The risk of heart failure (HF)-related hospitalization was lower with left bundle branch area pacing (LBBAP) compared with biventricular pacing (BiVp) as the initial strategy for cardiac resynchronization therapy (CRT), according to a late-breaking clinical trial presented at Heart Rhythm 2023 and simultaneously published May 21 in JACC: Clinical Electrophysiology.

Juan Carlos Diaz, MD, et al., conducted a prospective, multicenter, observational, nonrandomized study with 371 patients referred for a first CRT between January 2020 and August 2022 to compare outcomes between LBBAP (n=128) and BiVp (n=243) as an initial implant strategy. The groups were similar at baseline except for a lower percentage of patients in the LBBAP group had NYHA class II heart failure (28.1% vs. 40.3% in the BiVp group; p=0.02).

The primary efficacy outcome was the composite of HF-related hospitalization and all-cause mortality, and the primary safety outcomes were acute and long-term complications.   

Results showed that over the mean 340 days of follow-up, LBBAP vs. BiVp was associated with a significant reduction in the primary endpoint, which occurred in 24.2% and 42.4% of patients, respectively (hazard ratio [HR], 0.621; p=0.021), with a reduction in HF-related hospitalizations (22.6% vs. 39.5%; HR, 0.607; p=0.021) without a significant difference in all-cause mortality (5.5% vs. 11.9%; p=0.19) or long-term complications (9.4% vs. 15.2%, respectively; p=0.146).

In addition, procedural and fluoroscopy times were significantly shorter with LBBAP vs. BiVp, respectively  (95 minutes vs. 129 minutes; p<0.001) and (12 minutes vs. 21.7 minutes; p<0.001). Also seen with LBBAP vs. BiVp were improvements in left ventricular ejection fraction (34.1±12.5% vs. 31.4±10.8%; p=0.041) and shorter paced QRS duration (123.7±18 ms vs. 149.3±29.1 ms; p<0.001).

The authors note that “these results suggest that LBBAP could be used as an initial implant strategy to achieve CRT in HF treatment and may significantly impact HF-related hospitalizations.”

In an accompanying editorial comment, Jayanthi N. Koneru, MBBS, FACC, and Kenneth A. Ellenbogen, MD, FACC, state that the “study results suggest that LBBAP is an excellent alternative to BiVp with comparable safety profile; early follow-up results indicate better clinical response with LBBAP compared to BiVp in patients with HF and LBBB” and provides a foundation for future studies.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Nuclear Imaging

Keywords: Electrophysiology, Fluoroscopy, Hospitalization, Heart Failure, Ventricular Function, Left, Follow-Up Studies, Prospective Studies, Stroke Volume, Cardiac Resynchronization Therapy

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