HBP
Lead: 3830 (4.1 Fr) 49-59-69 (tradidtional), 74 (longest) cm
lumenless
helix exposed 1.8 mm single cable
Good tensile strength
Polyurethane
Steroid covered tip
cable inner conductor
2 pole dist 9 mm
Cathode to lead (black) - Anode to Weitlaner (red)
Sheaths:

C315
(8.5 Fr outer diameter)
via 7 Fr sheath peel away
2 curves:
1ary septal curve
2ary curve to ventricle
Sheath/dilator over wire to ventricle
Pull out
towards septum: pull back CCW
69 fits better gives you more lead distally
Sheaths:

C304
(8 Fr through a 9 Fr peel away)
deflectable sheath
helps you get higher and lower on the septum
Only has 1 curve
Large amount of CCW torque needed towards septum
Challenging to fix lead
better in trying to find his
Can switch back to 315
May need another set of hands help CCW while you
rotate the lead
Use in large RA patients
When RA dilates His migrates usually lower
(occasionally higher)
Hook up cables to atrial port (gives you higher gain setup) or to EP recording
system
Remington medical adapter
Shielded jumper cables
Cardiotronic reusable extension cable
Selective His Bundle Pacing:
Isoelectric interval from His to QRS
Stim-V ~ HV
Paced QRS similar to native QRS
Single capture threshold
Have all 12 leads displayed
Can be read as PPM malfunction on surface ECG
Non selective His Bundle Pacing:
Preexcited delta wave (like a midseptal,anteroseptal AP)
S-QRS<HV (usually 0)
Pseudo delta wave
At high outputs can recruit certain fibers of His but also V
Paced QRS>native QRS (rapid dV/dt of QRS identical to
native)
2 distinct capture thresholds: His and RV
Non selective HBP can sometimes be beneficial
Italian data: no significant difference in outcomes
C 315 over 0.35 wire
tip radio-opaque
move lead to tip of sheath
You can record EGMs not even at the tip
Shallow RAO 14 degrees
150 ms speed original mapping

Map -> advance lead, CW rotation
If A too big -> 05 atrial activation on V channel
you are looking for a signal similar to the slow pathway of AVNRT
Anatomically the His lead is screwed on the atrial  aspect of the TA
Depth of indication/if more distal disease -> more on V side

Sheath takes you only to one area. Gentle CCW movements
CCW -> posterior
CW -> anterior away from septum
Either C 315 takes you there quickly or it won't work

Gentle movements of CW/CCW
Come back CW across valve
Once you find His -> CCW gentle pull back movement
Sheath jumps
Pull back, little CW/far-field A comes in
Recommend to use a mapping catheter first 10 cases


Tough group is patients with TAVR core valve
the valve sits on LB/septum
His can be proximal don't now how
Disease process goes on

Someone with LBBB can be fixed with HBP by recruiting these fibers
Concept of longitudinal dissociation within the bundle of His
AVN slows down (toll booth)
If in AF bombarding AVN slows it down
West (left 2 lanes) East (right 2 lanes)
Lanes are separated as soon as toll booth even if separation is in 2 miles
So fibers are predestined to be LB early and RB
Disease is more proximal
C304
Swap to Sage sheath cause the one that comes with it bleeds
Directing tip towards where His is mapped
RB potential

Deflectable 304 is stiffer than 315 which is flexible and tip is atraumatic
Much more CCW torq on 304 than 315 cause no septal curve

CCW torq let it settle
Mapping catheter can interfere with fixing lead
Small motions/Patience

If CHB and escape junctional you can still map the His
If not use pace mapping as you get closer to His you get a narrow non selective
QRS
If CHB with temporary pacing just pace map

Lower sweep speed to 50 ms when pace mapping
Speed 150 when looking for His
10 volts -> non selective
3,5,4 -> selective

screw lead in 7 x
After 3-4 x hook lead up cause if you move as you try to screw it in you have gone too far
Mostly V/Basal septal: not a good spot

To remove lead advance sheath to tip then 7x remove
Everytime flush sheath - wash lead screw

Cutoff for upper limit threshold is 2-2.5
Rarely you can push it to 3 but not more

Non selective vs septal => fusion
Maybe extend tip of lead 2 mm to get better contact
Sometimes extend sheath to tip of lead to get more support cause the lead is lumenless
and has no support needs the sheath

If septal threshold is 0.8 but His threshold is 2.5 can't lower pacing threshold below 2.5
cannot do adaptive
Do not turn on autocapture
Unipolar threshold is lower than bipolar which is what you expect
Intermittent loss of His below 2 is acceptable (nice safety margin, if the threshold goes
up you still have septal RV capture)
Sensing R waves 3.2
Different range of R waves will never see >5 usually 2-3
Don't accept R < 1 can lead to oversensing
If big difference between uni and no accept it
Lower impedance below 5 V anything > 5 V you will see an increase in threshold later

5-7% may have an increase in threshold 1st year. You can program around it a lot of times
Revision: His potential screw lead. add lead more distal to location

Important to get slack in place before slit cause u can't push the lead back in
No curve on sheath when you take it out otherwise can pull lead
Slit A lead sheath before His
A lead implant through sheath of mapping catheter
Once you slit delivery system you still have a 7 Fr sheath recheck thresholds
(microdislodgement can give you higher thresholds)
Over time if you see an injury current threshold will get better (1.5->0.5) but generally stays the same
Patients stay overnight but non dependent can go same day
Xray before they go

How often injury current on His?
37% of cases (40-50% as experience gets better)
It's a good marker (lower threshold)
you don't have to see it but if you do it's a good thing
If large amount of myocardial tissue surrounding His => good injury

Higher impedances with similar thresholds: same battery life (bipolar vs unipolar)

AVN ablation with HBP
Do it same procedure.
Implant His lead
pull sheath back but don't slit it
Do AVN ablation (universal prep)
After that slit sheath after rechecking thresholds (if goes up reposition)
Pace His lead 0.5 V above threshold and watch for loss during ablation
Alternative is to use irrigated and go to SP area burn there for 1 min causes CHB far away from your lead
Alternative is you know where your His lead is burn proximal to it this forces you to be on the A side where you will generate an escape rhythm
Proximal to proximal electrode of His lead

Slurred pseudo Delta
as you decrease pacing output it gets wider
You don't have fusion in V pacing it's all or nothing
There is no selective HB potential nearfield is pulled in all the time
If selective HBP you have an isoelectric line before EGM which is not pulled in
QRS width not a good marker but in general narrower

Before coming on pacing could you see His
Have to get used to checking sensing and pacing
Both unipolar and bipolar
Pacing unipolar can give you pectoralis stim
Measure HV intervals
Unipolar pacing won't work out of pocket

PSA filter similar to unfiltered EGM
Recording system filtered and unfiltered
30/300 or 30/500 for filters
0.05/1000 for unfiltered

Hold it, rotate it, feel torque on the lead
Depends on how much contact on septum
If you don''t feel torque back more times

If Helix of lead at tip of sheath => It can only go into the septum
If you push lead too much be careful to push a few mm to advance fwd
Very small motions



Differentiate RB from A esp if the mapping catheter is up high and no A
Measure HV on His 1-2
9 Fr exchange for C315

TS puncture when there is a His lead? Don't do it first 3-4 months
AVNRT ablation is no problem

As you are advancing the sheath look at the wire in LAO make sure not wrapped around lead

Gently push lead a bit up against tissue or slide
HBP success 85-95%
Go LAO => maybe it's riding up so much not screwed in

Little CW Torq pulling away from septum
CCW pulls back the A
Do not screw perpendicular ot the septum you will get high thresholds
Pull system up so it's sitting higher
Shape 315
Outer sheath (worley multipurpose) to bring you higher (a little more of a reach)
You have to cutoff prox to have enough length to work with (off label)
Far field on unipolar
Look for injury on unfiltered
Hand shape 304 for tighter distal curve go higher
If you are getting same response in multiple areas take a septal lead
First case cheney

Very large RA

Had to go through an EH and through it the mapping livewire
catheter then with the 315 put the lead there
Still had a good his but once I screwed his moved away I may have
screwed it too far