Left Bundle Branch Pacing Postatrioventricular Junction Ablation for Atrial Fibrillation: Propensity Score Matching With His Bundle Pacing

Abstract

BACKGROUND: Left bundle branch pacing (LBBP) has emerged as a promising pacing modality to preserve physiological left ventricular activation; however, prospective data evaluating its long-term safety and efficacy in pacemaker-dependent patients following atrioventricular junction (AVJ) ablation are lacking. This study aimed to examine the feasibility, safety, and efficacy of LBBP in patients with atrial fibrillation and heart failure (HF) after AVJ ablation and compare LBBP with His bundle pacing (HBP) through a propensity score (PS) matching analysis. METHODS: We prospectively enrolled patients with atrial fibrillation and HF referred for AVJ ablation and LBBP between July 2017 and December 2019. The control group was patients selected from HBP implants performed from 2012 to 2019 using PS matching with a 1:1 ratio. RESULTS: A total of 99 patients were enrolled in the study. The LBBP implant success rate was 100%. Left ventricular ejection fraction improved from baseline 30.3±4.9 to 1-year 47.3±14.5 in HF patients with reduced ejection fraction and from baseline 56.3±12.1 to 1-year 62.3±9.1 in HF patients with preserved ejection fraction (both P <0.001), and left ventricular ejection fraction in both groups remained stable for up to 3 years of follow-up. A threshold increase >2 V at 0.5 ms occurred in only one patient. Of 176 (81.9%) of 215 patients who received permanent HBP post-AVJ ablation, 86 were matched to the LBBP group by 1:1 PS (propensity score matched His bundle pacing, N=86; propensity score matched left bundle branch pacing, N=86). No significant differences in echocardiographic or clinical outcomes were observed between the 2 groups ( P >0.05), whereas lower thresholds, greater sensed R-wave amplitudes, and fewer complications were observed in the propensity score matched left bundle branch pacing group ( P <0.05). CONCLUSIONS: LBBP is feasible, safe, and effective in patients with atrial fibrillation and HF post-AVJ ablation and has similar clinical benefits, a higher implant success rate, better pacing parameters, and fewer complications compared with HBP.

Ablate and pace: Comparison of outcomes between conduction system pacing and biventricular pacing

“…13,14 In the context of CSP, HBP and LBBAP were compared in two other recent observational studies. 15,16 In agreement with the findings of these studies, 15,16 we observed that, among the three pacing modalities compared, LBBAP was the one that required the lowest procedural and fluoroscopy times.…”

“…[12][13][14] Recently, observational studies have reported that LBBAP combined with AVJA is technically feasible, associated with low capture thresholds, and, when compared with HBP, appears to be associated with a lower risk of complications. 15,16 Comparison data on complications risk between BVP and CSP collected in a prospective fashion are limited. Accordingly, we conducted a multicenter registry aimed to prospectively compare the clinical outcomes, including the rate and nature of device-related complications, between BVP and CSP in a cohort of patients undergoing A&P.…”

Recruitment of the cardiac conduction system for optimal resynchronization therapy in failing heart

“…But no significant differences in death or HFH were observed between the HBP vs. LBBAP group. In the latest study including patients with AF after atrioventricular junction ablation, LBBP held higher successful implantation rates, better pacing parameters, and fewer lead-related complications compared with HBP, though both achieved similar improvement in clinical outcomes ( Cai et al, 2022 ). More recently, the first RCT (LBBP-RESYNC trail) to compare CRT efficacy between LBBP and BVP among heart failure patients with non-ischemic cardiomyopathy and LBBB found more improvement in LVEF by LBBP-CRT than BVP-CRT after 6-month follow-up ( Wang et al, 2022 ).…”

“…Previous studies and guidelines suggest that in patients with reduced LVEF and narrow QRS complex, BVP provides limited benefit ( Moss et al, 2009 ; Tracy et al, 2012 ). Compelling results of applying CSP in patients with PICM, RV pacing upgrading as well as AV node ablation in atrial fibrillation patients are accumulating ( Vijayaraman et al, 2017 ; Cai et al, 2022 ; Huang W. et al, 2022 ; Ivanovski et al, 2022 ). Hence, we expect that CSP may be a better option for primary and upgrading therapy in HF patients who have intact intraventricular conduction but need high RV pacing burden due to bradycardia or AV node ablation.…”

What Is the Threshold for Dyssynchrony in Patients Undergoing Atrioventricular Junction Ablation for Atrial Fibrillation?

“…In this issue, Cai et al 15 provide exactly such data. The authors report a prospective registry of patients who underwent atrioventricular junction ablation and attempted LBBP for AF and heart failure, alongside a retrospective cohort of patients who underwent HBP and atrioventricular junction ablation over a longer but overlapping study period.…”