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Evolving Concepts in Cardiac Physiologic Pacing in the Era of Conduction System Pacing
Jamario Skeete1, Henry D Huang1, Alex Mazur1
1Division of Cardiac Electrophysiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois.
Insights
Cardiac physiologic pacing (CPP) offers benefits for cardiomyopathy patients. Conduction system pacing (CSP) is an evolving alternative to traditional biventricular pacing, though more research is needed.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Pacing
Background:
- Cardiac physiologic pacing (CPP) is established for cardiomyopathy with left bundle branch block.
- CPP benefits patients with pacing-induced cardiomyopathy or high right ventricular pacing burden.
- Traditional biventricular pacing requires successful left ventricular lead implantation, which faces anatomical and substrate limitations.
Purpose of the Study:
- To provide a comprehensive review of cardiac physiologic pacing (CPP).
- To discuss the evolution and benefits of conduction system pacing (CSP) in cardiac resynchronization.
- To compare the evidence base for CSP versus traditional biventricular pacing.
Main Methods:
- Comprehensive literature review of cardiac physiologic pacing (CPP).
- Analysis of studies investigating conduction system pacing (CSP).
- Evaluation of data from leading CSP investigative centers.
Main Results:
- CPP is a recognized therapy for specific cardiomyopathy patient groups.
- Conduction system pacing (CSP) shows emerging benefits for cardiac resynchronization.
- Evidence supporting CSP for eligible patients is less extensive than for biventricular pacing.
Conclusions:
- Cardiac physiologic pacing (CPP) remains a key therapy.
- Conduction system pacing (CSP) represents a significant advancement in cardiac resynchronization.
- Further research is needed to fully establish CSP's role compared to traditional methods.
Abstract:
Cardiac physiologic pacing (CPP) has become a well-established therapy for patients with cardiomyopathy (left ventricular ejection fraction <35%) in the presence of a left bundle branch block. In addition, CPP can be highly beneficial in patients with pacing-induced cardiomyopathy and patients with existing cardiomyopathy expected to have a right ventricular pacing burden of >40%. The benefits of CPP with traditional biventricular pacing are only realized if adequate resynchronization can be achieved. However, left ventricular lead implantation can be limited by individual anatomic variation within the coronary venous system and can be adversely affected by underlying abnormal myocardial substrate (i.e., scar tissue), especially if located within the basal lateral wall. In the last 7 years the investigation of conduction system pacing (CSP) and its potential salutary benefits are being realized and have led to a rapid evolution in the field of cardiac resynchronization pacing. However, supportive evidence for CSP for patients eligible for cardiac resynchronization remains limited compared with data available for biventricular cardiac resynchronization, mostly derived from leading CSP investigative centers. In this review, we perform an up-to-date comprehensive review of the available literature on CPP.
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