Conduction System Pacing Versus Conventional Cardiac Resynchronization Therapy in Congenital Heart Disease
Jeremy P Moore1, Natasja M S de Groot2, Matthew O'Connor3
1Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, Department of Medicine, University of California Los Angeles Medical Center, Los Angeles, California, USA; Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA; Division of Cardiology, Department of Pediatrics, UCLA Medical Center, Los Angeles, California, USA.
Insights
Cardiac conduction system pacing (CSP) shows comparable efficacy to conventional cardiac resynchronization therapy (CRT) in congenital heart disease (CHD) patients. CSP offers greater QRS narrowing and similar left ventricular ejection fraction improvement with reliable achievement.
Area of Science:
- Cardiology
- Electrophysiology
- Congenital Heart Disease
Background:
- Left ventricular systolic dysfunction due to dyssynchrony is a significant issue in congenital heart disease (CHD).
- Conventional cardiac resynchronization therapy (CRT) offers benefits, but its comparative efficacy against cardiac conduction system pacing (CSP) remains unestablished.
Purpose of the Study:
- To compare the clinical outcomes of CSP versus conventional CRT in CHD patients with biventricular, systemic left ventricular anatomy.
Main Methods:
- A retrospective analysis compared 65 CSP cases from 7 centers with propensity score-matched conventional CRT controls.
- Outcomes assessed included lead performance, changes in left ventricular ejection fraction (LVEF), and QRS duration at 12 months.
Main Results:
- CSP was successfully achieved in 65 patients, with left bundle branch area pacing (LBBAP) showing superior electrical parameters compared to His bundle pacing (HBP).
- Improvement in LVEF was non-inferior between CSP and CRT (9.0% vs. 6.0%), while CSP demonstrated significantly greater QRS narrowing (35 ms vs. 14 ms).
- Complication rates were similar between the two groups (12% for CSP vs. 16% for CRT).
Conclusions:
- Cardiac conduction system pacing (CSP) is a reliably achievable option for biventricular, systemic left ventricular CHD patients.
- CSP demonstrated comparable LVEF improvement and superior QRS narrowing versus conventional CRT at one year.
- Left bundle branch area pacing (LBBAP) exhibited better electrical pacing parameters than His bundle pacing (HBP) within the CSP group.
Background:
Dyssynchrony-associated left ventricular systolic dysfunction is a major contributor to heart failure in congenital heart disease (CHD). Although conventional cardiac resynchronization therapy (CRT) has shown benefit, the comparative efficacy of cardiac conduction system pacing (CSP) is unknown.
Objectives:
The purpose of this study was compare the clinical outcomes of CSP vs conventional CRT in CHD with biventricular, systemic left ventricular anatomy.
Methods:
Retrospective CSP data from 7 centers were compared with propensity score-matched conventional CRT control subjects. Outcomes were lead performance, change in left ventricular ejection fraction (LVEF), and QRS duration at 12 months.
Results:
A total of 65 CSP cases were identified (mean age 37 ± 21 years, 46% men). The most common CHDs were tetralogy of Fallot (n = 12 [19%]) and ventricular septal defect (n = 12 [19%]). CSP was achieved after a mean of 2.5 ± 1.6 attempts per procedure (38 patients with left bundle branch pacing, 17 with HBP, 10 with left ventricular septal myocardial). Left bundle branch area pacing [LBBAP] vs HBP was associated with a smaller increase in pacing threshold (Δ pacing threshold 0.2 V vs 0.8 V; P = 0.05) and similar sensing parameters at follow-up. For 25 CSP cases and control subjects with baseline left ventricular systolic dysfunction, improvement in LVEF was non-inferior (Δ LVEF 9.0% vs 6.0%; P = 0.30; 95% confidence limits: -2.9% to 10.0%) and narrowing of QRS duration was more pronounced for CSP (Δ QRS duration 35 ms vs 14 ms; P = 0.04). Complications were similar (3 [12%] CSP, 4 [16%] conventional CRT; P = 1.00).
Conclusions:
CSP can be reliably achieved in biventricular, systemic left ventricular CHD patients with similar improvement in LVEF and greater QRS narrowing for CSP vs conventional CRT at 1 year. Among CSP patients, pacing electrical parameters were superior for LBBAP vs HBP.
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