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His‐purkinje conduction system pacing in atrial fibrillation and heart failure: A virtual dream coming true

Previous investigations have demonstrated that AF and HF coexist in approximately 30% of patients.1 A large proportion of these patients have pacemaker indications, including AF with symptomatic bradycardia, AF with atrioventricular node (AVN) ablation, AF and HF with left bundle branch block (LBBB), and AF with an ICD indication. For patients with atrioventricular block (AVB) and left ventricular ejection fraction (LVEF) 36−50%, physiological pacing with either CRT or HPCSP should be considered to prevent HF.2 However, in cases with AF and HF requiring ventricular pacing, it is unknown whether HPCSP is superior to BVP. In this issue of PACE,3 Ying xue Dong and colleagues report a comparison of HBP versus BVP in bradyarrhythmia patients with AF and low LVEF. As expected, the results showed that both HBP and BVP improved clinical HF and echocardiographic remodeling, while these improvements were more obvious in the HBP group than that in BVP group. However, the sample size is relatively small, and it is a nonrandomized retrospective study. Previous studies4–8 have confirmed the feasibility and efficacy of HPCSP in patients with AF and AVN ablation. These studies demonstrated that permanent HBP with AVN ablation leads to significant improvement in cardiac function in AF patients with narrow QRS who suffered from HF with preserved or reduced ejection fraction. In addition, study9 has confirmed the efficacy of HPCSP in patients with a wide QRS and narrow QRS. The result show that HPCSP with AVN ablation benefits patients with LBBB by improving LVEF and NYHA class function more than patients with narrow QRS. For patients with AF and ICD indications, AVN ablation combined with HPCSP does not only improve cardiac function, but also reduces the incidence of inappropriate shocks.8 2 THE IMPACT OF AF ON ELECTRICAL SYNCHRONY OF HPCSP AND BVP