Auto-threshold test for His-bundle pacing
Systems and methods for pacing cardiac conductive tissue are described. A medical system includes an electrostimulation circuit to generate His-bundle pacing (HBP) pulses. A sensing circuit senses a physiologic signal, and detect a local His-bundle activation discrete from a pacing artifact of the HBP pulse. A control circuit verifies capture status in response to the HBP pulses. Based on the capture status, the control circuit determines one or more pacing thresholds including a selective HBP threshold representing a threshold strength to capture only the His bundle but not the local myocardium, and a non-selective HBP threshold representing a threshold strength to capture both the His bundle and the local myocardium. The electrostimulation circuit may deliver HBP pulses based on the selective and non-selective HBP thresholds.
1. A system for pacing a heart, comprising:
an electrostimulation circuit configured to generate His-bundle pacing (HBP) pulses having a stimulation strength to stimulate a His bundle of the heart;
a sensing circuit configured to sense a physiologic signal and to detect, from the sensed physiologic signal, a presence or absence of a local His-bundle activation discrete from a pacing artifact of the delivered HBP pulses and an isoelectric interval that separates the local His-bundle activation from the pacing artifact of the delivered HBP pulse; and
a control circuit configured to:
classify a capture status as being one of two or more different types of capture status based at least on the presence or absence of the local His-bundle activation and the detected isoelectric interval; and
determine, using the classified capture status, one or more of (1) a selective HBP threshold (S-threshold) representing a threshold strength for the HBP pulses to capture only the His bundle but not local myocardium, or (2) a non-selective HBP threshold (NS-threshold) representing a threshold strength for the HBP pulses to capture both the His bundle and the local myocardium.
2. The system of claim 1 , wherein the control circuit is configured to classify the capture status at a specific stimulation strength using a plurality of detected local His-bundle activations in response to a plurality of HBP pulses having the specific stimulation strength.
3. The system of claim 1 , wherein the sensing circuit is configured to sense the physiologic signal including a His-bundle electrogram, and to detect the presence or absence of the local His-bundle activation using an amplitude or a morphology of the sensed His-bundle electrogram.
4. The system of claim 1 , wherein the control circuit is configured to classify the capture status as one of:
a selective His-bundle capture (S-capture) status if the local His-bundle activation is present, the S-capture status representing a capture of only the His bundle but not the local myocardium;
a non-selective His-bundle capture (NS-capture) status if the local His-bundle activation is absent, the NS-capture status representing a capture of both the His bundle and the local myocardium; or
a loss of capture (LOC) status indicative of a capture of neither the His bundle nor the local myocardium.
5. The system of claim 4 , wherein the control circuit is configured to:
detect a first transition from an S-capture status to an NS-capture status in response to HBP pulses delivered according to a ramp-up of the stimulation strength, or a second transition from an NS-capture status to an S-capture status in response to HBP pulses delivered according to a ramp-down of the stimulation strength; and
determine the NS-threshold corresponding to the detected first or second transition of capture status.
6. The system of claim 4 , wherein the control circuit is configured to:
detect a third transition from an LOC status to an S-capture status in response to HBP pulses delivered according to a ramp-down of the stimulation strength, or a fourth transition from an S-capture status to an LOC status in response to HBP pulses delivered according to a ramp-down of the stimulation strength; and
determine the S-threshold corresponding to the detected third or fourth transition of capture status.
7. The system of claim 1 , wherein the control circuit is configured to:
classify the capture status as one of (1) a selective His-bundle capture with conduction abnormality correction (Sc-capture), or (2) a selective His-bundle capture without conduction abnormality correction (Sn-capture); and
determine a selective HBP threshold with conduction abnormality correction (Sc-threshold) based on at least the classification of the Sc-capture status or the Sn-capture status.
8. The system of claim 7 , wherein the control circuit is configured to:
ramp up the stimulation strength, and determine the Sc-threshold corresponding to a transition from an Sn-capture status to an Sc-capture status in response to HBP pulses delivered according to the ramp-up of the stimulation strength; or
ramp down the stimulation strength, and determine the Sc-threshold corresponding to a transition from an Sc-capture status to an Sn-capture status in response to HBP pulses delivered according to the ramp-down of the stimulation strength.
9. The system of claim 4 , wherein:
the sensing circuit is further configured to sense a far-field cardiac electrical signal; and
the control circuit is configured to classify the capture status further using the sensed far-field cardiac electrical signal.
10. The system of claim 9 , wherein:
the sensing circuit is configured to extract a morphologic feature of the far-field cardiac electrical signal; and
the control circuit is configured to, in response to the extracted morphologic feature satisfying a specified condition, determine an NS-threshold corresponding to (1) a transition from an S-capture status to an NS-capture status in response to HBP pulses delivered according to a ramp-up of the stimulation strength, or (2) a transition from an NS-capture status to an S-capture status in response to HBP pulses delivered according to a ramp-down of the stimulation strength.
11. The system of claim 4 , wherein:
the electrostimulation circuit is configured to generate the HBP pulses having stimulation strength above the determined NS-threshold; and
the control circuit is configured to, in response to an S-capture status, increment the stimulation strength until the capture status becomes an NS-capture status.
12. The system of claim 4 , wherein:
the electrostimulation circuit is configured to generate the HBP pulses having stimulation strength above the determined S-threshold and below the determined NS-threshold; and
the control circuit is configured to:
in response to an NS-capture status, decrement the stimulation strength until the capture status becomes an S-capture status; and
in response to a loss of capture status, increment the stimulation strength until the capture status becomes an S-capture status.
13. A method for operating a pacing system to stimulate a heart, the method comprising:
generating, via an electrostimulation circuit, His-bundle pacing (HBP) pulses to stimulate a His bundle of the heart, the HBP pulses having a stimulation strength;
sensing, via a sensing circuit, a physiologic signal and determining a presence or absence of a local His-bundle activation discrete from a pacing artifact of the delivered HBP pulse;
detecting an isoelectric interval that separates the local His-bundle activation from the pacing artifact of the delivered HBP pulse;
classifying, via a control circuit, a capture status as being one of two or more different types of capture status based at least on the presence or absence of the local His-bundle activation and the detected isoelectric interval; and
determining, using the classified capture status, one or more of a selective HBP threshold (S-threshold) or a non-selective HBP threshold (NS-threshold) via the control circuit, the S-threshold representing a threshold strength for the HBP pulses to capture only the His bundle but not local myocardium, the NS-threshold representing a threshold strength for the HBP pulses to capture both the His bundle and the local myocardium.
14. The method of claim 13 , wherein classifying the capture status includes classifying the capture status as one of:
a selective His-bundle capture (S-capture) status if the local His-bundle activation is present, the S-capture status representing a capture of only the His bundle but not the local myocardium;
a non-selective His-bundle capture (NS-capture) status if the local His-bundle activation is absent, the NS-capture status representing a capture of both the His bundle and the local myocardium; or
a loss of capture (LOC) status indicative of a capture of neither the His bundle nor the local myocardium.
15. The method of claim 13 , further comprising:
classifying the capture status as one of (1) a selective His-bundle capture with conduction abnormality correction (Sc-capture), or (2) a selective His-bundle capture without conduction abnormality correction (Sn-capture); and
determining a selective HBP threshold with conduction abnormality correction (Sc-threshold) based on at least the classification of the Sc-capture status or the Sn-capture status.
16. The method of claim 15 , wherein determining the Sc-threshold includes at least one of:
ramping up the stimulation strength, and determining the Sc-threshold corresponding to a transition from an Sn-capture status to an Sc-capture status in response to HBP pulses delivered according to the ramp-up of the stimulation strength; or
ramping down the stimulation strength, and determining the Sc-threshold corresponding to a transition from an Sc-capture status to an Sn-capture status in response to HBP pulses delivered according to the ramp-down of the stimulation strength.
17. The method of claim 13 , comprising:
sensing a far-field cardiac electrical signal;
classifying the capture status further using the sensed far-field cardiac electrical signal; and
in response to the far-field cardiac electrical signal satisfying a specified condition, determining an NS-threshold corresponding to (1) a transition from an S-capture status to an NS-capture status in response to HBP pulses delivered according to a ramp-up of the stimulation strength, or (2) a transition from an NS-capture status to an S-capture status in response to HBP pulses delivered according to a ramp-down of the stimulation strength.
18. A system for pacing a heart, comprising:
an electrostimulation circuit configured to generate His-bundle pacing (HBP) pulses having a stimulation strength to stimulate a His bundle of the heart;
a sensing circuit configured to sense a physiologic signal, and to detect, from the sensed physiologic signal, a presence or absence of a local His-bundle activation separated from a pacing artifact of the delivered HBP pulses by an isoelectric interval; and
a control circuit configured to classify a capture status as being one of two or more different types of capture status based on the local His-bundle activation and the isoelectric interval that separates the local His-bundle activation and the pacing artifact.
19. The system of claim 18 , wherein the control circuit is configured to classify the capture status as one of:
a selective His-bundle capture (S-capture) status if the local His-bundle activation is present and the isoelectric interval is present, the S-capture status representing a capture of only the His bundle but not the local myocardium; or
a non-selective His-bundle capture (NS-capture) status if the local His-bundle activation is absent or the isoelectric interval is absent, the NS-capture status representing a capture of both the His bundle and the local myocardium.
20. The system of claim 18 , wherein the control circuit is configured to classify the capture status at a specific stimulation strength using a plurality of detected local His-bundle activations in response to a plurality of HBP pulses having the specific stimulation strength.