Single operator experience, learning curve, outcomes, and insights gained with conduction system pacing

Area of Science:

• Cardiology
• Electrophysiology
• Medical Device Technology

Background:

• Conduction system pacing (CSP) is increasingly used to manage cardiac dyssynchrony.
• Barriers to CSP adoption include limited training, variability in methods, and a lack of learning curve data.
• This study reports the learning curve and clinical outcomes of an experienced electrophysiologist new to CSP.

Purpose of the Study:

• To evaluate the learning curve and clinical outcomes of conduction system pacing (CSP) implantation.
• To compare His-bundle pacing (HBP) and left-bundle-area pacing (LBAP) in terms of procedural efficiency and patient outcomes.
• To provide insights for electrophysiologists new to CSP.

Main Methods:

• Retrospective analysis of 191 patients undergoing attempted CSP implantation from 2016-2023.
• Data collected included patient characteristics, ECGs, echocardiograms, fluoroscopy/procedure times, and lead parameters at implant and follow-up.
• Comparison between His-bundle pacing (HBP) and left-bundle-area pacing (LBAP) groups.

Main Results:

• Successful CSP lead implantation in 87.4% of patients (167/191) with a mean follow-up of 278 days.
• HBP (n=59) and LBAP (n=108) showed similar procedural/fluoroscopy times, QRS duration reduction, and ejection fraction improvement.
• LBAP demonstrated lower pacing thresholds, higher lead impedances, and greater R-wave amplitudes compared to HBP. A learning curve of 25 cases was observed for LBAP, after which procedural parameters improved significantly.

Conclusions:

• Experienced implanters can achieve proficiency in CSP after approximately 25 cases.
• Left-bundle-area pacing (LBAP) offers lower capture thresholds and higher success rates compared to His-bundle pacing (HBP).
• Electrophysiologists new to CSP can consider directly implementing LBAP, as adequate lead deployment does not necessitate pre-QRS Purkinje signals.