Comparison of Pacing Performance and Clinical Outcomes Between Left Bundle Branch and His Bundle Pacing

BackgroundConduction system pacing (CSP) is increasingly utilized to prevent and correct dyssynchrony. Barriers to CSP adoption include limited training, methodologic variability, laboratory slot allocation, and few data on learning curves. We report learning curves/clinical outcomes from a single experienced electrophysiologist who was new to CSP, and share gained insights.MethodsRetrospective analysis of all patients who underwent attempted CSP implantation (2016–2023). Patient characteristics, ECGs, echocardiograms, fluoroscopy/procedure times, lead data were recorded at implant and follow‐up.ResultsCSP leads were implanted successfully in 167/191(87.4%) patients with a follow‐up of 278 ± 378 days. His‐bundle pacing (HBP = 59) and left‐bundle‐area pacing (LBAP = 108) had similar procedure/fluoroscopy times, QRS duration decreases, and ejection fraction improvements (all p > NS). Eight HBP lead revisions were required for high capture thresholds LBAP demonstrated lower pacing thresholds, higher lead impedances, and greater R‐wave amplitudes at implant and follow‐up. After 25 HBP cases, implant pacing thresholds, fluoroscopy, procedural times did not decrease. After 25 LBAP cases, there were significant decreases in all these parameters (p < 0.05). A separate analysis in LBAP patients with recorded Purkinje signals showed no differences in paced ECG characteristics between patients with pre‐ QRS Purkinje signals versus patients with Purkinje signals post‐QRS onset.ConclusionsExperienced implanters who are new to CSP can achieve steady‐state procedural/fluoroscopy times after a learning curve of 25 implants. LBAP showed lower capture thresholds and higher success rates. Adequate depth of lead deployment (as determined by published parameters) does not require Purkinje potential to be pre‐QRS. Operators new to CSP.can forego HBP and directly implement LBAP.

Section: Discussioncontrasting

confidence: 72%

Single operator experience, learning curve, outcomes, and insights gained with conduction system pacing

Marion,

Schanz,

Patel

et al. 2024

“…Of the 10 studies, 727 patients undergoing HBP were compared to 869 patients undergoing LBBaP with follow-up durations between 3 and 26 months. [11][12][13][14][15][16][17][18][19][20] The characteristics of the studies are summarized in Table 1.…”

Section: Resultsmentioning

confidence: 99%

“…However, the studies included in this analysis reported small number of patients. Our analysis included a significantly larger cohort of patients and newer studies with longer follow‐up period 17–20 . In addition, our study reports data on lead revision that has not been previously reported.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of left bundle branch area pacing compared to His bundle pacing as a primary pacing strategy: Systematic review and meta‐analysis

Abdin,

Werner,

Burri

et al. 2023

BackgroundNovel pacing technologies, such as His bundle pacing (HBP) and left bundle branch area pacing (LBBaP), have emerged to maintain physiological ventricular activation. We investigated the outcomes of LBBP with HBP for patients requiring a de novo permanent pacing.Methods and ResultsSystematic review of randomized clinical trials and observational studies comparing LBBaP with HBP until March 01, 2023 was performed. Random and fixed effects meta‐analyses of the effect of pacing technology on outcomes were performed. Study outcomes included pacing metrics, QRS duration, lead revision, procedure parameters, all‐cause mortality and heart failure hospitalization (HFH). Overall, 10 studies with 1596 patients were included. Implant success rate was higher in LBBaP compared with HBP (RR 1.24, 95% CI: 1.08 to 1.42, p = .002). LBBaP was associated with lower capture threshold at implantation (mean difference (MD) −0.62 V, 95% CI: −0.74 to −0.51 V, p < .0001) and at follow‐up (MD −0.74 V, 95% CI: −0.96 to −0.53, p < .0001), shorter procedure duration (MD −14.66 min, 95% CI: −23.54 to −5.78, p = .001) and shorter fluoroscopy time (MD −4.2 min, 95% CI: −8.4 to −0.0, p = .05). Compared with HBP, LBBaP was associated with a decreased risk of all‐cause mortality (RR: 0.50, 95% CI: 0.33 to 0.77, p = .002) and HFH (RR: 0.57, 95% CI: 0.33 to 1.00, p = .05). No statistical differences were found in lead revisions and QRS duration before and after pacing.ConclusionThis meta‐analysis found that LBBaP was superior to HBP regarding pacing metrics and implant success rate as an initial pacing strategy, although absence of head‐to‐head randomized comparison warrants caution in interpretation of the results.

“…However, the QRSd was wider in the LBBAP group compared to the HBP group (99.7 ± 15.6 ms, p < .0001) and remained stable (118.4 ± 11.3 ms) over a mean follow‐up period of 4.5 months 15 . Conversely, Tan et al 22 . reported that mean QRSd was similar between HBP and LBBAP groups both before and after implantation, with a relatively longer follow‐up period (median follow‐up was 791 days for participants in the HBP group and 256 days for those in the LBBAP group).…”

Section: Clinical Outcomesmentioning

confidence: 88%

“…and remained stable (118.4 ± 11.3 ms) over a mean follow-up period of 4.5 months. 15 Conversely, Tan et al 22 reported that mean QRSd was similar between HBP and LBBAP groups both before and after implantation, with a relatively longer follow-up period (median follow-up was 791 days for participants in the HBP group and 256 days for those in the LBBAP group). Several studies have reported that LBBAP maintains ventricular electrical synchrony at a level close to intrinsic (narrow QRS) rhythm due to the activation of His-Purkinje system.…”

Section: Qrs Durationmentioning

confidence: 96%

Clinical outcomes of left bundle branch area pacing: Prognosis and specific applications

Yang,

Liang,

Chen

et al. 2023

Cardiac pacing has become a widely accepted treatment strategy for bradyarrhythmia and heart failure. However, conventional right ventricular pacing (RVP) has been associated with electrical dyssynchrony, which may result in atrial fibrillation and heart failure. To achieve physiological pacing, Deshmukh et al. reported the first case of His bundle pacing (HBP) in 2000. This strategy was reported to have preserved ventricular synchronization by activating the conventional conduction system. Nonetheless, due to the anatomical location of the His bundle (HB), several issues such as high pacing thresholds, lead fixation, and early battery depletion may pose a challenge. Recently, left bundle branch area pacing (LBBAP) has emerged as a novel physiological pacing strategy to achieve conduction system pacing by capturing the left bundle branch through the deep septum. Additionally, several studies have investigated the clinical outcomes of LBBAP. In this paper, we describe the pacing parameters, QRS duration (QRSd), cardiac function, complications, and specific applications of LBBAP in recent years.