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A new surgical technique has been applied in combination with the conventional pacemaker therapy, providing help for patients with heart failure in the long term for the first time in Hungary at the Heart Institute of the University of Pécs Clinical Centre. The main point of the procedure is that the cardiac resynchronization therapy is complemented by direct stimulation of the heart’s cardiac conduction system. Many patients responded to this method better than to the conventional procedure. Biotronik, a European company located in Berlin mainly focusing on cardiology, noticed the results achieved by the specialists in Pécs, and in recognition of their professional work, the company has been cooperating with them as a training centre since 2025 and as its only partner in Hungary. Physicians from all over the world attend their popular courses.

Written by Rita Schweier

„The heart has its own electrical conduction system, which transmits electrical impulses rapidly to all areas needed, ensuring that the heart contracts in a synchronized manner. This allows the left ventricle to pump enough blood to the organs. In case the cardiac conduction system or the tissue generating the impulses is damaged, we implant a pacemaker to ensure normal cardiac function. According to the traditional method, the pacemaker lead is inserted in the right ventricle via a vein. This lets the impulse spread, but with a significant delay hindering synchronized contractions. If a patient’s heart functions this way for years, the heart may lose its strength eventually and heart failure may develop. The chances are worse if the heart is already damaged. Having mapped the heart’s electrical network, the new technique helps to stimulate the cardiac conduction system with the lead directly, so the delayed spread of electrical impulses eliminates.” – said Dr. Attila Kónyi, Associate Professor at the Heart Institute of the University of Pécs Clinical Centre, the head of the programme and the pacemaker working group in Pécs.

He mentioned that the heart could be stimulated at several anatomical points, at the bundle of His originating from the atrioventricular node conducting impulses from the atrium to the ventricles, or further down at the left Tawara branch transmitting impulses from the atrioventricular node to the ventricular muscle. They use the latter approach, as it is technically simpler and leads to fewer complications.

More effective, well-tolerated treatment

The specialists in Pécs were the first in Hungary who combined the new LOT-CRT technique with the traditional cardiac resynchronization therapy. This new technique was introduced worldwide only in 2020, as 30–40% of patients did not respond well to the conventional cardiac resynchronization therapy. Despite numerous studies and scientific literature on the topic, the exact reason of this is still not fully understood yet. Procedures conducted with the new technique are highly effective, as 80–90% of patients react to it well.

„Although device manufacturers responded to the challenge in time, they developed special leads and generators suitable for this technique, but it is not fully refined, so it cannot be considered a routine procedure yet. Every patient has different anatomical variations, so the surgical procedure is often time-consuming and in addition to technical knowledge, the medical approach recquires thoroughness and patience. The lead has a small, metal component like a corkscrew, the so-called helix, which helps us screw it deeply into the cardiac septum between the two ventricles, where the cardiac conduction system is located. We monitor the area electrically and with X-ray imaging during the procedure to be sure that we reach the proper anatomical position. Sometimes the first attempt is not successful, and it can also happen that the septum perforates. In these cases, we try again from another angle until we find the best location for the lead.” – he added.

Prevention and treatment in one procedure

The technique is used if patients have heart failure and whose cardiac conduction system is damaged, for example after a massive heart attack. There are also cases when the cause of cardiac damage is not coronary artery disease, but previous inflammation of the heart muscle or toxic effects. Moreover, chemotherapy and radiotherapy to treat cancer-related diseases can also damage the heart muscle and also the cells of the cardiac conduction system. Dr. Attila Kónyi also meets patients who have a congenitall or an acquired condition, which means that the impulse conduction from the atrium to the ventricles is difficult or does not happen at all, this state is known as complete atrioventricular block. This new technique is the only option for these patients, as their cardiac activity is minimal or completely absent, which would lead to heart failure in the long term. In their case, the procedure is applied as a preventive measure.

„We began to introduce this new technique at the Heart Institute at the end of 2022 with my colleague Dr. Péter Ezer. Our goal is that all our colleagues, involved in pacemaker procedures, learn it. Some of them have already participated in international courses in Germany and in Spain, I learned it in Berlin. Fortunately, there are many opportunities to gain experience abroad.” – he said. He also added that the technique had been also known and used elsewhere in Hungary, but the training is currently available only in Pécs.

The team performs 40–50 procedures every year in Pécs, which is considered a high number in Hungary. In addition to having the appropriate training, a minimum of 20–30 surgeries are needed to reach the expert level.

The training programme is becoming more popular, the number of colleagues from abroad is growing

Biotronik has several centres in Europe where physicians from abroad can learn this new technique. They can apply from anywhere in the world, colleagues from Turkey, Germany, and Libya have already come to the Heart Institute. The programme is so popular that they apply as soon as the opportunity is announced.

„We operate as a training centre, as we were the first in Hungary to apply this new technique effectively and accordingly with the requirements of the company. Several factors were taken into account, such as patient safety, precision, and effectiveness, and we managed to met them all.” – emphasized Dr. Attila Kónyi. He added that although they did not have long-term data, spanning 5–10 years, regarding the use of this new technique, it is certain that patients tolerate it much better than traditional method.

Significant prestige and long-term benefits

Being part of the programme means significant prestige for the University of Pécs. The University of Pécs provides the support, the infrastructure, and the opportunities for local physicians to participate, while Biotronik covers the costs of the three-day-long courses and in some cases the acquisition of the devices needed for the procedures.

He said that the programme had many benefits on the long run, it builds an international network, enables joint professional meetings and exchanges of ideas, and it can lead to cooperation regarding research projects.

„There is tremendous innovation in the field of pacemaker therapy, as everything is becoming smaller, less invasive, and artificial intelligence is also becoming a factor in this area. I am sure that very exciting years are coming. Our team is open to development and learning, and we are committed to supporting our patients’ recovery while using the most advanced procedures available” – emphasized Dr. Attila Kónyi.

Photos:

Dávid Verébi,

UP Heart Institute