Treatment of atrial fibrillation with third-degree atrioventricular block by pacing His bundle and left bundle branch

Substantial advances in cardiac pacing technology have been developed in the past decades. However, efforts to improve pacing technology to achieve physiological electrical activity, such as with cardiac resynchronization therapy, are underway. Permanent His bundle pacing, which directly stimulates the His-Purkinje network and electrically activates both ventricles, simulates physiological electric activity in the heart, and has been considered an ideal pacing strategy to treat arrhythmias. For patients with atrial fibrillation complicated by third-degree atrioventricular block (AVB), permanent His bundle pacing is a better option than conventional right ventricular apical or septal pacing, the latter of which may be associated with risks, such as heart failure. However, His bundle pacing exhibits some shortcomings, including elevated pacing threshold, dislocation, and abnormal sensing.A 69-year-old female patient who had atrial fibrillation (AF) complicated by third-degree AVB and who was treated with permanent His bundle pacing combined with left bundle branch pacing.AF complicated by third-degree AVB.We used the left bundle branch as a backup pacing site to overcome any shortcomings related to permanent His bundle pacing.The patient recovered well without any events.We selected His bundle pacing as the primary pacing, but also used left bundle branch pacing as a backup approach. If His bundle pacing results in an increased sensing threshold, pacing threshold changes, or dislocations, left bundle branch pacing can compensate for dysfunction of permanent deficiencies in His bundle pacing, preserving physiological pacing.