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Left Bundle Branch Area Pacing for CRT
Quick Takes
- In this retrospective multicenter study, procedural success with left bundle branch area pacing (LBBAP) was achieved in 85% of patients who had remarkably low pacing thresholds at implant and during follow-up.
- LBBAP resulted in QRS narrowing from 152 to 137 ms (p < 0.01) and LVEF improved from 33% to 44% (p < 0.01).
Study Questions:
What are the feasibility and outcomes of left bundle branch area pacing (LBBAP) in patients eligible for cardiac resynchronization therapy (CRT)?
Methods:
In an international, eight center, collaborative study, patients with left ventricular ejection fraction (LVEF) <50% and indications for CRT or pacing underwent LBBAP. Procedural and clinical outcomes as well as lead complications were analyzed.
Results:
Among a total of 325 patients, LBBAP was successfully achieved in 277 (85%). QRS configuration at baseline was LBBB in 39% and non-LBBB in 46%. Procedure and fluoroscopy duration were an average of 105 and 19 minutes, respectively. LBBAP threshold and R-wave amplitudes were 0.6 V at 0.5 ms and 10.6 mV at implantation and remained stable during follow-up. LBBAP resulted in QRS narrowing from 152 to 137 ms (p < 0.01). LVEF improved from 33% to 44% (p < 0.01). Clinical improvement and LVEF improvement >5% were observed in 72% and 73% of patients. Baseline LBBB (odds ratio, 3.96; p < 0.01) and LV end-diastolic diameter (odds ratio, 0.62; p < 0.01) were independent predictors of echocardiographic response.
Conclusions:
LBBAP is feasible and safe and provides an alternative option for CRT. LBBAP provides low and stable pacing thresholds and was associated with improved clinical and echocardiographic outcomes.
Perspective:
Intraseptal LBBAP is a relatively new technique to provide pacing in patients with a wide QRS and heart failure. By pacing the area of the left bundle branch distal to the block, it employs the heart’s native conduction system along with its arborized Purkinje system to rapidly activate the ventricles. The current international study shows a high degree of feasibility and safety. Future studies will no doubt compare this method of pacing with the established biventricular method of pacing in heart failure. While predicting the future is a hazardous occupation, it is hard to conceive how LBBAP would not be shown at least as good as biventricular pacing, and quite likely superior to it.
Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound, Nuclear Imaging
Keywords: Arrhythmias, Cardiac, Bundle-Branch Block, Cardiac Pacing, Artificial, Cardiac Resynchronization Therapy, Echocardiography, Fluoroscopy, Geriatrics, Heart Conduction System, Heart Failure, Pacemaker, Artificial, Secondary Prevention, Stroke Volume, Ventricular Function, Left
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