Permanent parahisian pacing is feasible, effective and more physiologic: no more right ventricular apical pacing and no compulsive need for elaborate His bundle pacing

Q: What is the clinical evidence from this study?

Study design: Review. Population: Bradycardia, atrioventricular block, and heart failure requiring permanent cardiac pacing. Intervention: Parahisian pacing (PHP) vs. Right ventricular apical pacing and His bundle pacing.

Antonis A. Manolis; Apostolos Vouliotis; Theodora A. Manolis; Antonis S. Manolis

doi:10.18501/ija.2025.26.e6

January 1, 2025International Journal of ArrhythmiaOpen Access

Permanent parahisian pacing is feasible, effective and more physiologic: no more right ventricular apical pacing and no compulsive need for elaborate His bundle pacing

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Key result

Parahisian pacing provides a physiologic alternative to RVP without the procedural complexity of direct HBP.

Why the study?

Right ventricular apical or outflow-tract pacing causes long-term deleterious effects, while His-bundle pacing is elaborate and requires extra tools.

Is parahisian pacing a feasible and effective alternative to right ventricular apical pacing and His-bundle pacing?

Key Points

To evaluate the feasibility, clinical efficacy, and physiologic benefits of permanent parahisian pacing compared with conventional right ventricular and His-bundle pacing.
Reviewed approximately 20 years of clinical experience implementing permanent parahisian pacing.
Placed pacing leads near the His bundle or proximal right bundle branch guided by fluoroscopy and electrocardiography, achieving active fixation across the tricuspid valve septal leaflet to narrow the paced QRS complex.
Parahisian pacing provided a practical, physiologically favorable alternative to right ventricular apical pacing without requiring the elaborate delivery tools of His-bundle pacing.
Comparative trials revealed no significant differences in left ventricular function, mortality, or hospitalization rates between nonselective and selective His-bundle pacing modalities.

Structured PICO

Is parahisian pacing a feasible and effective alternative to right ventricular apical pacing and His-bundle pacing?

P

Population

Patients requiring permanent cardiac pacing

I

Intervention

Parahisian pacing (PHP) with the pacing lead placed near the His bundle or proximal right bundle branch

C

Comparator

Right ventricular apical or outflow-tract pacing, and His-bundle pacing (HBP)

O

Outcome

Feasibility and physiologic effectiveness (narrow-paced QRS)

Parahisian pacing offers a practical, physiologic alternative to right ventricular apical pacing without the technical complexity of His-bundle pacing.

Limitations

Technically demanding to achieve and requires a learning curve
Lack of randomized comparative trials between parahisian pacing and other conduction system pacing modalities
Possible chronic pacing threshold elevation
Need for technological improvements for better delivery systems, especially in patients with challenging cardiac anatomy
More comparative data with other pacing approaches are needed before PHP is widely adopted

Implication

May support parahisian pacing as a simpler physiologic option; leaves open randomized confirmation of long-term outcomes.

Abstract

Right ventricular apical or outflow-tract pacing is non-physiological, conferring longterm deleterious effects; His-bundle (HB) pacing (HBP) is more physiologic but elaborate requiring extra tools.Parahisian pacing (PHP), adopted by us for ~20 years, is an effective/ practical option, with the pacing lead placed near the HB or the proximal right bundle branch guided by fluoroscopy and electrocardiography, seeking a narrow-paced QRS by actively fixing the electrode across the tricuspid valve, against its septal leaflet.Comparative trials report that nonselective and selective HBP appear comparable regarding left-ventricular function, death or hospitalization.More comparative data with other pacing approaches are needed before PHP is widely adopted.

Discussion

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Cite This Study

Manolis et al. (2025) conducted a review in Bradycardia, atrioventricular block, and heart failure requiring permanent cardiac pacing. Parahisian pacing (PHP) vs. Right ventricular apical pacing and His bundle pacing was evaluated. Parahisian pacing is a feasible, effective, and physiologic alternative to right ventricular apical pacing that avoids the elaborate procedures and extra tools required for direct His bundle pacing.

synapsesocial.com/papers/6a0e97b38561d4cf804c5089 https://doi.org/10.18501/ija.2025.26.e6

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Permanent parahisian pacing is feasible, effective and more physiologic: no more right ventricular apical pacing and no compulsive need for elaborate His bundle pacing

Key Points

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Permanent parahisian pacing is feasible, effective and more physiologic: no more right ventricular apical pacing and no compulsive need for elaborate His bundle pacing

Key Points

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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