His bundle combined with deep septal left bundle branch area pacing for atrial fibrillation prior to atrioventricular node ablation

Figures

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  FIGURE 1. Example of electrocardiogram (ECG) and intracardiac recordings in the same patient who received combined His bundle pacing (HBP) and deep septal left bundle branch area pacing (dsLBBAP) pacing and connected to a biventricular CRT generator. (A) Intrinsic ECG showing atrial fibrillation with a ventricular rate of approximately 80 bpm. Intrinsic QRS duration 102 ms. (B) Intracardiac recordings were taken after AV node ablation (upper channel—dsLBBAP lead, middle channel—HBP lead, lower channel—atrial lead). Ventricular escape is seen upon cessation of pacing to reveal sensed ventricular electrograms after the 4th ventricular complex. Left bundle potential is seen immediately prior to the ventricular complex in the upper channel (blue arrow). His bundle potential is seen in the middle channel (red arrow). (C) Selective his pacing at VVI 110 0.5 V at 0.4 ms pulse width. Paced QRS duration 100 ms. (D) Left bundle pacing at VVI 110 0.5 V at 0.4 ms pulse width. Paced QRS duration 130 ms.

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  FIGURE 2. CT measurements of lead position using multiplanar reconstruction (measured distances denoted by red bilateral arrows). (A) Measurement of distance (mm) between His bundle pacing penetration point and level of aortic annulus—labeled [3]. (B) Measurement of depth of penetration of deep septal left bundle branch area pacing lead into muscular interventricular septum (mm)—labeled [1] and distance from the left ventricular septal wall (mm)—labeled [2].

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  FIGURE 3. Comparison of intrinsic QRS duration, HBP QRS, and left bundle paced QRS durations across all patients.