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Left Bundle Branch Area vs. Biventricular Pacing for CRT Candidates
Quick Takes
- Left bundle branch area pacing (LBBAP) was associated with a significant reduction in the primary composite endpoint of all-cause mortality or heart failure hospitalization (HFH) compared to biventricular pacing (BVP) in patients undergoing CRT.
- Furthermore, among patients with LBBB, LBBAP was associated with a greater reduction in clinical outcomes of death or HFH compared to BVP.
- Given the observational nature of the current study, randomized clinical trials with long-term follow-up are necessary to confirm the clinical benefits of permanent LBBAP compared to BVP in candidates for CRT.
Study Questions:
What are the clinical outcomes with biventricular pacing (BVP) versus left bundle branch area pacing (LBBAP) among patients undergoing cardiac resynchronization therapy (CRT)?
Methods:
The investigators conducted an observational study which included patients with left ventricular ejection fraction (LVEF) ≤35% who underwent BVP or LBBAP for the first time for Class I or II indications for CRT between January 2018–June 2022 at 15 international centers. The primary outcome was the composite endpoint of time to death or heart failure hospitalization (HFH). Secondary outcomes included endpoints of death, HFH, and echocardiographic changes. Univariate and multivariable Cox proportional hazard models were used to estimate survival probability for the composite primary outcome and secondary outcomes for the conduction system pacing (CSP) and BVP groups.
Results:
A total of 1,778 patients met inclusion criteria: BVP 981, LBBAP 797. The mean age was 69 ± 12 years, female 32%, coronary artery disease 48%, and LVEF 27 ± 6%. Paced QRSd in LBBAP was significantly narrower than baseline (128 ± 19 vs. 161 ± 28 ms, p < 0.001) and significantly narrower compared to BVP (144 ± 23 ms, p < 0.001). Following CRT, LVEF improved from 27 ± 6% to 41 ± 13% (p < 0.001) with LBBAP compared to an increase from 27 ± 7% to 37 ± 12% (p < 0.001) with BVP with significantly greater change from baseline with LBBAP (13 ± 12% vs. 10 ± 12%, p < 0.001). On multivariable regression analysis, the primary outcome was significantly reduced with LBBAP compared to BVP (20.8% vs. 28%; hazard ratio, 1.495; 95% confidence interval, 1.213-1.842; p < 0.001).
Conclusions:
The authors report that LBBAP improved clinical outcomes when compared to BVP in patients with CRT indications and may be a reasonable alternative to BVP.
Perspective:
This study reports that LBBAP was associated with a significant reduction in the primary composite endpoint of all-cause mortality or HFH compared to BVP in patients undergoing CRT. Furthermore, in patients with LBBB, LBBAP was associated with a greater reduction in clinical outcomes of death or HFH compared to BVP. Given the observational nature of the current study, randomized clinical trials with long-term follow-up are necessary to confirm the clinical benefits of permanent LBBAP compared to BVP in candidates for CRT.
Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound
Keywords: Arrhythmias, Cardiac, Bundle-Branch Block, Cardiac Conduction System Disease, Cardiac Resynchronization Therapy, Coronary Artery Disease, Echocardiography, Heart Failure, Hospitalization, Pacemaker, Artificial, Secondary Prevention, Stroke Volume, Ventricular Function, Left
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