Selective Versus Nonselective His Bundle Pacing: Does it Matter?
Selective Versus Nonselective His Bundle Pacing: Does it Matter?
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选择性与非选择性他的捆绑节奏：重要吗？
DOI：
10.1016/j.jacep.2019.05.022
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发表时间：
2019
期刊：
影响因子：
--
通讯作者：
K. Ellenbogen
中科院分区：
文献类型：
--
作者：
S. Padala;K. Ellenbogen
束束起搏 (HBP) 是迄今为止最符合生理学的起搏形式，可避免非生理性、慢性右心室 (RV) 起搏的有害影响。几位研究者已经报告了 HBP 相对于 RV 起搏的安全性、可行性和优越性。他的束起搏器已成功植入希氏-浦肯野传导正常、束支传导阻滞、房室 (AV) 结和结下传导阻滞的患者，并作为心脏再同步治疗的替代方案植入选定的患者 (1-9)。尽管最近备受关注，但由于精确的目标区域和可用工具的限制，HBP 引线植入在技术上可能具有挑战性。希氏束 (HB) 是 AV 结远端部分的延续，长度约为 20 毫米，直径约为 4 毫米。从解剖学上讲，它可以分为 3 个部分： 非穿透性（当它穿过纤维环时）；穿透性（在中央体和膜隔膜的纤维组织内）；和分支部分（在肌性室间隔顶部分叉成左束支和右束支）(10)。因此，根据 HBP 导联的位置，起搏可能会单独捕获 His-Purkinje 系统，从而产生正常的 QRS 形态（选择性 HBP [S-HBP]），或者捕获 His-Purkinje 系统和周围的 RV 心肌，从而产生融合的 QRS 形态（非选择性 [NS-HBP]）。尽管 S-HBP 恢复了原始 QRS 形态并且在心电图上令人满意，但据报道大约三分之一的病例可以实现这一目标。在这种情况下，NS-HBP 提供了另一个参与天然传导系统的机会，并且与 RV 心尖起搏相比，可能会导致相对较窄的 QRS。然而，NS-HBP 和 S-HBP 之间的临床结果是否存在差异尚不清楚。在本期《JACC：临床电生理学》中，Beer 等人 (11) 分析了 350 名连续使用 HB 起搏器的患者（S-HBP：n= 118；NS-HBP：n= 232）的全因死亡率或心力衰竭住院 (HFH) 的综合终点，这些患者在植入后 3 个月表现出 20% 的心室起搏。与 SHBP 组相比，NS-HBP 组患者的基线合并症较多，包括冠状动脉疾病、缺血性心肌病、纽约心脏协会功能分级 III 和 IV 级患者、永久性心房颤动和结下传导阻滞的发生率较高。在平均 1,022 天的随访期间，NS-HBP 组和 S-HBP 组的复合主要终点发生率分别为 36% 和 20%（风险比：1.49；95% 置信区间：0.95 至 2.35；p=0.09）。 NS-HBP 组和 S-HBP 组的次要终点全因死亡率分别为 28% 和 14%（风险比：1.65；95% 置信区间：0.96 至 2.86；p=0.07）。还对预计面临最大风险的患者进行了亚组分析
His bundle pacing (HBP) is by far the most physiological form of pacing to circumvent the deleterious effects of nonphysiological, chronic right ventricular (RV) pacing. The safety, feasibility, and superiority of HBP over RV pacing has been reported by several investigators. His bundle pacemakers have been successfully implanted in patients with normal His-Purkinje conduction, bundle branch block, atrioventricular (AV) nodal and infra-nodal block, and in selected patients as an alternative to cardiac resynchronization therapy (1–9). Despite the recent du jour, HBP lead implantation may be technically challenging due to the precise target zone and limitations of the available tools. The His bundle (HB) is a continuation of the distal part of the AV node and measures about 20 mm in length and 4 mm in diameter. Anatomically, it can be divided into 3 portions: nonpenetrating (as it passes through the annulus fibrosis); penetrating (within the fibrinous tissue of the central body and membranous septum); and branching portion (bifurcation into the left and right bundle branches at the crest of the muscular ventricular septum)(10). As such, depending on the location of the HBP lead, pacing may capture the His-Purkinje system alone, which results in a normal QRS morphology (selective HBP [S-HBP]), or the His-Purkinje system and surrounding RV myocardium, which results in a fused QRS morphology (nonselective [NS-HBP]). Although S-HBP restores the native QRS morphology and is electrocardiographically gratifying, it has been reported to be achieved in approximately one-third of the cases. In such cases, NS-HBP provides another opportunity to engage the native conduction system and may result in a relatively narrow QRS compared with RV apical pacing. However, whether the clinical outcomes differ between NS-HBP and S-HBP is unknown.In this issue of JACC: Clinical Electrophysiology, Beer et al.(11) analyzed a combined endpoint of allcause mortality or heart failure hospitalization (HFH) among 350 consecutive patients with HB pacemakers (S-HBP: n= 118; NS-HBP: n= 232) who demonstrated $20% ventricular pacing at 3 months post-implantation. Patients in the NS-HBP group had greater baseline comorbidities compared with the SHBP group, including a higher incidence of coronary artery disease, ischemic cardiomyopathy, patients in New York Heart Association functional classes III and IV, permanent atrial fibrillation, and infra-nodal block. During a mean follow-up of 1,022 days, the composite primary endpoint occurred in 36% versus 20% in the NS-HBP versus S-HBP groups, respectively (hazard ratio: 1.49; 95% confidence interval: 0.95 to 2.35; p= 0.09). The secondary endpoint of all-cause mortality occurred in 28% versus 14% in the NS-HBP versus S-HBP groups, respectively (hazard ratio: 1.65; 95% confidence interval: 0.96 to 2.86; p= 0.07). Subgroup analyses were also performed in patients who were anticipated to be at the greatest risk for the
影响因子：
5.5
作者：
Ajijola, Olujimi A.;Upadhyay, Gaurav A.;Tung, Roderick
通讯作者：
Tung, Roderick