Left Bundle Branch Area Pacing: A New Alternative to Biventricular Pacing?

Left bundle branch area pacing (LBBAP) is a safe and effective alternative to biventricular pacing (BVP) for patients undergoing cardiac resynchronization therapy (CRT) to treat reduced left ventricular ejection fraction (LVEF), heart failure and wide QRS or expected frequent ventricular pacing, according to a late-breaking clinical trial presented during Heart Rhythm 2023 and simultaneously published May 21 in JACC.

Pugazhendhi Vijayaraman, MD, FACC, et al., conducted a retrospective, observational, case-control study of patients receiving their first CRT to examine real-world clinical outcomes with LBBAP vs. the well-established approach of BVP. Inclusion criteria included NYHA class II to IV HF, LVEF ≤35% and an indication for CRT or a >40% expected frequency of CRT. The operator was free to choose LBBAP or BVS.

Results showed that a total of 1,778 patients were enrolled at 15 international centers between January 2018 and June 2022 and A total of 981 patients received BVP and 797 LBBAP. Their mean age was 69 years, 32% were women and 37% had atrial fibrillation; at baseline the mean LVEF was 27±6%. 

Over the mean duration of 33±16 months, paced QRSd with LBBAP was significantly narrower compared with baseline (128±19 vs. 161±28 ms and compared with BVP 144±23 ms; p<0.001 for both).

The improvement in LVEF post CRT was greater with LBBAP compared with BVP (to 41±13% vs. to 37±12%, respectively; p<0.001for both). The change from baseline in LVEF was significantly greater with LBBAP vs. BVS (13±12% vs. 10±12%; p<0.001).

The rate of the combined primary endpoint of time to all-cause death or the first heart failure hospitalization (HFH) was significantly lower in patients who underwent LBBAP rather than BVP (20.8% vs 28%; hazard ratio, 1.495; p<0.001). There were fewer deaths in patients who underwent LBBAP compared with BVP (12% vs. 17%), although the difference was not statistically significant. HFH was significantly reduced with LBBAP vs. BVP (12% vs. 19% of each group; HR, 1.494; p-0.002).

The authors note that the procedure time was longer with LBBAP but the fluoroscopy duration was similar in both groups and that it is likely further procedural efficacy can be achieved. They also note the need for a large prospective randomized trial with longer follow-up to confirm the finding of this study.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Implantable Devices, Nuclear Imaging

Keywords: Fluoroscopy, Ventricular Function, Left, Retrospective Studies, Prospective Studies, Follow-Up Studies, Stroke Volume, Cardiac Resynchronization Therapy

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