2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

Chung, Mina K.; Patton, Kristen K.; Lau, Chu-Pak; Dal Forno, Alexander R.J.; Al-Khatib, Sana M.; Arora, Vanita; Birgersdotter-Green, Ulrika Maria; Cha, Yong-Mei; Chung, Eugene H.; Cronin, Edmond M.; Curtis, Anne B.; Cygankiewicz, Iwona; Dandamudi, Gopi; Dubin, Anne M.; Ensch, Douglas P.; Glotzer, Taya V.; Gold, Michael R.; Goldberger, Zachary D.; Gopinathannair, Rakesh; Gorodeski, Eiran Z.; Gutierrez, Alejandra; Guzman, Juan C.; Huang, Weijian; Imrey, Peter B.; Indik, Julia H.; Karim, Saima; Karpawich, Peter P.; Khaykin, Yaariv; Kiehl, Erich L.; Kron, Jordana; Kutyifa, Valentina; Link, Mark S.; Marine, Joseph E.; Mullens, Wilfried; Park, Seung-Jung; Parkash, Ratika; Patete, Manuel F.; Pathak, Rajeev Kumar; Perona, Carlos A.; Rickard, John; Schoenfeld, Mark H.; Seow, Swee-Chong; Shen, Win-Kuang; Shoda, Morio; Singh, Jagmeet P.; Slotwiner, David J.; Sridhar, Arun Raghav M.; Srivatsa, Uma N.; Stecker, Eric C.; Tanawuttiwat, Tanyanan; Tang, W.H. Wilson; Tapias, Carlos Andres; Tracy, Cynthia M.; Upadhyay, Gaurav A.; Varma, Niraj; Vernooy, Kevin; Vijayaraman, Pugazhendhi; Worsnick, Sarah Ann; Zareba, Wojciech; Zeitler, Emily P.

doi:10.1016/j.hrthm.2023.03.1538

Cited by 205 publications

(85 citation statements)

References 451 publications

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“…According to the latest guidelines, LBBAP includes selective left bundle branch pacing (LBBP), nonselective LBBAP, or left ventricular septal pacing (LVSP). 13,14 The criteria for successful LBBAP in this study were (1) unipolar paced QRS morphology of late R-wave in lead V1 and (2) s-LVAT <90 ms (Figure 1). 6,15 LBB capture was confirmed based on the following criteria, as previously reported: 15,16 LVSP was defined as (1) late R-wave in V1, (2) s-LVAT <90 ms, 6,15 and (3) no evidence of LBB capture.…”

Section: Definition Of Successful Lbbap and The Lbb Capturementioning

confidence: 88%

Predictors of implantation failure in left bundle branch area pacing using a lumenless lead in patients with bradycardia

Kato

Sato

Shimeno

et al. 2023

Journal of Arrhythmia

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BackgroundLeft bundle branch area pacing (LBBAP) is a novel conduction system pacing technique. In this multicenter study, we aimed to evaluate the procedural success, safety, and preoperative predictors of procedural failure of LBBAP.MethodsLBBAP was attempted in 285 patients with pacemaker indications for bradyarrhythmia, which were mainly atrioventricular block (AVB) (68.1%) and sick sinus syndrome (26.7%). Procedural success and electrophysiological and echocardiographic parameters were evaluated.ResultsLBBAP was successful in 247 (86.7%) patients. Left bundle branch (LBB) capture was confirmed in 54.7% of the population. The primary reasons for procedural failure were the inability of the pacemaker lead to penetrate deep into the septum (76.3%) and failure to achieve shortening of stimulus to left ventricular (LV) activation time in lead V6 (18.4%). Thickened interventricular septum (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.15–5.35), severe tricuspid regurgitation (OR, 8.84; 95% CI, 1.22–64.06), and intraventricular conduction delay (OR, 8.16; 95% CI, 2.32–28.75) were preoperative predictors of procedural failure. The capture threshold and ventricular amplitude remained stable, and no major complications occurred throughout the 2‐year follow‐up. In patients with ventricular pacing burden >40%, the LV ejection fraction remained high regardless of LBB capture.ConclusionsSuccessful LBBAP was affected by abnormal cardiac anatomy and intraventricular conduction. LBBAP is feasible and safe as a primary strategy for patients with AVB, depending on ventricular pacing.

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Section: Definition Of Successful Lbbap and The Lbb Capturementioning

confidence: 88%

Predictors of implantation failure in left bundle branch area pacing using a lumenless lead in patients with bradycardia

Kato

Sato

Shimeno

et al. 2023

Journal of Arrhythmia

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“…46 In the recently published 2023 HRS/APHRS/ LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure, LBBP is recommended when effective CRT cannot be achieved by BVP in patients with LBBB and LVEF ≤ 35% (class 2a). 47 LBBP CRT is a promising and emerging alternative to BVP CRT with shorter procedural and fluoroscopy time and possible improved clinical outcomes. Further studies, especially randomized controlled trials, are required to demonstrate the long-term safety and efficacy of LBBP and elucidate the clinical benefit of LBBP CRT.…”

Section: Sensitivity Analysismentioning

confidence: 99%

Left bundle branch area pacing for heart failure patients requiring cardiac resynchronization therapy: A meta‐analysis

Jin,

Dai,

et al. 2023

Cardiovasc electrophysiol

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IntroductionLeft bundle branch area pacing (LBBP) is a novel conduction system pacing method to achieve effective physiological pacing and an alternative to cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) for patients with heart failure with reduced ejection fraction (HFrEF). We conduted this meta‐analysis and systemic review to review current data comparing BVP and LBBP in patients with HFrEF and indications for CRT.MethodsWe searched PubMed/Medline, Web of Science, and Cochrane Library from the inception of the database to November 2022. All studies that compared LBBP with BVP in patients with HFrEF and indications for CRT were included. Two reviewers performed study selection, data abstraction, and risk of bias assessment. We calculated risk ratios (RRs) with the Mantel–Haenszel method and mean difference (MD) with inverse variance using random effect models. We assessed heterogeneity using the I2 index, with I2 > 50% indicating significant heterogeneity.ResultsTen studies (9 observational studies and 1 randomized controlled trial; 616 patients; 15 centers) published between 2020 and 2022 were included. We observed a shorter fluoroscopy time (MD: 9.68, 95% confidence interval [CI]: 4.49–14.87, I2 = 95%, p < .01, minutes) as well as a shorter procedural time (MD 33.68, 95% CI: 17.80–49.55, I2 = 73%, p < .01, minutes) during the implantation of LBBP CRT compared to conventional BVP CRT. LBBP was shown to have a greater reduction in QRS duration (MD 25.13, 95% CI: 20.06–30.20, I2 = 51%, p < .01, milliseconds), a greater left ventricular ejection fraction improvement (MD: 5.80, 95% CI: 4.81–6.78, I2 = 0%, p < .01, percentage), and a greater left ventricular end‐diastolic diameter reduction (MD: 2.11, 95% CI: 0.12–4.10, I2 = 18%, p = .04, millimeter). There was a greater improvement in New York Heart Association function class with LBBP (MD: 0.37, 95% CI: 0.05–0.68, I2 = 61%, p = .02). LBBP was also associated with a lower risk of a composite of heart failure hospitalizations (HFH) and all‐cause mortality (RR: 0.48, 95% CI: 0.25–0.90, I2 = 0%, p = .02) driven by reduced HFH (RR: 0.39, 95% CI: 0.19–0.82, I2 = 0%, p = .01). However, all‐cause mortality rates were low in both groups (1.52% vs. 1.13%) and similar (RR: 0.98, 95% CI: 0.21–4.68, I2 = 0%, p = .87).ConclusionThis meta‐analysis of primarily nonrandomized studies suggests that LBBP is associated with a greater improvement in left ventricular systolic function and a lower rate of HFH compared to BVP. There was uniformity of these findings in all of the included studies. However, it would be premature to conclude based solely on the current meta‐analysis alone, given the limitations stated. Dedicated, well‐designed, randomized controlled trials and observational studies are needed to elucidate better the comparative long‐term efficacy and safety of LBBP CRT versus BIV CRT.

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“…Recently published 2023 Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society guidelines for cardiac physiologic pacing give a class IIb recommendation for the consideration of CSP with HisBP or LBBP as an alternative to BiVP in patients with left ventricular ejection fraction (LVEF) ≤35%, sinus rhythm, left bundle branch block (LBBB) with a QRS duration ≥150 ms, and NYHA class II-IV symptoms on guideline-directed medical therapy. 7 Furthermore, CSP is recommended if effective CRT cannot be achieved with BiVP (class IIa recommendation). 7 In patients with LVEF 36%-50% with anticipated substantial ventricular pacing, a class IIa recommendation is given for the consideration of CSP as an alternative pacing option to BiVP.…”

Section: Introductionmentioning

confidence: 99%

“…7 Furthermore, CSP is recommended if effective CRT cannot be achieved with BiVP (class IIa recommendation). 7 In patients with LVEF 36%-50% with anticipated substantial ventricular pacing, a class IIa recommendation is given for the consideration of CSP as an alternative pacing option to BiVP. 7 Similarly, latest European Society of Cardiology guidelines also give a class IIa recommendation for consideration of HisBP in CRT candidates in whom coronary sinus lead implantation is unsuccessful.…”

Section: Introductionmentioning

confidence: 99%

“…7 In patients with LVEF 36%-50% with anticipated substantial ventricular pacing, a class IIa recommendation is given for the consideration of CSP as an alternative pacing option to BiVP. 7 Similarly, latest European Society of Cardiology guidelines also give a class IIa recommendation for consideration of HisBP in CRT candidates in whom coronary sinus lead implantation is unsuccessful. 6 Observational studies and a handful of small randomized controlled trials (RCTs) to date have reported a greater improvement in surrogate endpoints such as LVEF, QRS duration, and other hemodynamic parameters with CSP as compared to BiVP.…”

Section: Introductionmentioning

confidence: 99%

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Clinical outcomes of conduction system pacing versus biventricular pacing for cardiac resynchronization therapy: A systematic review and meta‐analysis

Kim

Ellenbogen

et al. 2023

Cardiovasc electrophysiol

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IntroductionConduction system pacing (CSP) is observed to produce greater improvements in echocardiographic and hemodynamic parameters as compared to conventional biventricular pacing (BiVP). However, whether these surrogate endpoints directly translate to improvements in hard clinical outcomes such as death and heart failure hospitalization (HFH) with CSP remains uncertain as studies reporting these outcomes are scarce. The aim of this meta‐analysis was to analyze the existing data to compare the clinical outcomes of CSP versus BiVP.MethodsA systematic search of the Embase and PubMed database was performed for studies comparing CSP and BiVP for patients indicated to receive a CRT device. The coprimary endpoints were all‐cause mortality and HFH. Other secondary outcomes included change in left ventricular ejection fraction (LVEF), change in NYHA class, and increase in NYHA class ≥1. A random‐effects model was chosen a priori to analyze the composite effects given the anticipated heterogeneity of included trials.ResultsTwenty‐one studies (4 randomized and 17 observational) were identified reporting either primary outcome and were included in the meta‐analysis. In total 1960 patients were assigned to CSP and 2367 to BiVP. Median follow‐up time was 10.1 months (ranging 2–33 months). CSP was associated with a significant reduction in all‐cause mortality (odds ratio [OR] 0.68, 95% confidence interval [CI]: 0.56–0.83) and HFH (OR 0.52, 95% CI: 0.44–0.63). Mean improvement in LVEF was also greater with CSP (mean difference 4.26, 95% CI: 3.19–5.33). Reduction in NYHA class was significantly greater with CSP (mean difference −0.36, 95% CI: −0.49 to −0.22) and the number of patients with an increase in NYHA class ≥1 was significantly greater with CSP (OR 2.02, 95% CI: 1.70–2.40).ConclusionsCSP was associated with a significant reduction in all‐cause mortality and HFH when compared to conventional BiVP for CRT. Further large‐scale randomized trials are needed to verify these observations.

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2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

Cited by 205 publications

References 451 publications

Predictors of implantation failure in left bundle branch area pacing using a lumenless lead in patients with bradycardia

Predictors of implantation failure in left bundle branch area pacing using a lumenless lead in patients with bradycardia

Left bundle branch area pacing for heart failure patients requiring cardiac resynchronization therapy: A meta‐analysis

Clinical outcomes of conduction system pacing versus biventricular pacing for cardiac resynchronization therapy: A systematic review and meta‐analysis

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