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Gerra L, Bonini N, Mei DA, Imberti JF, Vitolo M, Bucci T, Boriani G, Lip GYH. Cardiac resynchronization therapy (CRT) non-responders in the contemporary era: A State-of-the-Art review. Heart Rhythm 2024:S1547-5271(24)02670-5. [PMID: 38848860 DOI: 10.1016/j.hrthm.2024.05.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024]
Abstract
Since 2000s CRT became a revolutionary therapy for heart failure with reduced left ventricular ejection fraction (HFrEF) and wide QRS. However, about one third of CRT recipients do not show a favorable response. This review of current literature aims to better define the concept of CRT response/non-response. The diagnosis of CRT non-responder should be viewed as a continuum, and it cannot rely solely on a single parameter. Moreover, several patients' baseline features might predict an unfavorable response. A strong collaboration between HF specialists and electrophysiologists is key to overcoming this challenge with multiple strategies. In the contemporary era, new pacing modalities, such as His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) represent a promising alternative to CRT. Observational studies demonstrated their potential; however, several limitations should be addressed. Large randomized controlled trials are needed to prove their efficacy in HFrEF with electromechanical dyssynchrony.
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Affiliation(s)
- Luigi Gerra
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Bonini
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Davide Antonio Mei
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo Francesco Imberti
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of General and Specialized Surgery, Sapienza University of Rome, Italy
| | - Giuseppe Boriani
- Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Palmisano P, Dell'Era G, Guerra F, Ammendola E, Ziacchi M, Laffi M, Donateo P, Guido A, Ghiglieno C, Parlavecchio A, Dello Russo A, Nigro G, Biffi M, Gaggioli G, Senes J, Patti G, Accogli M, Coluccia G. Complications of left bundle branch area pacing compared with biventricular pacing in candidates for resynchronization therapy: Results of a propensity score-matched analysis from a multicenter registry. Heart Rhythm 2024; 21:874-880. [PMID: 38428448 DOI: 10.1016/j.hrthm.2024.02.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/14/2024] [Accepted: 02/17/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) is a well-established therapy in patients with reduced left ventricular ejection fraction, heart failure, and left bundle branch block. Left bundle branch area pacing (LBBAP) has recently been shown to be a feasible and effective alternative to BVP. Comparative data on the risk of complications between LBBAP and BVP among patients undergoing CRT are lacking. OBJECTIVE The aim of this study was to compare the long-term risk of procedure-related complications between LBBAP and BVP in a cohort of patients undergoing CRT. METHODS This prospective, multicenter, observational study enrolled 668 consecutive patients (mean age 71.2 ± 10.0 years; 52.2% male; 59.4% with New York Heart Association class III-IV heart failure symptoms) with left ventricular ejection fraction 33.4% ± 4.3% who underwent BVP (n = 561) or LBBAP (n = 107) for a class I or II indication for CRT. Propensity score matching for baseline characteristics yielded 93 matched pairs. The rate and nature of intraprocedural and long-term post-procedural complications occurring during follow-up were prospectively collected and compared between the 2 groups. RESULTS During a mean follow-up of 18 months, procedure-related complications were observed in 16 patients: 12 in BVP (12.9%) and 4 in LBBAP (4.3%) (P = .036). Compared with patients who underwent LBBAP, those who underwent BVP showed a lower complication-free survival (P = .032). In multivariate analysis, BVP resulted an independent predictive factor associated with a higher risk of complications (hazard ratio 3.234; P = .042). Complications related to the coronary sinus lead were most frequently observed in patients who underwent BVP (50.0% of all complications). CONCLUSION LBBAP was associated with a lower long-term risk of device-related complications compared with BVP in patients with an indication for CRT.
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Affiliation(s)
| | - Gabriele Dell'Era
- Division of Cardiology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi," Ancona, Italy
| | - Ernesto Ammendola
- Department of Cardiology, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Matteo Ziacchi
- Istituto di Cardiologia, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Mattia Laffi
- Divisione Cardiologia, Ospedale Villa Scassi, Genova ASL 3, Genova, Italy
| | - Paolo Donateo
- Department of Cardiology, Arrhythmology Center, ASL 4 Chiavarese, Lavagna, Italy
| | | | - Chiara Ghiglieno
- Division of Cardiology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Antonio Parlavecchio
- Cardiology Unit, "Card. G. Panico" Hospital, Tricase, Italy; Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Umberto I - Lancisi - Salesi," Ancona, Italy
| | - Gerardo Nigro
- Department of Cardiology, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Mauro Biffi
- Istituto di Cardiologia, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Germano Gaggioli
- Divisione Cardiologia, Ospedale Villa Scassi, Genova ASL 3, Genova, Italy
| | - Jacopo Senes
- Department of Cardiology, Arrhythmology Center, ASL 4 Chiavarese, Lavagna, Italy
| | - Giuseppe Patti
- Division of Cardiology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
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Liang Y, Xiao Z, Liu X, Wang J, Yu Z, Gong X, Lu H, Yang S, Gu M, Zhang L, Li M, Pan L, Li X, Chen X, Su Y, Hua W, Ge J. Left Bundle Branch Area Pacing versus Biventricular Pacing for Cardiac Resynchronization Therapy on Morbidity and Mortality. Cardiovasc Drugs Ther 2024; 38:471-481. [PMID: 36459266 DOI: 10.1007/s10557-022-07410-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) has emerged as an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT). We aimed to compare the morbidity and mortality associated with LBBAP versus BVP in patients undergoing CRT implantation. METHODS Consecutive patients who received CRT from two high-volume implantation centers were retrospectively recruited. The primary endpoint was a composite of all-cause death and heart failure hospitalization, and the secondary endpoint was all-cause death. RESULTS A total of 491 patients receiving CRT (154 via LBBAP and 337 via BVP) were included, with a median follow-up of 31 months. The primary endpoint was reached by 21 (13.6%) patients in the LBBAP group, as compared with 74 (22.0%) patients in the BVP group [hazard ratio (HR) 0.70, 95% confidence interval (CI) 0.43-1.14, P = 0.15]. There were 10 (6.5%) deaths in the LBBAP group, as compared with 31 (9.2%) in the BVP group (HR 0.91, 95% CI 0.44-1.86, P = 0.79). No significant difference was observed in the risk of either the primary or secondary endpoint between LBBAP and BVP after multivariate Cox regression (HR 0.74, 95% CI 0.45-1.23, P = 0.24, and HR 0.77, 95% CI 0.36-1.67, P = 0.51, respectively) or propensity score matching (HR 0.72, 95% CI 0.41-1.29, P = 0.28, and HR 0.69, 95% CI 0.29-1.65, P = 0.40, respectively). CONCLUSION LBBAP was associated with a comparable effect on morbidity and mortality relative to BVP in patients with indications for CRT.
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Affiliation(s)
- Yixiu Liang
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zilong Xiao
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xi Liu
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingfeng Wang
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Ziqing Yu
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xue Gong
- Department of Cardiology, Deltahealth Hospital, Shanghai, China
| | - Hongyang Lu
- Cardiac Rhythm Management, Medtronic Technology Center, Medtronic (Shanghai) Ltd., Shanghai, China
| | - Shengwen Yang
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Min Gu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Zhang
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Minghui Li
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Lei Pan
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xiao Li
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xueying Chen
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yangang Su
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China.
| | - Wei Hua
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
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El Iskandarani M, Golamari R, Shatla I, Ujueta F, Mihos CG, Escolar E, Elajami TK, Weiss R. Left bundle branch area pacing in heart failure: A systematic review and meta-analysis with meta-regression. J Cardiovasc Electrophysiol 2024. [PMID: 38812213 DOI: 10.1111/jce.16304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/09/2024] [Accepted: 04/29/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Left bundle branch area pacing is an alternative to biventricular pacing. In this study, we aim to summarize the available evidence on the feasibility, efficacy, and safety of left bundle branch block area pacing (LBBAP). OBJECTIVES The study summarizes the available evidence on the feasibility, efficacy, and safety of left bundle branch block area pacing (LBBAP). BACKGROUND Cardiac resynchronization therapy (CRT) reduced mortality and hospitalizations in heart failure (HF) patients with a left ventricular ejection fraction (LVEF) ≤ 35% and concomitant LBBB. Recently LBBAP has been studied as a more physiological alternative to achieve CRT. METHOD A search of PubMed, EMBASE, and Cochrane databases were performed to identify studies examining the role of LBBAP for CRT in heart failure. Comprehensive meta-analysis version 4 was used for meta-regression to examine variables that contribute to data heterogeneity. RESULT Eighteen studies, 17 observational and one randomized controlled trial (RCT) were examined. A total of 3906 HF patients who underwent CRT (2036 LBBAP vs. 1870 biventricular pacing [BVP]) were included. LBBAP was performed successfully in 90.4% of patients. Compared to baseline, LBBAP was associated with a reduction in QRS duration (MD: -47.23 ms 95% confidence interval [CI]: -53.45, -41.01), an increase in LVEF (MD: 15.22%, 95% CI: 13.5, 16.94), and a reduction in NYHA class (MD: -1.23, 95% CI: -1.41, -1.05). Compared to BVP, LBBAP was associated with a significant reduction in QRS duration (MD: -20.69 ms, 95% CI: -25.49, -15.88) and improvement in LVEF (MD: 4.78%, 95% CI: 3.30, 6.10). Furthermore, LBBAP was associated with a significant reduction in HF hospitalization (odds ratio [OR]: 0.44, 95% CI: 0.34, 0.56) and all-cause mortality (OR: 0.67, 95% CI: 0.52, 0.86) compared to BVP. CONCLUSION LBBAP was associated with improved ventricular electrical synchrony compared to BVP, as well as better echocardiographic and clinical outcomes.
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Affiliation(s)
- Mahmoud El Iskandarani
- Department Internal Medicine, Eastern Connecticut Health Network, Manchester, Connecticut, USA
| | - Reshma Golamari
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Islam Shatla
- Department of Internal Medicine, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Francisco Ujueta
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Christos G Mihos
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Esteban Escolar
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Tarec K Elajami
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Raul Weiss
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, Florida, USA
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Lakshman H, Chowdhury M, Ahmed A, Woods E, Flemengos G, Abdou C, Patel H, Zughaib M, Bradley C. Clinical and Electrophysiological Outcomes of Left Bundle Area Pacing Compared to Biventricular Pacing: An Updated Meta-analysis. J Innov Card Rhythm Manag 2024; 15:5858-5865. [PMID: 38808170 PMCID: PMC11129831 DOI: 10.19102/icrm.2024.15053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/24/2024] [Indexed: 05/30/2024] Open
Abstract
Left bundle branch area pacing (LBBAP) is a novel pacing strategy that uses the conduction system distal to the left bundle branch block level for direct activation of the left bundle and right ventricular myocardium. Our meta-analysis compared the structural, electrophysiological, clinical, and procedural outcomes of LBBAP and biventricular pacing (BVP). The meta-analysis included two randomized controlled trials and showed significant reductions in the left ventricular (LV) systolic and diastolic volumes with LBBAP compared to BVP, together with statistically significant reductions in the QRS duration, New York Heart Association (NYHA) functional class, and heart failure (HF) hospitalizations. The fluoroscopic time was also significantly shorter in the LBBAP group. However, no significant change in the LV ejection fraction was noted. Procedural complications were slightly higher in the LBBAP group, albeit not to a statistically significant degree. Our findings suggest that LBBAP may be a superior alternative to standard BVP in improving the structural, electrophysiological, and clinical components of cardiomyopathy, including the NYHA class and HF hospitalizations. LBBAP is a more physiological pacing strategy that results in normal ventricular activation and may be a viable alternative to BVP for cardiac synchronization therapy.
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Affiliation(s)
- Harini Lakshman
- Department of Cardiology, Ascension Providence, Southfield, MI, USA
| | - Medhat Chowdhury
- Department of Cardiology, Ascension Providence, Southfield, MI, USA
| | - Ammar Ahmed
- Department of Cardiology, Ascension Providence, Southfield, MI, USA
| | - Everett Woods
- Department of Internal Medicine, Ascension Providence, Southfield, MI, USA
| | - George Flemengos
- Department of Internal Medicine, Ascension Providence, Southfield, MI, USA
| | - Claudine Abdou
- Department of Pharmacy, University of Rochester, Rochester, NY, USA
| | - Harshil Patel
- Department of Cardiology, Ascension Providence, Southfield, MI, USA
| | - Marcel Zughaib
- Department of Cardiology, Ascension Providence, Southfield, MI, USA
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Yasmin F, Moeed A, Ochani RK, Raheel H, Awan MAE, Liaquat A, Saleem A, Aamir M, Hawwa N, Surani S. Left bundle branch pacing vs biventricular pacing in heart failure patients with left bundle branch block: A systematic review and meta-analysis. World J Cardiol 2024; 16:40-48. [PMID: 38313392 PMCID: PMC10835470 DOI: 10.4330/wjc.v16.i1.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/21/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Left bundle branch pacing (LBBP) is a novel pacing modality of cardiac resynchronization therapy (CRT) that achieves more physiologic native ventricular activation than biventricular pacing (BiVP). AIM To explore the validity of electromechanical resynchronization, clinical and echocardiographic response of LBBP-CRT. METHODS Systematic review and Meta-analysis were conducted in accordance with the standard guidelines as mentioned in detail in the methodology section. RESULTS In our analysis, the success rate of LBBP-CRT was determined to be 91.1%. LBBP-CRT significantly shortened QRS duration, with significant improvement in echocardiographic parameters, including left ventricular ejection fraction, left ventricular end-diastolic diameter and left ventricular end-systolic diameter in comparison with BiVP-CRT. CONCLUSION A significant reduction in New York Heart Association class and B-type natriuretic peptide levels was also observed in the LBBP-CRT group vs BiVP-CRT group. Lastly, the LBBP-CRT cohort had a reduced pacing threshold at follow-up as compared to BiVP-CRT.
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Affiliation(s)
- Farah Yasmin
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06511, United States
| | - Abdul Moeed
- Department of Medicine, Dow University of Health Science, Karachi 74200, Sindh, Pakistan
| | - Rohan Kumar Ochani
- Department of Medicine, SUNNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Hamna Raheel
- Department of Medicine, Dow University of Health Science, Karachi 74200, Sindh, Pakistan
| | - Malik Ali Ehtsham Awan
- Department of Medicine, Dow University of Health Science, Karachi 74200, Sindh, Pakistan
| | - Ayesha Liaquat
- Department of Medicine, Dow University of Health Science, Karachi 74200, Sindh, Pakistan
| | - Arisha Saleem
- Department of Medicine, Dow University of Health Science, Karachi 74200, Sindh, Pakistan
| | - Muhammad Aamir
- Department of Cardiovascular Medicine, Lehigh Valley Heart and Vascular Institute, Allentown, PA 18105, United States
| | - Nael Hawwa
- Department of Cardiovascular Medicine, Lehigh Valley Heart and Vascular Institute, Allentown, PA 18105, United States
- Department of Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Salim Surani
- Department of Medicine & Pharmacology, Texas A&M University, College Station, TX 77843, United States.
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Diaz JC, Duque M, Aristizabal J, Marin J, Niño C, Bastidas O, Ruiz LM, Matos CD, Hoyos C, Hincapie D, Velasco A, Romero JE. The Emerging Role of Left Bundle Branch Area Pacing for Cardiac Resynchronisation Therapy. Arrhythm Electrophysiol Rev 2023; 12:e29. [PMID: 38173800 PMCID: PMC10762674 DOI: 10.15420/aer.2023.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/04/2023] [Indexed: 01/05/2024] Open
Abstract
Cardiac resynchronisation therapy (CRT) reduces the risk of heart failure-related hospitalisations and all-cause mortality, as well as improving quality of life and functional status in patients with persistent heart failure symptoms despite optimal medical treatment and left bundle branch block. CRT has traditionally been delivered by implanting a lead through the coronary sinus to capture the left ventricular epicardium; however, this approach is associated with significant drawbacks, including a high rate of procedural failure, phrenic nerve stimulation, high pacing thresholds and lead dislodgement. Moreover, a significant proportion of patients fail to derive any significant benefit. Left bundle branch area pacing (LBBAP) has recently emerged as a suitable alternative to traditional CRT. By stimulating the cardiac conduction system physiologically, LBBAP can result in a more homogeneous left ventricular contraction and relaxation, thus having the potential to improve outcomes compared with conventional CRT strategies. In this article, the evidence supporting the use of LBBAP in patients with heart failure is reviewed.
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Affiliation(s)
- Juan Carlos Diaz
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Clinica Las Vegas, Universidad CES Medical SchoolMedellin, Colombia
| | - Mauricio Duque
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Clinica Las Vegas, Universidad CES Medical SchoolMedellin, Colombia
| | - Julian Aristizabal
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Department of Medicine, Clinica Las AmericasMedellin, Colombia
| | - Jorge Marin
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Department of Medicine, Clinica Las AmericasMedellin, Colombia
| | - Cesar Niño
- Cardiac Arrhythmia and Electrophysiology Service, Hospital Pablo Tobón UribeMedellin, Colombia
| | - Oriana Bastidas
- Cardiac Arrhythmia and Electrophysiology Service, Hospital Pablo Tobón UribeMedellin, Colombia
| | | | - Carlos D Matos
- Cardiac Arrhythmia Service, Brigham and Women’s Hospital, Harvard Medical SchoolBoston, MA, US
| | - Carolina Hoyos
- Cardiac Arrhythmia Service, Brigham and Women’s Hospital, Harvard Medical SchoolBoston, MA, US
| | - Daniela Hincapie
- Cardiac Arrhythmia Service, Brigham and Women’s Hospital, Harvard Medical SchoolBoston, MA, US
| | - Alejandro Velasco
- Electrophysiology Section, University of Texas Health Sciences CentreSan Antonio, TX, US
| | - Jorge E Romero
- Cardiac Arrhythmia Service, Brigham and Women’s Hospital, Harvard Medical SchoolBoston, MA, US
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8
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Tavolinejad H, Kazemian S, Bozorgi A, Michalski R, Hoyer D, Sedding D, Arya A. Effectiveness of conduction system pacing for cardiac resynchronization therapy: A systematic review and network meta-analysis. J Cardiovasc Electrophysiol 2023; 34:2342-2359. [PMID: 37767743 DOI: 10.1111/jce.16086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/31/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) with biventricular pacing (BiV-CRT) is ineffective in approximately one-third of patients. CRT with Conduction system pacing (CSP-CRT) may achieve greater synchronization. We aimed to assess the effectiveness of CRT with His pacing (His-CRT) or left bundle branch pacing (LBB-CRT) in lieu of biventricular CRT. METHODS AND RESULTS The PubMed, Embase, Web of Science, Scopus, and the Cochrane Library were systematically searched until August 19, 2023, for original studies including patients with reduced left ventricular ejection fraction (LVEF) who received His- or LBB-CRT, that reported either CSP-CRT success, LVEF, QRS duration (QRSd), or New York Heart Association (NYHA) classification. Effect measures were compared with frequentist network meta-analysis. Thirty-seven publications, including 20 comparative studies, were included. Success rates were 73.5% (95% CI: 61.2-83.0) for His-CRT and 91.5% (95% CI: 88.0-94.1) for LBB-CRT. Compared to BiV-CRT, greater improvements were observed for LVEF (mean difference [MD] for His-CRT +3.4%; 95% CI [1.0; 5.7], and LBB-CRT: +4.4%; [2.5; 6.2]), LV end-systolic volume (His-CRT:17.2mL [29.7; 4.8]; LBB-CRT:15.3mL [28.3; 2.2]), QRSd (His-CRT: -17.1ms [-25.0; -9.2]; LBB-CRT: -17.4ms [-23.2; -11.6]), and NYHA (Standardized MD [SMD]: His-CRT:0.4 [0.8; 0.1]; LBB-CRT:0.4 [-0.7; -0.2]). Pacing thresholds at baseline and follow-up were significantly lower with LBB-CRT versus both His-CRT and BiV-CRT. CSP-CRT was associated with reduced mortality (R = 0.75 [0.61-0.91]) and hospitalizations risk (RR = 0.63 [0.42-0.96]). CONCLUSION This study found that CSP-CRT is associated with greater improvements in QRSd, echocardiographic, and clinical response. LBB-CRT was associated with lower pacing thresholds. Future randomized trials are needed to determine CSP-CRT efficacy.
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Affiliation(s)
- Hamed Tavolinejad
- Department of Cardiac Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sina Kazemian
- Department of Cardiac Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Bozorgi
- Department of Cardiac Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Roman Michalski
- Clinic and Polyclinic for Cardiology, Angiology and Intensive Care, University Hospital Halle, Martin-Luther University, Halle (Saale), Germany
| | - Daniel Hoyer
- Clinic and Polyclinic for Cardiology, Angiology and Intensive Care, University Hospital Halle, Martin-Luther University, Halle (Saale), Germany
| | - Daniel Sedding
- Clinic and Polyclinic for Cardiology, Angiology and Intensive Care, University Hospital Halle, Martin-Luther University, Halle (Saale), Germany
| | - Arash Arya
- Clinic and Polyclinic for Cardiology, Angiology and Intensive Care, University Hospital Halle, Martin-Luther University, Halle (Saale), Germany
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9
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Leventopoulos G, Travlos CK, Aronis KN, Anagnostopoulou V, Patrinos P, Papageorgiou A, Perperis A, Gale CP, Davlouros P. Safety and efficacy of left bundle branch area pacing compared with right ventricular pacing in patients with bradyarrhythmia and conduction system disorders: Systematic review and meta-analysis. Int J Cardiol 2023; 390:131230. [PMID: 37527751 DOI: 10.1016/j.ijcard.2023.131230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/03/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Right Ventricular Pacing (RVP) may have detrimental effects in ventricular function. Left Bundle Branch Area Pacing (LBBAP) is a new pacing strategy that appears to have better results. The aim of this systematic review and meta-analysis is to compare the safety and efficacy of LBBAP vs RVP in patients with bradyarrhythmia and conduction system disorders. METHODS MEDLINE, EMBASE and Pubmed databases were searched for studies comparing LBBAP with RVP. Outcomes were all-cause mortality, atrial fibrillation (AF) occurrence, heart failure hospitalizations (HFH) and complications. QRS duration, mechanical synchrony and LVEF changes were also assessed. Pairwise meta-analysis was conducted using random and fixed effects models. RESULTS Twenty-five trials with 4250 patients (2127 LBBAP) were included in the analysis. LBBAP was associated with lower risk for HFH (RR:0.33, CI 95%:0.21 to 0.50; p < 0.001), all-cause mortality (RR:0.52 CI 95%:0.34 to 0.80; p = 0.003), and AF occurrence (RR:0.43 CI 95%:0.27 to 0.68; p < 0.001) than RVP. Lead related complications were not different between the two groups (p = 0.780). QRSd was shorter in the LBBAP group at follow-up (WMD: -32.20 msec, CI 95%: -40.70 to -23.71; p < 0.001) and LBBAP achieved better intraventricular mechanical synchrony than RVP (SMD: -1.77, CI 95%: -2.45 to -1.09; p < 0.001). LBBAP had similar pacing thresholds (p = 0.860) and higher R wave amplitudes (p = 0.009) than RVP. CONCLUSIONS LBBAP has better clinical outcomes, preserves ventricular electrical and mechanical synchrony and has excellent pacing parameters, with no difference in complications compared to RVP.
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Affiliation(s)
| | - Christoforos K Travlos
- Department of Cardiology, University Hospital of Patras, Rio, Patras, Greece; Department of Medicine, University of Patras, Patras, Greece
| | - Konstantinos N Aronis
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Virginia Anagnostopoulou
- Department of Cardiology, University Hospital of Patras, Rio, Patras, Greece; Department of Medicine, University of Patras, Patras, Greece
| | - Panagiotis Patrinos
- Department of Cardiology, University Hospital of Patras, Rio, Patras, Greece
| | | | - Angelos Perperis
- Department of Cardiology, University Hospital of Patras, Rio, Patras, Greece
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK; Leeds Institute for Data Analytics, University of Leeds, Leeds, UK; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Periklis Davlouros
- Department of Cardiology, University Hospital of Patras, Rio, Patras, Greece
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10
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Yousaf A, Ahmad S, Peltz J, Ahsan MJ, Abbas KS, Muhammad S, Watson C, Asad ZUA, Kim MH. Left bundle branch area pacing vs biventricular pacing for cardiac resynchronization: A systematic review and meta-analysis. Heart Rhythm O2 2023; 4:671-680. [PMID: 38034886 PMCID: PMC10685169 DOI: 10.1016/j.hroo.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Abstract
Background Left bundle branch area pacing (LBBAP) may offer greater physiological benefits than traditional biventricular pacing (BiVP). However, there are limited data comparing the efficacy of LBBAP vs BiVP in patients with systolic heart failure (HF). Objective The purpose of this meta-analysis was to compare the feasibility and electromechanical and clinical outcomes of both LBBAP and BiVP. Methods We conducted a systematic review of studies retrieved from various databases including PubMed, Embase, Google Scholar, Scopus, and Cochrane Central Register of Control Trials (CENTRAL) published up to May 22, 2023. The risk ratio (RR) and standardized mean difference (SMD) with corresponding 95% confidence intervals (CIs) were calculated for dichotomous and continuous outcomes, respectively. Results We included 12 studies with a total of 3004 patients (LBBAP = 1242, BiVP = 1762). Pooled results showed that LBBAP resulted in a significant increase in left ventricular ejection fraction (SMD 0.40, 95% CI 0.25, 0.54, P < .00001), echocardiographic response (RR 1.19, 95% CI 1.10 to 1.29, P < .0001), improvement in New York Heart Association functional class (SMD -0.44, 95% CI -0.65 to -0.23, P < .0001), QRS duration reduction (SMD -0.90, 95% CI -1.14 to -0.66, P < .00001), left ventricular end-diastolic diameter reduction (SMD -0.31, 95% CI -0.57 to -0.05, P = .02), fewer HF hospitalizations (RR 0.72, 95% CI 0.62, 0.85, P < .0001), and improved survival (RR 0.73, 95% CI 0.58, 0.92, P = .007). In addition, LBBAP was associated with shorter fluoroscopy time (SMD -0.94, 95% CI -1.42 to -0.47, P < .0001) and lower pacing threshold at implantation (SMD -1.03, 95% CI -1.32 to -0.74, P < .00001) and at 6 months (SMD -1.44, 95% CI -2.11 to -0.77, P < .0001) as compared with BiVP. Conclusion Compared with BiVP, LBBAP was associated with better electromechanical and clinical outcomes, including left ventricular ejection fraction, QRS duration, echocardiographic response, New York Heart Association functional class, HF hospitalization, and all-cause mortality in patients with systolic HF.
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Affiliation(s)
- Amman Yousaf
- Department of Medicine, McLaren Flint-Michigan State University, Flint, Michigan
| | - Soban Ahmad
- Department of Medicine, East Carolina University, Greenville, North Carolina
| | - Joshua Peltz
- Department of Medicine, East Carolina University, Greenville, North Carolina
| | | | | | - Shoaib Muhammad
- Department of Medicine, Gulab Devi Hospital, Lahore, Pakistan
| | - Christopher Watson
- Department of Medicine, East Carolina University, Greenville, North Carolina
| | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Michael H. Kim
- Department of Medicine, Creighton University and CHI Health, Omaha, Nebraska
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11
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Zhang W, He L, Zhang J, Fu G, Sheng X, Pan Y, Zeng G, Li Z, Huang J, Lu H, Shi T, Zhou X, Stadler R, Demmer W, Li R. Electrical Synchrony Optimization for Left Bundle Branch Area Pacing in Patients With Bradycardia and Heart Failure. Am J Cardiol 2023; 203:436-443. [PMID: 37540902 DOI: 10.1016/j.amjcard.2023.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 08/06/2023]
Abstract
Left bundle branch area pacing (LBBAP) has emerged as a promising physiological pacing modality. This study was designed to investigate the acute impact of the atrioventricular delay (AVD) on cardiac electrical characteristics and identify an optimal range of AVDs for LBBAP to achieve electrical atrioventricular and interventricular synchrony. Patients indicated for ventricular or biventricular pacing were studied during routine follow-ups at least 3 months after LBBAP implantation. Patients were excluded if they had a complete AV block or persistent atrial fibrillation. AVD was programed from 40 to 240 ms or until intrinsic conduction occurred. Optimal AVD was determined by the electrocardiography criteria, including QRS duration, reduced R-wave in lead V1, reduced notching or slurring in lateral leads, and more desirable precordial QRS transition. A total of 38 patients (age 68.7 ± 10.3 years; 16 male (42%); 18 dual-chamber pacemakers and 20 cardiac resynchronization therapy devices; average follow-up period 15.1 ± 10.2 months) were included. The fusion of LBBAP and intrinsic right ventricular conduction occurred in 21 patients with corresponding optimal AVD determined. A great proportion (∼85%) of the optimal AVDs ranged from 50% to 80% of the observed atrium-to-left bundle branch-sensing (A-LBBS) intervals. The linear correlation between the optimal AVD and corresponding A-LBBS interval (optimal AVD = 0.84 × [A-LBSs interval] - 36 ms) produced R = 0.86 and p <0.0001. In conclusion, AVD selection during LBBAP greatly impacted the ventricular electrical characteristics and the optimal AVD was linearly correlated with the corresponding A-LBBS interval.
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Affiliation(s)
- Weiwei Zhang
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lang He
- Department of Cardiology, Greentown Hospital, Hangzhou, China
| | - Jiefang Zhang
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guosheng Fu
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xia Sheng
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiwen Pan
- Department of Cardiology, Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guang Zeng
- Department of Cardiology, Greentown Hospital, Hangzhou, China
| | - Zhidi Li
- Department of Cardiology, Greentown Hospital, Hangzhou, China
| | - Jingjuan Huang
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hongyang Lu
- Cardiac Rhythm Management, Medtronic Technology Center, Medtronic (Shanghai) Ltd., Shanghai, China
| | - Tianyi Shi
- Cardiac Rhythm Management, Medtronic Technology Center, Medtronic (Shanghai) Ltd., Shanghai, China
| | - Xiaohong Zhou
- Cardiac Rhythm Management, Medtronic plc., Mounds View, Minnesota
| | - Robert Stadler
- Cardiac Rhythm Management, Medtronic plc., Mounds View, Minnesota
| | - Wade Demmer
- Cardiac Rhythm Management, Medtronic plc., Mounds View, Minnesota
| | - Ruogu Li
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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12
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Jin C, Dai Q, Li P, Lam P, Cha YM. Left bundle branch area pacing for heart failure patients requiring cardiac resynchronization therapy: A meta-analysis. J Cardiovasc Electrophysiol 2023; 34:1933-1943. [PMID: 37548113 DOI: 10.1111/jce.16013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Left bundle branch area 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 with reduced ejection fraction (HFrEF). We conduted this meta-analysis and systemic review to review current data comparing BVP and LBBP in patients with HFrEF and indications for 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 for CRT were included. Two reviewers performed study selection, data abstraction, and risk of bias assessment. We calculated risk ratios (RRs) with the Mantel-Haenszel method and mean difference (MD) with inverse variance using random effect models. We assessed heterogeneity using the I2 index, with I2 > 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 (MD: 9.68, 95% confidence interval [CI]: 4.49-14.87, I2 = 95%, p < .01, minutes) as well as a shorter procedural time (MD 33.68, 95% CI: 17.80-49.55, I2 = 73%, p < .01, minutes) during the implantation of LBBP CRT compared to conventional BVP CRT. LBBP was shown to have a greater reduction in QRS duration (MD 25.13, 95% CI: 20.06-30.20, I2 = 51%, p < .01, milliseconds), a greater left ventricular ejection fraction improvement (MD: 5.80, 95% CI: 4.81-6.78, I2 = 0%, p < .01, percentage), and a greater left ventricular end-diastolic diameter reduction (MD: 2.11, 95% CI: 0.12-4.10, I2 = 18%, p = .04, millimeter). There was a greater improvement in New York Heart Association function class with LBBP (MD: 0.37, 95% CI: 0.05-0.68, I2 = 61%, p = .02). LBBP was also associated with a lower risk of a composite of heart failure hospitalizations (HFH) and all-cause mortality (RR: 0.48, 95% CI: 0.25-0.90, I2 = 0%, p = .02) driven by reduced HFH (RR: 0.39, 95% CI: 0.19-0.82, I2 = 0%, p = .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, I2 = 0%, p = .87). CONCLUSION This meta-analysis of primarily nonrandomized studies suggests that LBBP is associated with a greater improvement in left ventricular systolic function and a lower rate of HFH compared to BVP. There was uniformity of these findings in all of the included studies. However, it would be premature to conclude based solely on the current meta-analysis alone, given the limitations stated. Dedicated, well-designed, randomized controlled trials and observational studies are needed to elucidate better the comparative long-term efficacy and safety of LBBP CRT versus BIV CRT.
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Affiliation(s)
- Chengyue Jin
- Division of Cardiology, Department of Medicine, Mount Sinai-Beth Israel Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Qiying Dai
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Pengyang Li
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Patrick Lam
- Al-Sabah Arrhythmia Institute, Division of Cardiology, Department of Medicine, Mount Sinai-Morningside Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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13
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Moustafa AT, Tang ASL, Khan HR. Conduction system pacing on track to replace CRT? Review of current evidence and prospects of conduction system pacing. Front Cardiovasc Med 2023; 10:1220709. [PMID: 37649666 PMCID: PMC10463741 DOI: 10.3389/fcvm.2023.1220709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/31/2023] [Indexed: 09/01/2023] Open
Abstract
Conduction system pacing (CSP) has been emerging over the last decade as a pacing option instead of conventional right ventricular (RV) pacing and biventricular (BiV) pacing. Numerous case reports, some observational studies and a few randomized control trials have looked at optimum pacing strategies for heart failure (HF) with left bundle branch block (LBBB) or cases where left ventricular (LV) dysfunction is anticipated due to chronic RV pacing (RVP). Evolution of pacing strategies from standard RVP to septal RVP, BiV pacing and now CSP have shown improving hemodynamic responses and possible ease of implantation of CSP systems. In this review article, we review the literature on the evolution of CSP and common scenarios where it might be beneficial.
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Affiliation(s)
| | | | - Habib Rehman Khan
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
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14
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Padala SK, Ellenbogen KA. Pacing of Specialized Conduction System. Cardiol Clin 2023; 41:463-489. [PMID: 37321695 DOI: 10.1016/j.ccl.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Right ventricular pacing for bradycardia remains the mainstay of pacing therapy. Chronic right ventricular pacing may lead to pacing-induced cardiomyopathy. We focus on the anatomy of the conduction system and the clinical feasibility of pacing the His bundle and/or left bundle conduction system. We review the hemodynamics of conduction system pacing, the techniques to capture the conduction system and the electrocardiogram and pacing definitions of conduction system capture. Clinical studies of conduction system pacing in the setting of atrioventricular block and after AV junction ablation are reviewed and the evolving role of conduction system pacing is compared with biventricular pacing.
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Affiliation(s)
- Santosh K Padala
- Department of Cardiac Electrophysiology, Virginia Commonwealth University, Gateway Building, 3 Road Floor, 3-216, 1200 East Marshall Street, Richmond, VA, USA
| | - Kenneth A Ellenbogen
- Department of Cardiac Electrophysiology, Virginia Commonwealth University, Gateway Building, 3 Road Floor, 3-216, 1200 East Marshall Street, Richmond, VA, USA.
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15
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Kim JA, Kim SE, Ellenbogen KA, Vijayaraman P, Chelu MG. Clinical outcomes of conduction system pacing versus biventricular pacing for cardiac resynchronization therapy: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2023; 34:1718-1729. [PMID: 37343033 DOI: 10.1111/jce.15976] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/30/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Conduction system pacing (CSP) is observed to produce greater improvements in echocardiographic and hemodynamic parameters as compared to conventional biventricular pacing (BiVP). However, whether these surrogate endpoints directly translate to improvements in hard clinical outcomes such as death and heart failure hospitalization (HFH) with CSP remains uncertain as studies reporting these outcomes are scarce. The aim of this meta-analysis was to analyze the existing data to compare the clinical outcomes of CSP versus BiVP. METHODS A systematic search of the Embase and PubMed database was performed for studies comparing CSP and BiVP for patients indicated to receive a CRT device. The coprimary endpoints were all-cause mortality and HFH. Other secondary outcomes included change in left ventricular ejection fraction (LVEF), change in NYHA class, and increase in NYHA class ≥1. A random-effects model was chosen a priori to analyze the composite effects given the anticipated heterogeneity of included trials. RESULTS Twenty-one studies (4 randomized and 17 observational) were identified reporting either primary outcome and were included in the meta-analysis. In total 1960 patients were assigned to CSP and 2367 to BiVP. Median follow-up time was 10.1 months (ranging 2-33 months). CSP was associated with a significant reduction in all-cause mortality (odds ratio [OR] 0.68, 95% confidence interval [CI]: 0.56-0.83) and HFH (OR 0.52, 95% CI: 0.44-0.63). Mean improvement in LVEF was also greater with CSP (mean difference 4.26, 95% CI: 3.19-5.33). Reduction in NYHA class was significantly greater with CSP (mean difference -0.36, 95% CI: -0.49 to -0.22) and the number of patients with an increase in NYHA class ≥1 was significantly greater with CSP (OR 2.02, 95% CI: 1.70-2.40). CONCLUSIONS CSP was associated with a significant reduction in all-cause mortality and HFH when compared to conventional BiVP for CRT. Further large-scale randomized trials are needed to verify these observations.
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Affiliation(s)
- Jitae A Kim
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Seulgi E Kim
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kenneth A Ellenbogen
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Pugazhendhi Vijayaraman
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania, USA
| | - Mihail G Chelu
- Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA
- Baylor St. Luke's Medical Center, Houston, Texas, USA
- Texas Heart Institute, Houston, Texas, USA
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16
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Wang Y, Liu F, Liu M, Wang Z, Lu X, Huang J, Gu D. His-Purkinje system pacing versus biventricular pacing in clinical efficacy: a systematic review and meta-analysis. BMC Cardiovasc Disord 2023; 23:285. [PMID: 37270513 DOI: 10.1186/s12872-023-03307-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 05/16/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND His-Purkinje system pacing (HPSP), including his-bundle pacing (HBP) and left bundle branch area pacing (LBBaP), imitates the natural conduction of the heart as an alternative to biventricular pacing (BVP) in cardiac resynchronization therapy (CRT). However, the feasibility and efficacy of HPSP were currently only evidenced by studies with a limited sample size, so this study aimed to provide a comprehensive assessment through a systematic review and meta-analysis. METHODS In order to compare the clinical outcomes associated with HPSP and BVP in patients for CRT, PubMed, EMBASE, Cochrane Library and Web of Science database were searched from inception to April 10, 2023. Clinical outcomes of interest including QRS duration (QRSd), left ventricular (LV) function and New York Heart Association (NYHA) functional classification, pacing threshold, echocardiographic and clinical response, hospitalization rate of HF and all-cause mortality were also extracted and summarized for meta-analysis. RESULTS A total of 13 studies (ten observational studies and three randomized studies) involving 1,121 patients were finally included. The patients were followed up for 6-27 months. Compared with BVP, CRT patients treated by HPSP presented shorter QRSd [mean difference (MD): -26.23 ms, 95% confidence interval (CI): -34.54 to -17.92, P < 0.001, I2 = 91%], greater LV functional improvement with increased left ventricular ejection fraction (LVEF) (MD: 6.01, 95% CI: 4.81 to 7.22, P < 0.001, I2 = 0%), decreased left ventricular end-diastolic dimension (LVEDD) (MD: -2.91, 95% CI: -4.86 to -0.95, P = 0.004, I2 = 35%), and more improved NYHA functional classification (MD: -0.45, 95% CI: -0.67 to -0.23, P < 0.001, I2 = 70%). In addition, HPSP was more likely to have higher echocardiographic [odds ratio (OR): 2.76, 95% CI: 1.74 to 4.39, P < 0.001, I2 = 0%], clinical (OR: 2.10, 95% CI: 1.16 to 3.80, P = 0.01, I2 = 0%) and super clinical (OR: 3.17, 95% CI: 2.09 to 4.79, P < 0.001, I2 = 0%) responses than BVP, and a lower hospitalization rate of HF (OR: 0.34, 95% CI: 0.22 to 0.51, P < 0.001, I2 = 0%), while presented no difference (OR: 0.68, 95% CI: 0.44 to 1.06, P = 0.09, I2 = 0%) in all-cause mortality compared with BVP. With threshold change taking into account, BVP was less stable than LBBaP (MD: -0.12 V, 95% CI: -0.22 to -0.03, P = 0.01, I2 = 57%), but had no difference with HBP (MD: 0.11 V, 95% CI: -0.09 to 0.31, P = 0.28, I2 = 0%). CONCLUSION The present findings suggested that HPSP was associated with greater improvement of cardiac function in patients with indication for CRT and was a potential alternative to BVP to achieve physiological pacing through native his-purkinje system.
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Affiliation(s)
- Ya Wang
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Beijing, 100037, China
| | - Fangchao Liu
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Beijing, 100037, China
| | - Mengyao Liu
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Beijing, 100037, China
| | - Zefeng Wang
- Department of Cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Xiangfeng Lu
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Beijing, 100037, China
| | - Jianfeng Huang
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Beijing, 100037, China
| | - Dongfeng Gu
- Department of Epidemiology, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Beijing, 100037, China.
- School of Medicine, Southern University of Science and Technology, Shenzhen, 518055, China.
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17
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Siranart N, Chokesuwattanaskul R, Prasitlumkum N, Huntrakul A, Phanthong T, Sowalertrat W, Navaravong L, Cheungpasitporn W, Jongnarangsin K. Reverse of left ventricular remodeling in heart failure patients with left bundle branch area pacing: Systematic review and meta-analysis. Pacing Clin Electrophysiol 2023; 46:459-466. [PMID: 36633357 DOI: 10.1111/pace.14661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/19/2022] [Accepted: 12/30/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) has recently become a promising option for the near-natural restoration of electrical activation. However, the clinical relevance of therapeutic effects in individuals with heart failure with reduced ejection fraction (HFrEF) and dyssynchrony remains unknown. METHODS MEDLINE, EMBASE, and Cochrane databases were searched from inception until June 2022. Data from each study was combined using a random-effects model, the generic inverse variance method of DerSimonian and Laird, to calculate standard mean differences and pooled incidence ratio, with 95% confidence intervals (CIs). RESULTS A total of 772 HFrEF patients were analyzed from 15 observational studies per protocol. The success rate of LBBAP implantation was 94.8% (95% CI 89.9-99.6, I2 = 79.4%), which was strongly correlated with shortening QRS duration after LBBAP implantation, with a mean difference of -48.10 ms (95% CI -60.16 to -36.05, I2 = 96.7%). Over a period of 6-12 months of follow-up, pacing parameters were stable over time. There were significant improvements in left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic diameter (LVEDD), and left ventricular end-diastolic volume (LVEDV) with mean difference of 16.38% (95% CI 13.13-19.63, I2 = 90.2%), -46.23 ml (95% CI -63.17 to -29.29, I2 = 86.82%), -7.21 mm (95% CI -9.71 to -4.71, I2 = 84.6%), and -44.52 ml (95% CI -64.40 to -24.64, I2 = 85.9%), respectively. CONCLUSIONS LBBAP was associated with improvements in both cardiac function and electrical synchrony. The benefits of LBBAP in individuals with HFrEF and dyssynchrony should be further validated by randomized studies.
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Affiliation(s)
- Noppachai Siranart
- Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Cardiology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Ronpichai Chokesuwattanaskul
- Division of Cardiology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Narut Prasitlumkum
- Department of Cardiology, University of California Riverside, Riverside, California, USA
| | - Anurut Huntrakul
- Division of Cardiology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Tanattida Phanthong
- Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Walit Sowalertrat
- Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Krit Jongnarangsin
- Division of Cardiac Electrophysiology, University of Michigan Health Care, Ann Arbor, Michigan, USA
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Gin J, Chow CL, Voskoboinik A, Nalliah C, Wong C, Van Gaal W, Farouque O, Mohamed U, Lim HS, Kalman JM, Wong GR. Improved Outcomes of Conduction System Pacing in Heart Failure with Reduced Ejection Fraction - A Systematic Review and Meta-analysis. Heart Rhythm 2023:S1547-5271(23)02226-9. [PMID: 37172670 DOI: 10.1016/j.hrthm.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/25/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
Conduction system pacing (CSP) - His bundle pacing (HBP) and Left bundle branch area pacing (LBBAP) - are emerging alternatives to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT) in heart failure. However, evidence is largely limited to small and observational studies. We conducted a meta-analysis including a total of 15 randomized control trials (RCTs) and non-RCTs that compare CSP (HBP & LBBAP) with BVP in patients with CRT indications. We assessed the mean differences in QRS duration (QRSd), pacing threshold, left ventricular ejection fraction (LVEF), and New York Heart Association (NYHA) class score. CSP resulted in a pooled mean QRSd improvement of -20.3 ms (95% CI -26.1 - -14.5, p<0.05, I2=87.1%) versus BVP. For LVEF, a weighted mean increase of 5.2% (95% CI 3.5-6.9, p<0.05, I2=55.6) was observed following CSP versus BVP. The mean NYHA score was reduced by -0.40 (95% CI -0.6 - -0.2, p<0.05, I2=61.7) post-CSP versus BVP. Subgroup analysis of outcomes by LBBAP and HBP demonstrated statistically significant weighted mean improvements from both CSP modalities for QRSd and LVEF compared to BVP. LBBAP resulted in NYHA improvement compared to BVP without differences between CSP subgroups. LBBAP is associated with a significantly lowered mean pacing threshold of -0.51V (95% CI -0.68 - -0.38) whilst HBP had increased the mean threshold (0.62V, 95% CI -0.03 - 1.26) compared to BVP, however, this was associated with significant heterogeneity. Overall, both CSP techniques are feasible and effective CRT alternatives for heart failure. Further RCTs are needed to establish long-term efficacy and safety.
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Affiliation(s)
- Julian Gin
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Chee Loong Chow
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Alex Voskoboinik
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Chrishan Nalliah
- Department of Cardiology, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Chiew Wong
- Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - William Van Gaal
- Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Uwais Mohamed
- Department of Cardiology, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Jonathan M Kalman
- Department of Cardiac Electrophysiology, Royal Melbourne Hospital, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Geoffrey R Wong
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia.
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Bednarek A, Kiełbasa G, Moskal P, Ostrowska A, Bednarski A, Sondej T, Kusiak A, Rajzer M, Jastrzębski M. Left bundle branch area pacing prevents pacing induced cardiomyopathy in long-term observation. Pacing Clin Electrophysiol 2023. [PMID: 37154051 DOI: 10.1111/pace.14707] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/08/2023] [Accepted: 04/15/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) is one of the methods to deliver conduction system pacing which potentially avoids the negative impact of conventional right ventricular pacing. OBJECTIVE To assess echocardiographic outcomes in a long-term observation in patients with LBBAP implemented for bradyarrhythmia indications. METHODS AND RESULTS A total of 151 patients with symptomatic bradycardia and LBBAP pacemaker implanted, were prospectively included in the study. Subjects with left bundle branch block and CRT indications (n = 29), ventricular pacing burden <40% (n = 11), and loss of LBBAP (n = 10) were excluded from further analysis. At baseline and the last follow-up visit, echocardiography with global longitudinal strain (GLS) assessment, 12-lead ECG, pacemaker interrogation, and blood level of NT-proBNP were performed. The median follow-up period was 23 months (15.5-28). None of the analyzed patients fulfilled the criteria for pacing induced cardiomyopathy (PICM). Improvement in left ventricular ejection fraction (LVEF) and GLS was observed in patients with LVEF <50% at baseline (n = 39): 41.4 ± 9.2% versus 45.6 ± 9.9%, and 12.9 ± 3.6% versus 15.5 ± 3.7%, respectively. In the subgroup with preserved EF (n = 62), LVEF and GLS remained stable at follow-up: 59.3 ± 5.5% versus 60 ± 5.5%, and 19 ± 3.9% versus 19.4 ± 3.8%, respectively. CONCLUSION LBBAP prevents PICM in patients with preserved LVEF and improves left ventricle function in subjects with depressed LVEF. LBBAP might be the preferred pacing modality for bradyarrhythmia indications.
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Affiliation(s)
- Agnieszka Bednarek
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Grzegorz Kiełbasa
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Paweł Moskal
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Aleksandra Ostrowska
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Adam Bednarski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Tomasz Sondej
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Aleksander Kusiak
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Marek Rajzer
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
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Yu GI, Kim TH, Cho YH, Bae JS, Ahn JH, Jang JY, Park YW, Kwak CH. Left bundle branch area pacing in mildly reduced heart failure: A systematic literature review and meta-analysis. Clin Cardiol 2023. [PMID: 37144691 DOI: 10.1002/clc.24028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/09/2023] [Accepted: 04/21/2023] [Indexed: 05/06/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) strategy for heart failure with mildly reduced ejection fraction (HFmrEF) is controversial. Left bundle branch area pacing (LBBAP) is an emerging pacing modality and an alternative option to CRT. This analysis aimed to perform a systematic review of the literature and meta-analysis on the impact of the LBBAP strategy in HFmrEF, with left ventricular ejection fraction (LVEF) between 35% and 50%. PubMed, Embase, and Cochrane Library were searched for full-text articles on LBBAP from inception to July 17, 2022. The outcomes of interest were QRS duration and LVEF at baseline and follow-up in mid-range heart failure. Data were extracted and summarized. A random-effect model incorporating the potential heterogeneity was used to synthesize the results. Out of 1065 articles, 8 met the inclusion criteria for 211 mid-range heart failure patients with an implant LBBAP across the 16 centers. The average implant success rate with lumenless pacing lead use was 91.3%, and 19 complications were reported among all 211 enrolled patients. During the average follow-up of 9.1 months, the average LVEF was 39.8% at baseline and 50.5% at follow-up (MD: 10.90%, 95% CI: 6.56-15.23, p < .01). Average QRS duration was 152.6 ms at baseline and 119.3 ms at follow-up (MD: -34.51 ms, 95% CI: -60.00 to -9.02, p < .01). LBBAP could significantly reduce QRS duration and improve systolic function in a patient with LVEF between 35% and 50%. Application of LBBAP as a CRT strategy for HFmrEF may be a viable option.
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Affiliation(s)
- Ga-In Yu
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yun-Ho Cho
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Jae-Seok Bae
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Jong-Hwa Ahn
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Jeong Yoon Jang
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Yong Whi Park
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Choong Hwan Kwak
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
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21
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Zhang J, Li F, Zhang ZY, Yang F, Kong Q, Chen JY, Zhang L, Liu HH, Chen XF, Ye YH, Wang RX. Conduction system pacing is superior to biventricular pacing in patients with heart failure: Insights from the pooled clinical studies. Front Physiol 2023; 14:1125340. [PMID: 37215180 PMCID: PMC10196184 DOI: 10.3389/fphys.2023.1125340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/26/2023] [Indexed: 05/24/2023] Open
Abstract
Background: The effects of conduction system pacing (CSP) compared with conventional biventricular pacing (BVP) on heart function in patients with heart failure remain elusive. Methods: PubMed, Embase, Cochrane's Library and Web of science databases were searched up to 1 October 2022 for pertinent controlled studies. Random or fixed-effect model were used to synthesize the clinical outcomes. Subgroup analysis was performed to screen the potential confounding factors. Results: Fifteen studies including 1,347 patients were enrolled. Compared with BVP, CSP was significantly associated with shortened QRS duration [WMD -22.51 ms; p = 0.000], improved left ventricular ejection fraction [WMD 5.53%; p = 0.000], improved NYHA grade [WMD -0.42; p = 0.000], higher response rate and lower heart failure rehospitalization rate. CSP resulted in better clinical outcomes in higher male proportion group than lower one compared with BVP. No significant differences of clinical outcomes were observed between left bundle branch area pacing (LBBaP) and his bundle pacing (HBP) except the pacing threshold. The pacing threshold of LBBaP was significantly lower than those in BVP and HBP. Conclusion: This study suggests that CSP might be superior to conventional BVP for HF patients. In a higher male proportion group, CSP may be associated with more benefits than BVP. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022355991; Identifier: CRD42022355991.
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22
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Baroni M, Preda A, Varrenti M, Vargiu S, Carbonaro M, Giordano F, Gigli L, Mazzone P. Left Bundle Branch Area Pacing over His Bundle Pacing: How Far Have We Come? J Clin Med 2023; 12:jcm12093251. [PMID: 37176691 PMCID: PMC10179456 DOI: 10.3390/jcm12093251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
Implantable cardiac pacemakers have greatly evolved during the few past years, focusing on newer modalities of physiologic cardiac pacing [...].
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Affiliation(s)
- Matteo Baroni
- Cardio-Thoraco-Vascular Department, Electrophysiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Alberto Preda
- Cardio-Thoraco-Vascular Department, Electrophysiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Marisa Varrenti
- Cardio-Thoraco-Vascular Department, Electrophysiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Sara Vargiu
- Cardio-Thoraco-Vascular Department, Electrophysiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Marco Carbonaro
- Cardio-Thoraco-Vascular Department, Electrophysiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Federica Giordano
- Cardio-Thoraco-Vascular Department, Electrophysiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Lorenzo Gigli
- Cardio-Thoraco-Vascular Department, Electrophysiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Patrizio Mazzone
- Cardio-Thoraco-Vascular Department, Electrophysiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
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23
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Mariani MV, Piro A, Forleo GB, Della Rocca DG, Natale A, Miraldi F, Vizza CD, Lavalle C. Clinical, procedural and lead outcomes associated with different pacing techniques: a network meta-analysis. Int J Cardiol 2023; 377:52-59. [PMID: 36736670 DOI: 10.1016/j.ijcard.2023.01.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/14/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND His- Purkinje system pacing (HPSP) techniques have been proposed as alternative to biventricular pacing (BVP) and right ventricular pacing (RVP). OBJECTIVE To compare data regarding clinical, procedural and lead outcomes associated with different pacing techniques. METHODS An accurate search of online scientific libraries (from inception to May, 12,022) was performed. Thirty-three studies were included in the meta-analysis involving 4386 patients, of whom 1324 receiving RVP, 1032 patients receiving BVP, 1069 patients receiving his-bundle pacing (HBP) and 968 patients receiving left bundle branch pacing (LBBP). RESULTS LBBP provided a statistically significant increase in LVEF relative to HBP (0.4473 [0.0584; 0.8361] p = 0.0242) and BVP (0.6733 [0.4734; 0.8732] p < 0.0001) in patients with cardiac resynchronization therapy indication. LBBP and HBP significantly decreased QRS duration as compared to BVP, with largest QRS narrowing obtained by LBBP (-0.4951 [-0.9077; -0.0824] p = 0.0187). As compared to LBBP, HBP was associated with a significant increase of pacing threshold (p = 0.0369) and significant reduction of R-wave amplitude over time (p = 0.027). LBBP was associated with significant reduction in RR of hospitalization for HF (HFH) as compared to both BVP (p = 0.0343) and HBP (p = 0.0476), whereas, as compared to RVP, the risk of lead issues was significantly higher with BVP (p = 0.0424) and HBP (p = 0.0298), but not for LBBP (p = 0.425). CONCLUSIONS As compared to other pacing techniques, LBBP significantly improved LVEF, narrowed QRS duration and reduced HFHs, with steadily lower capture thresholds and higher R-wave amplitude, and without increasing lead issues.
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Affiliation(s)
- Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Rome, Italy.
| | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Giovanni Battista Forleo
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX 78705, USA
| | - Fabio Miraldi
- Cardio Thoracic-Vascular and Organ Transplantation Surgery Department, Policlinico Umberto I Hospital, Rome, Italy
| | - Carmine Dario Vizza
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Rome, Italy
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Parlavecchio A, Vetta G, Caminiti R, Coluccia G, Magnocavallo M, Ajello M, Pistelli L, Dattilo G, Foti R, Carerj S, Della Rocca DG, Crea P, Palmisano P. Left bundle branch pacing versus biventricular pacing for cardiac resynchronization therapy: A systematic review and meta-analysis. Pacing Clin Electrophysiol 2023; 46:432-439. [PMID: 37036831 DOI: 10.1111/pace.14700] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/23/2023] [Accepted: 03/30/2023] [Indexed: 04/11/2023]
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) reduces heart failure (HF) hospitalization and all-cause mortality in HF patients with left bundle branch block (LBBB). Biventricular pacing (BVP) is the gold standard for achieving CRT, but about 30%-40% of patients do not respond to BVP-CRT. Recent studies showed that left bundle branch pacing (LBBP) provided remarkable results in CRT. Therefore, we conducted a meta-analysis aiming to compare LBBP-CRT versus BVP-CRT in HF patients. METHODS We systematically searched the electronic databases for studies published from inception to December 29, 2022 and focusing on LBBP-CRT versus BVP-CRT in HF patients. The primary endpoint was HF hospitalization. The effect size was estimated using a random-effect model as Risk Ratio (RR) and mean difference (MD). RESULTS Ten studies enrolling 1063 patients met the inclusion criteria. Compared to BVP-CRT, LBBP-CRT led to significant reduction in HF hospitalization [7.9% vs.14.5%; RR: 0.60 (95%CI: 0.39-0.93); p = .02], QRSd [MD: 30.26 ms (95%CI: 26.68-33.84); p < .00001] and pacing threshold [MD: -0.60 (95%CI: -0.71 to -0.48); p < .00001] at follow up. Furthermore, LBBP-CRT improved LVEF [MD: 5.78% (95%CI: 4.78-6.77); p < .00001], the rate of responder [88.5% vs.72.5%; RR: 1.19 (95%CI: 1.07-1.32); p = .002] and super-responder [60.8% vs. 36.5%; RR: 1.56 (95%CI: 1.27-1.91); p < .0001] patients and the NYHA class [MD: -0.42 (95%CI: -0.71 to -0.14); p < .00001] compared to BVP-CRT. CONCLUSION In HF patients, LBBP-CRT was superior to BVP-CRT in reducing HF hospitalization. Further significant benefits occurred within the LBBP-CRT group in terms of QRSd, LVEF, pacing thresholds, NYHA class and the rate of responder and super-responder patients.
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Affiliation(s)
- Antonio Parlavecchio
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giampaolo Vetta
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Rodolfo Caminiti
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Michele Magnocavallo
- Arrhythmology Unit, Ospedale San Giovanni Calibita, Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Manuela Ajello
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Lorenzo Pistelli
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Dattilo
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Scipione Carerj
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Giovanni Della Rocca
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Pasquale Crea
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Rademakers LM, van den Broek JLPM, Bracke FA. Left bundle branch pacing as an alternative to biventricular pacing for cardiac resynchronisation therapy. Neth Heart J 2023; 31:140-149. [PMID: 35920989 PMCID: PMC10033770 DOI: 10.1007/s12471-022-01712-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Left bundle branch pacing (LBBP) is a novel physiological pacing technique which may serve as an alternative to biventricular pacing (BVP) for the delivery of cardiac resynchronisation therapy (CRT). This study assessed the feasibility and outcomes of LBBP in comparison to BVP. METHODS LBBP was attempted in 40 consecutive patients as the first-line method for delivering CRT. To evaluate LBBP versus BVP, 40 patients with identical inclusion criteria who received BVP were compared with the LBBP group. Acute success rate, complications, functional and echocardiographic outcomes as well as hospitalisation for heart failure and all-cause mortality 6 months after implantation were evaluated. RESULTS LBBP was successfully performed in 31 (78%) patients and resulted in significant QRS narrowing (from 166 ± 16 to 123 ± 18 ms, p < 0.001), improvement in left ventricular ejection fraction (LVEF; from 28 ± 8 to 43 ± 12%, p < 0.001) and New York Heart Association functional class (from 2.8 ± 0.5 to 1.6 ± 0.6, p < 0.001) at 6 months. No LBBP-related complications occurred. Compared to BVP, LBBP resulted in a greater reduction in QRS duration (44 ± 17 vs 15 ± 26 ms, p < 0.001) with comparable absolute improvement in LVEF (15.2 ± 11.7 vs 9.6 ± 12.1%, p = 0.088). Hospitalisation for heart failure and all-cause mortality were similar in the two groups. CONCLUSIONS LBBP is feasible and was safe in 78% of patients with favourable electrical resynchronisation and functional improvement and may serve as an alternative to BVP.
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Affiliation(s)
- L M Rademakers
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands.
| | | | - F A Bracke
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
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26
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Grieco D, Bressi E, Sedláček K, Čurila K, Vernooy K, Fedele E, De Ruvo E, Fagagnini A, Kron J, Padala SK, Ellenbogen KA, Calò L. Feasibility and safety of left bundle branch area pacing-cardiac resynchronization therapy in elderly patients. J Interv Card Electrophysiol 2023; 66:311-321. [PMID: 35266067 DOI: 10.1007/s10840-022-01174-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/27/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) is an emerging technique to achieve cardiac resynchronization therapy (CRT), but its feasibility and safety in elderly patients with heart failure with reduced ejection fraction and left bundle branch block is hardly investigated. METHODS We enrolled consecutive patients with an indication for CRT comparing pacing parameters and complication rates of LBBAP-CRT in elderly patients (≥ 75 years) versus younger patients (< 75 years) over a 6-month follow-up. RESULTS LBBAP was successful in 55/60 enrolled patients (92%), among which 25(45%) were elderly. In both groups, LBBAP significantly reduced the QRS duration (elderly group: 168 ± 15 ms to 136 ± 12 ms, p < 0.0001; younger group: 166 ± 14 ms to 134 ± 11 ms, p < 0.0001) and improved LVEF (elderly group: 28 ± 5% to 40 ± 7%, p < 0.0001; younger group: 29 ± 5% to 41 ± 8%, p < 0.0001). The pacing threshold was 0.9 ± 0.8 V in the elderly group vs. 0.7 ± 0.5 V in the younger group (p = 0.350). The R wave was 9.5 ± 3.9 mV in elderly patients vs. 10.7 ± 2.7 mV in younger patients (p = 0.341). The fluoroscopic (elderly: 13 ± 7 min vs. younger: 11 ± 7 min, p = 0.153) and procedural time (elderly: 80 ± 20 min vs. younger: 78 ± 16 min, p = 0.749) were comparable between groups. Lead dislodgement occurred in 2(4%) patients, 1 in each group (p = 1.000). Intraprocedural septal perforation occurred in three patients (5%), 2(8%) in the elderly group (p = 0.585). One patient (2%) in the elderly group had a pocket infection. CONCLUSIONS LBBAP is a feasible and safe technique for delivering physiological pacing in elderly patients who are candidates for CRT with suitable pacing parameters and low complication rates.
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Affiliation(s)
- Domenico Grieco
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169, Rome, Italy
| | - Edoardo Bressi
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169, Rome, Italy. .,Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands. .,Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA.
| | - Kamil Sedláček
- 1st Department of Internal Medicine - Cardiology and Angiology, Faculty of Medicine, University Hospital and Charles University, Hradec Králové, Czech Republic
| | - Karol Čurila
- Department of Cardiology, Cardiocenter, Third Faculty of Medicine, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Elisa Fedele
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169, Rome, Italy
| | - Ermenegildo De Ruvo
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169, Rome, Italy
| | - Alessandro Fagagnini
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169, Rome, Italy
| | - Jordana Kron
- Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Santosh K Padala
- Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Kenneth A Ellenbogen
- Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Leonardo Calò
- Department of Cardiovascular Sciences, Policlinico Casilino of Rome, Via Casilina, 1049, 00169, Rome, Italy
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Conduction System Pacing Today and Tomorrow. J Clin Med 2022; 11:jcm11247258. [PMID: 36555877 PMCID: PMC9780948 DOI: 10.3390/jcm11247258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
Conduction system pacing (CSP) encompassing His bundle (HBP) and left bundle branch area pacing (LBBAP) is gaining increasing attention in the electrophysiology community. These relatively novel physiological pacing modalities have the potential to outperform conventional pacing approaches with respect to clinical endpoints, although data are currently still limited. While HBP represents the most physiological form of cardiac stimulation, success rates, bundle branch correction, and electrical lead performance over time remain a concern. LBBAP systems may overcome these limitations. In this review article, we provide a comprehensive overview of the current evidence, implantation technique, device programming, and follow-up considerations concerning CSP systems. Moreover, we discuss ongoing technical developments and future perspectives of CSP.
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Abstract
PURPOSE OF THE REVIEW Dyssynchrony occurs when portions of the cardiac chambers contract in an uncoordinated fashion. Ventricular dyssynchrony primarily impacts the left ventricle and may result in heart failure. This entity is recognized as a major contributor to the development and progression of heart failure. A hallmark of dyssynchronous heart failure (HFd) is left ventricular recovery after dyssynchrony is corrected. This review discusses the current understanding of pathophysiology of HFd and provides clinical examples and current techniques for treatment. RECENT FINDINGS Data show that HFd responds poorly to medical therapy. Cardiac resynchronization therapy (CRT) in the form of conventional biventricular pacing (BVP) is of proven benefit in HFd, but is limited by a significant non-responder rate. Recently, conduction system pacing (His bundle or left bundle branch area pacing) has also shown promise in correcting HFd. HFd should be recognized as a distinct etiology of heart failure; HFd responds best to CRT.
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Affiliation(s)
- Sean J Dikdan
- Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | | | - Behzad B Pavri
- Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA.
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Qian Z, Xue S, Zou F, Qin C, Wang Y, Zhang X, Qiu Y, Wu H, Hou X, Zou J. New criterion to determine left bundle branch capture on the basis of individualized His bundle or right ventricular septal pacing. Heart Rhythm 2022; 19:1984-1992. [PMID: 35932987 DOI: 10.1016/j.hrthm.2022.07.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/17/2022] [Accepted: 07/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Left bundle branch pacing (LBBP) is an emerging physiological pacing modality. How to differentiate LBBP from left ventricular septal pacing (LVSP) remains challenging. OBJECTIVE We aimed to develop a new personalized intraoperative criterion to confirm left bundle branch (LBB) capture in patients with or without heart failure (HF). METHODS Patients were enrolled if 12-lead surface electrocardiograms of LBBP, LVSP, temporary His bundle pacing (HBP), and right ventricular septal pacing (RVSP) were recorded during the procedure, with the leads placed in the basal midseptal region. Left ventricular activation time (LVAT) was measured during different pacing modalities. ΔLVAT1 was defined as the difference in LVAT between HBP and LBBP/LVSP. ΔLVAT2 was estimated by the difference in LVAT between RVSP and LBBP/LVSP. ΔLVAT1% and ΔLVAT2% were calculated as the percent reduction of ΔLVAT1 and ΔLVAT2, respectively. RESULTS A total of 105 consecutive patients were included, of whom 80 (76.2%) had normal cardiac function (65 LBBP and 15 LVSP) and 25 had HF. Patients with LBBP showed significantly shorter LVAT than did those with LVSP. In patients with normal cardiac function, a cutoff value of ΔLVAT1 > 12.5 ms showed 73.9% sensitivity and 93.3% specificity to confirm LBB capture. In patients with HF, a cutoff value of ΔLVAT1% > 9.8% exhibited great accuracy for LBB capture (sensitivity 92.0%; specificity 92.3%). The optimal value of ΔLVAT2% for differentiating LBBP from LVSP was 21.2%. CONCLUSION Temporary HBP and RVSP can serve as references to confirm LBB capture in an individualized fashion in patients with or without HF.
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Affiliation(s)
- Zhiyong Qian
- Department of Cardiology, the First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Siyuan Xue
- Department of Cardiology, the First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Fengwei Zou
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Bronx, New York
| | - Chaotong Qin
- Department of Cardiology, the First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Yao Wang
- Department of Cardiology, the First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Xinwei Zhang
- Department of Cardiology, the First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Yuanhao Qiu
- Department of Cardiology, the First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Hongping Wu
- Department of Cardiology, the First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaofeng Hou
- Department of Cardiology, the First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Jiangang Zou
- Department of Cardiology, the First Affiliated Hospital, Nanjing Medical University, Nanjing, China.
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Fu Y, Liu P, Jin L, Li Y, Zhang Y, Qin X, Zheng Q. Left bundle branch area pacing: A promising modality for cardiac resynchronization therapy. Front Cardiovasc Med 2022; 9:901046. [PMID: 36465440 PMCID: PMC9715961 DOI: 10.3389/fcvm.2022.901046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/31/2022] [Indexed: 12/19/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) is recognized as the first-line management for patients with heart failure (HF) and conduction disorders. As a conventional mode for delivering CRT, biventricular pacing (BVP) improves cardiac function and reduces HF hospitalizations and mortality, but there are still limitations given the high incidence of a lack of response rates. Alternative pacing methods are needed either for primary or rescue therapy. In recent years, conduction system pacing (CSP) has emerged as a more physiological pacing modality for simultaneous stimulation of the ventricles, including His bundle pacing (HBP) and left bundle branch pacing (LBBP). CSP activates the His-Purkinje system, allowing normal ventricular stimulation. However, HBP is technically challenging with a relatively low success rate, high pacing threshold, and failure to correct distal conduction abnormalities. Therefore, LBBP stands out as a novel ideal physiological pacing modality for CRT. Several non-randomized studies compared the feasibility and safety of LBBP with BVP and concluded that LBBP is superior to BVP for delivering CRT with a narrower QRS and greater improvements in left ventricular ejection fraction (LVEF) and New York Heart Association (NYHA) functional class. Concurrently, some studies showed lower and stable pacing thresholds and greater improvement of B-type natriuretic peptide (BNP) levels, as well as better mechanical synchronization and efficiency. LBBP ensures better ventricular electromechanical resynchronization than BVP. In this review, we discuss current knowledge of LBBP, compare LBBP with BVP, and explore the potential of LBBP to serve as an alternative primary therapy to realize cardiac resynchronization.
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Affiliation(s)
- Yuping Fu
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Peng Liu
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Lingyan Jin
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yingqi Li
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yudi Zhang
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Xinghua Qin
- School of Life Sciences, Northwestern Polytechnical University, Xi’an, Shaanxi, China
| | - Qiangsun Zheng
- Department of Cardiology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
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Feasibility of Left Bundle Branch Area Pacing Combined with Atrioventricular Node Ablation in Atrial Fibrillation Patients with Heart Failure. J Cardiovasc Dev Dis 2022; 9:jcdd9100338. [PMID: 36286290 PMCID: PMC9604476 DOI: 10.3390/jcdd9100338] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/13/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Pacemaker implantation combined with atrioventricular node ablation (AVNA) could be a practical choice for atrial fibrillation (AF) patients with heart failure (HF). Left bundle branch area pacing (LBBaP) has been widely reported. OBJECTIVES To explore the safety and efficacy of LBBaP combined with AVNA in AF patients with HF. METHODS AND RESULTS Fifty-six AF patients with HF attempted LBBaP and AVNA from January 2019 to December 2020. Standard LBBaP was achieved in forty-six patients, and another ten received left ventricular septal pacing (LVSP). The cardiac function indexes and pacemaker parameters were evaluated at baseline, and we conducted a 1-month and 1-year follow-up. RESULT At the time of implantation and 1-month and 1-year follow-up, QRS duration of LVSP group was longer than that of LBBaP group. The pacemaker parameters remained stable in both the LBBaP and LVSP groups. At 1-month and 1-year follow-up after LBBaP and AVNA, left ventricular ejection fraction, left ventricular end-diastolic diameter, and NYHA classification continued to improve. Baseline left ventricular ejection fraction and QRS duration change at implantation can predict the magnitude of improvement of left ventricular ejection fraction at 1-year after LBBaP. Baseline right atrial left-right diameter, the degree of tricuspid regurgitation, and interventricular septum thickness may be the factors affecting the success of LBBaP. CONCLUSION LBBaP combined with AVNA is safe and effective for patients with AF and HF. Baseline right atrial left-right diameter, the degree of tricuspid regurgitation, and interventricular septum thickness may be the factors affecting the success of LBBaP.
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Hua BT, Pu LJ, Tian X, Song WJ, Li H, Wang C, Shao XX, Li R, Li SM, Li ZX, Zou JH, Zhao L, Wang J. Three-dimensional electroanatomical mapping guidelines for the selection of pacing site to achieve cardiac resynchronization therapy. Front Cardiovasc Med 2022; 9:843969. [PMID: 36247431 PMCID: PMC9562822 DOI: 10.3389/fcvm.2022.843969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesWe aimed to evaluate the feasibility of left ventricular electroanatomical mapping to choose between left bundle branch area pacing (LBBAP) or coronary venous pacing (CVP).BackgroundThere are several ways to achieve left ventricular activation in cardiac resynchronization therapy (CRT): LBBAP and CVP are two possible methods of delivering CRT. However, the criteria for choosing the best approach remains unknown.MethodsA total of 71 patients with heart failure, reduced ejection fraction, and left bundle branch block (LBBB) were recruited, of which 38 patients underwent the three-dimensional electroanatomical mapping of the left ventricle to accurately assess whether the left bundle branch was blocked and the block level, while the remaining 33 patients were not mapped. Patients with true LBBB achieved CRT by LBBAP, while patients with pseudo-LBBB achieved CRT by CVP. After a mean follow-up of 6 months and 1 year, the QRS duration and transthoracic echocardiography, including mechanical synchrony indices, were evaluated.ResultsTwenty-five patients with true LBBB received LBBAP, while 13 without true LBBB received CVP. Seventeen patients received LBBAP, and 16 patients received CVP without mapping. Paced QRS duration after the implantation of LBBAP and CVP was significantly narrower in the mapping subgroup compared to the non-mapping subgroup. A significant increase in post-implantation left ventricular ejection fraction was observed in patients with LBBAP or CVP, and the mapping subgroup were better than the non-mapping subgroup. After a 12-month follow-up, atrioventricular, intraventricular, and biventricular synchronization were significantly improved in the mapping subgroup compared to non-mapping groups in both LBBAP and CVP.ConclusionIn our study, three-dimensional electroanatomical mapping was used to choose LBBAP or CVP for heart failure patients, which proved feasible, with better cardiac resynchronization in the long-term follow-up. Therefore, three-dimensional electroanatomical mapping before CRT appears to be a reliable method for heart failure patients with LBBB who are indicated for CRT.
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Affiliation(s)
- Bao-Tong Hua
- Department of Geriatric Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Li-Jin Pu
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xin Tian
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Wen-Juan Song
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hao Li
- Department of Geriatric Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Chao Wang
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xiao-Xia Shao
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Rui Li
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shu-Min Li
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhi-Xuan Li
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jun-Hua Zou
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ling Zhao
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
- Ling Zhao
| | - Jing Wang
- Department of Geriatric Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
- *Correspondence: Jing Wang
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Wang Y, Zhu H, Hou X, Wang Z, Zou F, Qian Z, Wei Y, Wang X, Zhang L, Li X, Liu Z, Xue S, Qin C, Zeng J, Li H, Wu H, Ma H, Ellenbogen KA, Gold MR, Fan X, Zou J. Randomized Trial of Left Bundle Branch vs Biventricular Pacing for Cardiac Resynchronization Therapy. J Am Coll Cardiol 2022; 80:1205-1216. [PMID: 36137670 DOI: 10.1016/j.jacc.2022.07.019] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/02/2022] [Accepted: 07/01/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Left bundle branch pacing (LBBP) is the most rapidly growing conduction system pacing technique that is capable of correcting intrinsic left bundle branch block (LBBB). As such, it is potentially an optimal alternative to cardiac resynchronization therapy (CRT) with biventricular pacing (BiVP). OBJECTIVES The authors sought to compare the efficacy of LBBP-CRT with BiVP-CRT in patients with heart failure and reduced left ventricular ejection fraction (LVEF). METHODS This is a prospective, randomized trial of patients with nonischemic cardiomyopathy and LBBB with 6-month preplanned follow-up. Crossovers were allowed if LBBP or BiVP were unsuccessful. The primary endpoint was the difference in LVEF improvement between 2 groups. The secondary endpoints included changes in echocardiographic measurements, N-terminal pro-B-type natriuretic peptide (NT-proBNP), New York Heart Association functional class, 6-minute walk distance, QRS duration, and CRT response. RESULTS The study included 40 consecutive patients (20 males, mean age 63.7 years, LVEF 29.7% ± 5.6%). Crossovers occurred in 10% of LBBP-CRT and 20% of BiVP-CRT. All patients completed follow-up. Intention-to-treat analysis showed significantly higher LVEF improvement at 6 months after LBBP-CRT than BiVP-CRT (mean difference: 5.6%; 95% CI: 0.3-10.9; P = 0.039). LBBP-CRT also appeared to have greater reductions in left ventricular end-systolic volume (-24.97 mL; 95% CI: -49.58 to -0.36 mL) and NT-proBNP (-1,071.80 pg/mL; 95% CI: -2,099.40 to -44.20 pg/mL), and comparable changes in New York Heart Association functional class, 6-minute walk distance, QRS duration, and rates of CRT response compared with BiVP-CRT. CONCLUSIONS LBBP-CRT demonstrated greater LVEF improvement than BiVP-CRT in heart failure patients with nonischemic cardiomyopathy and LBBB. (Left Bundle Branch Pacing Versus Biventricular Pacing for Cardiac Resynchronization Therapy [LBBP-RESYNC]; NCT04110431).
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Affiliation(s)
- Yao Wang
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Haojie Zhu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaofeng Hou
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Zhao Wang
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengwei Zou
- Montefiore Medical Center, Bronx, New York, USA
| | - Zhiyong Qian
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Yongyue Wei
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Xiang Wang
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Longyao Zhang
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Xiaofei Li
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhimin Liu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siyuan Xue
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Chaotong Qin
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Jiaxin Zeng
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Hui Li
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongping Wu
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Hong Ma
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | | | - Michael R Gold
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Xiaohan Fan
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Jiangang Zou
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, China; Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing, China.
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Hua J, Kong Q, Chen Q. Alternative pacing strategies for optimal cardiac resynchronization therapy. Front Cardiovasc Med 2022; 9:923394. [PMID: 36237907 PMCID: PMC9551024 DOI: 10.3389/fcvm.2022.923394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/06/2022] [Indexed: 12/02/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) via biventricular pacing (BVP) improves morbidity, mortality, and quality of life, especially in subsets of patients with impaired cardiac function and wide QRS. However, the rate of unsuccessful or complicated left ventricular (LV) lead placement through coronary sinus is 5–7%, and the rate of “CRT non-response” is approximately 30%. These reasons have pushed physicians and engineers to collaborate to overcome the challenges of LV lead implantation. Thus, various alternatives to BVP have been proposed to improve CRT effectiveness. His bundle pacing (HBP) has been increasingly used by activating the His–Purkinje system but is constrained by challenging implantation, low success rates, high and often unstable thresholds, and low perception. Therefore, the concept of pacing a specialized conduction system distal to the His bundle to bypass the block region was proposed. Multiple clinical studies have demonstrated that left bundle branch area pacing (LBBAP) has comparable electrical resynchronization with HBP but is superior in terms of simpler operation, higher success rates, lower and stable capture thresholds, and higher perception. Despite their well-demonstrated effectiveness, the transvenous lead-related complications remain major limitations. Recently, leadless LV pacing has been developed and demonstrated effective for these challenging patient cohorts. This article focuses on the current state and latest progress in HBP, LBBAP, and leadless LV pacing as alternatives for failed or non-responsive conventional CRT as well as their limits and prospects.
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Physiologic Pacing Targeting the His Bundle and Left Bundle Branch: a Review of the Literature. Curr Cardiol Rep 2022; 24:959-978. [PMID: 35678938 DOI: 10.1007/s11886-022-01723-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Conduction system pacing (CSP) has emerged as a means to preserve or restore physiological ventricular activation via pacing at the His bundle or at more distal targets in the conduction system, including the left bundle branch area. This review examines strengths, weaknesses, and clinical applications of CSP performed via these approaches. RECENT FINDINGS His bundle pacing (HBP) has been successfully utilized for standard bradyarrhythmia indications and for QRS correction among patients receiving devices for cardiac resynchronization therapy (CRT). Limitations of HBP pacing have included implant complexity and rising pacing thresholds over time. Left bundle branch area pacing (LBBAP) appears to deliver similar physiological benefits with shorter implant times and more stable thresholds. More recently, hybrid systems utilizing HBP or LBBAP in combination with left ventricular leads have been used to treat heart failure (HF) patients, and may be useful in multilevel or mixed conduction blocks. There is growing interest in CSP for bradycardia and HF indications, although high quality data with randomized controlled trials are needed to help guide future treatment paradigms.
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Kaza N, Keene D, Whinnett ZI. Generating Evidence to Support the Physiologic Promise of Conduction System Pacing: Status and Update on Conduction System Pacing Trials. Card Electrophysiol Clin 2022; 14:345-355. [PMID: 35715090 DOI: 10.1016/j.ccep.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Conduction system pacing avoids the potential deleterious effects of right ventricular pacing in patients with bradycardia and provides an alternative approach to cardiac resynchronization therapy. We focus on the available observational and randomized evidence and review studies supporting the safety, feasibility, and physiologic promise of conduction system approaches. We evaluate the randomized data generated from the available clinical trials of conduction system pacing, which have led to the recent inclusion of CSP in international guidelines. The scope for future randomized trials will building on the physiologic promise of conduction system approaches and offering information on clinical end points is explored.
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Affiliation(s)
- Nandita Kaza
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London W12 0HS, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London W12 0HS, UK.
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London W12 0HS, UK
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Rademakers LM, Bouwmeester S, Mast TP, Dekker L, Houthuizen P, Bracke FA. Feasibility, safety and outcomes of upgrading to left bundle branch pacing in patients with right ventricular pacing induced cardiomyopathy. Pacing Clin Electrophysiol 2022; 45:726-732. [PMID: 35510824 DOI: 10.1111/pace.14515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/13/2022] [Accepted: 04/29/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Right ventricular pacing (RVP) induces abnormal electrical activation and asynchronous ventricular contraction and leads to pacing induced cardiomyopathy (PICM) in 10-20% of patients. Cardiac resynchronization therapy (CRT) utilizing biventricular pacing (BVP) is the recommended treatment. Left bundle branch pacing (LBBP) is a novel physiological pacing technique which may serve as an alternative to CRT. This study assessed feasibility and outcomes of LBBP delivered CRT in patients with PICM. METHODS Twenty consecutive patients with PICM who received an upgrade of their pacemaker to LBBP were prospectively studied. Acute success rate, complications, functional and echocardiographic response and hospitalization for heart failure within six months from implantation were evaluated. RESULTS LBBP was successfully delivered in all patients. Median duration of RVP before upgrade to LBBP was 3.8 years and the RVP percentage was 99. LBBP resulted in significant QRS narrowing (from 193 ± 18 to 130 ± 17 ms (p<0.001)), improvement in LVEF (from 32 ± 6 percent to 47 ± 8 percent (p<0.001)) and NYHA class (from 2.8 ± 0.4 to 1.4 ± 0.5 (p<0.001)) at 6 months. No LBBP-related complications occurred. No patients were hospitalized for heart failure or died. CONCLUSION LBBP is feasible and safe in delivering CRT in PICM. Preliminary analyses demonstrated significant electrical resynchronization and favourable improvement in LV function and NYHA functional class at short term follow-up. Data need to be validated in large randomized controlled trials. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Sjoerd Bouwmeester
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Thomas P Mast
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Lukas Dekker
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Patrick Houthuizen
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Frank A Bracke
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
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Chen K, Liu XB, Hou X, Qiu Y, Lin J, Dai Y, Xu YN, Jiang LY, Zhou X, Zhang X, Lu H, Mara N, Demmer W, Cheng A, Zou J. Computed tomography imaging-identified location and electrocardiographic characteristics of left bundle branch area pacing in bradycardia patients. J Cardiovasc Electrophysiol 2022; 33:1244-1254. [PMID: 35419908 DOI: 10.1111/jce.15493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/12/2022] [Accepted: 04/09/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Left bundle branch area pacing (LBBAP) is a novel physiological pacing modality. The relationship between the pacing lead tip location and paced electrocardiographic (ECG) characteristics remains unclear. The objectives are to determine the lead tip location within the interventricular septum (IVS) and assess the location-based ECG QRS duration (QRSd) and left ventricular activation time (LVAT). METHODS This multi-center study enrolled 50 consecutive bradycardia patients who met pacemaker therapy guidelines and received LBBAP implantation via the trans-ventricular septal approach. After at least 3 months post implant, 12-lead ECGs and pacing parameters were obtained. Cardiac computed tomography (CT) imaging was performed to assess the LBBAP lead tip distance from the LV blood pool. RESULTS Among the 50 patients, analyzable CT images were obtained in 42. In 23 of the 42 patients, the lead tips were within 2 mm to the LV blood pool (the LV subendocardial (LVSE) group), 13 between 2 mm and 4 mm (the Near-LVSE group), and the remaining 6 beyond 4 mm (the mid-LV septal (Mid-LVS) group). No significant differences in paced QRSd were found among the 3 groups (LVSE, 107±15 ms; Near-LVSE, 106±13 ms; Mid-LVS, 104±15 ms; P=0.87). LVAT in the LVSE (64±7 ms) was significantly shorter than in the Mid-LVS (72±8 ms; P<0.05), but not significantly different from that in the Near-LVSE (69±8 ms; P>0.05). CONCLUSION In routine LBBAP practice, paced narrow QRSd and fast LVAT, indicative of physiological pacing, was consistently achieved for lead tip location in the LV subendocardial or near LV subendocardial region. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Keping Chen
- Arrhythmia Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xing-Bin Liu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaofeng Hou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuanhao Qiu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinxuan Lin
- Arrhythmia Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Dai
- Arrhythmia Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan-Ning Xu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ling-Yun Jiang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaohong Zhou
- Cardiac Rhythm Management, Medtronic plc., Mounds View, MN, USA
| | - Xue Zhang
- Cardiac Rhythm Management, Medtronic Technology Center, Medtronic (Shanghai) Ltd., Shanghai, China
| | - Hongyang Lu
- Cardiac Rhythm Management, Medtronic Technology Center, Medtronic (Shanghai) Ltd., Shanghai, China
| | - Nicki Mara
- Cardiac Rhythm Management, Medtronic plc., Mounds View, MN, USA
| | - Wade Demmer
- Cardiac Rhythm Management, Medtronic plc., Mounds View, MN, USA
| | - Alan Cheng
- Cardiac Rhythm Management, Medtronic plc., Mounds View, MN, USA
| | - Jiangang Zou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Liu X, Li W, Zhou X, Huang H, Wang L, Wu M. Clinical Outcomes of Left Bundle Branch Area Pacing in Comparison with Right Ventricular Septal Pacing in Patients with High Ventricular Pacing Ratio ≥40%. Int J Gen Med 2022; 15:4175-4185. [PMID: 35469262 PMCID: PMC9034894 DOI: 10.2147/ijgm.s360522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/01/2022] [Indexed: 11/23/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Xing Liu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, People’s Republic of China
| | - Wenbin Li
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, People’s Republic of China
| | - Xiaolin Zhou
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, People’s Republic of China
| | - Haobo Huang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, People’s Republic of China
| | - Lei Wang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, People’s Republic of China
| | - Mingxing Wu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, People’s Republic of China
- Correspondence: Mingxing Wu, Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, People’s Republic of China, Email
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Qian Z, Qin C, Zou F, Xue S, Wang Y, Zhang X, Qiu Y, Wu H, Hou X, Zhou W, Zou J. Complete electrical reverse remodeling of native conduction after resynchronization therapies. Int J Cardiol 2022; 357:81-87. [PMID: 35337937 DOI: 10.1016/j.ijcard.2022.03.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/12/2022] [Accepted: 03/21/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Electrical reverse remodeling of native conduction is associated with better clinical outcome following cardiac resynchronization therapy (CRT). We aimed to describe characteristics, time course and long-term outcome of patients with complete electrical reverse remodeling (CERR) after resynchronization therapies. METHODS CRT candidates were treated with bi-ventricular, His bundle or left bundle branch pacing. CERR was defined if native QRS duration post-implantation was narrowed to ≤120 ms. RESULTS A total of 322 patients met the inclusion criteria. Among them, 66 were super-responders and 12 exhibited CERR. All 12 patients were diagnosed of non-ischemic cardiomyopathy with left bundle branch block (LBBB) meeting the Strauss criteria. The mean native QRS duration when CERR was achieved was 110.8 ± 10.0 ms, significantly shorter than the baseline (175.0 ± 18.8 ms). The occurrence of CERR varied from several days post-implantation to 18-month follow-up. The persistence of CERR also showed great variations. Eleven patients (91.7%, 11/12) showed echocardiographic super-response. Patients with CERR showed similar baseline characteristics compared to those with echocardiographic super-response but without CERR. Two patients with CERR showed different responses after bi-ventricular pacing was turned off. One patient remained stable with narrow QRS complex and great response. The other patient had reappearance of LBBB and decreased cardiac function, but recovered by turning on the device again. CONCLUSIONS Patients with CERR exhibited great response to different resynchronization therapies. The time course of CERR and echocardiographic super-response varied greatly. The variability of native conduction system and accompanied changes of mechanical remodeling suggest the mechanisms of electrical-disorder related cardiomyopathy.
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Affiliation(s)
- Zhiyong Qian
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Chaotong Qin
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Fengwei Zou
- Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467, USA
| | - Siyuan Xue
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Yao Wang
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Xinwei Zhang
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Yuanhao Qiu
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Hongping Wu
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Xiaofeng Hou
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Weihua Zhou
- College of Computing, Michigan Technological University, Houghton, MI, USA
| | - Jiangang Zou
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China.
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Liu X, Li W, Zeng J, Huang H, Wang L, Tian S, Wu M. Evaluation of clinical safety and efficacy of left bundle branch area pacing in comparison with right ventricular septal pacing. Medicine (Baltimore) 2022; 101:e29071. [PMID: 35356932 PMCID: PMC10684246 DOI: 10.1097/md.0000000000029071] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 02/23/2022] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Left bundle branch area pacing (LBBaP) has recently emerged as a new physiological pacing strategy. The purpose of this study is to compare LBBaP with right ventricular sepal pacing (RVSP) in terms of their clinical safety and efficacy.From February 2019 to May 2020, consecutive pacing-indicated patients were prospectively enrolled and divided into 2 groups. Ventricular synchrony indexes such as QRS duration (QRSd), interventricular mechanical delay and septal-posterior wall motion delay, left ventricular function such as left ventricular end-diastolic diameter (LVEDD) and left ventricular ejection fraction (LVEF), pacing parameters, and complications were evaluated in the perioperative period and during follow-up.LBBaP was successful in 45 patients (88.2%), and finally 46 patients underwent RVSP. With LBBaP, ventricular electricalmechanical synchrony were similar to those of native-conduction system (P = .78). However, the ventricular electrical synchrony (QRSd, 108.47±7.64 vs 130.63±13.63ms, P < .001) and mechanical synchrony (interventricular mechanical delay, 27.68±4.33 vs 39.88±5.83, P < .001; septal-posterior wall motion delay, 40.39±23.21 vs 96.36±11.55, P < .001) in the LBBaP group were significantly better than those in the RVSP group. No significant differences in LVEDD (46 [44-48.5] vs 47 [44-52] mm, P = .49) and LVEF% (66 [62.5-70] vs 64 [61-68], P = .76) was observed between 2 groups at last follow-up. But, in the subgroup analysis, LVEDD was shorter (46 [44-49] vs 50 [47-58] mm, P = .03) and the LVEF% was higher (65 [62-68] vs 63 [58-65], P = .02) in the LBBaP-H (high ventricular pacing ratio >40%) group compared with RVSP-H group at last follow-up. There were lower capture thresholds (0.59±0.18V vs 0.71 ± 0.26 V, P = 0.01) at implantation in the LBBaP group than those in the RVSP group, with R-wave amplitudes and pacing impedances showing no significant difference between 2 groups. No serious complications were found in both 2 groups at implantation and follow-ups.This study confirms the clinical safety and efficacy of LBBaP, and it produces better ventricular electrical-mechanical synchrony than RVSP. The event of pacing-induced left ventricular dysfunction is lower in the LBBaP-H group than RVSP-H group.
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Affiliation(s)
- Xing Liu
Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, China.
| | - Wenbin Li
Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, China.
| | - Jianping Zeng
Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, China.
| | - He Huang
Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, China.
| | - Lei Wang
Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, China.
| | - Shaohua Tian
Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, China.
| | - Mingxing Wu
Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, China.
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Zhang S, Shan Q. Discussion of LBBP synchronization effects in HF patients with LBBB and comparison with BiV-CRT. Heart Fail Rev 2022; 27:2181-2186. [DOI: 10.1007/s10741-021-10213-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2021] [Indexed: 11/24/2022]
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Gui Y, Ye L, Wu L, Mai H, Yan Q, Wang L. Clinical Outcomes Associated With His-Purkinje System Pacing vs. Biventricular Pacing, in Cardiac Resynchronization Therapy: A Meta-Analysis. Front Cardiovasc Med 2022; 9:707148. [PMID: 35224028 PMCID: PMC8873383 DOI: 10.3389/fcvm.2022.707148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
AimsHis-Purkinje system pacing has recently emerged as an alternative to biventricular pacing (BIVP) in cardiac resynchronization therapy (CRT). The aim of this study was to conduct a meta-analysis comparing the clinical outcomes associated with His-Purkinje system pacing (HPSP) vs. BIVP in patients with heart failure. There is also a comparison of clinical outcomes of His-bundle pacing (HBP) and left bundle branch pacing (LBBP) in the His-Purkinje system.MethodsWe searched the Cochrane Library, Embase, and PubMed, for studies published between January 2010 and October 2021 that compared the clinical outcomes associated with HPSP vs. BIVP and HBP vs. LBBP in HPSP in patients who underwent CRT. The pacing threshold, R-wave amplitudes, QRS duration, New York Heart Association functional (NYHA), left ventricular ejection fraction (LVEF), and LV end-diastolic diameter (LVEDD) of heart failure, at follow-up, were extracted and summarized for meta-analysis.ResultsA total of 18 studies and 1517 patients were included in our analysis. After a follow-up period of 9.3 ± 5.4 months, the HPSP was found to be associated with shorter QRS duration in the CRT population compared to that in the BIVP (SMD, −1.17; 95% CI, −1.56 to −0.78; P < 0.00001; I2 = 74%). No statistical difference was verified between HBP and LBBP on QRS duration (SMD, 0.04; 95% CI, −0.32 to 0.40; P = 0.82; I2 = 84%). In the comparison of HPSP and BIVP, the LBBP subgroup showed improved LVEF (SMD, 0.67; 95% CI, 0.42–0.91; P < 0.00001; I2 = 0%), shorter LVEDD (SMD, 0.59; 95% CI, 0.93–0.26; P = 0.0005; I2 = 0%), and higher New York Heart Association functional class (SMD, −0.65; 95% CI, −0.86 to −0.43; P < 0.00001; I2 = 45%). In terms of pacing threshold and R-wave amplitude clinical outcomes, LBBP has a lower pacing threshold (SMD, 1.25; 95% CI, 1.12–1.39; P < 0.00001; I2 = 47%) and higher R-wave amplitude (MD, −7.88; 95% CI, −8.46 to −7.31; P < 0.00001; I2 = 8%) performance compared to HBP.ConclusionOur meta-analysis showed that the HPSP produced higher LVEF, shorter QRS duration, and higher NYHA functional class in the CRT population than the BIVP as observed on follow-up. LBBP has a lower pacing threshold and higher R-wave amplitude. HPSP may be a new and promising alternative to BIVP in the future.
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Affiliation(s)
- Yang Gui
- BengBu Medical College, Bengbu, China
| | - Lifang Ye
- Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Liuyang Wu
- Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Haohui Mai
- Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Qiqi Yan
- Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Lihong Wang
- Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
- *Correspondence: Lihong Wang
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Hua J, Wang C, Kong Q, Zhang Y, Wang Q, Xiong Z, Hu J, Li J, Chen Q, Hong K. Comparative effects of left bundle branch area pacing, His bundle pacing, biventricular pacing in patients requiring cardiac resynchronization therapy: A network meta-analysis. Clin Cardiol 2022; 45:214-223. [PMID: 35128691 PMCID: PMC8860481 DOI: 10.1002/clc.23784] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 01/01/2022] [Accepted: 01/13/2022] [Indexed: 12/21/2022] Open
Abstract
Background The comparative effects of different types of cardiac resynchronization therapy (CRT) delivered by biventricular pacing (BVP), His bundle pacing (HBP), and left bundle branch area pacing (LBBAP) remain inconclusive. Hypothesis HBP and LBBAP may be advantageous over BVP for CRT. Methods PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched for studies that reported the effects after BVP, HBP, and LBBAP for CRT. The effects between groups were compared by a frequentist random‐effects network meta‐analysis (NMA), by which the mean differences (MDs) and 95% confidence intervals (CIs) were calculated. Results Six articles involving 389 patients remained for the final meta‐analysis. The mean follow‐up of these studies was 8.03 ± 3.15 months. LBBAP resulted in a greater improvement in LVEF% (MD = 7.17, 95% CI = 4.31 to 10.04), followed by HBP (MD = 4.06, 95% CI = 1.09 to 7.03) compared with BVP. HBP resulted in a narrower QRS duration (MD = 31.58 ms, 95% CI = 12.75 to 50.40), followed by LBBAP (MD = 27.40 ms, 95% CI = 10.81 to 43.99) compared with BVP. No significant differences of changes in LVEF improvement and QRS narrowing were observed between LBBAP and HBP. The pacing threshold of LBBAP was significantly lower than those of BVP and HBP. Conclusion The NMA first found that LBBAP and HBP resulted in a greater LVEF improvement and a narrower QRS duration compared with BVP. Additionally, LBBAP resulted in similar clinical outcomes but with lower pacing thresholds, and may therefore offer advantages than does HBP for CRT.
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Affiliation(s)
- Juan Hua
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chenxi Wang
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qiling Kong
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yichu Zhang
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qijun Wang
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ziyi Xiong
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jinzhu Hu
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Juxiang Li
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qi Chen
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Kui Hong
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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Long-term outcomes of left bundle branch area pacing versus biventricular pacing in patients with heart failure and complete left bundle branch block. Heart Vessels 2022; 37:1162-1174. [PMID: 35088204 PMCID: PMC9142423 DOI: 10.1007/s00380-021-02016-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/17/2021] [Indexed: 11/11/2022]
Abstract
Left bundle branch area pacing (LBBAP) has developed in an effort to improve cardiac resynchronization therapy (CRT). We aimed to compare the long-term clinical outcomes between LBBAP and biventricular pacing (BIVP) in patients with heart failure (HF) and complete left bundle branch block (CLBBB). Consecutive patients with HF and CLBBB requiring CRT received either LBBAP or BIVP were recruited at the Second Affiliated Hospital of Nanchang University from February 2018 to May 2019. We assessed their implant parameters, electrocardiogram (ECG), clinical outcomes at implant and during follow-up at 1, 3, 6, 12, and 24 months. Forty-one patients recruited including 21 for LBBAP and 20 for BIVP. Mean follow-up duration was 23.71 ± 4.44 months. LBBAP produced lower pacing thresholds, shorter procedure time and fluoroscopy duration compared to BIVP. The QRS duration was significantly narrower after LBBAP than BIVP (129.29 ± 31.46 vs. 156.85 ± 26.37 ms, p = 0.005). Notably, both LBBAP and BIVP significantly improved LVEF, LVEDD, NYHA class, and BNP compared with baseline. However, LBBAP significantly lowered BNP compared with BIVP (416.69 ± 411.39 vs. 96.07 ± 788.71 pg/ml, p = 0.007) from baseline to 24-month follow-up. Moreover, patients who received LBBAP exhibited lower number of hospitalizations than those in the BIVP group (p = 0.019). In addition, we found that patients with moderately prolonged left ventricular activation time (LVAT) and QRS notching in limb leads in baseline ECG respond better to LBBAP for CLBBB correction. LBBAP might be a relative safe and effective resynchronization therapy and as a supplement to BIVP for patients with HF and CLBBB.
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Wielandts JY, Almorad A, Hilfiker G, Gauthey A, Knecht S, Duytschaever M, Vandekerckhove Y, Tavernier R, le Polain de Waroux JB. Left bundle branch area pacing as alternative to his bundle pacing for cardiac resynchronisation therapy: a case report. Acta Cardiol 2021; 76:1162-1164. [PMID: 33131421 DOI: 10.1080/00015385.2020.1838127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
| | | | | | - Anaïs Gauthey
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Mattias Duytschaever
- Department of Cardiology, Sint-Jan Hospital, Bruges, Belgium
- Department of Internal Medicine, Ghent University, Belgium
| | | | - René Tavernier
- Department of Cardiology, Sint-Jan Hospital, Bruges, Belgium
| | - Jean-Benoît le Polain de Waroux
- Department of Cardiology, Sint-Jan Hospital, Bruges, Belgium
- Department of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Initial experience, feasibility and safety of permanent left bundle branch pacing: results from a prospective single-centre study. Neth Heart J 2021; 30:258-266. [PMID: 34837151 PMCID: PMC9043049 DOI: 10.1007/s12471-021-01648-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 11/17/2022] Open
Abstract
Background Left bundle branch (LBB) pacing is a novel pacing technique which may serve as an alternative to both right ventricular pacing for symptomatic bradycardia and cardiac resynchronisation therapy (CRT). A substantial amount of data is reported by relatively few, highly experienced centres. This study describes the first experience of LBB pacing in a high-volume device centre. Methods Success rates (i.e. the ability to achieve LBB pacing), electrophysiological parameters and complications at implant and up to 6 months of follow-up were prospectively assessed in 100 consecutive patients referred for various pacing indications. Results The mean age was 71 ± 11 years and 65% were male. Primary pacing indication was atrioventricular (AV) block in 40%, CRT in 42%, and sinus node dysfunction or refractory atrial fibrillation prior to AV node ablation in 9% each. Baseline left ventricular ejection fraction was < 50% in 57% of patients, mean baseline QRS duration 145 ± 34 ms. Overall LBB pacing was successful in 83 of 100 (83%) patients but tended to be lower in patients with CRT pacing indication (69%, p = ns). Mean left ventricular activation time (LVAT) during LBB pacing was 81 ms and paced QRS duration was 120 ± 19 ms. LBB capture threshold and R‑wave sense at implant was 0.74 ± 0.4 mV at 0.4 ms and 11.9 ± 5.9 V and remained stable at 6‑month follow-up. No complications occurred during implant or follow-up. Conclusion LBB pacing for bradycardia pacing and resynchronisation therapy can be easily adopted by experienced implanters, with favourable success rates and safety profile.
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Cheng Y, Wang Z, Li Y, Qi J, Liu J. Left bundle branch pacing in heart failure patients with left bundle branch block: a systematic review and meta-analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 45:212-218. [PMID: 34766359 DOI: 10.1111/pace.14405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/22/2021] [Accepted: 11/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The clinical benefit of cardiac resynchronization therapy (CRT) in heart failure patients with left bundle branch block (LBBB) has been demonstrated. However, a non-response rate of CRT nearly 1/3. Recent studies have reported left bundle branch pacing (LBBP) has achieved remarkable effect in CRT. This study aim to explore the efficacy and safety of LBBP in heart failure patients with LBBB. METHODS We searched PubMed, Cochrane Library, Web of science and CNKI databases for studies about LBBP in heart failure patients with LBBB. QRS duration (QRSd), New York Heart Association (NYHA) classification, B-type natriuretic peptide (BNP) concentration, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), pacing threshold and other related data were extracted and summarized. RESULTS A total of 6 studies were included, and the success rate of LBBP was 93.2%. Compared with baseline, LBBP could shorten QRSd (MD = 61.23, 95%CI: 58.21 ∼ 64.25, P < 0.01). Echocardiographic parameters including LVEF and LVEDD significantly improved (both with P < 0.01). Clinical outcomes including NYHA classification and BNP dramatically reduced (both with P < 0.01). Compared with biventricular pacing (BVP), LBBP could further improve QRSd, LVEF, LVEDD, and NYHA classification (all with P < 0.01). However, the pacing threshold at follow-up was 0.06V higher than that at baseline (P < 0.01), and the incidence of complications was 2.4%. CONCLUSIONS LBBP is effective and safe in heart failure patients with LBBB, whether it is better than BVP needs to be verified by randomized controlled trials. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yuda Cheng
- Affiliated Hospital of Hebei University, Baoding, Hebei, 071000, China
| | - Zhanqi Wang
- Affiliated Hospital of Hebei University, Baoding, Hebei, 071000, China
| | - Yujun Li
- Affiliated Hospital of Hebei University, Baoding, Hebei, 071000, China
| | - Jinlei Qi
- Affiliated Hospital of Hebei University, Baoding, Hebei, 071000, China
| | - Jinyu Liu
- Affiliated Hospital of Hebei University, Baoding, Hebei, 071000, China
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Abstract
Right ventricular pacing for bradycardia remains the mainstay of pacing therapy. Chronic right ventricular pacing may lead to pacing-induced cardiomyopathy. We focus on the anatomy of the conduction system and the clinical feasibility of pacing the His bundle and/or left bundle conduction system. We review the hemodynamics of conduction system pacing, the techniques to capture the conduction system and the electrocardiogram and pacing definitions of conduction system capture. Clinical studies of conduction system pacing in the setting of atrioventricular block and after AV junction ablation are reviewed and the evolving role of conduction system pacing is compared with biventricular pacing.
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Manolis AS, Manolis AA, Manolis TA, Melita H. Electrocardiography of cardiac resynchronization therapy: Pitfalls and practical tips. J Cardiovasc Electrophysiol 2021; 32:3228-3244. [PMID: 34664758 DOI: 10.1111/jce.15267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/11/2021] [Accepted: 09/29/2021] [Indexed: 12/25/2022]
Abstract
Cardiac resynchronization therapy (CRT) has been established as an effective mode of therapy in patients with heart failure and concurrent cardiac dyssynchrony, principally in the form of left bundle branch block (LBBB). The widespread use of CRT has ushered in a new landscape in 12-lead electrocardiography (ECG). ECG readings in these patients are most important to guide troubleshooting and also appropriate device programming, as well as discerning and managing nonresponders. A set of four ECG recordings need to accompany each patient with a CRT device, including a baseline ECG and recordings from monochamber (right and left ventricular) and biventricular pacing, which can be compared against a new recording to facilitate the evaluation of proper versus problematic biventricular pacing. Precordial ECG leads V1/2 acquired at the fourth intercostal space and limb leads, I and III, together with a quick assessment of perpendicular leads I and aVF to determine the quadrant of the QRS axis in the hexaxial diagram, may provide the framework for proper ECG interpretation in these patients. This important issue of 12-lead ECG in CRT patients is herein reviewed, pitfalls are pointed out and practical tips are provided for ECG reading to help recognize and manage problems with CRT device function. Furthermore, several pertinent ECG recordings and tabulated data are provided, and an algorithm is suggested that integrates prior algorithms and relevant information from current literature.
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Affiliation(s)
- Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | | | | | - Helen Melita
- Central Laboratories, Onassis Cardiac Surgery Center, Athens, Greece
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