His-Purkinje Conduction System Pacing Optimized Trial of Cardiac Resynchronization Therapy vs Biventricular Pacing:
Pugazhendhi Vijayaraman1, Parash Pokharel2, Faiz A Subzposh1
1Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania, USA.
Insights
His-Purkinje conduction system pacing (HPCSP) improved cardiac function more than biventricular pacing (BVP) in patients needing cardiac resynchronization therapy (CRT). HOT-CRT showed greater LVEF increase and fewer complications.
Area of Science:
- Cardiology
- Electrophysiology
- Heart Failure Management
Background:
- His-Purkinje conduction system pacing (HPCSP), including His bundle pacing (HBP) and left bundle branch pacing (LBBP), is an emerging alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT).
- Patients with heart failure and reduced ejection fraction often require CRT to improve cardiac function.
Purpose of the Study:
- To compare the feasibility and clinical efficacy of the His-Purkinje conduction system pacing Optimized Trial of Cardiac Resynchronization Therapy (HOT-CRT) with standard BVP in patients indicated for CRT.
- To evaluate changes in left ventricular ejection fraction (LVEF) and safety outcomes.
Main Methods:
- A prospective, randomized, controlled trial involving 100 patients with LVEF <50% indicated for CRT.
- Patients were randomized to either HOT-CRT or BVP. A coronary sinus lead was added to HOT-CRT if incomplete electrical resynchronization occurred.
- Primary outcome was the change in LVEF at 6 months; primary safety endpoint was freedom from major complications.
Main Results:
- HOT-CRT achieved successful pacing in 96% of patients, compared to 82% for BVP-CRT (P=0.03).
- The primary outcome, change in LVEF at 6 months, was significantly greater with HOT-CRT (12.4%) than with BVP (8.0%) (P=0.02).
- Complication rates were lower in the HOT-CRT group (6%) versus the BVP group (20%) (P=0.03).
Conclusions:
- HPCSP-guided CRT demonstrated superior efficacy in improving LVEF compared to BVP.
- HOT-CRT offers a potentially more effective and safer approach for CRT.
- Further randomized clinical trials with long-term follow-up are warranted to confirm these findings.
Background:
His-Purkinje conduction system pacing (HPCSP) using His bundle pacing (HBP) or left bundle branch pacing (LBBP) has emerged as an alternative to biventricular pacing (BVP) in patients requiring cardiac resynchronization therapy (CRT).
Objectives:
The aim of the study was to compare the feasibility and clinical efficacy of HOT-CRT (His-Purkinje conduction system pacing Optimized Trial of Cardiac Resynchronization Therapy) with BVP in patients with heart failure, reduced ejection fraction, and indication for CRT.
Methods:
This was a prospective, randomized, controlled trial of HOT-CRT and BVP in patients with LVEF <50% and indications for CRT. If HPCSP resulted in incomplete electrical resynchronization, a coronary sinus (CS) lead was added. The primary outcome was the change in left ventricular ejection fraction (LVEF) at 6 months. The primary safety endpoint was freedom from major complications.
Results:
A total of 100 patients (female 31%, aged 70 ± 12 years, LVEF 31.5% ± 9.0%) were randomized. HOT-CRT was successful in 48 of 50 (96%) and BVP-CRT in 41 of 50 (82%) patients (P = 0.03). QRS duration significantly decreased from 164 ± 26 ms to 137 ± 20 ms with HOT-CRT and 166 ± 28 ms to 141 ± 19 ms with BVP. Fluoroscopy results (18.8 ± 12.4 min vs 23.8 ± 12.4 min, P = 0.05) and procedure duration (119 ± 42 min vs 114 ± 36 min, P = 0.5) were similar. The primary outcome of change in LVEF at 6 months was greater in HOT-CRT than in BVP (12.4% ± 7.3% vs 8.0% ± 10.1%, P = 0.02). The primary safety endpoint was similar (98% vs 94%, P = 0.62). Echocardiographic response of improvement in LVEF >5% occurred in 80% vs 61% (P = 0.06). Complications occurred in 3 (6%) in HOT-CRT vs 10 (20%) in BVP (P = 0.03).
Conclusions:
HPCSP-guided CRT resulted in greater change in LVEF compared with BVP. Randomized clinical trials with long-term follow-up are necessary. (His-Purkinje Conduction System Pacing Optimized Trial of Cardiac Resynchronization Therapy [HOT-CRT]; NCT04561778).
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