Elsevier

Heart Rhythm

Volume 19, Issue 1, January 2022, Pages 3-11
Heart Rhythm

Late Breaking Clinical Trials
Clinical outcomes of left bundle branch area pacing compared to right ventricular pacing: Results from the Geisinger-Rush Conduction System Pacing Registry

https://doi.org/10.1016/j.hrthm.2021.08.033Get rights and content

Background

Left bundle branch area pacing (LBBAP) has been shown to be a feasible option for patients requiring ventricular pacing.

Objective

The purpose of this study was to compare clinical outcomes between LBBAP and RVP among patients undergoing pacemaker implantation

Methods

This observational registry included patients who underwent pacemaker implantations with LBBAP or RVP for bradycardia indications between April 2018 and October 2020. The primary composite outcome included all-cause mortality, heart failure hospitalization (HFH), or upgrade to biventricular pacing. Secondary outcomes included the composite endpoint among patients with a prespecified burden of ventricular pacing and individual outcomes.

Results

A total of 703 patients met inclusion criteria (321 LBBAP and 382 RVP). QRS duration during LBBAP was similar to baseline (121 ± 23 ms vs 117 ± 30 ms; P = .302) and was narrower compared to RVP (121 ± 23 ms vs 156 ± 27 ms; P <.001). The primary composite outcome was significantly lower with LBBAP (10.0%) compared to RVP (23.3%) (hazard ratio [HR] 0.46; 95%T confidence interval [CI] 0.306–0.695; P <.001). Among patients with ventricular pacing burden >20%, LBBAP was associated with significant reduction in the primary outcome compared to RVP (8.4% vs 26.1%; HR 0.32; 95% CI 0.187–0.540; P <.001). LBBAP was also associated with significant reduction in mortality (7.8% vs 15%; HR 0.59; P = .03) and HFH (3.7% vs 10.5%; HR 0.38; P = .004).

Conclusion

LBBAP resulted in improved clinical outcomes compared to RVP. Higher burden of ventricular pacing (>20%) was the primary driver of these outcome differences.

Introduction

Conventional right ventricular pacing (RVP) has been associated with an increased incidence of atrial fibrillation (AF), heart failure (HF), pacing-induced cardiomyopathy, and mortality.1, 2, 3 Earlier studies have suggested that ventricular pacing burden ≥40% is associated with increased risk for death or heart failure hospitalization (HFH) and incident AF.2 More recent data suggest that ventricular pacing burden ≥20% may be associated with an increased risk of a pacing-induced cardiomyopathy.4,5

Large observational studies have demonstrated that permanent His-bundle pacing (HBP) may be a physiological alternative to RVP and has been associated with improved clinical outcomes compared to RVP.6, 7, 8 HBP has been associated with a decreased risk of HFH6, 7, 8 and a lower incidence of AF9 compared to conventional RVP. However, HBP has procedural challenges with variable success rates (65%–92%)6,8,10,11 due to inability to localize the His bundle (HB) or inability to place the lead distal to the site of block, particularly in patients with infranodal atrioventricular (AV) block. Furthermore, performance challenges with unpredictable rise in HB capture thresholds and loss of HB capture have been reported in 8%–17% of cases in published reports.7,8,12 Left bundle branch area pacing (LBBAP) has gained greater acceptance over the past few years since its initial description in a patient with cardiomyopathy and left bundle branch block (LBBB) by Huang et al.13 Various observational studies have demonstrated the feasibility and safety of this technique with better success rates and more stable capture thresholds compared to HBP.14, 15, 16 However, no large-scale studies have compared the clinical outcomes of patients undergoing LBBAP compared to conventional RVP.

The primary aim of the present study was to evaluate the clinical outcome differences between LBBAP and RVP in a large cohort of patients.

Section snippets

Study design

We studied consecutive patients referred to Geisinger Health System, Pennsylvania and Rush University Medical Center (Chicago, Illinois) from April 2018 to October 2020 for permanent pacemaker implantation for standard indications.17 All patients underwent an attempt at permanent HBP, LBBAP, or conventional right ventricular (RV) lead implantation (RV apex or septum) based on operator preference and/or the clinical practice at that institution. The study protocol was approved by the

Baseline characteristics

A total of 1141 patients underwent permanent pacemaker implantations during the study period at the 2 health systems. A total of 703 patients (581 patients in the Geisinger Health System and 122 patients in the Rush Health System) met final inclusion criteria and were included in the analysis (Figure 1). LBBAP was successful in 321 patients, whereas 382 patients underwent successful RVP. Mean age of the cohort was 75.13 ± 12 years, 48% were women, 34% of patients had a history of HF (systolic

Discussion

The primary findings from this large multicenter study were as follows. (1) LBBAP was associated with a significant reduction in the primary composite endpoint of all-cause mortality or HFH or upgrade to BVP compared to conventional RVP in patients undergoing permanent pacemaker implantations for routine bradycardia indications. (2) LBBAP was associated with a significant reduction in HFH compared to RVP. (3) LBBAP was also associated with a significant reduction in mortality compared to RVP.

Conclusion

In this large multicenter cohort, LBBAP was associated with a significant reduction in the composite outcome of all-cause mortality, HFH, or upgrade to BVP compared to conventional RVP. These differences in clinical outcomes were primarily driven by patients who needed >20% ventricular pacing.

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Funding Sources: The authors have no funding sources to disclose. Disclosure: Dr Sharma has received honoraria from Medtronic; and has served as a consultant to Medtronic, Abbott, Biotronik, and Boston Scientific. Dr Krishnan has served as a consultant to Abbott/St. Jude Medical, Cardiva, and Zoll; and has received research funding from Abbott/St. Jude Medical. Dr Trohman has served as an advisor to Boston Scientific; has received research grants from Boston Scientific, Medtronic Inc, Abbott/St. Jude Medical, Vitatron, and Wyeth Ayerst/Wyeth Pharmaceuticals; has served as a consultant to Biosense Webster, Alta Thera Pharmaceuticals, and St. Jude Medical Newron Pharmaceuticals P.s.A.; and has received honoraria from Boston Scientific/Guidant CRM, Medtronic Inc, Alta Thera Pharmaceuticals, Daiichi Sankyo, and Abbott/St. Jude Medical. Dr Huang has received honoraria from Cardiofocus, Medtronic, and Biotronik; and has served as a consultant to Cardiofocus. Dr Vijayaraman has received honoraria, served as a consultant to, and received research and fellowship support from Medtronic; has served as a consultant to Abbott, Biotronik, and Eaglepoint LLC; and declares a patent for an HBP delivery tool. All other authors have reported that they no relationships relevant to the contents of this paper to disclose.

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