Elsevier

Heart Rhythm

Volume 20, Issue 7, July 2023, Pages 984-991
Heart Rhythm

Clinical
Devices
Rate and nature of complications of conduction system pacing compared with right ventricular pacing: Results of a propensity score–matched analysis from a multicenter registry

https://doi.org/10.1016/j.hrthm.2023.03.009Get rights and content

Background

Conduction system pacing (CSP) using His bundle pacing (HBP) or left bundle branch area pacing (LBBAP) has emerged as an alternative to right ventricular pacing (RVP). Comparative data on the risk of complications between CSP and RVP are lacking.

Objective

This prospective, multicenter, observational study aimed to compare the long-term risk of device-related complications between CSP and RVP.

Methods

A total of 1029 consecutive patients undergoing pacemaker implantation with CSP (including HBP and LBBAP) or RVP were enrolled. Propensity score matching for baseline characteristics yielded 201 matched pairs. The rate and nature of device-related complications occurring during follow-up were prospectively collected and compared between the 2 groups.

Results

During a mean follow-up duration of 18 months, device-related complications were observed in 19 patients: 7 in RVP (3.5%) and 12 in CSP (6.0%) (P = .240). On dividing the matched cohort into 3 groups with similar baseline characteristics according to pacing modality (RVP, n = 201; HBP, n = 128; LBBAP, n = 73), patients with HBP showed a significantly higher rate of device-related complications than did patients with RVP (8.6% vs 3.5%; P = .047) and patients with LBBAP (8.6% vs 1.3%; P = .034). Patients with LBBAP showed a rate of device-related complications similar to that of patients with RVP (1.3% vs 3.5%; P = .358). Most of the complications observed in patients with HBP (63.6%) were lead related.

Conclusion

Globally, CSP was associated with a risk of complications similar to that of RVP. Considering HBP and LBBAP separately, HBP showed a significantly higher risk of complications than did both RVP and LBBAP whereas LBBAP showed a risk of complications similar to that of RVP.

Introduction

Right ventricular pacing (RVP) has been the standard practice for patients requiring permanent ventricular pacing, with a shorter procedure time, an easier learning curve, and a relatively low rate of complications, compared with other pacing modalities.1,2 However, long-term RVP may result in electrical and mechanical ventricular dyssynchrony, leading to deleterious pathological remodeling and a higher risk of heart failure hospitalization and atrial fibrillation.3 Conduction system pacing (CSP) using His bundle pacing (HBP)4,5 or left bundle branch area pacing (LBBAP)6 has emerged as an alternative to RVP in order to avoid the adverse hemodynamic effect of RVP on left ventricular systolic function. This pacing modality can be delivered with a single lead, recruits the intrinsic conduction system, and therefore may preserve normal physiological ventricular activation. However, compared with RVP, CSP requires longer procedure times6,7, 8, 9 and a longer learning curve10,11 and is associated with a non-negligible risk of complications, ranging from 1.6% to 11.7%,10, 11, 12, 13, 14, 15, 16, 17, 18, 19 mainly related to the CSP lead. This is especially true for HBP, which is limited by higher capture thresholds compared with RVP, reducing battery longevity, and concerns over increasing capture thresholds.5,7,8 These limitations seem to be overcome by LBBAP, which shows improved lead stability and better long-term pacing thresholds, resulting in a lower risk of lead-related complications.9,20

The feasibility, efficacy, and safety of CSP have been evaluated in several studies10, 11, 12,15, 16, 17, 18, 19; however, comparative data focused on the risk of complications between CSP and RVP, within CSP, and between HBP and LBBAP are lacking. Accordingly, we conducted a multicenter registry aimed to prospectively compare the rate and nature of device-related complications between CSP and RVP in a cohort of patients undergoing pacemaker (PM) implantation. As a secondary analysis in patients treated with CSP, we also compared the risk of device-related complications between HBP and LBBAP.

Section snippets

Study design and participants

The POINTED (Impact on Patient Outcome and healthcare utilization of cardiac ImplaNTble Electronic Devices complications) Registry was a prospective, multicenter, observational study designed to collect data on the long-term outcome of patients undergoing cardiac implantable electronic device implantation.2 The study was conducted in accordance with the Declaration of Helsinki. The protocol was approved by the ethics committee of the promoting institution, and the study was registered with //ClinicalTrials.gov

Overall study population

The flowchart of the study population enrollment is shown in Online Supplemental Figure 1. The study population consisted of 1029 consecutive patients who underwent PM implantation, of whom 636 received RVP and 393 received CSP (228 HBP, 165 LBBAP). The rate of use of the 2 pacing modalities during the study period was similar in all participating centers (Online Supplemental Figure 2).

In the unmatched cohort, several baseline characteristics and indications for PM implantation differed

Discussion

To our knowledge, this is the first multicenter, observational study prospectively comparing the risk of complications of CSP with that of RVP. The main findings of this study were as follows: (1) after adjustment for patient characteristics, the long-term risk of major device-related complications associated with CSP was similar to that of RVP; (2) considering HBP and LBBAP separately, HBP was associated with a significantly higher risk of complications than both RVP and LBBAP, mainly because

Conclusion

The results of this prospective, multicenter, observational study show that globally CSP is associated with a risk of complications similar to that of RVP. However, when analyzing HBP and LBBAP separately, HBP is associated with a significantly higher risk of complications compared with both RVP and LBBAP, mainly because of a higher rate of lead-related complications, whereas LBBAP is associated with a risk of complications similar to that of RVP.

Although these findings come from an

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    Funding Sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

    Disclosures: The authors have no conflicts to disclose.

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