Key result
His-optimized cardiac resynchronization therapy combined with left-sided atrioventricular node ablation increased LVEF from 41% to 51% and decreased right ventricular dimension from 41 mm to 35 mm.
Why the study?
Patients with heart failure and right bundle branch block have potentially worse outcomes than those with left bundle branch block, and traditional cardiac resynchronization therapy can worsen deterioration rates. His bundle pacing may improve outcomes, though atrioventricular node ablation for atrial fibrillation can be challenging with His region leads.
Case Report (n=1)
No
His-optimized CRT combined with AV node ablation may offer an effective strategy to overcome profound conduction delays and improve reverse remodeling in patients with heart failure, permanent AF, and right bundle branch block.
Hypothesis-generating for His-optimized CRT plus AVNA in HF with AF and RBBB; prospective trials needed before clinical adoption.
BACKGROUND: Cardiac resynchronization therapy (CRT) is an option for treatment for chronic heart failure (HF) associated with left bundle branch block (LBBB). Patients with HF and right bundle branch block (RBBB) have potentially worse outcomes in comparison to LBBB. Traditional CRT in RBBB can increase mortality and HF deterioration rates over native disease progression. His bundle pacing may improve the results of CRT in those patients. Furthermore, atrioventricular node ablation (AVNA) for rate control in atrial fibrillation (AF) can be challenging in patients with previously implanted leads in His region. CASE SUMMARY: We report the case of 74-year-old gentleman with a 5-year history of HF, permanent AF with a rapid ventricular response, and RBBB. He was admitted to the hospital with complaints of severe weakness and shortness of breath. Left ventricular ejection fraction (LVEF) was decreased (41%), right ventricle (RV) was dilated (41 mm), and QRS was prolonged (200 ms) with RBBB morphology. The patient underwent His-optimized CRT with further left-sided AVNA. As a result, LVEF increased to 51%, RV dimensions decreased to 35 mm with an improvement of the clinical status during a 6-month follow-up. DISCUSSION: Patients with AF, RBBB, and HF represent the least evaluated clinical subgroup of individuals with less beneficial clinical outcomes according to CRT studies. Achieving the most effective resynchronization could require pacing fusion from sites beyond traditional with the intention to recruit intrinsic conduction pathways. This approach can be favourable for reducing RV dilatation, improving LVEF, and maximizing electrical resynchronization.
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Volkov et al. (2021) conducted a case report in Heart failure with right bundle branch block and permanent atrial fibrillation (n=1). His-optimized cardiac resynchronization therapy and atrioventricular node ablation was evaluated on Echocardiographic parameters and NYHA functional class. His-optimized cardiac resynchronization therapy combined with left-sided atrioventricular node ablation increased LVEF from 41% to 51% and decreased right ventricular dimension from 41 mm to 35 mm.
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