His Resynchronization Versus Biventricular Pacing in Patients With Heart Failure and Left Bundle Branch Block
Ahran D Arnold1, Matthew J Shun-Shin1, Daniel Keene1
1National Heart and Lung Institute, Imperial College London, London, United Kingdom.
Insights
His bundle pacing offers superior ventricular resynchronization and hemodynamic improvement compared to biventricular pacing for cardiac resynchronization therapy (CRT). This novel approach enhances patient outcomes by optimizing cardiac function.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- His bundle pacing is an emerging technique for cardiac resynchronization therapy (CRT).
- Conventional biventricular CRT is a standard treatment for heart failure patients with left bundle branch block.
Purpose of the Study:
- To directly compare the efficacy of His bundle pacing against conventional biventricular pacing.
- To assess the impact of His bundle pacing on ventricular activation and acute hemodynamic function.
Main Methods:
- A head-to-head, acute crossover study was conducted in patients undergoing CRT.
- Noninvasive epicardial electrocardiographic imaging identified suitable candidates for His bundle pacing.
- Hemodynamic effects and ventricular activation were compared using a high-precision, repeated alternation protocol.
Main Results:
- His bundle pacing significantly shortened left ventricular activation time in 18 of 23 patients.
- Compared to biventricular pacing, His bundle pacing resulted in greater reductions in QRS duration, left ventricular activation time, and dyssynchrony index.
- His bundle pacing demonstrated a superior acute hemodynamic response (4.6 mm Hg increase in cardiac output).
Conclusions:
- His bundle pacing provides superior ventricular resynchronization compared to biventricular pacing.
- This method leads to greater improvements in hemodynamic parameters.
- His bundle pacing represents a promising advancement in cardiac resynchronization therapy.
Background:
His bundle pacing is a new method for delivering cardiac resynchronization therapy (CRT).
Objectives:
The authors performed a head-to-head, high-precision, acute crossover comparison between His bundle pacing and conventional biventricular CRT, measuring effects on ventricular activation and acute hemodynamic function.
Methods:
Patients with heart failure and left bundle branch block referred for conventional biventricular CRT were recruited. Using noninvasive epicardial electrocardiographic imaging, the authors identified patients in whom His bundle pacing shortened left ventricular activation time. In these patients, the authors compared the hemodynamic effects of His bundle pacing against biventricular pacing using a high-multiple repeated alternation protocol to minimize the effect of noise, as well as comparing effects on ventricular activation.
Results:
In 18 of 23 patients, left ventricular activation time was significantly shortened by His bundle pacing. Seventeen patients had a complete electromechanical dataset. In them, His bundle pacing was more effective at delivering ventricular resynchronization than biventricular pacing: greater reduction in QRS duration (-18.6 ms; 95% confidence interval [CI]: -31.6 to -5.7 ms; p = 0.007), left ventricular activation time (-26 ms; 95% CI: -41 to -21 ms; p = 0.002), and left ventricular dyssynchrony index (-11.2 ms; 95% CI: -16.8 to -5.6 ms; p < 0.001). His bundle pacing also produced a greater acute hemodynamic response (4.6 mm Hg; 95% CI: 0.2 to 9.1 mm Hg; p = 0.04). The incremental activation time reduction with His bundle pacing over biventricular pacing correlated with the incremental hemodynamic improvement with His bundle pacing over biventricular pacing (R = 0.70; p = 0.04).
Conclusions:
His resynchronization delivers better ventricular resynchronization, and greater improvement in hemodynamic parameters, than biventricular pacing.
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