AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2641-0419/129
*Corresponding Author: Kristin Ellison, MD Division of Cardiovascular Medicine; The Gill Heart & Vascular Institute 900 South Limestone Street, CTW 326 Lexington, KY 40536.
Citation: Kristin Ellison., Andrew Kolodziej., Sateesh Kesari., Karam Ayoub., Ethan Fry., Aaron Hesselson., (2021) His Bundle Pacing with Recruitment of Right Bundle Branch after Orthotopic Heart Transplant. J. Clinical Cardiology and Cardiovascular Interventions, 4(3); Doi:10.31579/2641-0419/129
Copyright: © 2021 Kristin Ellison, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, sand reproduction in any medium, provided the original author and source are credited.
Received: 22 January 2021 | Accepted: 01 February 2021 | Published: 08 February 2021
Keywords: orthotopic heart transplant; primary graft failure; his bundle pacemaker; myocardial biopsy
The incidence of permanent pacemaker implant after orthotopic heart transplant is between 2-24%. We present a 63-year-old male with ischemic cardiomyopathy who underwent orthotopic heart transplant. His post-operative course was complicated by recurrent asystole from sinus bradycardia and complete heart block. He had baseline right bundle branch block and right ventricular dysfunction. The decision was made to proceed with His-bundle pacing to provide physiologic cardiac activation, and provide anatomical benefit for subsequent endomyocardial biopsy. He did well after receiving a His bundle pacemaker with recruitment of his right bundle branch.
AF - Atrial Fibrillation, AV-Atrial ventricular, PPM - Permanent Pacemaker, SND - Sinus node dysfunction, HBP - His bundle pacing, CHB – Complete Heart Block, POD - Post-Operative Day, RBBB - Right Bundle Branch Block, LBBB - Left Bundle Branch Block, OTH - Orthotopic Heart Transplant, RV - Right Ventricle, CRT -Cardiac Resynchronization Therapy
Introduction
The incidence of permanent pacemaker implant after orthotopic heart transplant is between 2-24%. Most early implants are for sinus node dysfunction (SND), while atrioventricular block (AVB) contributes to later implants [1,2]. His bundle pacing allows for physiologic cardiac depolarization and can be beneficial compared to traditional pacing techniques [3,4]. His bundle pacing can also overcome bundle branch block from His-purkinje disease by recruiting bundle fibers beyond the level of block [5,6]. We present a 63-year-old male with ischemic cardiomyopathy who underwent orthotopic heart transplant. His post-operative course was complicated by recurrent asystole from sinus bradycardia and complete heart block with baseline right bundle branch block and right ventricular dysfunction. He did well after subsequent His bundle pacemaker with successful recruitment of the right bundle branch.
Case Report
A 63-year-old male with past medical history of hypertension, diabetes, coronary artery disease, ischemic cardiomyopathy with an ejection fraction (EF) of < 20% on continuous infusion of intravenous Milrinone, chronic obstructive lung disease, and pulmonary hypertension, underwent orthotopic heart transplant (OHT) with bi-caval anastomosis. Immediately following surgical anastomosis, the donor’s left ventricle became dilated and hypokinetic in addition to significant right ventricular (RV) failure. During reperfusion, he had several episodes of ventricular fibrillation that were successfully treated with defibrillation. Twenty minutes after coming off bypass, his condition deteriorated necessitating placement back on bypass. After starting inotropic and vasoactive agents, Milrinone and norepinephrine, patient was able to be slowly weaned off of bypass. Temporary epicardial pacer leads were placed secondary to sinus bradycardia and the sternotomy site was closed appropriately.
He received induction immunosuppressive therapy with intravenous Basiliximab and Methylprednisolone. On postoperative day one (POD 1), vasoactive agents were weaned off, and he was successfully extubated. His post-operative course was complicated by acute renal failure requiring intermittent renal replacement therapy. His intrinsic rhythm was normal sinus rhythm with rates between 73 and 110 beats per minute (BPM), up until POD 13. At that time, patient had an episode of feeling poorly while standing and was placed back in bed, but subsequently suffered transient loss of consciousness. Patient’s telemetry during this episode revealed sinus bradycardia followed by complete heart block (CHB). He had several minutes of a ventricular escape rhythm which then converted into atrial fibrillation (AF) lasting several minutes, before spontaneous converting back to normal sinus rhythm at 80-90 beats per minute. Patient was not on any atrialventricular (AV) nodal blocking agents, and all RV endomyocardial biopsies were negative for acute rejection.
The following morning, he had another episode of sudden onset sinus slowing and CHB leading to asystole requiring transcutaneous pacing for nearly 10 minutes. Due to recurrent episodes of unexplained sinus bradycardia and CHB the decision was made to proceed with implanting a dual chamber His bundle permanent pacemaker (HBP).
The left cephalic vein was accessed by cut down. A C315-His non-deflectable sheath was used with the 3830 Medtronic His bundle lead. Mapping of the His bundle was done through unipolar hook up of the pacing lead and electrograms before and after fixation are shown in (figures 1A and B).
The implanted lead values were threshold 0.75 Volts at 1 millisecond, R wave of 2.8 millivolts, and an impedance of 663 Ohms. Pacing from this sight also recruited the right bundle as shown in (figure 1C).
Figure 1: Electrograms during His Bundle Lead Placement
The sheath was slit, and the lead was secured. The atrial lead was placed. During the case, the patient had another episode of sinus bradycardia and CHB associated with hypotension. HBP pacing rate was increased to 90 bpm with immediate improvement of blood pressure. Electrocardiograms (ECGs) before and after HBP placement are provided in Figure 2, which demonstrate the patients underlying right bundle branch block (RBBB) (figure 2A) with favorable narrowing following HBP (figure 2B).
Figure 2: 12 lead ECGs Before and After His Bundle Pacing
He continued to undergo RV endomyocardial biopsies as part of allograft rejection surveillance program without complications. The location of the bioptome relative to the His lead is shown with fluoroscopy in (figure 3). Patient continued to recover after HBP placement and was successfully discharged from the hospital.
Figure 3: Fluoroscopic Image during Myocardial Biopsy
Indications for permanent pacing after OHT are bimodal with early and late implantations [1, 2]. In adults, early implants tend to be for SND. Surgical trauma, surgical technique, myocardial preservation and reperfusion, cardiac denervation, and donor characteristics all play a role in post-transplant SND. SND may resolve with limited pacing required after 6 months. Late PPM implantations, 1-6 months post-transplant, are for both SND and AVB and may correlate with acute rejection or transplant vasculopathy. The bicaval technique introduced in the early 90’s has been associated with decrease PPM requirements [2]. A study by Mallidi in 2017, correlated pre-transplant ischemic cardiomyopathy, increased donor age, and number of treated rejection episodes with greater PPM implantation [1]. Our patient experienced episodic asystole resulting from both SND and CHB with baseline RBBB on Milrinone for primary graft failure. Patient had pulmonary hypertension pre-operatively and RV failure post-operatively.
Significant data has been emerging regarding the clinical benefits of HBP compared to traditional RV pacing [3, 4]. HBP results in the activation of the heart through the intrinsic conduction system. When achieved, this avoids the harmful consequences imposed by standard RV pacing such as: ventricular dyssynchrony, impaired contractility, increased mitral regurgitation, decline in ejection fraction, and increased burden of atrial fibrillation [7-9].
HBP can also be utilized to recruit/activate the left or right bundle branches beyond the level of the block within the His bundle. Which subsequently narrows the QRS and provides cardiac resynchronization therapy (CRT) [5,6,10]. HBP for LBBB was shown to be equivalent to CRT with Biventricular pacing at the late-breaking trial presented at the Heart Rhythm Society in May 2019 [6]. While HBP in an OHT with underlying LBBB has previously been described in the literature [11], HBP with underlying RBBB has not. Sharma, et al. presented data on patients with low EF and RBBB, with successful HBP achieved in 37/39 patients. In 78% of these patients, the RBBB was narrowed with resultant improved heart failure outcomes. As RBBB is associated with RV asynchrony, the proposed benefit of RBBB narrowing was resynchronization of the RV. The other possibility is AV optimization without deleterious effects of conventional RV pacing [6].
Our patient had potential need for ventricular pacing with episodic CHB and baseline RBBB. HBP avoided the harmful consequences of RV pacing in this patient with primary graft failure. Our patient also suffered from RV failure in setting of pulmonary hypertension and recruitment of the RBBB provided the potential to synchronize and optimize RV function. An additional merit to HBP in transplant populations is the proximal position of the His lead, leaving the full RV septum available for biopsy (Figure 3). Two months out from his transplant, his pacer requirements at a rate of 90 BPM are 87% in the atrium and 99.2% in the ventricle. Thresholds remain stable at 1.65 volts at 0.4 milliseconds with R wave of 4.4 millivolts and impedance of 399 ohms.
Conclusions
Pacemakers are occasionally indicated post OHT. Due to the complex nature of transplant graft function, HBP is an attractive pacing technique in this population. Our patient received a dual-chamber, His bundle pacemaker. The atrial lead provides atrial rate support and facilitates the management of atrial fibrillation, while the His bundle lead provides physiologic pacing and recruitment of the RBBB in a patient with primary graft failure. Use of His bundle pacing will prevent the deleterious effects of RV pacing, leave the RV septum available for biopsy, and the correction of his underlying RBBB may provide benefit to his RV function.
Disclosures all Authors: None
Conflict of interest: None
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
