Biventricular or Conduction System Pacing for Cardiac Resynchronization Therapy: A Strategy for Cardiac
Amato Santoro1, Federico Landra2, Carmine Marallo2
1Division of Cardiology, Azienda Ospedaliera Universitaria Senese, Viale Bracci 1, 53100 Siena, Italy.
Insights
A new algorithm using interventricular conduction delays (IVCD) guides cardiac resynchronization therapy (CRT) choices between biventricular pacing (BiVP) and conduction system pacing (CSP). This approach reduced adverse cardiovascular events by guiding the selection of pacing methods.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Cardiac resynchronization therapy (CRT) traditionally uses biventricular pacing (BiVP).
- Conduction system pacing (CSP) is an emerging alternative, particularly when BiVP is challenging or fails.
- Interventricular conduction delays (IVCD) are key indicators for pacing strategy selection.
Purpose of the Study:
- To develop and evaluate a treatment algorithm for selecting between BiVP and CSP based on IVCD.
- To compare the efficacy of the IVCD-guided algorithm against standard CRT practices.
Main Methods:
- Prospective enrollment of 160 patients (delays-guided resynchronization group, DRG) using the IVCD algorithm from 2018-2020.
- Comparison with a historical cohort of 132 patients (resynchronization standard guide group, SRG) treated from 2016-2017.
- Primary endpoint: composite of cardiovascular mortality, heart failure hospitalization, or HF event at 1 year post-intervention.
Main Results:
- The IVCD algorithm guided 25.6% of DRG patients to CSP.
- The primary endpoint occurred in 21.8% of the DRG versus 36.4% in the SRG (HR: 1.72; 95% CI: 1.12-2.65; p=0.013).
- The delays-guided resynchronization group demonstrated a significantly lower rate of adverse cardiovascular outcomes.
Conclusions:
- An IVCD-based algorithm effectively redirected approximately one in four patients from BiVP to CSP.
- This strategy led to a significant reduction in major adverse cardiovascular events post-implantation.
- The IVCD algorithm is a valuable tool for optimizing CRT strategy selection between BiVP and CSP.
Background:
Cardiac resynchronization therapy (CRT) is usually performed with biventricular pacing (BiVP), but recently, conduction system pacing (CSP) has been proposed as an alternative in case of BiVP failure. The aim of this study is to define an algorithm to choose between BiVP and CSP resynchronization using the interventricular conduction delays (IVCD) as a guide.
Methods:
Consecutive patients from January 2018 to December 2020 with an indication for CRT were prospectively enrolled in the study group (delays-guided resynchronization group, DRG). A treatment algorithm based on IVCD was used to decide whether to leave the left ventricular (LV) lead to perform BiVP or pull it out and perform CSP. Outcomes from the DRG group were compared to a historical cohort of CRT patients who underwent CRT procedures between January 2016 and December 2017 (resynchronization standard guide group, SRG). The primary endpoint was a composite of cardiovascular mortality, heart failure (HF) hospitalization, or HF event at 1 year after the date of intervention.
Results:
The study population consisted of 292 patients, of which 160 (54.8%) were in the DRG and 132 (45.2%) in the SRG. In the DRG, 41 of 160 patients underwent CSP based on the treatment algorithm (25.6%). The primary endpoint was significantly higher in the SRG (48/132, 36.4%) compared to the DRG (35/160, 21.8%) (hazard ratio (HR): 1.72; 95% confidence interval (CI): 1.12-2.65; p = 0.013).
Conclusions:
A treatment algorithm based on IVCD shifted one patient out of every four from BiVP to CSP, with consequent reduction in the primary endpoint after implantation. Therefore, its application could be useful to determine whether to perform BiVP or CSP.
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