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LV lead implantation along with other options such as surgical epicardial leads424,440 (see section 6.7). An interesting population is patients with RBBB, who are known to respond less well to biventricular pacing, in whom HBP has shown promising preliminary results in a series of 37 patients.441 HBP may sometimes incompletely correct BBB, and can be used in conjunction with RV, LV, or biventricular pacing, as in the HOT-CRT study.319 This is of particular interest in patients with permanent AF, in whom a His lead may be connected to the vacant atrial port, thus offering additional therapeutic options.

7.3 Left bundle branch area pacing

With left bundle branch area pacing, the lead is implanted slightly distal to the His bundle and is screwed deep in the LV septum, ideally to capture the left bundle branch.442 Advantages of this technique are that electrical parameters are usually excellent, it may be successful in blocks that are too distal to be treated with HBP, and it also facilitates AVJ ablation, which may be challenging with HBP. However, although the technique is very promising, data on this modality are still scarce (Supplementary Table 11), and there is concern regarding long-term lead performance and feasibility of lead extraction. Recommendations for using left bundle branch area pacing cannot therefore be formulated at this stage. However, conduction system pacing (which includes HBP and left bundle branch area pacing) is very likely to play a growing role in the future, and the current recommendations will probably need to be revised once more solid evidence of safety and efficacy (from randomized trials) is published. A comparison of RV pacing, HBP, and left bundle branch area pacing is provided in Supplementary Table 12. 7.4 Leadless pacing

Leadless pacemakers have been developed to address limitations typically related to pulse generator pocket and transvenous leads of conventional pacemaker systems. Currently, two leadless pacemaker systems have been studied in clinical trials, of which one is currently available for clinical use. Both are inserted into the RV cavity by a femoral venous approach using a specially designed catheter-based delivery system. A number of prospective registries have reported that implantation success rates are high, with adequate electrical results both at implant and at follow-up (Supplementary Table 13). ‘Real-world’ results of one leadless pacemaker system, including 1817 patients, reported serious adverse events in 2.7% of patients.50 The prevalence of leadless device infections is low as the principal sources of infection (i.e. the subdermal surgical pocket and pacemaker leads) are absent. However, during the initial operator experience, there was a higher incidence of peri-operative major complications (6.5%), including perforation and tamponade, vascular complications, ventricular arrhythmias, and death.445 These data highlight the importance of adequate training and supervision in this domain when starting with leadless pacemaker implantation. In addition, implanting physicians should have the same competency and accreditation as those required for standard transvenous pacing to be able to offer the most suitable system for a given patient. Implantation of leadless pacemakers should be performed in an adequate setting (i.e. with highresolution multiplane fluoroscopy) and with cardiac surgery available on site due to the risk of tamponade, which may be more difficult to manage than with standard pacing.446,447 Leadless pacemakers that only function in the VVI(R) mode restrict indications to patients with AF or very infrequent pacing (e.g. paroxysmal AVB). Recently, VDD pacing (by detection of atrial contraction by the accelerometer) has been introduced, which extends indications to patients with AVB with preserved sinus node function. AV synchrony is maintained 7090% of the time, depending on the patient’s position and activity, based on data from two studies including 73 patients in SR and high-degree AV block.448 There may in future be an alternative to standard DDD pacemakers in selected patients if the potential benefits of leadless pacing outweigh the potential benefits of 100% AV synchrony, atrial pacing, and atrial arrhythmia monitoring. Indications for leadless pacemakers include obstruction of the venous route used for standard pacemaker implantation (e.g. bilateral venous thoracic outlet syndrome or chronic obstruction of the superior vena cava), pocket issues (e.g. in the case of cachexia or dementia), or particularly increased infection risk [e.g. in the case of dialysis

Recommendations for using His bundle pacing

Recommendations Classa Levelb

In patients treated with HBP, device programming tailored to specific requirements of HBP is recommended.430,431 I C In CRT candidates in whom coronary sinus lead implantation is unsuccessful, HBP should be considered as a treatment option along with other techniques such as surgical epicardial lead.318,424,440,443 IIa B In patients treated with HBP, implantation of an RV lead used as ‘backup’ for pacing should be considered in specific situations (e.g. pacemaker dependency, high-grade AVB, infranodal block, high pacing threshold, planned AVJ ablation) or for sensing in the case of issues with detection (e.g. risk of ventricular undersensing or oversensing of atrial/His potentials).423,426,444 IIa C HBP with a ventricular backup lead may be considered in patients in whom a ‘pace-and-ablate’ strategy for rapidly conducted supraventricular arrhythmia is indicated, particularly when the intrinsic QRS is narrow.197,199,200,318 IIb C

Continued HBP may be considered as an alternative to RV

pacing in patients with AVB and LVEF >40%, who are anticipated to have >20% ventricular pacing.42,433 IIb C

AVB = atrioventricular block; AVJ = atrioventricular junction; CRT = cardiac resynchronization therapy; HBP = His bundle pacing; LVEF = left ventricular ejection fraction; RV = right ventricular. aClass of recommendation. bLevel of evidence. ESC 2021

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