His-bundle pacing and atrioventricular nodal ablation for noncontrolled atrial arrhythmia: A technical challenge with major clinical benefits

BACKGROUND His-bundle pacing (HBP) is an appealing alterna-tive to right ventricular pacing in patients referred for permanent ventricular pacing and atrioventricular nodal ablation (AVNA) because it preserves physiological ventricular activation. Only limited data regarding HBP combined with AVNA are available in the literature.OBJECTIVE The purpose of this study was to provide further evi-dence on the feasibility and efficacy of this therapeutic approach in patients with uncontrolled atrial arrhythmia.METHODS We prospectively included all patients who had under-gone AVNA after HBP in 3 different hospitals between 2017 and 2022.RESULTS AVNA following HBP lead implantation was performed in 75 patients. Complete atrioventricular (AV) block was obtained in 58 patients (77%), and significant modulation of AV nodal conduc-tion (heart rate <60 bpm) was obtained in 12 patients (16%). AVNA failure was observed in 5 patients (7%). Recording of an atrial signal by the HBP lead was more frequently observed in patients with AVNA modulation/failure than in patients with complete AV block (11/17 vs 5/58; P <.001). No lead dislodgment occurred during the AVNA procedures. Acute His-bundle (HB) capture threshold increase >1 V occurred in 11 patients (15%), with return to baseline value on day 1 in 9 patients. New York Heart Association functional class and left ventricular ejection fraction significantly improved from baseline to last follow-up (3.0 +/- 0.7 vs 1.6 +/- 0.5; P <.001; and 47% +/- 14% vs 60% +/- 9%; P <.0001, respectively).CONCLUSION AVNA combined with HBP for noncontrolled atrial arrhythmia was feasible and clinically efficient. Implanting the HB lead on the ventricular aspect of the tricuspid annulus avoiding atrial signal recording can facilitate AVNA.