Electrophysiological observations of acute His bundle injury during permanent His bundle pacing.

BACKGROUND: Permanent His bundle pacing (HBP) is a physiological alternative to right ventricular pacing (RVP). Catheter manipulation during HBP can cause trauma to the His bundle during implantation. We sought to determine acute and long-term incidence of His bundle (HB) injury with HBP.

METHODS: Patients undergoing permanent HBP at Geisinger Wyoming Valley Medical Center from 2006 to 2014 formed the study group. Patients with pre-existing His-Purkinje disease (HPD) were excluded from the study. Any development of new bundle branch block (BBB) or AV block (B) during acute HBP lead-induced block was recorded. Resolution of AVB and/or BBB was documented.

RESULTS: HBP was attempted in 450 patients. In 358 patients without HPD, 28 (7.8%) developed acute HB injury in the form of complete AVB (4, 1.1%), RBBB (21, 5.9%) or LBBB (3, 0.8%) during HBP lead placement. In all 7 patients with AVB or LBBB, conduction completely recovered. The HB electrogram from the lead displayed injury current in all 7 patients. Lead-induced RBBB resolved in 12 of 21 patients and persisted in 9 (2.5%) patients. Pacing from the HBP lead resulted in correction of acute conduction block in 27 of 28 patients and 8 of 9 patients with chronic RBBB. None of the patients with transient conduction block developed new conduction disease during follow-up of 21±19months.

CONCLUSIONS: Despite acute trauma to HB in 7.8% of patients undergoing permanent HBP, complete resolution of conduction block occurred in 19 of 28 patients (68%). RBBB persisted in 9 patients (32%) but mostly normalized with HBP.