Template Beat
2021; Lippincott Williams & Wilkins; Volume: 14; Issue: 4 Linguagem: Inglês
10.1161/circep.120.009677
ISSN1941-3149
AutoresShunmuga Sundaram Ponnusamy, Vithiya Ganesan, Thabish Syed, Suryakumar Balasubramanian, Pugazhendhi Vijayaraman,
Tópico(s)Cardiac electrophysiology and arrhythmias
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 14, No. 4Template Beat Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBTemplate BeatA Novel Marker for Left Bundle Branch Capture During Physiological Pacing Shunmuga Sundaram Ponnusamy, MD, Vithiya Ganesan, MD, Thabish Syed, MD, Suryakumar Balasubramanian, MBBS and Pugazhendhi Vijayaraman, MD Shunmuga Sundaram PonnusamyShunmuga Sundaram Ponnusamy Correspondence to: Shunmuga Sundaram Ponnusamy, MD, DM, PDF, CEPS, Department of Cardiology, Velammal Village, Velammal Medical College Hospital and Research Institute, Madurai 625009, Tamilnadu, India. Email E-mail Address: [email protected] https://orcid.org/0000-0002-7059-425X Departments of Cardiology (S.S.P., T.S., S.B.), Velammal Medical College, Madurai, Tamil Nadu, India. , Vithiya GanesanVithiya Ganesan Microbiology (V.G.), Velammal Medical College, Madurai, Tamil Nadu, India. , Thabish SyedThabish Syed https://orcid.org/0000-0002-3144-8655 Departments of Cardiology (S.S.P., T.S., S.B.), Velammal Medical College, Madurai, Tamil Nadu, India. , Suryakumar BalasubramanianSuryakumar Balasubramanian Departments of Cardiology (S.S.P., T.S., S.B.), Velammal Medical College, Madurai, Tamil Nadu, India. and Pugazhendhi VijayaramanPugazhendhi Vijayaraman https://orcid.org/0000-0003-2230-100X Department of Cardiology, Geisinger Heart Institute, Wilkes Barre, PA (P.V.). Originally published16 Apr 2021https://doi.org/10.1161/CIRCEP.120.009677Circulation: Arrhythmia and Electrophysiology. 2021;14Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 16, 2021: Ahead of Print Physiological pacing has witnessed a revolutionary growth in the last decade. Left bundle branch (LBB) pacing (LBBP), where direct capture of the proximal main left bundle could be achieved at low capture threshold, has overcome the limitations of His bundle pacing.1,2 The criteria for confirming the capture of the LBB had been defined but never validated.3 We had recently proposed a novel method of performing LBBP by observing the premature ventricular complexes (PVCs) generated during lead deployment.4 A PVC with right bundle branch delay morphology (qR/rSR in lead V1) with a QRS duration of <130 ms would be generated as the lead reaches the LBB area. We labeled this PVC as template beat as it mimicked the LBB paced QRS morphology (Figure [A]). Further rotations would be avoided if a template beat was noted during rapid lead deployment. We aimed at analyzing the incidence of template beat as a marker of LBB capture during LBBP and its clinical significance.Download figureDownload PowerPointFigure. Template beat–guided left bundle branch pacing (LBBP).A, Left bundle branch block (LBBB) correction by LBBP. Rapid deployment resulted in premature ventricular complexes (PVCs) with changing morphology until a template beat is obtained. Final paced QRS duration was 98 ms after right bundle branch delay correction by atrioventricular delay optimization. B, Template beat–guided LBBP in a patient with LBBB with left ventricular dysfunction. Nonselective to selective capture transition could be demonstrated at near threshold output, and final paced QRS duration was 100 ms. C, Template beat–guided LBBP in a patient with complete heart block. Initial 4 rapid turns resulted in QS pattern PVCs, which mimicked the paced QRS morphology at the site. Few more turns were given till the appearance of template beat, which matched the final paced QRS morphology. Final paced QRS duration was 110 ms with T-wave memory. HB indicates His bundle; LAO, left anterior-oblique; LBB, left bundle branch; and RV, right ventricle.This was a prospective observational study that included 90 consecutive patients who had undergone successful LBBP using C315-sheath and 3830 Selectsecure lead (Medtronic, Minneapolis). The study was approved by the institutional review board, and patients gave informed consent. Continuous rapid rotations were given to deploy the lead in the proximal septum until a template beat was obtained. If there were no PVCs during lead deployment, the final placement was decided on paced QRS morphology, unipolar pacing impedance, and peak left ventricular activation time. The data that support the findings of the study are available from the corresponding author upon reasonable request.The study population was divided into 2 groups based on the occurrence of template beat during lead deployment: group I with template beat (n=53; 59%) and group II without template beat (n=37; 41%). Female patients had higher incidence (67%) of template beat. There was no difference in septal thickness, basal QRS duration, and ejection fraction in both groups. The lead depth inside the septum was 10.3±2.1 mm in group I and 10.5±2.1 mm in group II (P=0.67). Both the groups demonstrated capture of LBB. No patients in group I developed septal perforation during implantation, but 8 patients in group II had perforation (0% versus 21.6%; P=0.004). The final LBB paced QRS morphology mimicked the template beat in group I (Figure [A–C]).The fluoroscopy time for LBBP lead deployment and total fluoroscopy time were significantly less in group I as compared with group II (14.5±7.8 versus 20.4±14.2 minutes, P=0.04, and 19.7±9.9 versus 26.3±16.6 minutes, P=0.02). Only rapid lead deployment generated template beat as opposed to slow gradual deployment with impedance and paced QRS morphology monitoring after each set of rotations. Cardiac magnetic resonance imaging was not done in all patients, which could have documented late gadolinium enhancement as one of the reasons for slow progression of lead movement inside the septum. Template beats showed right bundle branch delay pattern with a mean QRS duration of 121.1±3.7 ms. If the rotations were interrupted for some reason with narrow QS pattern as last generated PVC, additional turns were given till template beat was observed (Figure [C]).Paced QRS duration after correction of right bundle branch delay by atrioventricular interval optimization was significantly less in group I as compared with group II (108.9±8.3 versus 116.1±13.3 ms; P=0.002). There was a trend toward better Tpeak-Tend/QTc ratio (0.18±0.03 versus 0.19±0.02; P=0.08) and peak left ventricular activation time (68.3±13.8 versus 73.6±13.1 ms; P=0.07) in group I. Peak cTnI (cardiac troponin-I) measured after the procedure was significantly higher in group II as compared with group I (232.9±373.5 versus 123.1±106.1 pg/mL; P=0.04 [independent samples t test]), indicating less myocardial injury in patients who had undergone PVC-guided lead deployment.The main findings of our study were (1) template beat with right bundle branch delay pattern was observed in 58% of patients and can be considered as marker of LBB capture; (2) predicts less fluoroscopy time, narrow paced QRS duration, and shorter peak left ventricular activation time; (3) template beat–guided lead deployment would confer minimal myocardial injury and avoid septal perforation during lead deployment.It may be difficult to confirm conduction system capture based on the published criteria in some patients. PVC (template beat)-guided lead deployment can help as it confirms the capture of LBB. Template beats are generated from the Purkinje fibers due to mechanical trauma induced by the pacing lead as it moves rapidly into the LBB area.4 In the presence of scar, rapid penetration of the septum may not be possible and template beats would not be seen. This might result in repeated attempts in lead positioning and increase in cTnI release from myocardium. Avoiding further rotations once the template beats are observed would prevent further progression of lead into the septum, resulting in perforation.LBBP is emerging as an alternative to His bundle pacing. Template beat–guided lead placement would help in safe positioning of the lead in the LBB area, avoiding septal perforation, and minimizing the myocardial damage. Further studies are required to validate this novel technique as a criterion for LBB capture.Sources of FundingNone.Disclosures Dr Ponnusamy has received honoraria from Medtronic. Dr Vijayaraman has received honoraria, consulting fees, and research support form Medtronic and consulting fees from Boston Scientific, Abbott, Biotronik, and Eaglepoint. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 450.Correspondence to: Shunmuga Sundaram Ponnusamy, MD, DM, PDF, CEPS, Department of Cardiology, Velammal Village, Velammal Medical College Hospital and Research Institute, Madurai 625009, Tamilnadu, India. Email shunmuga.[email protected]comReferences1. Huang W, Chen X, Su L, Wu S, Xia X, Vijayaraman P. A beginner's guide to permanent left bundle branch pacing.Heart Rhythm. 2019; 16:1791–1796. doi: 10.1016/j.hrthm.2019.06.016CrossrefMedlineGoogle Scholar2. Ponnusamy SS, Arora V, Namboodiri N, Kumar V, Kapoor A, Vijayaraman P. Left bundle branch pacing: a comprehensive review.J Cardiovasc Electrophysiol. 2020; 31:2462–2473. doi: 10.1111/jce.14681CrossrefMedlineGoogle Scholar3. Vijayaraman P, Ponnusamy S, Cano Ó, Sharma PS, Naperkowski A, Subsposh FA, Moskal P, Bednarek A, Dal Forno AR, Young W, et al. Left bundle branch area pacing for cardiac resynchronization therapy: results from the International LBBAP Collaborative Study Group.JACC Clin Electrophysiol. 2021; 7:135–147. doi: 10.1016/j.jacep.2020.08.015CrossrefMedlineGoogle Scholar4. Ponnusamy SS, Vijayaraman P. Left bundle branch pacing guided by premature ventricular complexes during implant.HeartRhythm Case Rep. 2020; 6:850–853. doi: 10.1016/j.hrcr.2020.08.010CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Vijayaraman P, Herweg B, Verma A, Sharma P, Batul S, Ponnusamy S, Schaller R, Cano O, Molina-Lerma M, Curila K, Huybrechts W, Wilson D, Rademakers L, Sreekumar P, Upadhyay G, Vernooy K, Subzposh F, Huang W, Jastrzebski M and Ellenbogen K (2022) Rescue left bundle branch area pacing in coronary venous lead failure or nonresponse to biventricular pacing: Results from International LBBAP Collaborative Study Group, Heart Rhythm, 10.1016/j.hrthm.2022.04.024, Online publication date: 1-Apr-2022. Jastrzębski M (2022) Left bundle branch area pacing lead implantation using an uninterrupted monitoring of endocardial signals, Journal of Cardiovascular Electrophysiology, 10.1111/jce.15427, 33:5, (1055-1057), Online publication date: 1-May-2022. Ponnusamy S and Vijayaraman P (2021) Axis deviation in nonischemic cardiomyopathy with left bundle branch block: Insights from left bundle branch pacing, Journal of Cardiovascular Electrophysiology, 10.1111/jce.15334, 33:2, (318-321), Online publication date: 1-Feb-2022. Ponnusamy S, Syed T and Vijayaraman P (2022) Response of functional mitral regurgitation in nonischemic cardiomyopathy to left bundle branch pacing, Heart Rhythm, 10.1016/j.hrthm.2022.01.019, 19:5, (737-745), Online publication date: 1-May-2022. Ponnusamy S, Basil W and Vijayaraman P (2022) Electrophysiological characteristics of septal perforation during left bundle branch pacing, Heart Rhythm, 10.1016/j.hrthm.2022.01.018, 19:5, (728-734), Online publication date: 1-May-2022. Jastrzębski M, Moskal P, Huybrechts W, Curila K, Sreekumar P, Rademakers L, Ponnusamy S, Herweg B, Sharma P, Bednarek A, Rajzer M and Vijayaraman P (2022) Left bundle branch–optimized cardiac resynchronization therapy (LOT-CRT): Results from an international LBBAP collaborative study group, Heart Rhythm, 10.1016/j.hrthm.2021.07.057, 19:1, (13-21), Online publication date: 1-Jan-2022. Ponnusamy S and Vijayaraman P (2022) Evaluation of Criteria for Left Bundle Branch Capture, Cardiac Electrophysiology Clinics, 10.1016/j.ccep.2021.12.011, 14:2, (191-202), Online publication date: 1-Jun-2022. Ponnusamy S, Syed T and Basil W (2022) Left Bundle Branch Optimized Cardiac Resynchronization Therapy in Mesocardia With Bilateral Superior Vena Cava, JACC: Clinical Electrophysiology, 10.1016/j.jacep.2021.09.005, 8:3, (406-409), Online publication date: 1-Mar-2022. Ponnusamy S and Vijayaraman P (2022) Electroanatomical mapping assisted conduction system pacing, Indian Pacing and Electrophysiology Journal, 10.1016/j.ipej.2022.06.003, 22:4, (186-187), Online publication date: 1-Jul-2022. Ponnusamy S and Vijayaraman P (2021) Electrocardiography guided left bundle branch pacing, Journal of Electrocardiology, 10.1016/j.jelectrocard.2021.07.001, 68, (11-13), Online publication date: 1-Sep-2021. Cano Ó and Vijayaraman P (2021) Left Bundle Branch Area Pacing: Implant Technique, Definitions, Outcomes, and Complications, Current Cardiology Reports, 10.1007/s11886-021-01585-1, 23:11, Online publication date: 1-Nov-2021. Ponnusamy S and Vijayaraman P (2021) How to Implant His Bundle and Left Bundle Pacing Leads: Tips and Pearls, Cardiac Failure Review, 10.15420/cfr.2021.04, 7 Shen J, Jiang L, Jiang F, Wu H, Cai X, Zhuo S and Pan L (2022) Premature beat of selective left bundle branch: a novel marker for reaching and capturing the left bundle branch, Journal of Interventional Cardiac Electrophysiology, 10.1007/s10840-022-01203-2 Ponnusamy S, Basil W and Vijayaraman P (2022) M‐beat—A novel marker for selective left bundle branch capture, Journal of Cardiovascular Electrophysiology, 10.1111/jce.15597 April 2021Vol 14, Issue 4 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.120.009677PMID: 33858179 Originally publishedApril 16, 2021 Keywordsbundle of Hisventricular premature complexesincidencephysiologyheart conduction systemPDF download Advertisement SubjectsElectrophysiologyPacemaker
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