Conduction system pacing compared with biventricular pacing for cardiac resynchronization therapy in patients with
Pugazhendhi Vijayaraman1, Francesco Zanon2, Shunmuga Sundaram Ponnusamy3
1Geisinger Heart Institute, Wilkes Barre, Pennsylvania.
Insights
Conduction system pacing (CSP) improved outcomes for heart failure patients compared to biventricular pacing (BVP). CSP reduced the risk of death or hospitalization for heart failure, offering a potentially superior CRT option.
Area of Science:
- Cardiology
- Electrophysiology
- Heart Failure Management
Background:
- Cardiac resynchronization therapy (CRT) is recommended for heart failure with mildly reduced ejection fraction (HFmrEF) and conduction abnormalities.
- Conduction system pacing (CSP) offers a physiologic alternative to traditional biventricular pacing (BVP).
Purpose of the Study:
- To compare clinical outcomes between BVP and CSP in patients with HFmrEF undergoing CRT.
Main Methods:
- A retrospective analysis of 1004 HFmrEF patients undergoing CRT (BVP or CSP) across 16 international centers (Jan 2018-June 2023).
- Primary outcome: composite of death or heart failure hospitalization (HFH). Secondary outcomes: changes in left ventricular ejection fraction (LVEF), death, and HFH.
Main Results:
- CSP resulted in a narrower paced QRS duration compared to BVP (129±21 ms vs 144±19 ms).
- CSP was independently associated with a significant reduction in the composite endpoint of death or HFH (22% vs 34%; HR 0.64; P=.025).
- LVEF improved similarly in both groups.
Conclusions:
- CSP demonstrated improved clinical outcomes compared to BVP in a large cohort of HFmrEF patients receiving CRT.
- Further randomized controlled trials are needed to validate these findings.
Background:
Cardiac resynchronization therapy (CRT) is a guideline-recommended therapy in patients with heart failure with mildly reduced ejection fraction (HFmrEF, 36%-50%) and left bundle branch block or indication for ventricular pacing. Conduction system pacing (CSP) using left bundle branch area pacing or His bundle pacing has been shown to be a safe and physiologic alternative to biventricular pacing (BVP).
Objective:
The aim of this study was to compare the clinical outcomes between BVP and CSP for patients with HFmrEF undergoing CRT.
Methods:
Consecutive patients who underwent BVP or CSP with HFmrEF between January 2018 and June 2023 at 16 international centers were included. The primary outcome was the composite end point of time to death or heart failure hospitalization (HFH). Secondary end points included change in left ventricular ejection fraction (LVEF) and individual end points of death and HFH.
Results:
A total of 1004 patients met inclusion criteria: BVP, 178; CSP, 826 (His bundle pacing, 154; left bundle branch area pacing, 672). Mean age was 73 ± 13 years; female, 34%; and LVEF, 42% ± 5%. Paced QRS duration in CSP was significantly narrower compared with BVP (129 ± 21 ms vs 144 ± 19 ms; P < .001). LVEF improved during follow-up in both groups (49% ± 10% vs 48% ± 10%; P = .32). CSP was independently associated with significant reduction in the primary end point of time to death or HFH compared with BVP (22% vs 34%; hazard ratio, 0.64; 95% confidence interval, 0.43-0.94; P = .025).
Conclusion:
CSP was associated with improved clinical outcomes compared with BVP in this large cohort of patients with HFmrEF undergoing CRT. Randomized controlled trials comparing CSP with BVP will be necessary to confirm these results.
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