Clinical outcomes of conduction system pacing compared to biventricular pacing in patients requiring cardiac
Pugazhendhi Vijayaraman1, Dipen Zalavadia2, Abdul Haseeb2
1Geisinger Heart Institute, Wilkes Barre, Pennsylvania; Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania.
Insights
Conduction system pacing (CSP) offers improved clinical outcomes compared to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT). CSP significantly reduced the composite endpoint of death or heart failure hospitalization in patients with reduced ejection fraction.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) is standard for heart failure patients with low ejection fraction and conduction delays.
- Conduction system pacing (CSP), including His-bundle pacing (HBP) and left bundle branch area pacing (LBBAP), presents a more physiological alternative to BVP.
Purpose of the Study:
- To compare the clinical outcomes of CSP versus BVP in patients undergoing CRT.
Main Methods:
- An observational study included 477 patients with LVEF ≤35% and CRT indications.
- Patients received either BVP or CSP (HBP or LBBAP).
- The primary outcome was the composite of death or heart failure hospitalization (HFH); secondary outcomes included subgroup analyses and individual endpoints.
Main Results:
- CSP resulted in a narrower paced QRS duration (133 ms vs 153 ms) and greater LVEF improvement compared to BVP.
- The composite endpoint of death or HFH was significantly lower in the CSP group (28.3%) versus the BVP group (38.4%).
- CSP demonstrated a hazard ratio of 1.52 for improved outcomes (P = .013).
Conclusions:
- CSP significantly improved clinical outcomes, including reduced mortality and heart failure hospitalizations, compared to BVP in patients requiring CRT.
- CSP is a safe and effective alternative to BVP for CRT, offering more physiological cardiac activation.
Background:
Cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) is well-established therapy in patients with reduced left ventricular ejection fraction (LVEF) and bundle branch block or indication for pacing. Conduction system pacing (CSP) using His-bundle pacing (HBP) or left bundle branch area pacing (LBBAP) has been shown to be a safe and more physiological alternative to BVP.
Objective:
The purpose of this study was to compare the clinical outcomes between CSP and BVP among patients undergoing CRT.
Methods:
This observational study included consecutive patients with LVEF ≤35% and class I or II indications for CRT who underwent successful BVP or CSP at 2 major health care systems. The primary outcome was the composite endpoint of time to death or heart failure hospitalization (HFH). Secondary outcomes included subgroup analysis in left bundle branch block as well as individual endpoints of death and HFH.
Results:
A total of 477 patients (32% female) met inclusion criteria (BVP 219; CSP 258 [HBP 87, LBBAP 171]). Mean age was 72 ± 12 years, and mean LVEF was 26% ± 6%. Comorbidities included hypertension 70%, diabetes mellitus 45%, and coronary artery disease 52%. Paced QRS duration in CSP was significantly narrower than BVP (133 ± 21 ms vs 153 ± 24 ms; P <.001). LVEF improved in both groups during mean follow-up of 27 ± 12 months and was greater after CSP compared to BVP (39.7% ± 13% vs 33.1% ± 12%; P <.001). Primary outcome of death or HFH was significantly lower with CSP vs BVP (28.3% vs 38.4%; hazard ratio 1.52; 95% confidence interval 1.082-2.087; P = .013).
Conclusion:
CSP improved clinical outcomes compared to BVP in this large cohort of patients with indications for CRT.
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