His Pacing vs Biventricular Pacing for Cardiac Resynchronization Therapy: Long-Term Follow-Up From the
Emil Anton Frandsen1, Johanna Krøll1, Ulrik Winsløw1
1Department of Cardiology, The Heart Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.
Insights
His bundle pacing (His-CRT) and biventricular pacing (BiV-CRT) showed similar long-term performance and echocardiographic response in heart failure patients. Low implantation thresholds for His-CRT matched BiV-CRT outcomes.
Area of Science:
- Cardiology
- Electrophysiology
- Heart Failure Management
Background:
- The His-Alternative I trial was the first European randomized trial comparing His bundle pacing (His-CRT) with conventional biventricular pacing (BiV-CRT) in symptomatic heart failure patients with left bundle branch block.
- This study aimed to evaluate the long-term outcomes of these two cardiac resynchronization therapy (CRT) approaches.
Purpose of the Study:
- To compare the long-term lead performance, survival rates, and echocardiographic response between His-CRT and BiV-CRT.
- To assess the durability and effectiveness of His-CRT in patients with heart failure and left bundle branch block.
Main Methods:
- 50 patients with symptomatic heart failure (HF), LVEF ≤35%, and LBBB were randomized to His-CRT or BiV-CRT.
- Primary analyses included lead revisions, generator replacements, reinterventions, all-cause mortality or HF hospitalization, and echocardiographic response over 5 years of follow-up.
Main Results:
- While His-CRT showed higher rates of lead revisions (37% vs 3%) and generator replacements (47% vs 10%), no significant differences in reinterventions or threshold development were found between His-CRT (with low implantation thresholds) and BiV-CRT.
- All-cause mortality or HF hospitalization risk was similar (HR: 0.32; P = 0.147), and echocardiographic response rates were comparable (89% for His-CRT vs 90% for BiV-CRT).
Conclusions:
- His-CRT with low implantation thresholds demonstrates comparable long-term performance and echocardiographic response to BiV-CRT in heart failure patients.
- These findings suggest His-CRT is a viable alternative to BiV-CRT for selected patients, particularly when achieving low implantation thresholds.
Background:
The His-Alternative I (A Randomized Trial of His Pacing Versus Biventricular Pacing in Symptomatic Heart Failure Patients With Left Bundle Branch Block) trial was the first randomized European trial to compare cardiac resynchronization therapy (CRT) delivered by His bundle pacing (His-CRT) vs CRT delivered by conventional biventricular pacing (BiV-CRT).
Objectives:
The goal of this study was to compare long-term lead performance, survival, and echocardiographic response between His-CRT and BiV-CRT.
Methods:
A total of 50 patients with symptomatic heart failure (HF), left ventricular ejection fraction ≤35%, and left bundle branch block were randomized 1:1 to undergo His-CRT or BiV-CRT. Following crossover at implantation, 19 patients received His-CRT and 31 received BiV-CRT. The primary analyses were conducted by these groups, with 5 years of follow-up. Outcomes included the occurrence of reinterventions, an endpoint of all-cause mortality or hospitalization for HF, and echocardiographic response (≥15% reduction in left ventricular end-systolic volume compared with baseline).
Results:
The median follow-up was 5.3 years (Q1-Q3: 4.6-5.7 years). More lead revisions (37% vs 3%; P = 0.003) and generator replacements (47% vs 10%; P = 0.005) occurred in the His-CRT group compared with the BiV-CRT group. However, no statistically significant differences in reinterventions and threshold development over time were observed between the His-CRT patients with implantation thresholds ≤2.5 V/1 millisecond and the BiV-CRT group. The risk of all-cause mortality or hospitalization for HF was similar between groups (HR: 0.32; 95% CI: 0.07-1.49; P = 0.147), and echocardiographic response was comparable between the 2 groups (89% in His-CRT and 90% in BiV-CRT; P = 1.0).
Conclusions:
No statistically significant difference in long-term performance was detected between His-CRT with low implantation thresholds and BiV-CRT, and echocardiographic response was comparable.
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