Clinical impact of left bundle branch area pacing in heart failure with preserved ejection fraction and mid‐range ejection fraction

Okubo, Yousaku; Miyamoto, Shoko; Uotani, Yukimi; Ikeuchi, Yoshihiro; Miyauchi, Shunsuke; Okamura, Sho; Tokuyama, Takehito; Nakano, Yukiko

doi:10.1111/pace.14470

Cited by 9 publications

(4 citation statements)

References 41 publications

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“…The improvement in interventricular synchrony by EKG findings (QRSd) and clinical outcomes we had observed may not be limited to HFrEF patients but to patients with heart failure with preserved ejection fraction (HFpEF) and heart failure with midrange ejection fraction (HFmrEF), as one recent study suggests 27 . Echocardiographic parameters of interventricular synchrony assessment including interventricular mechanical delay (defined as difference between the pre-ejection intervals from QRS onset to the beginning of ventricular ejection at pulmonary and aortic valve level), the regional time intervals of left ventricular 12 segments between the onset of the QRS complex and the peak of systolic myocardial velocity during the ejection phase (Ts), standard deviation of Ts (Ts-SD) and peak strain dispersion had greater improvement with LBBP compared to BVP but they were only studied in two of included studies 34,35 .…”

Section: Discussionmentioning

confidence: 86%

“…Since the introduction of LBBP, multiple studies have explored the feasibility, safety, and clinical comparison of other existing pacing methods in various indications including heart failure requiring CRT [23][24][25][26][27][28][29][30] . A previous study had shown LBBP, if optimized AV delay, can achieve better interventricular synchrony compared to BVP in ex-vivo heart models 18 .…”

Section: Discussionmentioning

confidence: 99%

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

Jin

Dai

et al. 2023

Preprint

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Background: Left bundle area branch 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 and reduced ejection fraction (HFrEF). Objective: To review current data comparing BVP and LBBP in patients with HFrEF and indication CRT. Methods: We 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 of CRT were included. Two reviewers performed the study selection, data abstraction, and risk of bias assessment. We calculated risk ratios with the Mantel-Haenszel method and mean difference with inverse variance using random effect models. We assessed heterogeneity using the I index, with I > 50% indicating significant heterogeneity. Results: Ten 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 [mean difference (MD) 9.68, 95% CI 4.49-14.87, I =95%, P<0.01, minutes] as well as a shorter procedure time (MD 33.68, 95% CI 17.80-49.55, I =73%, P<0.01, minutes) during implantation of LBBP CRT compared to conventional BVP CRT. LBBP was shown to have a greater reduction in QRSd (MD 25.13, 95%CI 20.06-30.20, I = 51%, P<0.01, milliseconds) a greater left ventricular ejection fraction (LVEF) improvement (MD 5.80, 95% CI 4.81-6.78, I =0%, P<0.01, percentage) and a greater ventricular end-diastolic diameter (LVEDD) reduction (MD 2.11, 95% CI 0.12-4.10, I =18%, P=0.04, millimeter). There was a greater improvement in New York Heart Association function (NYHA) class with LBBP (MD 0.37, 95% CI 0.05-0.68, I =61%, P=0.02).LBBP was also associated with a lower risk of a composite of heart failure hospitalizations and all-cause mortality [Risk ratio (RR) 0.48, 95% CI 0.25-0.90, I =0%, p=0.02] driven by reduced heart failure hospitalizations (RR 0.39, 95% CI 0.19-0.82, I =0%, p=0.01). 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, I =0%, p=0.87). Conclusion: Compared to BVP, LBBP is associated with, a greater improvement in LV systolic function, and a lower rate of heart failure-related hospitalization. Dedicated randomized controlled trials and larger patient populations are needed to further elucidate the long-term safety and efficacy of LBBP CRT.

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Section: Discussionmentioning

confidence: 86%

Section: Discussionmentioning

confidence: 99%

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

Jin

Dai

et al. 2023

Preprint

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show abstract

“…Since the introduction of LBBP, multiple studies have explored the feasibility, safety, and clinical comparison of other existing pacing methods in various indications, including heart failure requiring CRT 33–40 . A previous study had shown that LBBP, with optimized atrioventricular delay, can achieve better interventricular synchrony compared to BVP in ex vivo heart models 18 .…”

Section: Discussionmentioning

confidence: 99%

“…41 Our findings were also consistent with recently published LBBP The improvement in interventricular synchrony by EKG findings (QRSd) and clinical outcomes we had observed may not be limited to HFrEF patients but to patients with heart failure with preserved ejection fraction (HFpEF) and heart failure with midrange ejection fraction (HFmrEF), as one recent study suggests. 37 Compared to BVP, LBBP also had greater improvement in echocardiographic parameters of interventricular synchrony assessment, including (1) interventricular mechanical delay (defined as the difference between the pre-ejection intervals from QRS onset to the beginning of ventricular ejection at the pulmonary and aortic valve level), (2) the regional time intervals of left ventricular 12 segments from QRS onset to the peak systolic myocardial velocity during the ejection phase (Ts), (3) the standard deviation of Ts, and (4) peak strain. 28,44 Despite a greater hemodynamic improvement and a lower HFH rate with LBBP, we did not observe a clear benefit in all-cause mortality compared with BVP 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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Mid-term clinical outcomes of left bundle branch area pacing compared to accurate right ventricular septal pacing

Okubo,

Sakai,

Miyamoto

et al. 2024

J Interv Card Electrophysiol

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Background Although left bundle branch area pacing (LBBAP) reportedly results in fewer adverse outcomes after implantation than conventional stylet-guided right ventricular septal pacing (RVSP), previous studies have not compared LBBAP with accurate RVSP using a delivery catheter. The aim of this study was to compare clinical outcomes between LBBAP and accurate RVSP among patients with atrioventricular block (AVB). Methods This single-center observational study enrolled 160 patients requiring RV pacing due to symptomatic AVB between September 2018 and December 2021. Primary composite outcomes included all-cause death, hospitalization due to heart failure (HF), and upgrading to biventricular pacing. Secondary composite outcomes included any procedural and postprocedural complications. Results Overall, 160 patients were analyzed (LBBAP, n = 81; RVSP, n = 79). No significant differences in baseline characteristics were observed between the two groups. The RV pacing burden at 1 year after implantation was 90.8% ± 20.4% and 86.2% ± 22.6%, respectively (p = 0.21). During a mean follow-up of 840 ± 369 days, the incidence of the primary outcome was significantly lower with LBBAP (4.9%) compared to RVSP (22.8%) (Log-rank p = 0.02). There was no significant difference in the incidence of the secondary outcome between the two groups (3.7% vs. 5.1%, p = 0.65). In the multivariate analysis, baseline QRS duration, RV pacing burden, and LBBAP were independently associated with the primary outcome (baseline QRS duration: hazard ratio [HR], 1.01; 95% confidence interval [CI], 1.00–1.02; p < 0.001; RV pacing burden: HR, 1.01; 95% CI, 1.00–1.02; p < 0.001; LBBAP: HR, 0.45; 95% CI, 0.31–0.64; p < 0.001). Conclusion In patients requiring frequent RV pacing, LBBAP was associated with reduced adverse clinical outcome compared to accurate RVSP using a delivery catheter. Graphical Abstract

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Clinical impact of left bundle branch area pacing in heart failure with preserved ejection fraction and mid‐range ejection fraction

Cited by 9 publications

References 41 publications

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

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

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

Mid-term clinical outcomes of left bundle branch area pacing compared to accurate right ventricular septal pacing

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