It's an honor to be here to present my topic to introduce how to successfully implant his bundle pacing lead. It's very hard for me to introduce in 12 minutes, but I try. First, we should choose proper indication for his bundle pacing. I mean, who is a good candidate, who is not good for his bundle pacing. We know we should place the pacing lead beyond the side block. So, intranodal AV block, okay. If the patient with infranodal heart block, it's not a good candidate because we cannot beyond his bundle. So, another condition is with level bundle bench block. For most patients, not lesion, disease, not at his bundle, but possible level bundle. So, first we should choose proper indication for his bundle pacing. Then we choose the right tools. Maybe C304 is better for his bundle pacing implantation, but I haven't experienced. Now, we choose C3015. It's popular because it's easy to perform. We should keep the deliver sheets towards the septal. And this is a flow chart for his bundle pacing implantation. I think the key technique is due leads technique to go distal, to go in, to achieve better his bundle pacing. It's very important. And during the procedure, we should test again and again why we should achieve better fixation. This is a major step for his bundle pacing lead implantation. First, how to locate his bundle. We can use his potential of pacing, his bundle pacing, but we should know what the characteristic of his bundle pacing. We should know select his bundle pacing and then we know it's true, it's successful. Then we should know distal and proximal his bundle. Usually, distal his bundle at ventricular site. Proximal at right HM side. But now, I feel maybe distal his bundle pacing with better pacing parameter, but maybe cause tricalpaling regurgitation. And this is how to locate his bundle by his potential mapping. Usually, we use pacing lead 30 to 30. In our center, we use right anterior oblique view because that is allowed to show the long axis of heart better. It's very important. We know this is right HM side and this ventricular side, so I like right anterior oblique. And also, we can use clockwise and counterclockwise to turn the deliver sheets to left bundle area, his bundle area. We usually to keep the lead inside the sheets when moving, attending the sheets significantly to avoid damage cardium or right bundle. Once his potential is identified to start the testing, then if we achieve acceptable pacing parameter, then screen. I think pacing mapping is very useful. I like pacing mapping because for example, escapement, ventricular escape, no potential. And some patient pacing dependent, but his bundle is normal. So I like to use his bundle pacing to locate his bundle. It's very useful for complicated case. And in some case, we should use mapping catheter. For example, patients with AV node ablation failed to find his potential for select secure system to shorten time, especially for beginner to map his potential. I think it's true. It's help beginner to learn quickly. And how to fix the lead? First, we should keep the lead or deliver sheets perpendicular to the septum. It's very important. If not perpendicular, when we're screwing, we'll move away and cannot screwing deeper. And we should make a little force between the lead and endocardium, and the lead steady before turning. It's very important. Usually, we set 30% pacing lead a tip or more outside, not longer, just a little. Then the pacing lead rotate clockwise by one hand or two hands. I like one hand. You can slowly or rapidly, but no more than four turns at a time. If more than, the lead will be damaged after fixation. What is good lead fixation? I think the good tissue holder is very important. And injury, current of injury is very important, especially my cardiac injury current is very important because fixation, not by his bundle, by tissue, not by his bundle. His injury current means close to his bundle. The lead is very close to his bundle. And higher pacing impedance, that indicates deep enough. I think it's important. Pacing parameters remain stable during the bond and the slag test. Very important. And the gradual declines are posed as fixation. And we can use by contrast to determine where the lead, how deep the lead. This is injury of, current of injury of local myocardium. And this is dual lead method. I think it's very, very important for much more success rate and low tissue hold. One lead for, if one lead, we use one lead, cannot get acceptable pacing parameters, then we use second lead around the first lead around. Then we can find much lower tissue hold. So, this is benefits for dual lead and PACER method. I get to know characteristics and clinical benefits of distal his bundle pacing. We, you will find distal is better. And we will understand the mechanism. And we will get more information about whether we place the lead beyond the site block. Because pacing beyond the block is very important. If not, you will higher tissue hold in the future. This is difference between supposed bundle pacing and distal bundle pacing. Distal bundle pacing have many advantage. For example, lower tissue hold, higher amplitude for sensation, and lower far-fielder atrial sensation. Yes, of course, will cause right bundle injury more often. And this is illustration to why we should place lead distal. For example, for atrial node ablation. During atrial node ablation, we should avoid damaged pacing site, especially distal conduction. So, if we place lead distal, then we have a space for atrial node ablation. Near his bundle, it's easier to ablate every node completely. So, this is a case to demonstrate how we know to place a lead beyond the site block. This is distal his bundle pacing lead. This is plausible his bundle. This is LBBB pacing lead. Potential, potential. Different interval. Yes, this is true LBBB potential. Then, distal his bundle pacing with low tissue hold. We select LBBB pacing. This is pacing from distal his bundle pacing lead. It's very clear. But this patient with AV block, do you know which the pacing site is beyond the block? Then, we use LBBB pacing. Then, we find there is a retrograde his potential with short interval. That means from distal to pacing from LBBB pacing lead to plausible his bundle, conduction is normal. So, we believe distal his bundle pacing beyond the block. It's okay. So, I think distal and deep his bundle pacing have many, many advantages compared to LBBB pacing. For example, without right bundle branch block, more physiological. And get stable and better pacing parameters compared to plausible his bundle pacing. But, of course, we know cross the track hospital will cause track hospital regurgitation. This is an NGO algorithm to show how deep the lead is. It's true. I can, but it's hard. This is his lead. I think it's more than five millimeter deep. This is a left bundle pacing lead. And the echo showed how deep the lead is. It's clear. This case illustrates during the screwing the lead, then the potential getting larger and larger. Then, we have a lower and lower threshold. It's okay. This is a rebound test. This is a slack test. During the test, the threshold should be remaining stable. And this is how to remove the delivery sheets. Okay. This is for complications. We should reship, and also we can use other guiding cassette for this condition. Last, I stressed the 4D technique is very, very useful. If we wanted to get lower threshold and accept other pacing parameters, dual lead, distal, deep, and streak demand. It means in our sense, if the patient's threshold more than 1.5 at 0.5 milliseconds, we will try again or we give up. And also, we should direct evidence of pacing lead beyond the site block. This is a complication we should be concerned. I think proper his bundle pacing indication is very, very important. We cannot use his bundle pacing for infrasample. Yes, we can try. We can try. Maybe successful his bundle capture, but it is not reliable. It is not pacing safe. Also, we should be familiar with impacting tools and his bundle anatomy. And the pacing site model will be beyond the block. Ventricular backup pacing lead is needed in patient with level bundle before his bundle implantation. Whether we should provide permanent backup of our pacing depends on where the patient is pacing dependent. Maybe distal can solve this problem. Thank you for your attention. Thank you. So, awesome talk.

His bundle pacing

dual lead method

distal His bundle pacing

lead placement

complications