New guidance has been issued on how to implant new pacing systems that mimic the heart’s normal function.
The guidance, internationally agreed, is published in Europace, has been launched at the EHRA Conduction System Pacing (CSP) Summit and will be discussed during EHRA 2023, in Barcelona.
Describing it as having a “promising future”, Professor Haran Burri of the University Hospital of Geneva, Switzerland, said about half of the 1.4 million patients worldwide who will receive a pacemaker in 2023 could potentially benefit from conduction system pacing, which connects to the body’s own electrical cables.
He said: “Standard pacing electrically activates a single point in the ventricle, rather than the whole heart simultaneously, leading to uncoordinated contraction in different areas of the heart. In around one-fifth of patients this can damage the heart and lead to heart failure.
“Conduction system pacing places leads directly along different sites of the heart’s intrinsic conduction system, leading to simultaneous contraction across the heart.”
The guidance says conduction system pacing may also benefit patients with heart failure whose left ventricle is weak and not pumping properly due to left bundle branch block. The current treatment is cardiac resynchronisation therapy (CRT), which delivers biventricular pacing to coordinate contractions, but it does not work in all patients.
The use of conduction system pacing is increasing, with thousands of procedures performed worldwide, but an EHRA survey of European physicians published last year reported the main reason for not adopting the method was lack of training.
Professor Burri said: “Until now, there was no consensus on how to carry out this procedure and check that it had been done correctly.
“This document provides a standardised approach agreed by worldwide experts, which should optimise success rates and avoid complications. The guidance will be useful for physicians learning the method and those wishing to improve their technique. The increase in expertise will also enable large, high-quality randomised trials to be conducted.”
The paper describes the implantation technique for two types of pacing: His bundle pacing and left bundle branch area pacing, which are named according to the target site of the heart’s conduction system.
“With His bundle pacing, a simple test can be done to check that the electrical connection has been achieved,” explained Prof Burri.
“Left bundle branch area pacing requires more detailed checks and the paper outlines what physicians should aim for and what good pacing looks like.”
The document is accompanied by 30 figures with detailed illustrations, 11 videos, an executive summary published as a separate paper, and a key messages app, all of which are available free of charge.
Professor Burri said: “Conduction system pacing is entering mainstream clinical practice and, based on limited data, the therapy has a promising future. It is crucial that physicians adopt a standardised approach to ensure that it is delivered safely and effectively. Today’s consensus paper is set to become the reference on how to perform this procedure.”
Burri H, Jastrzebski M, Cano O et al. EHRA clinical consensus statement on conduction system pacing implantation. Endorsed by the Asia-Pacific Heart Rhythm Society (APHRS), Canadian Heart Rhythm Society (CHRS) and Latin-American Heart Rhythm Society (LAHRS). Europace 15 April 2023. doi:10.1093/europace/euad043.
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