Scroll Top

Conduction System Pacing: A New Standard in Pacemaker Therapy

Conduction System Pacing (CSP) has established itself as a pioneering technique in modern pacemaker therapy. In contrast to conventional methods, CSP enables a more direct stimulation of the heart’s natural conduction system, which leads to a more physiological propagation of excitation. This is particularly relevant for patients with block patterns such as left bundle branch block (LBBB), where the aim is to optimize QRS duration.

International professional societies such as the Latin American Heart Rhythm Society and the Asia Pacific Heart Rhythm Society are increasingly recommending CSP procedures due to their promising clinical results. In particular, the reduction of pacing-induced cardiomyopathy (PIC) due to more physiological pacing patterns makes CSP an attractive alternative to biventricular pacing in Cardiac Resynchronization Therapy (CRT). 

conduction system pacing

Physiological principles of conduction system pacing

The basic idea of conduction system pacing is based on the targeted stimulation of the heart’s natural conduction system. In a healthy heart, electrical activity begins in the sinus node and spreads via the atrial myocardium to the atrioventricular node (AV node). From there, the excitation travels via the His bundle to the Tawara bundles and finally to the Purkinje fibers, which ensure synchronous contraction of the ventricles.

Patients with disorders of this conduction system, such as bundle branch block (BBB), experience asynchronous ventricular activation, which can lead to a long-term deterioration in cardiac function and the development of heart failure. Conventional right ventricular pacing can even exacerbate this asynchrony and increase the risk of pacemaker-induced cardiomyopathy.

Conduction System Pacing aims to restore the natural propagation of excitation by targeted stimulation of the His bundle (His Bundle Pacing, HBP) or the left Tawara bundle branch (Left Bundle Branch Area Pacing, LBBAP). This more physiological pacing can optimize pacing thresholds and reduce QRS duration, leading to improved hemodynamic function and better long-term clinical outcomes.

The challenges of conduction system pacing

Precise lead placement during His Bundle Pacing (HBP) or Left Bundle Branch Area Pacing (LBBAP) presents cardiologists with special challenges:

  • The exact identification of optimal stimulation points requires high-precision electrophysiological measurements
  • Monitoring the capture thresholds and pacing thresholds is crucial for long-term success
  • The risk of septal perforation must be minimized by precise control of electrode placement
  • The assessment of the electrophysiological effects of stimulation requires specialized measuring devices

Especially at higher stimulation rates, the differences between intrinsic and stimulated conduction can be decisive. A detailed analysis of the signal quality is therefore essential for the long-term success of CSP procedures.

Technical Requirements for Modern EP Systems

The successful performance of CSP procedures places high technical demands on electrophysiological measurement systems. The following properties are essential for optimum electrode placement:

  1. High-resolution signal display: Precise identification of the His bundle or the left Tawara leg requires outstanding signal quality that reliably displays the smallest electrical potentials.
  2. Real-time monitoring: Immediate assessment of the stimulation effects during placement of the stimulation electrodes is crucial for the success of the procedure.
  3. Flexible filter settings: Different patients and anatomical conditions require customizable filter parameters to achieve optimal signal representations.
  4. Simultaneous display of several leads: The parallel visualization of surface ECG and intracardiac leads enables a comprehensive assessment of cardiac electrophysiology.
  5. Comparison functions: The direct comparison of intrinsic and stimulated signals helps to assess stimulation efficiency.

Modern EP systems must also offer intuitive operation, as there is no time for complicated menu navigation during complex procedures. Integration into existing cardiology information systems and compatibility with various catheter types and pacing devices round off the requirements for modern systems for conduction system pacing.

EP-TRACER CSP: Measure the Difference

Schwarzer Cardiotek, a leader in electrocardiology measurement systems, has developed the EP-TRACER CSP, a portable electrophysiology measurement system specifically designed for conduction system pacing procedures. With an impressive installation base of over 1,400 EP systems worldwide, Schwarzer Cardiotek combines decades of experience with state-of-the-art technology.

Core functions of the EP-TRACER CSP:

  1. Sharply defined His signals
     The precise display of His potentials enables exact localization for HBP lead placement. This signal quality is crucial for successful CSP procedures.
  2. 12-lead surface ECG and 2 additional His channels
     The comprehensive representation of cardiac activity by the 12-lead ECG in combination with specialized His channels provides an optimal basis for assessing the QRS duration and the effectiveness of the pacing strategy.
  3. Integrated stimulator
     The built-in stimulator allows immediate assessment of stimulation effects and facilitates optimization of pacing thresholds directly during the procedure.
  4. LVAT and V1-V6 interval measurements
    Seamless evaluation of these parameters in real time or in a triggered view enables accurate assessment of conductivity during CSP implantation and helps to optimize pacing electrode placement.
  5. Current of Injury (COI)
    The Current of Injury signal indicates the correct contact of the electrode with the septum and serves as a real-time indicator to improve placement and avoid septal perforation.
  6. Derivation of pressure over time (dp/dt)
    The function dp/dt shows a correct derivation from the contractility of the left ventricle.
  7. Split screen mode
     The innovative side-by-side comparison between intrinsic and stimulated signal speeds up diagnosis and improves process efficiency when evaluating stimulation effects.
  8. Display of invasive blood pressure
    Continuous monitoring of the invasive blood pressure (IBP) during the procedure supports statements about the contractility of the left ventricle.
  9. The world’s first portable system
    The unique mobility of the EP-TRACER CSP enables spatial flexibility when performing CSP procedures – a decisive advantage for modern cath labs.
  10. Ready for use in less than 5 minutes
    The fast installation and operational readiness reduces lead times and optimizes the clinical workflow.

The innovative Smart Keyboard: Optimized user-friendliness for CSP processes

A key innovation of the EP-TRACER CSP is the new Smart Keyboard, which has been specially developed for CSP procedures. It provides the essential functions on an intuitive interface and optimally supports the workflow during treatment.

Key functions of the Smart Keyboard:

  • Accelerated diagnosis through side-by-side visualization mode (comparison intrinsic vs paced)
  • Faster operation of the integrated stimulator
  • Faster navigation through the procedure by setting markers
  • Adjustable time axis – customizable speed display for optimal readability
  • Precise event tracking during the entire implantation process
  • Simplified recording control for a better workflow
  • Effortless navigation through the complex tasks of CSP procedures thanks to intuitive design

The comprehensive guide facilitates rapid learning and smooth integration into clinical practice.

Scientific consensus and clinical relevance

The EHRA consensus paper emphasizes the growing importance of conduction system pacing as a forward-looking alternative to conventional pacing techniques. It explicitly advocates the use of EP systems for CSP pacemaker implantations.

This recommendation underlines the central importance of high-precision electrophysiological measurements for the success of CSP procedures. A link to the full EHRA consensus paper is available at https://academic.oup.com/europace/article/25/4/1208/7121146.

The clinical relevance of the EP-TRACER CSP is particularly evident in:

  • Reduction of the risk of septal perforations through improved visualization (more safety through the display of the Current of Injury – COI)
  • improved treatment of patients with bundle branch block
  • the achievement of tailor-made Cardiac Resynchronization Therapy (CRT) with individualized pacing parameters (pacing strategy)

With the EP-TRACER CSP, Schwarzer Cardiotek offers a system that is optimally adapted to this new pacing strategy and meets the high requirements for precision and user-friendliness.

The role of EP-TRACER in a CSP procedure

The EP-TRACER CSP supports a wide range of conduction system pacing procedures, which are used depending on the anatomical conditions and clinical situation:

His-bundle stimulation (HBP)

Direct stimulation of the His bundle is considered the most physiological form of conduction system pacing. With its high-resolution signal display, the EP-TRACER CSP enables precise localization of the His bundle, which is essential for exact placement of the electrode. This is particularly advantageous:

  • the clear differentiation between atrial, His and ventricular signals
  • the ability to differentiate between Selective His-Capture (S-HBP) versus Non-Selective His-Capture (NS-HBP) by QRS analysis
  • Continuous monitoring of the detection thresholds during implantation (via the programmer)
  • Immediate documentation of successful stimulation parameters (via the programmer)

In complex anatomical conditions or after heart surgery, identifying the His bundle can be particularly challenging. Here, the EP-TRACER CSP offers decisive advantages for the cardiologist thanks to its optimized filtering and flexible amplifier setting.

Left Bundle Branch Area Pacing (LBBAP)

Stimulation in the area of the left Tawara leg has emerged as a promising alternative when His bundle stimulation is technically difficult or associated with high stimulation thresholds. The EP-TRACER CSP offers specific advantages for successful LBBAP electrode placement:

  • The split-screen mode enables direct comparison between different stimulation positions
  • The visualization of the injury current (COI) provides further indications of successful electrode placement

The LBBAP technique is increasingly recommended by leading electrophysiology societies, especially for patients with heart failure and conduction disorders such as left bundle branch block (LBBB).

Combined His-Purkinje system stimulation

Newer approaches combine different CSP techniques in order to optimize the advantages of the individual methods. The EP-TRACER CSP also supports these more complex scenarios by:

  • Simultaneous visualization of multiple intracardiac leads
  • Flexible configuration of the stimulation protocol via the integrated stimulator
  • Precise analysis of the fusion beats with different types of stimulation
  • Comprehensive documentation of stimulation parameters for long-term follow-up

These advanced CSP techniques require the highest precision in electrophysiological measurement, which the EP-TRACER CSP guarantees with its innovative technology.

Technical specifications of the EP-TRACER CSP

The EP-TRACER CSP combines the latest technology in a compact, portable system that has been specially optimized for the requirements of conduction system pacing. The technical specifications underline the performance of the device:

Main components:

    • Amplifier unit: 12-channel surface ECG plus 2 dedicated His channels with high-resolution signal processing
    • Integrated stimulator: programmable stimulation parameters for optimal CSP procedures
    • Smart Keyboard: Specially developed user interface for intuitive operation in CSP scenarios
    • Data processing unit: Powerful signal analysis and real-time processing
    • Recording and analysis software: Customized display for optimal visualization in CSP procedures
    • Software

Technical features:

  • Sampling rate: High-frequency sampling rate for detailed signal display
  • Filter: Adaptive filter settings for optimum signal quality in different clinical scenarios
  • Signal amplification: Precisely adjustable amplification for optimum display of even the smallest electrical potentials
  • Stimulation parameters: Comprehensive setting options for various CSP techniques
  • Memory capacity: Generous memory for long-term recording of complex procedures

Connectivity and integration:

  • Interfaces: Standardized connections for integration into existing cath lab environments
  • Network capability: Seamless connection to internal hospital networks and PACS systems
  • DICOM compatibility: Standardized data exchange with other medical imaging systems (available from Q3 2025)
  • Export functions: Versatile export options for scientific evaluations and documentation

The unique combination of portability, powerful signal processing, important conductivity and safety features such as LVAT/V1-V6 interval measurements and COI, and intuitive operation makes the EP-TRACER CSP the ideal solution for modern CSP procedures in any cardiology facility.

One of the strengths of the EP-TRACER CSP is its seamless integration into existing hospital information systems and cardiology workflows. Schwarzer Cardiotek attaches great importance to interoperability and has implemented numerous interfaces that ensure smooth collaboration with other medical systems.

Economic advantages of the EP-TRACER CSP

In addition to the clinical benefits, the EP-TRACER CSP also offers significant economic advantages for modern cardiology facilities. The investment in this innovative system pays off through various factors:

Increased efficiency:

  • Reduced procedure time: The intuitive operation and clear signal display reduce the duration of procedures
  • Improved results with precise electrode placement and optimal electrical conduction through LVAT/V1-V6 interval measurements and COI signal
  • Quick set-up: the device is ready for use in less than 5 minutes, minimizing preparation times
  • Simple operation: the Smart Keyboard minimizes the need for user training
  • Intuitive design: Enables new employees to be trained quickly

Resource optimization:

  • Better room utilization: The portability of the system allows flexible use of space and therefore additional treatments
  • Space-saving: the compact design saves valuable space in the cath lab
  • Energy-saving: Modern design with optimized energy consumption
  • Durable hardware: Robust construction for long-term use
  • Future-proof investment: regular software updates keep the system up to date

The only EP system with automated LVAT measurement and COI visualization

The EP-TRACER CSP differs from conventional electrophysiological measurement systems in several key aspects. These differences are particularly relevant for modern CSP procedures that require maximum precision and user-friendliness.

Automated LVAT measurement:

  • EP-TRACER CSP: LVAT and V1-V6 interval measurements
    Continuous analysis of these parameters in real time or in a triggered view enables precise assessment of conductivity during CSP implantation and supports optimal placement of the pacing electrode.

Current of Injury Visualization – COI:

  • Current of Injury (COI)
    The Current of Injury signal confirms proper contact of the electrode with the septum and acts as a real-time indicator to optimize placement and prevent septal perforation.

Specific CSP optimization:

  • EP-TRACER CSP: Specially developed for the requirements of conduction system pacing, with customized functions for HBP and LBBA

Signal quality and processing:

  • EP-TRACER CSP: Particularly sharply delineated His signals and 12-channel surface ECG with 2 additional His channels for optimal signal display during CSP procedures

This superior signal quality is critical for accurate lead placement in His bundle or left bundle branch area pacing, where minimal deviations can have a major impact on acquisition thresholds and clinical success.

Mobility

The mobility of the EP-TRACER CSP enables its flexible use in different clinical environments and thus improves the utilization of resources in modern cardiology departments.

Ease of use:

  • EP-TRACER CSP: Specially developed smart keyboard for intuitive operation during CSP procedures, optimized for the clinical workflow
  • Conventional systems: More complex user interfaces, often not specifically designed for CSP processes

The intuitive operating concept of the EP-TRACER CSP with the special Smart Keyboard shortens the learning curve and enables procedures to be carried out more efficiently.

Integrated stimulator:

  • EP-TRACER CSP: Fully integrated stimulator with specific functions for CSP processes

The seamless integration of the stimulator into the EP-TRACER CSP enables a more efficient assessment of QRS pacing and optimizes the workflow during the CSP procedure.

Split screen functionality:

  • EP-TRACER CSP: Dedicated split-screen mode for direct comparison of intrinsic and stimulated signals

This function of the EP-TRACER CSP improves efficiency when optimizing the stimulation parameters.

Integration of invasive blood pressure measurement

  • EP-TRACER CSP: Direct display of invasive blood pressure for immediate hemodynamic assessment, including the display of pressure changes in the left ventricle dp/dt, which are also synonymous with the contractility of the left ventricle.

These points of comparison illustrate why the EP-TRACER CSP from Schwarzer Cardiotek represents a significant advance in modern CSP procedures and why leading cardiology centers worldwide rely on this technology.

EP-TRACER CSP – The future of Conduction System Pacing

The EP-TRACER CSP from Schwarzer Cardiotek represents the pinnacle of technological innovation in the field of conduction system pacing. With its unique combination of precise measurement technology, user-friendly operation and portable flexibility, it sets new standards for modern electrophysiological diagnostics and therapy.

At a time when the importance of physiological pacing and optimized clinical outcomes is becoming increasingly important, the EP-TRACER CSP offers the necessary technological support for advanced pacing strategies. The precise visualization of His signals, the intuitive split-screen mode and the fast operational readiness make it an indispensable tool for modern cath labs.

For cardiologists working with the latest developments in physiologic pacing, the EP-TRACER CSP offers a future-proof solution that improves the quality of patient care. The specially designed Smart Keyboard, excellent signal quality and portability of the system help to manage the complexity of modern CSP procedures and achieve consistently excellent results.

The scientific collaboration with leading cardiology centers worldwide and the continuous further development of the system ensure that the EP-TRACER CSP will continue to meet the highest requirements in the future and actively shape the evolution of conduction system pacing.


Are you interested or do you have questions about our system?

Contact:

info@schwarzercardiotek.com
+49 (0)7131 2774 500