Jeffrey L. Anderson, MD, FACC, FAHA, Chair 

Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect 

Nancy M. Albert, PhD, RN, FAHA

Biykem Bozkurt, MD, PhD, FACC, FAHA

Ralph G. Brindis, MD, MPH, MACC

Mark A. Creager, MD, FACC, FAHA[#][1]

Lesley H. Curtis, PhD, FAHA

David DeMets, PhD[#][1]

Robert A

/pdf/2014-aha-acc-hrs-guideline-for-the-management-of-patients-1v8ficsqox.pdf

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society

Preamble 2072

1. Introduction 2074

2. Clinical Characteristics and Evaluation of AF 2076

3. Thromboembolic Risk and Treatment 2077

4. Rate Control: Recommendations 2079

5. Rhythm Control: Recommendations 2080

6. Specific Patient Groups and AF: Recommendations 2086

7. Evidence Gaps and Future Research Directions 2089

References 2090

Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 2095

Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 2097

Appendix 3. Initial Clinical Evaluation in Patients With AF 2104

The medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized …

/pdf/2014-aha-acc-hrs-guideline-for-the-management-of-patients-4kflhgi5zh.pdf

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary

https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000628

2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society

Background—Direct His-bundle pacing (DHBP) produces synchronous ventricular depolarization and improved cardiac function relative to apical pacing. Although it has been performed transiently in the electrophysiology laboratory and persistently in open-chested canines, permanent DHBP in humans has not been achieved. Methods and Results—A total of 18 patients aged 69±10 years who had a history of chronic atrial fibrillation, dilated cardiomyopathy, and normal activation (ie, QRS≤120 ms) were screened for permanent DHBP using an electrophysiology catheter. In 14 patients, the His bundle could be reliably stimulated. Of these 14, permanent DHBP using a fixed screw-in lead was successful in 12 patients. Radiofrequency atrioventricular node ablation was performed in patients exhibiting a fast ventricular response. All patients received single-chamber rate-responsive pacemakers. Acute pacing thresholds were 2.4±1.0 V at a pulse duration of 0.5 ms. Lead complications included exit block requiring reoperative adju...

Permanent, Direct His-Bundle Pacing A Novel Approach to Cardiac Pacing in Patients With Normal His-Purkinje Activation

Alexis A. Topjian, MD, MSCE, Chair; Tia T. Raymond, MD, Vice-Chair; Dianne Atkins, MD; Melissa Chan, MD; Jonathan P. Duff, MD, Med; Benny L. Joyner Jr, MD, MPH; Javier J. Lasa, MD; Eric J. Lavonas, MD, MS; Arielle Levy, MD, Med; Melissa Mahgoub, PhD; Garth D. Meckler, MD, MSHS; Kathryn E. Roberts, MSN, RN; Robert M. Sutton, MD, MSCE; Stephen M. Schexnayder, MD; On behalf of the Pediatric Basic and Advanced Life Support Collaborators

https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000916

Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This study describes a new method (NM) for estimation of sinoatrial conduction time (SACT), which utilizes constant atrial pacing (AP) instead of the premature atrial beats (PABs) used in the method reported in 1973 by Strauss et al. The SACTs were obtained by both methods in 20 patients. The SACT by the Strauss method (SM) was calculated as A2A3 minus A1A1. The NM consists of high right AP for a train of eight consecutive beats at rates less than or equal to 10 beats/min faster than the sinus rhythm. The interval between the last paced atrial electrogram (Ap) and the first escape atrial electrogram (A) of sinus origin (Ap-A) was measured along with several post pacing sinus cycles. The SACT by the NM was calculated as follows: SACT = Ap-A minus A1A1. The effect of AP at higher rates was also analyzed. In two patients, the SACT with the SM could not be defined, as all the A2A3 intervals were fully compensatory; with the NM the SACT was 217 and 320 msec. In the remaining 18 patients the SACT was obtainable by both methods. With SM, the SACT ranged 105--452 msec (mean 219 +/- 102 SD) and with the NM it was 85--492 msec (mean 201 +/- 112 SD), and the difference was statistically significant (P = 0.0162). The coefficient of correlation between the two methods was r = 0.97. During AP at faster rates, a rate related increment in Ap-A intervals and also post pacing sinus cycles was noted. This study describes a new and simple method for measurement of SACT in man.

A new method for measurement of sinoatrial conduction time.

Atrioventricular block: Localization and classification by his bundle recordings

Fourteen patients with conduction defects were analyzed by using bundle of His (BH) recordings. The BH electrograms were validated by BH and right atrial pacing (AP). In 12 patients with Mobitz type II A-V block, failure in impulse transmission for the dropped beats was localized distal to the recording site of the BH. Three of these 12 patients showed normal QRS complexes. In two of these three, the QRS complexes remained unchanged during intermittent periods of complete heart block (CHB), and thus represent His bundle rhythm with subsidiary pacemaker arising above the bifurcation of the BH. The A-H time in this group of 12 patients ranged from 60 to 160 msec and the H-V time ranged from 40 to 90 msec. At any atrial rate (NSR or AP) conduction time through the A-V node (A-H), and His-Purkinje system (H-V) remained constant. With increasing atrial (A) rates during AP, the number of impulses blocked distal to the BH increased. At high AP rates Wenckebach phenomenon between A and BH occurred concomitantly w...

Wenckebach and Mobitz Type II A-V Block Due to Block Within the His Bundle and Bundle Branches

His bundle electrograms were recorded in 20 patients. Conduction times from atrium to His bundle (A-H time) and His bundle to ventricle (H-V time) were measured and the sites of delay or block were localized to the proximal or distal A-V junction. On progressively increasing the atrial rate by atrial pacing, the A-H time lengthened, while the H-V time remained constant. Premature atrial beats usually resulted in prolongation of the A-H time only. In some instances, premature atrial beats also resulted in prolongation of the H-V time and aberrant ventricular conduction (change in configuration of the QRS complex). In patients with first degree heart block during sinus rhythm the A-H time was prolonged and the H-V time was either normal or prolonged. In higher degrees of heart block, the block was localized either in the proximal or distal A-V junction.

Localization of A-V conduction defects in man by recording of the his bundle electrogram

His bundle electrograms were recorded and A-V junction pacing was achieved in 30 patients by a pervenous electrode catheter technic. His bundle pacing was achieved in 26, and A-V node pacing in five patients. Conduction time from atrium to the His bundle (A-H time) and His bundle to ventricular activation (H-V time) were measured. During His bundle pacing, the pacing impulse to ventricular activation time (PI-R) was the same as the H-V time during normal sinus rhythm and remained constant at different pacing rates. With A-V node pacing, the PI-R interval was shorter than the conduction time from atrium to the ventricle (sum of the A-H and the H-V time) but longer than the H-V time, and there was progressive lengthening of PI-R interval, with increase in pacing rates. The QRS complex remained unchanged in all ECG leads with BH and A-V node pacing from that during normal sinus rhythm. During BH pacing, the retrograde Wenckebach phenomenon was demonstrated. Bundle of His pacing was used to establish a His bundle rhythm in a patient with complete heart block localized within the His bundle. BH pacing is of value for validation of His bundle electrograms and differentiation from that of right bundle branch. Clinically, this technic has proved extremely useful in definitive diagnosis of bilateral bundle-branch block in patients with right bundle-branch block and left axis deviation and infarction.

Onkar S. Narula

Papers

A new method for measurement of sinoatrial conduction time.

Atrioventricular block: Localization and classification by his bundle recordings

Wenckebach and Mobitz Type II A-V Block Due to Block Within the His Bundle and Bundle Branches

Localization of A-V conduction defects in man by recording of the his bundle electrogram

Pervenous Pacing of the Specialized Conducting System in Man His Bundle and A-V Nodal Stimulation