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Within patient comparison of His-bundle pacing, right ventricular pacing and right ventricular pacing avoidance algorithms in patients with PR prolongation: Acute haemodynamic study
  • +11
  • Daniel Keene,
  • Matthew Shun-Shin,
  • Ahran Arnold,
  • Katherine March,
  • Norman Qureshi,
  • Fu Siong Ng,
  • Mark Tanner,
  • Nicholas Linton,
  • Phang Lim,
  • David Lefroy,
  • Prapa Kanagaratnam,
  • Nicholas Peters,
  • Darrel Francis,
  • Zachary Whinnett
Daniel Keene
Imperial College
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Matthew Shun-Shin
Imperial College
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Ahran Arnold
Imperial College
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Katherine March
Imperial College
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Norman Qureshi
Imperial College Healthcare NHS Trust
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Fu Siong Ng
Imperial College London
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Mark Tanner
Imperial College Healthcare NHS Trust
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Nicholas Linton
Imperial College Healthcare NHS Trust
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Phang Lim
Imperial College Healthcare NHS Trust
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David Lefroy
Imperial college Healthcare
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Prapa Kanagaratnam
Imperial College Healthcare NHS Trust
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Nicholas Peters
St. Mary's Hospital
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Darrel Francis
St Mary's Hospital and Imperial College London
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Zachary Whinnett
Imperial College London
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Peer review status:UNDER REVIEW

26 May 2020Submitted to Journal of Cardiovascular Electrophysiology
01 Jun 2020Assigned to Editor
01 Jun 2020Submission Checks Completed
02 Jun 2020Reviewer(s) Assigned
11 Jul 2020Review(s) Completed, Editorial Evaluation Pending

Abstract

Aims: A prolonged PR interval may adversely affect ventricular filling and therefore cardiac function. AV delay can be corrected using right-ventricular-pacing (RVP) but this induces ventricular dyssynchrony, itself harmful. Therefore, in intermittent heart-block, pacing-avoidance algorithms are often implemented. We tested His-bundle pacing (HBP) as an alternative. Methods: Out-patients with a long PR interval(>200ms) and intermittent need for ventricular pacing were recruited. We measured within patient differences in high-precision haemodynamics between AV-optimized RVP, and HBP, as well as a pacing-avoidance algorithm [Managed Ventricular Pacing (MVP)]. Results We recruited 18 patients. Mean left ventricular ejection fraction was 44.3±9%. Mean intrinsic PR interval was 266±42ms and QRS duration was 123±29ms. RVP lengthened QRS duration(+54 ms, 95%CI 42 to 67ms, p<0.0001) whilst HBP delivered a shorter QRS duration than RVP(-56 ms, 95%CI -67 to -46ms, p<0.0001). HBP did not increase QRS duration(-2ms 95%CI -8 to 13ms, p=0.6). HBP improved acute systolic blood pressure by mean of 5.0 mmHg(95%CI 2.8 to 7.1mmHg, p<0.0001) compared to RVP and by 3.5 mmHg(95%CI 1.9 to 5.0mmHg, p=0.0002) compared to the pacing avoidance algorithm. There was no significant difference in haemodynamics between RVP and ventricular pacing avoidance (p=0.055). Conclusions HBP provides better acute cardiac function than pacing avoidance algorithms and RVP, in patients with prolonged PR intervals. HBP allows normalisation of prolonged AV delays (unlike pacing avoidance) and does not cause ventricular dyssynchrony (unlike RVP). Clinical trials may be justified to assess whether these acute improvements translate into longer term clinical benefits in patients with bradycardia indications for pacing.