His bundle pacing and AV nodal ablation for non-controlled atrial arrhythmia: a technical challenge with major clinical benefits

FUNDING ACKNOWLEDGEMENTS: Type of funding sources: None. BACKGROUND: His bundle pacing (HBP) is an appealing alternative to right ventricular pacing in patients referred for permanent ventricular pacing and AV nodal ablation (AVNA) as it preserves physiological ventricular activation. Only limited amount of data is available in the literature regarding HBP combined with AVNA. PURPOSE: To provide further evidence on the feasibility and efficacy of this therapeutic approach in patients with uncontrolled atrial arrhythmia. METHODS: We prospectively included all patients who underwent AVNA after HBP in three different hospitals between 2017 and 2022. RESULTS: AVNA following HBP lead implantation was performed in 75 patients. A complete AV block was obtained in 58 patients (77%) whereas significant modulation of the AV node conduction (heart rate < 60bpm) was obtained in 12 (16%). AVNA failure was observed in 5 (7%). The recording of an atrial signal by the HBP lead was more frequently observed in patients with AVNA modulation/failure compared to patients with complete AV block (11/17 vs 5/58; p < 0.001). There was no lead dislodgment during the AVNA procedures. Acute HB capture threshold increase > 1V occurred in 11 patients (15%) with return to baseline value at day one in 9. NYHA class and LVEF significantly improved from baseline to last follow-up (3.0 ± 0.7 vs 1.6 ± 0.5, p < 0.001; 47 ± 14% vs 60 ± 9%; p < 0.0001, respectively), CONCLUSION: AVNA combined with HBP for non-controlled 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. [Figure: see text] [Figure: see text]