Authors

• Richard Matasić — Klinički bolnički centar Zagreb, Zagreb, Hrvatska — ORCID: 0000-0003-1289-1704
• Davor Radić — Klinički bolnički centar Zagreb, Zagreb, Hrvatska — ORCID: 0000-0002-9132-1568
• Davor Puljević — Klinički bolnički centar Zagreb, Zagreb, Hrvatska — ORCID: 0000-0003-3603-2242
• Vedran Velagić — Klinički bolnički centar Zagreb, Zagreb, Hrvatska — ORCID: 0000-0001-5425-5840

Abstract

**Introduction:** Traditionally, ventricular pacing leads are placed at right ventricular (RV) apex. This approach has several advantages. First of all, RV apex is easily identified under fluoroscopy and most of the time lead can be easily placed. There is minimal risk of lead dislodgement and reliable parameters are obtained. However, since pacing stimulus starts at the RV apex, iatrogenic left bundle branch block pattern is created. This results in interventricular and intraventricular dyssynchrony (early activation of the right ventricle and interventricular septum and delayed activation of the LV lateral wall). Most of the patients tolerate this very well for some time. In some patients and especially those who require constant ventricular pacing, dilatation, and remodeling of the left ventricle, a decline in left ventricular ejection fraction and even congestive heart failure can occur (1, 2). His bundle pacing activates the ventricles through the native His-Purkinje system, resulting in more physiological pacing. Since activation occurs through the normal conduction system of the heart, there is no intraventricular or interventricular dyssynchrony. Because of that, there are no deleterious effects on ventricular dimensions and functions (3). **Case report:** 15-year-old female patient with congenital total atrioventricular block has been referred for pacemaker therapy to prevent sudden death and insufficient chronotropy. We have successfully implanted dual chamber pacemaker with the ventricular lead placed at the His bundle. This resulted in a narrow QRS complex. **Conclusion:** Technical limitations and higher thresholds at His bundle pacing have restricted use of His pacing in the past but, in recent years development of dedicated tools has made His pacing feasible in most patients.

Keywords

His pacing, total atrioventricular block, pacing

DOI

Literature

1. Tantengco MV, Thomas RL, Karpawich PP. Left ventricular dysfunction ater long-term right ventricular apical pacing in the young. J Am Coll Cardiol. 2001 Jun 15;37(8):2093–100. https://doi.org/10.1016/S0735-1097(01)01302-X
2. Thambo JB, Bordachar P, Garrigue S, Lafitte S, Sanders P, Reuter S, et al. Detrimental ventricular remodeling in patients with congenital complete heart block and chronic right ventricular apical pacing. Circulation. 2004 Dec 21;110(25):3766–72. https://doi.org/10.1161/01.CIR.0000150336.86033.8D
3. Catanzariti D, Maines M, Manica A, Angheben C, Varbaro A, Vergara G. Permanent His-bundle pacing maintains long-term ventricular synchrony and left ventricular performance, unlike conventional right ventricular apical pacing. Europace. 2013 Apr;15(4):546–53. https://doi.org/10.1093/europace/eus313