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Conduction System Pacing vs. RV Pacing in Bradycardia
Quick Takes
- Conduction system pacing (CSP) significantly reduced adverse clinical outcomes for bradycardic patients with ventricular pacing requirements >20% compared to right ventricular pacing (RVP).
- Event-free survival was similar between CSP patients with >20% pacing burden and all patients requiring <20% ventricular pacing burden.
Study Questions:
What are the differences in clinical outcomes in patients receiving conduction system pacing (CSP) and right ventricular pacing (RVP)?
Methods:
Consecutive patients with pacemakers implanted for bradycardia from 2016 to 2021 in two centers were prospectively followed for the primary composite outcome of heart failure (HF) hospitalizations, upgrade to biventricular pacing or all-cause mortality, stratified by ventricular pacing burden (Vp).
Results:
Among 860 patients, 628 received RVP and 231 received CSP (95 His-bundle pacing, 136 left bundle branch pacing). The primary outcome occurred in 217 (25%) patients, more commonly in patients with RVP than CSP (30% vs. 13%, p < 0.001). CSP was independently associated with 47% reduction of the primary outcome and 60% reduction in HF hospitalization, among only patients with Vp >20%. The incidence of the primary outcome was highest among RVP with Vp >20% and lowest in CSP with Vp >20% (35% vs. 10%, p < 0.001). Compared to RVP with Vp >20%, both CSP with Vp >20% and all patients with Vp ≤20% were independently associated with reduced primary outcome, mainly due to reductions in HF hospitalizations. Event-free survival was similar between CSP with Vp >20% and those needing ≤20% Vp.
Conclusions:
The authors conclude that CSP significantly reduced adverse clinical outcomes for patients requiring ventricular pacing and should be the preferred pacing modality of choice.
Perspective:
The deleterious effects of higher RVP burden on clinical outcomes were described over two decades ago in the DAVID and MOST trials. At the time, a Vp threshold of >40% was identified as associated with increased risk of adverse clinical events, such as reduced left ventricular ejection fraction and increased risks of HF hospitalizations and atrial fibrillation. Conduction system pacing has gained a great deal of attention due to its more physiological ventricular activation. The current study mostly confirms prior findings and extends them to a non-Western patient population. Randomized controlled trials are needed to determine the superiority of CSP over RVP as well as the specific type of CSP providing the greatest benefit.
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, Bradycardia, Bundle-Branch Block, Cardiac Conduction System Disease, Cardiac Resynchronization Therapy, Heart Failure, Hospitalization, Pacemaker, Artificial, Patient Outcome Assessment, Ventricular Function, Left
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