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W2959273870 abstract "HomeCirculation: Arrhythmia and ElectrophysiologyVol. 12, No. 7Anatomical Considerations for His Bundle Pacing Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBAnatomical Considerations for His Bundle Pacing Venkat D. Nagarajan, MBBS, CEPS, ECDS, Siew Yen Ho, MD and Sabine Ernst, PhD Venkat D. NagarajanVenkat D. Nagarajan Department of Cardiology, Royal Brompton and Harefield Hospital (V.D.N., S.E.), Royal Brompton & Harefield NHS Trust, Imperial College London, United Kingdom Department of Cardiology, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, United Kingdom (V.D.N.). Search for more papers by this author , Siew Yen HoSiew Yen Ho Cardiac Morphology, Paediatrics (S.Y.H.), Royal Brompton & Harefield NHS Trust, Imperial College London, United Kingdom. Search for more papers by this author and Sabine ErnstSabine Ernst Sabine Ernst, PhD, Department of Cardiology, National Heart and Lung Institute, Imperial College, Royal Brompton and Harefield Hospital, Sydney St, London SW3 6NP, United Kingdom. Email E-mail Address: [email protected] Department of Cardiology, Royal Brompton and Harefield Hospital (V.D.N., S.E.), Royal Brompton & Harefield NHS Trust, Imperial College London, United Kingdom Search for more papers by this author Originally published12 Jul 2019https://doi.org/10.1161/CIRCEP.118.006897Circulation: Arrhythmia and Electrophysiology. 2019;12:e006897Over the last few decades, pacing indications have been expanded including biventricular pacing for heart failure. It is now evident that long-term right ventricular (RV) apical pacing can be deleterious to cardiac function. This has heightened the interest in alternative pacing sites, including RV septal and outflow tract. However, the results have not been as expected. More recently, His bundle pacing (HBP) has emerged as a possible alternative to RV apical pacing as it is more physiological with partial or complete recruitment of the His-Purkinje system (HPS). Unlike pacing the RV from apical, septal, or outflow tract sites, HBP targets the precise area of the septum that directly captures the conduction system. It necessitates identification of the His bundle (HB) by endocardial mapping. Therefore, sound knowledge of anatomic landmarks and a keen eye to identify local electrocardiograms are essential for the successful identification of the appropriate target site.In this review, we aim to define appropriate anatomic landmarks that would aid in HBP.Historic PerspectiveEvidence of a dedicated conduction system in the heart as being myogenic was proposed by Stannius1 in the early 19th century. Atrioventricular electrical connections were first described in the same year of 1893 separately by His2 and Kent.3 Although Sir Wilheim His described the penetrating portion of the atrioventricular conduction, he was unaware of its atrial or ventricular extensions. The sinoatrial node was described by Keith and Flack in 1907,4 following the elegant description of Tawara5 in 1906 of specialized myocytes that make up the atrioventricular conduction in its totality, including ventricular cells of Purkinje. Kaufmann and Rothberger6 first postulated the idea of functional longitudinal dissociation within the HB in 1919. This theory was later supported by James and Sherf7 in 1971 who observed that HB cells were mainly arranged longitudinally and separated by fine collagen. They further noted continuity of these cells into the left and right bundle branches (RBBs). The findings of Narula8 findings further supported this theory in 1977. He demonstrated QRS narrowing with pacing slightly distal to proximal HB in patients with left bundle branch block (BBB) and baseline prolonged HV intervals.Conduction System of the HeartNormal cardiac impulses originate from the sinus node, which is located at the junction of the superior caval vein and right atrium (RA). The sinus node is a tadpole-shaped structure which lies in the terminal groove at the anterolateral margin of the junction with its head portion in the subepicardial region. It is richly innervated with sympathetic and parasympathetic inputs and receives its blood supply via a nodal artery.9Interatrial and intra-atrial impulse conduction occurs over the major muscle bundles that make up the atrial walls, especially along with bundles where the myocytes are predominantly organized along longitudinal myocardial strands, for example, surrounding the tricuspid valve (TV), limbus of fossa ovalis, and the crista terminalis. Similarly, Bachmann bundle connects the RA activation across the anterior interatrial groove to the left atrium.The atrioventricular conduction system includes an atrial component which is the compact atrioventricular node that resides in the interatrial position although the landmarks for the triangle of Koch are on the endocardial surface of the RA (Figures 1 and 2). The compact atrioventricular node is about 5 mm long and wide and nearly 1 mm thick.10 It is composed of specialized cells which differ histologically from cells in the transitional zone and surrounding atrial myocardium (Figure 2). From its position near the apex of the Koch triangle, the nodal body extends posteroinferiorly toward the triangle’s base marked by the orifice of the coronary sinus (CS). The inferior part of the node bifurcates into 2 extensions or prongs which are implicated in slow pathway conduction. The atrioventricular nodal artery is usually found in the area between these 2 extensions. The atrioventricular node primarily acts as an electrical filter delaying the conduction between atria and ventricles, facilitating atrial contraction and ventricular filling. Atrial electrical activity is channeled into the central compact atrioventricular node via its outer zone comprising of transitional cells and connective tissue. This is a zone of very slow conduction with conduction velocities around 0.01 to 0.05 m/s.Download figureDownload PowerPointFigure 1. Location of the triangle of Koch in human heart specimens.Left shows the macroscopic findings in a quasi right anterior oblique (RAO) position. Please note this special preparation with removed endocardial surface to illustrate the fiber orientation of the atrial myocardium and the conduction system superimposed (red shapes). This figure demonstrates the Koch triangle with its components of the tendon of Todaro, coronary sinus (CS) ostium and septal leaflet of the tricuspid valve (TV). Note the atrioventricular (AV) and interventricular (IV) components of the membranous septum and their relation to annulus of the septal leaflet of TV. Right shows 3 examples of variations in TV tissue and the annulus (black broken line) at the membranous septum (blue dotted line). The IV membranous septum is mostly covered by leaflet tissue that can be lifted up from underneath (top), partly covered by aneurysmal TV tissue (middle), and with adherent valvar tissue (bottom) leaving a gap in the valvular closure line. Red dot and broken line represent the location of AV node (AVN) and bundle. EV indicates Eustachian valve; and SCV, superior caval vein.Download figureDownload PowerPointFigure 2. Atrioventricular (AV) conduction system. The left panel shows a schematic of the atrial and ventricular components. The right schematic Schematic of the AV conduction system with depiction of atrial and ventricular components (left). Right demonstrate the histological sections at 5 levels from the branching bundle to the inferior extensions of the compact AV node (AVN). Level 4 shows the transition from AVN to His (*). Note the sandwich configuration of the AV septum between the mitral valve (MV) and tricuspid valve (TV) hinges. Masson trichrome stain coloring myocardium in red and fibrous tissue in green. Ao indicates aortic valve; CFB, central fibrous body; CS, coronary sinus; EV, Eustachian valve; LBB, left bundle branch; PB, penetrating bundle; RBB, right bundle branch; and ToT, Tendon of Todaro.Although the location of Koch triangle is commonly perceived to be on the atrioventricular septum, this part of the heart is not truly septal.11 Position wise, it separates the RA from the left ventricle (LV) owing to the more apical hinge line or annulus of the TV relative to the mitral valve. This part of the heart is where the atrial walls overlie the deep ingress of epicardial tissues from the inferior atrioventricular groove known as the inferior pyramidal space10 (Figure 2). The epicardial tissues represent the filling between the muscle of the atrial walls and ventricular septum in the sandwich that is the so-called atrioventricular septum.12 The pyramid, with the central fibrous body (CFB) at its apex, ensures the atrioventricular node is completely insulated from ventricular tissues other than via the HB (also known as the penetrating atrioventricular bundle). The CFB comprises of the right fibrous trigone together with its adjoining membranous septum of the heart (Figure 3). The trigone is a dense accretion of fibrous tissue at the extreme right end of the region of fibrous continuity between the aortic and mitral valves that extends rightward to link with the hinge line of the septal leaflet of the TV. The tendon of Todaro inserts into it at the apex of Koch triangle.Download figureDownload PowerPointFigure 3. Heart dissections to demonstrate the spatial relationship of the cardiac chambers.A and B, The right and left ventricular (RV and LV) aspects respectively of the membranous septum (blue dotted line) and the right fibrous trigone (black dotted line). The latter is the thickest component of the central fibrous body. C, The 4-chamber cut through the heart that profiles the atrioventricular (AV) component of the membranous septum. Close-up view in (D) shows the relationship between the membranous septum and the right fibrous trigone. Red broken line marks the course of the AV bundle and the right bundle branch in the septomarginal trabeculation (SMT) in (A), and the AV bundle with left bundle branch in (B). Ao indicates aortic valve; LA, left atrium; MV, mitral valve; RA, right atrium; RVOT, right ventricular outflow tract; and TV, tricuspid valve.Pertinent to this review is the definition of HB. Although His described a muscular continuity between atria and ventricles, it was Tawara who demonstrated in 1906 the connection of this bundle to the atrioventricular node proximally and to the branching bundle distally to form the histologically specialized conduction system. He also noted the system is enclosed in an insulating fibrous sheath extending through the subendocardium before joining with the ventricular Purkinje cells that ramified within the apical parts of both ventricles. As defined by Tawara,5 the atrioventricular node becomes the HB at the point where the conduction tissues become surrounded by the tissues of the CFB (Figure 2). In the description of Tawara, the HB could be interpreted as that part of the conduction system that lies between the atrioventricular node and the bifurcating atrioventricular bundle. In the later decades of the last century, however, the HB was also termed the penetrating bundle. As such, according to Kurosawa and Becker,13 the most distal point of the penetrating bundle is defined by the first section in which the bundle is positioned on the crest of the ventricular septum and no longer fully encapsulated by fibrous tissue of the CFB (Figure 2). Be that as it may be, the atrioventricular bundle varies from almost circular to triangular shape in cross section.Histologically, the interweaving nodal cells become oriented predominantly longitudinally in more parallel fashion with few cross connections in the atrioventricular bundle. James and Sherf7 observed thin septa of fibrous tissue separating some of these longitudinal sub-bundles and suggested they could account for longitudinal and rapid atrioventricular conduction. Indeed, some sub-bundles may appear predestined to the left or the RBB (Figure 4A). A histological study on 17 postmortem adult hearts showed the penetrating bundle to be 2.3+0.4 mm long, 1.1+0.3 mm thick, 7.3+1.2 mm wide, and at a distance of 0.5+0.2 (0.1–1.1) from the endocardial surface of the RA.10 It has dual arterial supply receiving both from the atrioventricular nodal artery and the first septal branch of left anterior descending artery.14Download figureDownload PowerPointFigure 4. Histological step sections from 3 hearts cut in similar plane to those depicted in Figure 2 stained similarly with Masson trichrome stain. These show variations in depths of the His and atrioventricular (AV) bundle (*) from the endocardial surface of the right ventricle (RV). A, From a 24-y-old male. A1, The last part of the compact AV node (AVN; blue arrows) and the extension of the conduction tissues leftward into the right fibrous trigone (or central fibrous body [CFB]). A2, The His bundle is located on the left ventricle (LV) side of the septal crest. A3, The branching bundle is astride the septal crest, immediately adjacent to the MS. Note the prominent fibrous septa (green colored tissue) within the His and the branching bundle that separate the conduction bundle longitudinally into smaller aggregates. B, From a 15-y-old male. B1 and B2, The nodal-bundle axis is leftward into the CFB, resulting in a left-sided His bundle. B3, The branching bundle is to the left of the septal crest, some distance from the RV endocardium, and remains adjacent to the MS. C, An adult heart. C1, The His bundle is on the right. C2, The bundle is on the septal crest adjacent to the MS. C3, The branching bundle is on the left side of the septum but no longer adjacent to the membranous septum which has an irregular border. Muscle of ventricular septum (S) interposes between MS and bundle. LBB indicates left bundle branch; MS, membranous septum; RA, right atrium; RBB, right bundle branch; ToT, Tendon of Todaro; and TV, tricuspid valve.Emerging from the thick fibrous trigone/CFB the conduction bundle is still encased in a fibrous sheath as it continues in an antero-cephalad direction either staying on the right side or more often it shifts leftward to be related to the left side of the ventricular septal crest.15 In most normally structured hearts, the HB begins to branch as soon as it emerges from the ventricular side of the CFB. In other hearts, there is a nonbranching segment of this atrioventricular bundle before it bifurcates. This segment is considered the nonpenetrating part of the HB.16 It is usually sandwiched between the membranous septum and the muscular septal crest. Owing to its location, the hinge line of the septal leaflet of the TV runs across the membranous septum and divides it into 2 components (Figures 1 and 3). There is a pretricuspid atrioventricular component that separates the RA from the LV and a post-tricuspid interventricular component. The latter component may be covered by valve tissues or there may be a gap in the leaflet (Figure 1). Anatomic studies have described variations in the course of the atrioventricular bundle such as passing within the membranous septum or in the septal musculature several millimeters below the membranous septum.13,15 We demonstrate in Figure 4 some variations as seen in histological sections from 3 random heart specimens. There are differences in distances from the endocardial surface of the RA, course within the right fibrous trigone and course relative to the membranous septum and muscular septum. Using mainly gross dissections, Kawashima and Sasaki17 described 3 distinct locational variations in atrioventricular bundle course including the commonest one along the lower border of the membranous part of the ventricular septum under a thin layer of ventricular myocardium, a course extending from lower border of the membranous septum into the muscular ventricular septum, and the third and the least common location being immediately subendocardial on membranous septum superficially which they described as a naked atrioventricular bundle.Descending from the branching bundle, the left bundle branch takes an immediate subendocardial course on the left septal aspect whereas the RBB usually takes a short intramuscular course within the septum before it emerges in the subendocardium of the RV at the base of the medial papillary muscle. The bundle branches remain covered by a fibrous sheath electrically insulating them from surrounding septal musculature and thereby allowing for fast conduction. The left bundle often trifurcates into 3 fascicles with interconnections which further ramify extensively toward the ventricular apex and also extend into the 2 groups of papillary muscles of the mitral valve as well as the ventricular walls toward the cardiac base. In the RV, the RBB continues superficially in the subendocardium of the septomarginal trabeculation, below the medial papillary muscle, and further divides distally before reaching the RV apex. From the septum, it also gives a branch which courses within the moderator band to continue into the RV free wall and subpulmonary outlet. Fascicles finally lose their fibrous sheaths as they extensively ramify into peripheral conduction network referred to as the Purkinje fibers.How to Find the HB?The bundle (HB) can be accessed both at atrioventricular and interventricular regions of the membranous septum at the level of tricuspid annulus (TA). The interventricular portion of the membranous septum may be covered over by the septal leaflet, but it is not uncommon to find a bare membranous septum, with the septal leaflet showing a gap (Figure 1).18 The commissure between septal and anterosuperior TV leaflets is supported by the medial papillary muscle (a small out budding from the septum). Traditionally, electroanatomic mapping of the His region is performed in an electrophysiology lab using a multipolar catheter or sequential electroanatomical mapping (Figure 5). The catheter is usually introduced via the femoral vein and inferior caval vein into RA. Using a right anterior oblique projection, the catheter is advanced across the TV and stabilized with a clockwise rotation which abuts the catheter tip against the membranous septum and also aids in anchoring the catheter in the fold of the TV. Alternatively, using a nonsteerable multipolar catheter (His/RV catheter) with distal electrodes in the RV helps to stabilize the catheter position.Download figureDownload PowerPointFigure 5. Tracking the various components of the conduction system by recording bipolar electrograms.Left: Spatial depiction of the right-sided conduction system demonstrated by intracardiac signals from 3-dimensional electroanatomical mapping along the septum. Please note the timing between the high-frequency local signal and the onset of the QRS complex on the surface electrocardiograms in right anterior oblique (RAO). Right: Postero-anterior (PA) projection of the AO and left ventricle (LV). The green tags localize sites with intervals beyond 35 ms and the yellow tags with shorter intervals, pink tags demonstrated the high-frequency signal after the onset of the surface QRS complex. LA indicates left atrium; RA, right atrium; and RV, right ventricle.Approaching the RA from a subclavian or axillary vein would necessitate a counter-clockwise torque for the catheter to achieve a stable HB position.When mapping for HB, the following structures may be encountered and these can be identified by local intracardiac signals (Figures 5 and 6). TV annulus could be recognized by large atrial and ventricular signals, which are approximately of equal size. Moving either side of the annulus would decrease the amplitude of one of the 2 signals, being far field before they completely disappear depending on the cardiac chamber being mapped. Pacing at the TV annulus may result in capture of either or both of the cardiac chambers.Download figureDownload PowerPointFigure 6. Comparison of gross anatomical sites, fluoroscopy and electrogram findings in a case of His bundle (HB) pacing.Left shows the macroscopic findings of right atrium (RA) and right ventricle in a quasi right anterior oblique (RAO) position. Depicted in this image are region of HB (1), peri-Hisian regions (2-more towards atrial side; 3-towards ventricular side), coronary sinus (4), region of slow pathway (5), and tricuspid annular region (6). Middle depicts fluoroscopic image in RAO (above) and left anterior oblique (LAO) below. The right represents unipolar sensed signals from HB pacing (HBP) lead via the Pacing System Analyzer (PSA) while mapping for HB region. Note the sharp HB potential between atrial and ventricular signals in the region of HB (1). Electrograms (EGMs) from peri-Hisian region on ventricular aspect (3) appear very similar to the HB region except for the absence of His signal. Pacing from this region resulted in left bundle branch block (LBBB) morphology with pseudo delta wave. Pacing from peri-Hisian region on the atrial aspect (2) did not result in ventricular capture. Note EGMs from coronary sinus (CS) region show large atrial and far-field ventricular signals and the reverse in the case for the slow pathway region (no slow pathway potentials are seen in this trace; 5). Tricuspid annular signals (6) show prominent atrial and ventricular signals of almost equal amplitude.Moving from TV annulus towards the septal region posteriorly, the area of Koch triangle is encountered. At the center of Koch triangle is the atrioventricular nodal region; atrial and ventricular endocardial signals are again seen. Pacing at this region can capture atrioventricular node and hence conduction system distally, resulting in ventricular activation that is identical to native His-Purkinje activation. However, incremental pacing in this region would show decremental ventricular conduction and may result in Mobitz type 1 block at higher rates. Atrial sensing and capture during pacing can occur in this region.At the base of the Koch triangle is the region of slow pathway which can be identified by a small atrial far-field signal, relatively larger ventricular signal and a low amplitude slow pathway signal may be seen between atrial and ventricular signals. Pacing in this region would result in ventricular and atrial capture and a decremental atrioventricular conduction at higher rates may also be seen.The ostium of the CS is located posteroseptally to the region of slow pathway and is identified by a large atrial and a small ventricular far-field signal. Pacing at this region would usually result in atrial capture. The CS is also identified on fluoroscopy by the movement of the catheter towards the left heart (catheter crosses the midline septal region across onto the left side in a left anterior oblique 40 degrees fluoroscopic view).Moving anterosuperiorly from the base of the Koch triangle towards the septum (with an anticlockwise torque on the catheter when approaching superiorly from the subclavian vein), is the region of the fast pathway approaching towards the apex of the Koch triangle. The regional electrograms show atrial and ventricular signals that are almost of equal size and a far-field His signal may also be seen. Pacing from this region can the capture conduction system directly and can result in ventricular activation similar to the native His-Purkinje conduction but would still demonstrate decremental atrioventricular nodal properties resulting in atrioventricular block at higher rates.The zone of transition between atrioventricular node and HB is encountered when the catheter is manipulated towards the junction of septum and TA (best done in right anterior oblique fluoroscopic view). Because the TV is more apically placed than the mitral valve, this area of the septum above the TA is often referred as the atrioventricular membranous septum between the right atrial and LV chambers. This is the region of the proximal HB. Atrial, ventricular, and near-field His signals are seen while mapping in this region. The H-V interval in the adult population is usually in the range between 35 and 55 ms and may be shorter in the pediatric population.19,20 Pacing from this region can selectively capture conduction system (HB) resulting in paced ventricular activation identical to native HBP conduction. Decremental conduction properties of the atrioventricular node are not seen with HB pacing. However, peri-Hisian (nonselective) pacing with direct ventricular myocardial capture at low outputs may not be feasible in this region because of paucity of ventricular myocardium in this part of the membranous septum.Mapping more ventricularly from this site encounters the interventricular membranous septal region just below the TV through the commissure between septal and anterosuperior TV leaflets; showing distal HB signals with small far-field atrial signals and near-field His and ventricular signals. Pacing here would result in direct (selective) conduction system capture with ventricular activation along the HBP system. Peri-Hisian (nonselective) pacing from this site would be possible at high output with direct capture of ventricular myocardium along with the HB capture resulting in ventricular fusion complexes on 12 lead ECG showing similar QRS concordance when compared with the native QRS. Pacing in slightly adjacent areas to this region of membranous septum could result in direct ventricular myocardial activation at low outputs and conduction system capture at high pacing outputs.Apical to this area along the membranous septum is the crest of the muscular interventricular septum where the distal HB branches into the RBB and the left bundle branch. In this region, a high-frequency signal in front of the ventricular complex is seen and could represent an HB signal or alternatively RBB signal. Atrial far-field signals are rarely seen in this region. The RBB signal is differentiated from HB by its interval to earliest ventricular activation usually being <30 ms. Pacing at this site would selectively capture the RBB and would result in left BBB pattern on surface ECG. It has also been recognized that pacing in this region at high outputs can also retrogradely capture left bundle via septal branch in addition to the RBB resulting in narrow QRS morphology on surface ECG.21,22The atrioventricular septum representing the proximal HB and distal HB at the membranous interventricular septum just below the TV are preferred sites for HB pacing. At these sites, selective conduction system capture can be ensured at the lowest possible pacing output. The membranous interventricular septum has the additional advantage of consistent peri-Hisian pacing (nonselective) because of the presence of adjacent RV myocardium. Pacing at both these sites is feasible without affecting TV function as the membranous atrioventricular septum is proximal to the free and mobile TV leaflets, and distal HB regions can be reached via the commissure between the free septal and anterosuperior leaflets (Figure 4).Possible difficulties in catheter manipulation stem from many reasons including abnormal anatomy, such as right atrial dilatation, excessive trabeculations in the RV, displacement of the TV valve apparatus, and abnormal position of the moderator band. The close proximity of the TV apparatus to the area of interest can sometimes restrict catheter mobility.HB PacingEarly Reports on HB PacingHB recordings in humans have been made for over past 6 decades.23 Narula was the first to demonstrate feasibility of HBP in 1970.24 A multipolar catheter was used to record HB signals just above the septal leaflet of the TV at the membranous septum. However, it was not till the year 2000 that Deshmukh et al25 successfully implanted HB permanent pacing systems in humans. The HB location was mapped using multipolar electrophysiology catheter introduced via the femoral vein. A conventional screw in pacing lead with a fixed nonretractable helix measuring 1.5 mm (with a quickly dissolving mannitol coating) was then sited at this location using a modified J shaped stylet with a secondary distal curve. They implanted HBP leads in a cohort of patients with cardiomyopathy and atrial fibrillation with narrow QRS. HBP improved LV ejection fraction (EF) with reduction of LV dimensions.The authors noted that a slight advancement of the pacing helix into the septum often yielded significantly lower pacing thresholds and concluded that 1.5 mm helix is inadequate in its ability to sufficiently penetrate the membranous septum.Feasibility of permanent HBP (PHBP) in patients with an infra-Hisian block was first demonstrated in 2006.26 Patients with infra-Hisian block, ventricular dyssynchrony, no CS access, and narrow QRS complex with temporary HBP were selected. HBP lead implantation was successful in 5 of 7 patients. An additional RV lead was also sited. HBP and RV leads were connected to LV and RV ports of a biventricular pacemaker generator, respectively, and device programmed to dual chamber pacemaker mode with HBP preceding RV pacing by 80 ms. The study demonstrated that LV dyssynchrony disappeared with HBP.Catanzariti et al27 demonstrated improved indices of LV dyssynchrony, reduced MR, and improved LVEF with HBP compared with acute RV apical pacing. These benefits were seen both with Hisian (selective HBP) and para-Hisian pacing (nonselective HBP). These findings were further supported by a subsequent study by Zanon et al28 who also demonstrated improved coronary perfusion with HBP compared with RV apical pacing and Occhetta et al29 who also demonstrated additional benefits of improved New York Heart Association (NYHA) class, exercise tolerance and quality of life scores with HBP (nonselective) compared with RV apical pacing.In a r" @default.
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W2959273870 title "Anatomical Considerations for His Bundle Pacing" @default.
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