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Multicenter Experience With Left Bundle Branch Area Pacing
Quick Takes
- His bundle pacing is superior to chronic right ventricular pacing, as it avoids inter- and intra-ventricular dyssynchrony and pacing-induced cardiomyopathy.
- Left bundle branch area pacing is an alternative to His bundle pacing; it is technically easier, has higher acute implantation success rates, and has stable lead parameters during follow-up.
Study Questions:
What is the safety and feasibility of left bundle branch area pacing (LBBAP)?
Methods:
Patients referred for pacemaker implantation were considered for LBBAP. LBBAP was performed by implanting a lumen-less, exposed helix lead approximately 2 cm distal to the His bundle and deep into the septum using a specialized delivery sheath. Implant success rates, complications, and electrophysiological parameters were assessed.
Results:
Acute procedural success for LBBAP was 89% (305/341 patients). At baseline, 39% had QRS >130 ms, 22% right bundle branch block, 11% left bundle branch block, and 6% intraventricular conduction defect. Mean procedural duration was 75 minutes and fluoroscopic time was 10 minutes. The mean baseline QRS and paced QRS was 114 ms and 112 ms (p < 0.001) and in patients with infra-Hisian disease, it was 145 and 115 (p < 0.001), respectively. Pacing thresholds and R waves were 0.74 at 0.4 ms and 10.7 mV at time of implantation and were stable up to 12 months. There were three LBBAP lead dislodgements.
Conclusions:
LBBAP is safe, and a reliable alternative to His bundle pacing. Randomized controlled studies are needed to confirm clinical outcomes of LBBAP.
Perspective:
Chronic right ventricular pacing has deleterious effects on the hemodynamics, introduces dyssynchrony, and is associated with increased risk of heart failure and atrial fibrillation. His bundle pacing is an attempt at more physiological pacing; however, the His lead implantation is very challenging, as it targets a small area of the conduction system surrounded by electrically inert fibrous tissue. The authors present the largest to date experience with LBBAP and show that it is safe and effective (LBBAP is still achieved by pacing right ventricular septum, obviating any need for anticoagulation). The next step is to confirm the anticipated clinical benefits in a large randomized clinical trial, and to develop new delivery tool leads to optimize LBBAP.
Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure
Keywords: Arrhythmias, Cardiac, Bundle of His, Bundle-Branch Block, Cardiomyopathies, Heart Conduction System, Heart Failure, Hemodynamics, Pacemaker, Artificial, Ventricular Septum
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