A systematic review and Bayesian network meta-analysis comparing left bundle branch pacing, his bundle branch pacing, and right ventricular pacing for atrioventricular block

Abstract

BackgroundAlthough right ventricular pacing (RVP) is recommended by most of the guidelines for atrioventricular block, it can cause electrical and mechanical desynchrony, impair left ventricular function, and increase the risk of atrial fibrillation. Recently, the His–Purkinje system pacing, including His bundle pacing (HBP) and left bundle branch pacing (LBBP), has emerged as a physiological pacing modality. However, few studies have compared their efficacy and safety in atrioventricular block (AVB).Methods and results:The PubMed, Web of Science, Cochrane Library, and ScienceDirect databases were searched for observational studies and randomized trials of patients with atrioventricular block requiring permanent pacing, from database inception until 10 January 2022. The primary outcomes were complications and heart failure hospitalization. The secondary outcomes included changes in left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter (LVEDD), pacing parameters, procedure duration, and success rate. After extracting the data at baseline and the longest follow-up duration available, a pairwise meta-analysis and a Bayesian random-effects network meta-analysis were performed. Odds ratios (ORs) with 95% confidence intervals (CIs) or 95% credible intervals (CrIs) were calculated for dichotomous outcomes, whereas mean differences (MDs) with 95% CIs or 95% CrIs were calculated for continuous outcomes. Seven studies and 1,069 patients were included. Overall, 43.4% underwent LBBP, 33.5% HBP, and 23.1% RVP. Compared with RVP, LBBP and HBP were associated with a shorter paced QRS duration and a more preserved LVEF. HBP significantly increased the pacing threshold and reduced the R-wave amplitude. There was no difference in the risk of complications or the implant success rate. The pacing threshold remained stable during follow-up for the three pacing modalities. The pacing impedance was significantly reduced in HBP, while a numerical but non-significant pacing impedance decrease was observed in both LBBP and RVP. LBBP was associated with an increased R-wave amplitude during follow-up.ConclusionIn this systematic review and network meta-analysis, HBP and LBBP were superior to RVP in paced QRS duration and preservation of LVEF for patients with atrioventricular block. LBBP was associated with a lower pacing threshold and a greater R-wave amplitude than HBP. However, the stability of the pacing output of LBBP may be a concern. Further investigation of the long-term efficacy in left ventricular function and the risk of heart failure hospitalization is needed.Systematic review registration[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=315046], identifier [CRD42022315046].

Utility of a guiding catheter for conduction system pacing: An early multicenter experience

“… 2 , 3 , 17 , 18 , 25 However, many publications reported much lower HBP implant success (63%–85%), especially in patients with left bundle branch block. 10 , 12 , 15 , 26 , 27 If CSP is to play a significant role in the world of pacing, it must be applicable outside highly specialized centers. In the present study, of the 10 cases in which no CSP could be established, 8 occurred in centers that had never tried LBBAP, and 1 case occurred in a center that had never tried HBP.…”

“…At the predischarge control, LBBAP pacing threshold and sensing amplitudes were comparable to values known for conventional right ventricular pacing but were more challenging in HBP cases, confirming existing literature. 6 , 9 , 11 , 12 , 13 , 14 , 15 , 19 The fact that pacing thresholds are high enough to limit pacemaker battery life in a significant proportion of HBP cases is another reason for the preference of LBBAP by many implanters nowadays. 13 , 14 , 15 …”

“…Although the present study made no direct comparisons, it is well known that CSP shortens QRS duration compared with traditional right ventricular pacing sites, which is the main reason for the increasing use of CSP. 2 , 3 , 4 , 6 , 9 , 12 …”

“…For the sample size, an acute SADE rate of 3% was assumed and a hypothesis was set for the 7-day SADE-free rate to be >90%. 3 , 12 For a 1-sided hypothesis with an alpha of 2.5% and 90% power, a minimal sample size was 141 patients. Taking into account a dropout rate of 10%, the total calculated sample size was 157 patients.…”

“… 1 , 2 , 3 , 4 , 5 Alternatively, pacing at the bundle of His or in the left bundle branch area directly stimulates parts of the cardiac conduction system and is collectively referred to as conduction system pacing (CSP). 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 CSP is attracting increasing attention because it maintains the physiological contraction pattern and better preserves the mechanical function of the ventricles.…”