New-onset atrial fibrillation following left bundle branch area pacing vs. right ventricular pacing: a two-centre prospective cohort study

Abstract

Aims To investigate whether left bundle branch area pacing (LBBAP) can reduce the risk of new-onset atrial fibrillation (AF) compared with right ventricular pacing (RVP). Methods and results Patients with indications for dual-chamber pacemaker implant and no history of AF were prospectively enrolled if they underwent successful LBBAP or RVP. The primary endpoint was time to the first occurrence of AF detected by pacemaker programming or surface electrocardiogram. Follow-up at clinic visit was performed and multivariate Cox regression models were applied to evaluate the effect of LBBAP on new-onset AF. The final analysis included 527 patients (mean age 65.3 ± 12.6, male 47.3%), with 257 in the LBBAP and 270 in the RVP groups. During a mean follow-up of 11.1 months, LBBAP resulted in significantly lower incidence of new-onset AF (7.4 vs. 17.0%, P < 0.001) and AF burden (3.7 ± 1.9 vs. 9.3 ± 2.2%, P < 0.001) than RVP. After adjusting for confounding factors, LBBAP demonstrated a lower hazard ratio for new-onset AF compared with RVP {hazard ratio (HR) [95% confidence interval (CI)]: 0.278 (0.156, 0.496), P < 0.001}. A significant interaction existed between pacing modalities and the percentage of ventricular pacing (VP%) (P for interaction = 0.020). In patients with VP ≥ 20%, LBBAP was associated with decreased risk of new-onset AF compared with RVP [HR (95% CI): 0.199 (0.105, 0.378), P < 0.001]. The effect of pacing modalities was not pronounced in patients with VP < 20% [HR (95% CI): 0.751 (0.309, 1.823), P = 0.316]. Conclusion Left bundle branch area pacing demonstrated a reduced risk of new-onset AF compared with RVP. Patients with a high ventricular pacing burden might benefit from LBBAP.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

“…13 Early nonrandomized evidence suggests that His bundle and left bundle pacing may reduce AF incidence and progression when compared with RV pacing in patients with high burden ventricular pacing. 14,15 In 1 study, left bundle branch area pacing reduced the incidence of new AF when compared with RV pacing, but this benefit was only evident in those patients with ventricular pacing >20%. 14 However, a meta-analysis that has evaluated all published evidence has only demonstrated a trend toward reduced AF.…”

Arrhythmic Risk in Biventricular Pacing Compared With Left Bundle Branch Area Pacing: Results From the I-CLAS Study

“…40 The data in the era of conduction system pacing appear to be more encouraging. Zhu et al 41 prospectively studied new-onset AF in a cohort of 527 patients undergoing either LBBAP (n=270) or right ventricular pacing (n=257). During a follow-up of 11 months, LBBAP resulted in a lower incidence of new-onset AF compared with right ventricle pacing (7.4% versus 17.0%; P <0.001) and AF burden, respectively (3.7±1.9% versus 9.3±2.2%; P <0.001).…”

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

“…This was due to a significantly lower rate of new‐onset AF (7.3% vs. 18.8%, 20.4% of patients with RV septal/RV apical pacing) with no significant reduction in AF progression 189 . Compared to RVP, LBBAP was associated with lower new‐onset AF risk (relative risk reduction of 59% for AF episodes ≥6 min; p = .035) in a retrospective cohort 60 of 410 patients and in a prospective cohort 192 of 527 patients, especially if patients required >20% ventricular pacing (relative risk reduction 72%; p < .001).…”

“…In patients undergoing AVJ ablation, it may be reasonable to implant an LBBAP lead. 186–188 2bC‐LD5. In patients with a high burden of ventricular pacing, HBP or LBBAP may be reasonable to decrease the risk of AF. 189–192 …”