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Conduction System vs Biventricular Pacing in Heart Failure: The PhysioSync-HF Randomized Clinical Trial.

André Zimerman1,2,3,4, Alexander Dal Forno5, Luis E Rohde1,2,3,4,6

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Conduction system pacing (CSP) was inferior to biventricular pacing (BiVP) for heart failure outcomes in patients with heart failure with reduced ejection fraction and left bundle-branch block. These results do not support CSP as a first-line therapy.

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Area of Science:

  • Cardiology
  • Electrophysiology
  • Heart Failure Management

Background:

  • Conduction system pacing (CSP) presents a potential alternative to biventricular pacing (BiVP) for heart failure patients with reduced ejection fraction (HFrEF) and left bundle-branch block (LBBB).
  • The comparative efficacy of CSP versus BiVP on heart failure (HF) outcomes in this specific patient population remains incompletely understood.
  • Investigating novel pacing strategies is crucial for optimizing treatment and improving outcomes in HFrEF patients with LBBB.

Purpose of the Study:

  • To compare the effectiveness of CSP against BiVP in patients diagnosed with HFrEF and LBBB.
  • To evaluate the impact of CSP versus BiVP on key heart failure-related clinical outcomes.
  • To determine the noninferiority of CSP compared to BiVP for HF management in this cohort.

Main Methods:

  • A multicenter, noninferiority randomized clinical trial (PhysioSync-HF) was conducted.
  • Adult patients with symptomatic HFrEF (NYHA classes II-III), LVEF ≤35%, and LBBB (QRS ≥130 ms) were randomized 1:1 to CSP or BiVP.
  • The primary outcome was a composite of death, HF hospitalizations, urgent HF visits, and change in LVEF at 12 months.

Main Results:

  • CSP failed to demonstrate noninferiority and was found to be inferior to BiVP for the primary composite endpoint (OR, 2.36; P=.002).
  • The composite of death, HF hospitalizations, or urgent HF visits occurred more frequently with CSP (HR, 2.35).
  • While both pacing methods improved LVEF, QRS duration, and quality of life metrics, BiVP showed a statistically significant greater increase in LVEF.
  • CSP was associated with lower direct medical costs compared to BiVP.

Conclusions:

  • In patients with HFrEF and LBBB, CSP was inferior to BiVP regarding a composite of major HF events and LVEF change at 12 months.
  • The study findings do not support the routine use of CSP as the initial resynchronization strategy for this patient group.
  • Further research may be needed to identify specific subgroups who might benefit from CSP or to refine CSP techniques.