures

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  Figure 1:. Electrocardiogram demonstrating complete heart block with a right bundle branch block pattern wide complex escape rhythm.

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  Figure 2:. Ventricular paced electrocardiogram obtained prior to lead fracture. Note the wide left bundle branch block pattern QRS duration of approximately 170 ms. In this patient, the lead was found to be in the middle cardiac vein.

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  Figure 3:. Intracardiac electrograms as recorded by the pacing lead through the pace-sense analyzer. The pacing lead is connected in a unipolar configuration, and back-up ventricular pacing is being performed through a temporary transvenous pacing wire. (a) Complete infranodal heart block with a paced ventricular rhythm. (b) Acute His bundle current of injury (asterisk) after the lead is screwed into the tissue.

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  Figure 4:. A 12-lead electrocardiogram (ECG) with non-selective His-bundle pacing (NSHBP) taken immediately after the procedure was completed. Note the deep T-wave inversions seen right after the His-bundle tissue is recruited with pacing, due to T-wave memory phenomenon. The T-wave inversions normalized by four weeks after the procedure. The magnified ECG shows leads V4 to V6, with the highlighted area showing local myocardial capture with no isoelectric segment between the pacing stimulus and QRS onset, confirming NSHBP. This ECG demonstrates that even in a patient with longstanding infra-nodal complete heart block (>15 years), permanent His-bundle tissue recruitment can occur with pacing at the site of block.

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  Figure 5:. A chest X-ray taken post-procedure. (a) His-bundle pacing lead. (b) The new high voltage lead in the right ventricle. (c) The old high voltage lead in the middle cardiac vein. (d) A pacing lead in the right atrium.