ClinicalDevicesRate and nature of complications of conduction system pacing compared with right ventricular pacing: Results of a propensity score–matched analysis from a multicenter registry
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
References (31)
- et al.
Impact on all-cause and cardiovascular mortality of cardiac implantable electronic device complications: results from the POINTED Registry
JACC Clin Electrophysiol
(2020) - et al.
Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function
Heart Rhythm
(2016) - et al.
Permanent His-bundle pacing: long-term lead performance and clinical outcomes
Heart Rhythm
(2018) - et al.
A novel pacing strategy with low and stable output: pacing the left bundle branch immediately beyond the conduction block
Can J Cardiol
(2017) - et al.
Permanent His-bundle pacing is feasible, safe, and superior to right ventricular pacing in routine clinical practice
Heart Rhythm
(2015) - et al.
Clinical outcomes of His bundle pacing compared to right ventricular pacing
J Am Coll Cardiol
(2018) - et al.
Left bundle branch area pacing for cardiac resynchronization therapy: results from the international LBBAP Collaborative Study Group
JACC Clin Electrophysiol
(2021) - et al.
Initial experience, safety, and feasibility of left bundle branch area pacing: a multicenter prospective study
JACC Clin Electrophysiol
(2020) - et al.
Electrophysiological characteristics of septal perforation during left bundle branch pacing
Heart Rhythm
(2022) - et al.
A beginner’s guide to permanent left bundle branch pacing
Heart Rhythm
(2019)
Leadless transcatheter pacemaker: indications, implantation technique and peri-procedural patient management in the Italian clinical practice
Int J Cardiol
Prevention of ventricular desynchronization by permanent para-Hisian pacing after atrioventricular node ablation in chronic atrial fibrillation: a crossover, blinded, randomized study versus apical right ventricular pacing
J Am Coll Cardiol
Rate, causes, and impact on patient outcome of implantable device complications requiring surgical revision: large population survey from two centres in Italy
Europace
Permanent, direct His-bundle pacing: a novel approach to cardiac pacing in patients with normal His-Purkinje activation
Circulation
Safety and efficacy of His-bundle pacing/left bundle branch area pacing versus right ventricular pacing: a systematic review and meta-analysis
J Interv Card Electrophysiol
Cited by (11)
Diagnostic electrocardiographic trap: A case of conduction system pacing
2023, Journal of ElectrocardiologyEarly effects of left bundle branch area pacing on ventricular activation by speckle tracking echocardiography
2024, Journal of Interventional Cardiac ElectrophysiologySuperior approach from the pocket for atrioventricular junction ablation performed at the time of conduction system pacing implantation
2023, PACE - Pacing and Clinical Electrophysiology
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.