His Bundle Pacing vs. RV Pacing and Outcomes
What are the clinical outcomes of His bundle pacing (HBP) compared to right ventricular pacing (RVP)?
This study was comprised of a series of patients undergoing pacemaker implantation over a 3-year span at two hospitals. HBP was attempted in consecutive patients at one hospital and RVP at a sister hospital. Implant characteristics, all-cause mortality, heart failure hospitalization (HFH), and upgrades to biventricular pacing (BiVP) were tracked. The primary outcome was the combined endpoint of death, HFH, or upgrade to BiVP. Secondary endpoints were mortality and HFH.
HBP was successful in 304 of 332 (92%) patients, while 433 patients underwent RVP. The primary endpoint of death, HFH, or upgrade to BiVP occurred significantly less in the HBP group (25%) compared to the RVP group (32%; hazard ratio [HR], 0.71; p = 0.02). This difference was noted primarily in patients with ventricular pacing >20% (25% in HBP vs. 36% in RVP, HR, 0.65; p = 0.02). The incidence of HFH was significantly reduced in HBP (12.4% vs. 17.6%, HR, 0.63; p = 0.02). There was a trend towards reduced mortality in HBP (17.2% vs. 21.4%, p = 0.06).
In this study, HBP was associated with reduction in the combined endpoint of death, HFH, or upgrade to BiVP compared to RVP.
The development of reliable and practicably deployed HBP has been a goal of electrophysiologists for years. Newer lead and sheath designs have shortened the procedural and fluoroscopy times and improved acute success rates up to the low 90s among implanters with a great deal of experience, although the authors of this article argue that “20-25 implants would be adequate to complete the necessary learning curve and achieve consistent results.” Due to its intuitive superiority and some encouraging clinical reports, HBP has become one of the most exciting advances in device therapy. Having said that, randomized clinical trial data showing safety and efficacy, as well as long-term outcomes, are still lacking.
Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Nuclear Imaging
Keywords: ACC18, ACC Annual Scientific Session, Arrhythmias, Cardiac, Bundle of His, Cardiac Electrophysiology, Cardiac Resynchronization Therapy, Fluoroscopy, Geriatrics, Heart Failure, Pacemaker, Artificial, Secondary Prevention, Treatment Outcome
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