Electrophysiologic Insights Into Site of Atrioventricular Block
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Objectives This study sought to report the feasibility of permanent His bundle pacing (HBP) in patients with advanced atrioventricular block (AVB) and electrophysiological observations into site of block in patients with infranodal AVB.Background HBP is a physiological alternative to right ventricular pacing. Historic studies have reported a low incidence of intra-His AVB. Recent studies of permanent HBP reported limited success in patients with infranodal AVB.Methods Consecutive patients with advanced AVB underwent permanent HBP using Medtronic 3830 lead (Minneapolis, Minnesota) and a fixed-shaped catheter (C315 His). The HB was mapped using unipolar recording from the lead tip or by pace mapping. Success of HBP, type of AVB, and pacing outcomes were documented. Patients were followed at 2 weeks, 2 months, and then yearly.Results A total of 100 patients with advanced AVB (age 75 ± 12 years; male 62%; AV nodal 46%; infranodal 54%) underwent permanent HBP. HBP was successful in 84 patients (84%; AV nodal 93%, infranodal 76%). Mean procedure time was 71 ± 21 min, mean fluoroscopy time was 11 ± 6 min. Baseline QRS duration was 122 ± 27 ms; paced QRSd was 124 ± 22 ms. The HB pacing threshold at implant, 2 weeks, 2 months, and last follow-up (19 ± 12 months; range: 6 to 46 months) was 1.3 ± 0.9 V, 1.6 ± 1.0 V, 1.6 ± 1.1 V, and 1.7 ± 1.0 V at 0.5 ms, respectively. Five patients required lead revision.Conclusions Permanent HBP was successful in 84% of unselected patients with AVB. His-Purkinje conduction could be normalized in 76% of patients with infranodal block, suggesting intra-His block. Incidence of infra-His AVB was low (24%) in this series. Routine HBP in patients with AVB is feasible and safe for at least up to 18 months.
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It is often difficult to distinguish nodal from infranodal AVB using surface ECG alone, particularly when these conditions coexist.
“As is very well known, complete AVB does not necessarily imply an infranodal origin, and it is often difficult to distinguish nodal from infranodal AVB using surface ECG alone, particularly when these conditions coexist [21].”
From Clinical Significance and Management of Atrioventricular Block Associated With Bradycardic/Antiarrhythmic Drug Therapy: Drug-Induced or Drug-Revealed? (2025) · cites this paper as [21]
The “AV Nodal Versus Infranodal Block” section describes using His-bundle electrograms to identify the site of block, supporting the point that a surface ECG alone may not settle it. The passages do not address whether nodal and infranodal block coexist or whether distinguishing them is particularly difficult when they do. (LLM, conf=0.78)
Experimental — accuracy not yet measuredComplete AVB does not necessarily imply an infranodal origin.
“As is very well known, complete AVB does not necessarily imply an infranodal origin, and it is often difficult to distinguish nodal from infranodal AVB using surface ECG alone, particularly when these conditions coexist [21].”
From Clinical Significance and Management of Atrioventricular Block Associated With Bradycardic/Antiarrhythmic Drug Therapy: Drug-Induced or Drug-Revealed? (2025) · cites this paper as [21]
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Self-citationJCS/JHRS 2021 Guideline Focused Update on Non-Pharmacotherapy of Cardiac Arrhythmias
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Approach to permanent His bundle pacing in challenging implants
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Self-citationAnatomical Considerations for His Bundle Pacing
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Long-Term Results of His Bundle Pacing
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Self-citationLeft bundle branch pacing utilizing three dimensional mapping
Vijayaraman, P., Panikkath, R., Mascarenhas, V., & Bauch, T. D. (2019) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.14242 · Cited by 38 · see citing works
Self-citationHis-Purkinje Conduction System Pacing in Atrioventricular Block
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Mid-term feasibility, safety and outcomes of left bundle branch pacing–single center experience
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Permanent His Bundle Pacing Implantation Facilitated by Visualization of the Tricuspid Valve Annulus
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How to Implant His Bundle and Left Bundle Pacing Leads: Tips and Pearls
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Self-citationZanon, F., Marcantoni, L., Zuin, M., Pastore, G., Baracca, E., Tiribello, A., Raffagnato, P., Boaretto, G., Roncon, L., & Vijayaraman, P. (2020) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.14366 · Cited by 27 · see citing works
Self-citationZheng, R., Wu, S., Wang, S., Su, L., Ellenbogen, K. A., & Huang, W. (2021) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2021.744079 · Cited by 27 · see citing works
Self-citationGuía ESC 2021 sobre estimulación cardiaca y terapia de resincronización
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His-bundle pacing is the best approach to physiological pacing
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Physiology of Left Ventricular Septal Pacing and Left Bundle Branch Pacing
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Clinical outcomes of His‐Purkinje conduction system pacing
Muthumala, A. G., & Vijayaraman, P. (2020) · Pacing and Clinical Electrophysiology · doi:10.1111/pace.14050 · Cited by 19 · see citing works
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Self-citationHis-bundle pacing: impact of social media
Beer, D. A., Dandamudi, G., Mandrola, J. M., Friedman, P. A., & Vijayaraman, P. (2019) · EP Europace · doi:10.1093/europace/euz169 · Cited by 19 · see citing works
Self-citationNon-selective His bundle pacing with a biphasic waveform: enhancing septal resynchronization
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Self-citationSafety of Distal His Bundle Pacing Via the Right Ventricle Backed Up by Adjacent Ventricular Capture
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His Bundle Pacing in the Era of Left Bundle Branch Pacing
Jastrzębski, M., Huang, W., Vázquez, P. M., & Vijayaraman, P. (2025) · Arrhythmia & Electrophysiology Review · doi:10.15420/aer.2024.31 · Cited by 15 · see citing works
Self-citationCurrent developments in cardiac rhythm management devices
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Physiologic Pacing Targeting the His Bundle and Left Bundle Branch: a Review of the Literature
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Left bundle branch pacing: An evolving site for physiological pacing
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Pacing of Specialized Conduction System
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Electrical characteristics of pacing different portions of the His bundle in bradycardia patients
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Long-Term Outcomes and Safety of His-Purkinje Conduction System Pacing in China
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Left Bundle Branch Pacing: A Perfect Compromise?
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Permanent His‐Bundle Pacing: Case Studies
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Self-citationSelective Versus Nonselective His Bundle Pacing
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Self-citationConduction System Pacing: Hope, Challenges, and the Journey Forward
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2025 Clinical practice guidelines for Bradyarrhythmias and conduction disorders
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Self-citationCurrent Role of Conduction System Pacing in Patients Requiring Permanent Pacing
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Effects of Rhythm and Rate-Controlling Drugs in Patients With Permanent His-Bundle Pacing
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- Authors
- Vijayaraman, P., Naperkowski, A., Ellenbogen, K. A., & Dandamudi, G.
- Affiliations
- Geisinger Wyoming Valley Medical Center (US)
- Virginia Commonwealth University (US)
- Corresponding author
- Vijayaraman, Pugazhendhi
- Venue
- JACC: Clinical Electrophysiology
- Publisher
- Elsevier BV
- Published
- 2015-12
- Volume
- 1
- Issue
- 6
- Pages
- 571-581
- ISSN
- 2405-500X (ISSN-L)
- OpenAlex
- W2177929870
- Cited by
- 173
- References
- 53
- Citations by year
- 2026: 5 · 2025: 4 · 2024: 14 · 2023: 19 · 2022: 16 · 2021: 31 · 2020: 22 · 2019: 27 · 2018: 15 · 2017: 10 · 2016: 9 · 2012: 1
- FWCI
- 8.31
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- JACC. Clinical electrophysiology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- St. Jude Medical
- Boston Scientific Corporation
- Medtronic
- Biotronik
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Keywords
- atrioventricular block, pacing threshold
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