Indiana University Professor Emeritus, Dr. Douglas Zipes has been observing His-bundle pacing for decades. In this interview, by Jennifer N. Caudle DO, he presents the technique as the normative standard that has taken decades for the practice of medicine to gain.
As Dr. Zipes affirms, it is “far more beneficial” and “far preferable” to the leading alternative.
The essential interview:
Dr. Caudle: Could you briefly explain for those who are unfamiliar with His-bundle pacemakers how they differ from a traditional pacemaker?
Dr. Zipes: The normal cardiac impulse starts in the sinus node, goes through the atrium, down through the AV node, His-bundle, and then the bundle branches. When we pace through the customary application of pacemakers, the lead is placed in the apex of the right ventricle. And we’ve seen that, that can create abnormal ventricular contraction, subsequently reduce ventricular function and reduce ejection fraction in symptomatic patients.
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The normal cardiac impulse going to the ventricle begins in the His-bundle, divides through both bundle branches and creates a homogeneous and harmonious ventricular contraction.
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When we pace just the right ventricle, we are making that abnormal. So the ideal would be to pace the His-bundle in patients requiring a pacemaker. Today, to circumvent or try to prevent the abnormal ventricular contraction of pacing in the right ventricle we do CRT, which is cardiac resynchronous pacing with a lead in the coronary sinus to pace the left ventricle as well. That’s a complex, expensive and difficult procedure. It would be far more beneficial to the patient to simply pace the His-bundle.
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The problem has been, and we’ve faced this for 40 or 50 years, how can we put a lead on the His-bundle to pace it in a reliable long-term fashion? And that’s been a goal for many, many years. Recently, several investigators one from my institution, Gopi Dandamudi, has demonstrated the ability to put a lead on the His-bundle itself and be able to pace the His-bundle reliably long-term, thus mimicking nature’s normal conduction pattern. And this would be far preferable than all the machinations we go through with biventricular pacing.
Dr. Caudle: So, what benefits of His-bundle pacing do the findings from the Geisinger Registry suggest are available for patients with this type of pacemaker?
Dr. Zipes: Well, they’ve demonstrated that first of all, we can do it, and they’ve demonstrated the technique on how to do it. That eliminates multiple leads in the patient’s heart by simply having one lead with the electrodes at the His-bundle to reliably and long-term pace that area to then produce a normal QRS complex and cardiac contraction.
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This is a very important step and I think that approach will be substituted for many patients who have required CRT pacing.
Dr. Caudle: Okay. And finally, do you see any barriers to a broader adoption of this type of pacemaker?
Dr. Zipes: The barrier is educational and teaching physicians exactly how to do it. But I think that’s easily accomplished and we will see that in the near future and I think we will see far more physicians using His-bundle pacing than ever in the past.