Conduction System Pacing (CSP)

Denisherline1*, Sripreethi2, Hemalatha3, Jaya Menon4

1Non Critical Ward Staff, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

2Nurse Educator, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

3Non Critical Ward Nursing Supervisor, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

4Nursing superintendent, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

*Correspondence

Abstract

Conduction system pacing CSP is an innovative physiological pacing strategy that directly stimulates the native his punkinji conduction network to pressure normal ventricular activation.  Conventional right ventricular (RV) apical pacing although used for treatment of brady arrythmia procures non-physiological electrical activation that can lead to ventricular desynchrony, adverse remodeling reduced left ventricular ejection fraction and pacing induced cardiomyopathy in response to the limitations CSP has emerged as a promising alternative designed to maintain or restore synchronized ventricular depolarization. The two principal modalities of CSP are his bundle pacing (HBP) and left bundle branch area pacing (LBBAP). HBP captured his bundle directly resulting in here normal ventricular activation and narrow ARS complexes. However, it may be associated with higher pacing thresholds and technical challenges related to lead placement and long-term stability LBBAP has gained increasing acceptance due to its favorable electrical parameters, higher implant success rates and broader applicability.  Importantly BBAP can correct bundle branch block pattern and may be severe as an effective alternative to conventional cardiac resynchronization therapy is in selected patients. Clinical studies have demonstrated that CSP improves ventricular synchrony. Pressures left ventricular function and reduced heart failure hospitalization compared with traditional RV pacing.  IT has shown particular benefit in patients with atrioventricular block. Sinus nodes dysfunction refusing high pacing and heart failure with conduction abnormalities although long-term randomized are devaluing advances in implantation techniques and device technology continue to enhance feasibility and safety. Overall CSP represents a significant advancement in cardiac rhythm management, offering a more physiological and potentially outcome. Improving approach to permanent pacing therapy.

Key words: Conduction system pacing CSP; Left bundle branch area pacing (LBBAP).

Introduction

Cardiac pacing has been a fundamental therapy for the management of symptomatic bradyarrhythmia’s and conduction disturbances for more than half a century. Conventional right ventricular (RV) apical pacing has long been the standard techniques because of its technical simplicity, procedural reliability and consistent electrical capture, However, chronic RV pacing procedures non- physiological ventricular activation by bypassing the native his Purkinje system resulting in electrical mechanical desynchrony. Overtime this desynchrony may lead to adverse left ventricular remodeling reduced ejection fraction increased risk of heart failure and the development of pacing induced cardiomyopathy. Conduction system pacing (CSP) has emerged as a physiological alternative that aims to pressure or restore normal ventricular activation by directly stimulating the intrinsic conduction pathways. By engaging his Purkinje network CSP procedures as more synchronized pattern of ventricular depolarization closely resembling natural cardiac conduction. This approach seeks to minimize the detrimental effects associated with this conventional RV pacing and improve long-term clinical outcomes. The two principal techniques of CSP are his bundle pacing (HBP) and let bundle branch area pacing (LBBAP). HBP involves direct capture of his bundle and offers near, normal ventricular activation but may present technical challenges such as higher pacing thresholds and lead in stability. LLBBAP, more recent development, targets the left bundle branch or its surrounding septal area and has demonstrated favorable pacing parameters higher procedural success rates and broader applicability importantly CPS has shower promise in patients with atrioventricular block, high pacing burden and heart failure including there refiring cardiac resynchronization therapy with growing clinical evidence and technological advancement CSP is increasingly recognized as an important evaluation in modern cardiac rhythm management.

Relevant Clinical Findings

Symptoms & Clinical Presentation

CSP is considered in patients with symptomatic bradycardia.

  • Fatigue
  • Dizziness
  • Syncope or presyncope
  • High grade AV block

Heart – grade failure symptoms

  • Dyspnea
  • Reduced exercise tolerance
  • Pacing induced cardiomyopathy (from chronic RV pacing)
  • Patients needing frequent ventricular pacing (>20 – 40%)

ECG Findings

Before CSP

  • Wide QRS complex (especially with bundle branch block)
  • Left bundle branch block (LBBB) morphology
  • High grade AV block
  • Ventricular desynchrony

After CSP

  • Narrowed QRS complex
  • Correction of LBBB (in successful LBBAP / HBP)
  • More physiological ventricular activation pattern
  • Improved electrical synchrony

Hemodynamic

  • Improved left ventricular ejection fraction (LVEF)
  • Reduced heart failure symptoms
  • Improved NYHA functional class
  • Reduced hospitalization

Procedural Findings

  • During implantation
  • Selective or non-selective his capture (HBP)
  • Left bundle branch capture

Potential Complications to monitor

  • Raising pacing thresholds
  • Lead dislodgement
  • Septal perforation(rare)
  • Failure to correct conduction delay infection

Relevant Investigation and results

  • 12-lead ECG
  • ECHO cardiography
  • Holter monitoring / ambulatory ECG

Laboratory tests

  • Renal function
  • Electrolytes (K+, Mg+)
  • Thyroid function
  • Cardio biomarkers

Intraprocedural

  • Fluoroscopy
  • Intra cardiac electrogram (ECG)

Post

  • ECG
  • ECHO
  • Chest X-Ray

Conduction system Pacing Diagnosis

  • A symptomatic bradyarrhythmia’s
  • Sinus node dysfunction
  • High grade AV block (Mobit Z11, Complete heart block)
  • Chronotropic in competence

Diagnostic Tools

  • 12 leads ECG
  • Holter monitoring
  • Event recorder
  • Conduction system disease

ECHO Findings

  • Normal chamber dimension
  • Mild concentric LVH
  • Global hypokinesia of LV
  • Mild to moderate LV dysfunction (EF – 40%)
  • Grade II Diastolic Dysfunction
  • E – 19
  • Mild MR

Aortic Valve

  • Aortic Sclerosis
  • Mild AR / AS
  • Mild TR / Mild PAH
  • RVSP – 32 + RAP
  • Septate intact
  • No Pericardial Effusion / Clot

Impression

  • Global Hypokinesia of LV
  • Mild to moderate LV dysfunction
  • Grade II Diastolic Dysfunction
  • Mild MR

Aortic Sclerosis

  • Mild AR
  • Mild TR / Mild PAH
  • Mild Concentric LVH

Wound Care

  • Keep site clean and dry
  • Remove dressing after days
  • Shower after days

Monitor for

  • Redness
  • Swelling
  • Drainage
  • Fever
  • Increasing pain

When seeking immediate Care

  • Syncope or pre syncope
  • Persistent dizziness
  • Palpitations
  • Chest pain
  • Shortness breath
  • Sings of infection
  • Device swelling or bleeding

Device follow up

  • Wound check 7 – 14 days
  • Device clinic follow up 4 – 6 weeks
  • Remote monitoring enrolled confirmed

Medical Management

Conduction system pacing including his bundle pacing (HBP) and left bundle branch pacing (LBBB) is a device bared therapy.  However optimal outcomes refuse appropriate medical management.

Before permanent pacing exclude.

  • Electrolyte imbalance.
  • Drug induced AV block (B- blockers, calcium channel blockers, digoxin, amiodarone)
  • Hypothyroidism
  • Acute ischemia
  • Acute symptomatic bradycardia

If unstable

  • Temporary pacing (Transcutaneous or transvenous)
  • Dopamine or isoproterenol infusion (if need)

Surgical Management

Surgical management of CSP conduction system pacing is performed Via transvenous pacemaker implantation technique targeting the nature cardiac conduction system instead of the right ventricular apex.

Nursing Management

  • Monitor closely for early loss of capture
  • LBBAR generally has more stable thresholds but still requires.

Promptly notify provide if:

  • Capture failure suspected
  • Hematoma expanding
  • Sign of infection

Symptomatic brady cardia

  • A nursing care plan
  • A bedside monitoring checklist
  • OSCE style viva questions
  • A teaching handout for patients
  • A teaching on ICU specific nursing consideration.

Discharge medication

Resume home medication unless otherwise specified

  • Anticoagulation
  • Antibiotics
  • Analgesia

Activity restrictions (Typically 2 – 4 weeks)

  • No lifting >10 – 15 Lbs with prolateral arm
  • Avoid raising affected arm above shoulder level
  • Avoid vigorous pushing / Pulling
  • No driving for days.

Conclusion

Conduction system pacing shifts cardiac rhythm management from simply maintaining heart rate to restring physiologic ventricular activation.  As evidence continuous to grow CSR is becoming an important standard in moderate electro physiology practice offering improved long term cardiac outcomes compared to conventional pacing strategies.

 

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