Conduction System Pacing vs Biventricular Pacing in Heart Failure and Wide QRS Patients

Pujol-López, Margarida; Jiménez‐Arjona, Rafael; Garre, Paz; Guasch, Eduard; Borràs, Roger; Doltra, Adelina; Ferró, Elisenda; García-Ribas, Cora; Niebla, Mireia; Carro, Esther; Puente, Jose L.; Vázquez-Calvo, Sara; Invers-Rubio, Eric; Roca‐Luque, Ivo; Castel, María Ángeles; Arbelo, Elena; Sitges, Marta; Brugada, Josép; Tolosana, José Marı́a; Mont, Lluís

doi:10.1016/j.jacep.2022.08.001

Cited by 55 publications

(75 citation statements)

References 22 publications

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“…Our findings were also consistent with recently published Left bundle branch area pacing outcomes: the multicenter European (MELOS) study and the Left Ventricular Activation Time Shortening With Conduction System Pacing vs Biventricular Resynchronization Therapy (LEVEL-AT) trial 32,33 . The MELOS study was a registry-based observational study comprised of 2,533 patients attempted LBBP with 27.5% of whom had an indication from heart failure.…”

Section: Discussionsupporting

confidence: 91%

Left bundle branch area pacing for heart failure patients requiring cardiac resynchronization therapy: a meta-analysis

Jin

Dai

et al. 2023

Preprint

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Background: Left bundle area branch pacing (LBBP) is a novel conduction system pacing method to achieve effective physiological pacing and an alternative to cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) for patients with heart failure and reduced ejection fraction (HFrEF). Objective: To review current data comparing BVP and LBBP in patients with HFrEF and indication CRT. Methods: We searched PubMed/Medline, Web of Science, and Cochrane Library from the inception of the database to November 2022. All studies that compared LBBP with BVP in patients with HFrEF and indications of CRT were included. Two reviewers performed the study selection, data abstraction, and risk of bias assessment. We calculated risk ratios with the Mantel-Haenszel method and mean difference with inverse variance using random effect models. We assessed heterogeneity using the I index, with I > 50% indicating significant heterogeneity. Results: Ten studies (9 observational studies and 1 randomized controlled trial; 616 patients; 15 centers) published between 2020 and 2022 were included. We observed a shorter fluoroscopy time [mean difference (MD) 9.68, 95% CI 4.49-14.87, I =95%, P<0.01, minutes] as well as a shorter procedure time (MD 33.68, 95% CI 17.80-49.55, I =73%, P<0.01, minutes) during implantation of LBBP CRT compared to conventional BVP CRT. LBBP was shown to have a greater reduction in QRSd (MD 25.13, 95%CI 20.06-30.20, I = 51%, P<0.01, milliseconds) a greater left ventricular ejection fraction (LVEF) improvement (MD 5.80, 95% CI 4.81-6.78, I =0%, P<0.01, percentage) and a greater ventricular end-diastolic diameter (LVEDD) reduction (MD 2.11, 95% CI 0.12-4.10, I =18%, P=0.04, millimeter). There was a greater improvement in New York Heart Association function (NYHA) class with LBBP (MD 0.37, 95% CI 0.05-0.68, I =61%, P=0.02).LBBP was also associated with a lower risk of a composite of heart failure hospitalizations and all-cause mortality [Risk ratio (RR) 0.48, 95% CI 0.25-0.90, I =0%, p=0.02] driven by reduced heart failure hospitalizations (RR 0.39, 95% CI 0.19-0.82, I =0%, p=0.01). However, all-cause mortality rates were low in both groups (1.52% vs. 1.13%) and similar (RR 0.98, 95%CI 0.21-4.68, I =0%, p=0.87). Conclusion: Compared to BVP, LBBP is associated with, a greater improvement in LV systolic function, and a lower rate of heart failure-related hospitalization. Dedicated randomized controlled trials and larger patient populations are needed to further elucidate the long-term safety and efficacy of LBBP CRT.

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Section: Discussionsupporting

confidence: 91%

Left bundle branch area pacing for heart failure patients requiring cardiac resynchronization therapy: a meta-analysis

Jin

Dai

et al. 2023

Preprint

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“…A similar decrease in LVAT -evaluated with the non-invasive 3-dimensional mapping system (ECGi) -was achieved by CSP and BiVP (−28 ± 26 m vs. −21 ± 20 m; p < 0.001 for non-inferiority). Both groups showed a similar change in left ventricular end-systolic volume (−37 ± 59 ml CSP vs. −30 ± 41 ml BVP; p = 0.04 for non-inferiority) and similar rates of mortality or heart failure hospitalizations (2.9% CSP vs. 11.4% BVP, p = 0.002 for non-inferiority) (Pujol-Lopez et al, 2022).…”

Section: Lbbap For Crt In Lbbbmentioning

confidence: 78%

Conduction system pacing for cardiac resynchronization therapy: State of the art, current controversies, and future perspectives

et al. 2023

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Biventricular pacing (BVP) is the established treatment to perform cardiac resynchronization therapy (CRT) in patients with heart failure (HF) and left bundle branch block (LBBB). However, BVP is an unnatural pacing modality still conditioned by the high percentage of non-responders and coronary sinus anatomy. Conduction system pacing (CSP)—His bundle pacing (HBP) and Left bundle branch area pacing (LBBAP)- upcomes as the physiological alternative to BVP in the quest for the optimal CRT. CSP showed promising results in terms of better electro-mechanical ventricular synchronization compared to BVP. However, only a few randomized control trials are currently available, and technical challenges, along with the lack of information on long-term clinical outcomes, limit the establishment of a primary role for CSP over conventional BVP in CRT candidates. This review provides a comprehensive literature revision of potential applications of CSP for CRT in diverse clinical scenarios, underlining the current controversies and prospects of this technique.

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“…1 Conduction system pacing (CSP), performed either through His bundle pacing (HBP) or left bundle pacing (LBBP), has emerged as an effective alternative approach to deliver CRT in LBBB patients. [2][3][4][5] Although clinical studies have shown HBP feasibility and efficacy, 2,6 HBP is challenging to deliver and results in high pacing thresholds. 6 On the other hand, LBBP is easier to perform, does not result in high pacing thresholds, 6 and leads to comparable synchrony to HBP when atrioventricular (AV) delay optimization is possible.…”

Section: Introductionmentioning

confidence: 99%

“…Conduction system pacing (CSP), performed either through His bundle pacing (HBP) or left bundle pacing (LBBP), has emerged as an effective alternative approach to deliver CRT in LBBB patients 2–5 . Although clinical studies have shown HBP feasibility and efficacy, 2,6 HBP is challenging to deliver and results in high pacing thresholds 6 .…”

Section: Introductionmentioning

confidence: 99%

Effect of scar and His–Purkinje and myocardium conduction on response to conduction system pacing

Strocchi

Gillette

Neic³

et al. 2023

Cardiovasc electrophysiol

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Introduction Conduction system pacing (CSP), in the form of His bundle pacing (HBP) or left bundle branch pacing (LBBP), is emerging as a valuable cardiac resynchronization therapy (CRT) delivery method. However, patient selection and therapy personalization for CSP delivery remain poorly characterized. We aim to compare pacing‐induced electrical synchrony during CRT, HBP, LBBP, HBP with left ventricular (LV) epicardial lead (His‐optimized CRT [HOT‐CRT]), and LBBP with LV epicardial lead (LBBP‐optimized CRT [LOT‐CRT]) in patients with different conduction disease presentations using computational modeling. Methods We simulated ventricular activation on 24 four‐chamber heart geometries, including His–Purkinje systems with proximal left bundle branch block (LBBB). We simulated septal scar, LV lateral wall scar, and mild and severe myocardium and LV His–Purkinje system conduction disease by decreasing the conduction velocity (CV) down to 70% and 35% of the healthy CV. Electrical synchrony was measured by the shortest interval to activate 90% of the ventricles (90% of biventricular activation time [BIVAT‐90]). Results Severe LV His–Purkinje conduction disease favored CRT (BIVAT‐90: HBP 101.5 ± 7.8 ms vs. CRT 93.0 ± 8.9 ms, p < .05), with additional electrical synchrony induced by HOT‐CRT (87.6 ± 6.7 ms, p < .05) and LOT‐CRT (73.9 ± 7.6 ms, p < .05). Patients with slow myocardium CV benefit more from CSP compared to CRT (BIVAT‐90: CRT 134.5 ± 24.1 ms; HBP 97.1 ± 9.9 ms, p < .01; LBBP: 101.5 ± 10.7 ms, p < .01). Septal but not lateral wall scar made CSP ineffective, while CRT was able to resynchronize the ventricles in the presence of septal scar (BIVAT‐90: baseline 119.1 ± 10.8 ms vs. CRT 85.1 ± 14.9 ms, p < .01). Conclusion Severe LV His–Purkinje conduction disease attenuates the benefits of CSP, with additional improvements achieved with HOT‐CRT and LOT‐CRT. Septal but not lateral wall scars make CSP ineffective.

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Conduction System Pacing vs Biventricular Pacing in Heart Failure and Wide QRS Patients

Cited by 55 publications

References 22 publications

Left bundle branch area pacing for heart failure patients requiring cardiac resynchronization therapy: a meta-analysis

Left bundle branch area pacing for heart failure patients requiring cardiac resynchronization therapy: a meta-analysis

Conduction system pacing for cardiac resynchronization therapy: State of the art, current controversies, and future perspectives

Effect of scar and His–Purkinje and myocardium conduction on response to conduction system pacing

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