Electrocardiographic imaging of His bundle, left bundle branch, epicardial, and endocardial left ventricular pacing to achieve cardiac resynchronization therapy

Elliott, Mark K.; Mehta, Vishal; Sidhu, Baldeep S.; Niederer, Steven; Rinaldi, Christopher A.

doi:10.1016/j.hrcr.2020.04.012

Cited by 11 publications

(7 citation statements)

References 15 publications

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“…Other techniques, such as noninvasive electrocardiographic mapping or invasive activation mapping, provide more accurate results but are more difficult to use intraoperatively. Nevertheless, reports using the latter techniques support our findings that LBBAP leads to rapid and synchronous ventricular activation [ 21 ].…”

Section: Discussionsupporting

confidence: 81%

Comparison of Depolarization and Repolarization Parameters in Left vs. Right Ventricular Septal Pacing—An Intraprocedural Electrocardiographic Study

Pestrea

Cicala

Ivascu

et al. 2023

JCDD

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Compared with conventional right ventricular septal pacing (RVSP), several studies have shown a net clinical benefit of left bundle branch area pacing (LBBAP) in terms of ejection fraction preservation and reduced hospitalizations for heart failure. The purpose of this study was to compare acute depolarization and repolarization electrocardiographic parameters between LBBAP and RVSP in the same patients during the LBBAP implant procedure. We prospectively included 74 consecutive patients subjected to LBBAP from 1 January to 31 December 2021 at our institution in the study. After the lead was placed deep into the ventricular septum, unipolar pacing was performed and 12-lead ECGs were recorded from the distal (LBBAP) and proximal (RVSP) electrodes. QRS duration (QRSd), left ventricular activation time (LVAT), right ventricular activation time (RVAT), QT and JT intervals, QT dispersion (QTd), T-wave peak-to-end interval (Tpe), and Tpe/QT were measured for both instances. The final LBBAP threshold was a 0.7 ± 0.31 V at 0.4 ms duration with a sensing threshold of 10.7 ± 4.1 mV. RVSP produced a significantly larger QRS complex than the baseline QRS (194.88 ± 17.29 ms vs. 141.89 ± 35.41 ms, p < 0.001), while LBBAP did not significantly change the mean QRSd (148.10 ± 11.52 ms vs. 141.89 ± 35.41 ms, p = 0.135). LVAT (67.63 ± 8.79 ms vs. 95.89 ± 12.02 ms, p < 0.001) and RVAT (80.54 ± 10.94 ms vs. 98.99 ± 13.80 ms, p < 0.001) were significantly shorter with LBBAP than with RVSP. Moreover, all the repolarization parameters studied were significantly shorter in LBBAP than in RVSP (QT—425.95 ± 47.54 vs. 487.30 ± 52.32; JT—281.85 ± 53.66 vs. 297.69 ± 59.02; QTd—41.62 ± 20.07 vs. 58.38 ± 24.44; Tpe—67.03 ± 11.19 vs. 80.27 ± 10.72; and Tpe/QT—0.158 ± 0.028 vs. 0.165 ± 0.021, p < 0.05 for all), irrespective of the baseline QRS morphology. LBBAP was associated with significantly better acute depolarization and repolarization electrocardiographic parameters compared with RVSP.

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Section: Discussionsupporting

confidence: 81%

Comparison of Depolarization and Repolarization Parameters in Left vs. Right Ventricular Septal Pacing—An Intraprocedural Electrocardiographic Study

Pestrea

Cicala

Ivascu

et al. 2023

JCDD

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“…Previous studies with epicardial activation mapping indicated that electrical dyssynchrony remained despite the use of BVP, suggesting that activation time and pattern could not be corrected to a physiological level by BVP delivered CRT ( 21 ). Among new strategies of conduction system pacing, although LBBAP could not achieve normal physiological activation maintained via the right bundle as HBP ( 22 , 23 ), compared with BVP, LBBAP is associated with a significantly further decreased QRSd of −29.2 ms, as evidenced in our meta-analysis. In this meta-analysis, greater improvement of LVEF was achieved by LBBAP delivered CRT compared with BVP delivered CRT, which is paralleled with the more remarkable shortened QRSd in patients after LBBAP delivered CRT.…”

Section: Discussionmentioning

confidence: 58%

Left Bundle Branch Area Pacing vs. Biventricular Pacing for Cardiac Resynchronization Therapy: A Meta-Analysis

Liu

Sun

Wang

et al. 2021

Front. Cardiovasc. Med.

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Background: Left bundle branch area pacing (LBBAP) is a recently proposed method for conduction system pacing. We performed a meta-analysis of controlled studies to compare the clinical outcome in patients who received LBBAP vs. biventricular pacing (BVP) for cardiac resynchronization therapy (CRT).Methods: PubMed, Embase, and Cochrane's Library databases were searched for relevant controlled studies. A random-effect model incorporating the potential heterogeneity was used to synthesize the results.Results: Four non-randomized controlled studies including 249 patients with heart failure (HF) for CRT were included, and the patients were followed for 6–12 months. Compared with BVP, LBBAP was associated with significantly shortened QRS duration [mean difference (MD): −29.18 ms, 95% confidence interval (CI): −33.55–24.80, I2 = 0%, P < 0.001], improved left ventricular ejection fraction (MD: 6.93%, 95% CI: 4.69–9.17, I2 = 0%, P < 0.001), reduced left ventricular end-diastolic dimension (MD: −2.96 mm, 95% CI: −5.48 to −0.44, I2 = 0%, P = 0.02), and improved New York Heart Association class (MD: −0.54, 95% CI: −0.84 to −0.24, I2 = 65%, P < 0.001). Moreover, patients who received LBBAP were more likely to achieve echocardiographic [odds ratio (OR): 5.04, 95% CI: 2.17–11.69, I2 = 0%, P < 0.001] and clinical (OR: 7.33, 95% CI: 1.62–33.16, I2 = 0%, P = 0.01) CRT responses.Conclusion: Current evidence from non-randomized studies suggests that LBBAP appears to be a promising method for CRT, which is associated with more remarkable improvements of symptoms and cardiac function in HF patients with indication for CRT.

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“…Questions remain regarding several areas of leadless LBBAP related to efficacy and patient selection, which will determine its eventual utility amongst all available CRT modalities. Initially, EAM studies are needed to determine whether LV septal WiSE-CRT implantation targeting the LBP achieves conduction system capture, as is postulated by current limited data ( Elliott et al, 2020 ; Elliott et al, 2021 ). Such studies would also address pertinent questions in the field of CSP regarding potential dyssynchrony.…”

Section: Discussion: Limitations Unanswered Questions and Future Dire...mentioning

confidence: 99%

“…The WISE-CRT electrode was not specifically designed to ensure sufficient LV endocardial penetration of the 3.6 mm tines to capture septal Purkinje tissue. However, whilst LBBAP from an RV approach requires approximately 11–18 mm of septal penetration, it is likely that only superficial penetration is needed from an LV approach, given the close proximity of the LBB to the endocardial surface ( Vijayaraman et al, 2019 ; Elliott et al, 2020 ; Elliott et al, 2021 ). demonstrated using electrocardiographic imaging (ECGi) that temporary LV endocardial pacing at the LBP site resulted in improved dyssynchrony metrics compared to conventional CRT, and similar results to HBP and BiV endocardial pacing from the RV and lateral LV.…”

Section: Assessing the Potential Efficacy Of Leadless Lbbapmentioning

confidence: 99%

Leadless Left Bundle Branch Area Pacing in Cardiac Resynchronisation Therapy: Advances, Challenges and Future Directions

et al. 2022

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Leadless left bundle branch area pacing (LBBAP) represents the merger of two rapidly progressing areas in the field of cardiac resynchronisation therapy (CRT). It combines the attractive concepts of pacing the native conduction system to allow more physiological activation of the myocardium than conventional biventricular pacing, with the potential added benefits of avoiding long-term complications associated with transvenous leads via leadless left ventricular endocardial pacing. This perspective article will first review the evidence for the efficacy of leadless pacing in CRT. We then summarise the procedural steps and pilot data for leadless LBBAP, followed by a discussion of the safety and efficacy of this novel technique. Finally, we will examine how further mechanistic evidence may shed light to which patients may benefit most from leadless LBBAP, and how improvements in current experience and technology could promote widespread uptake and expand current clinical indications.

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Electrocardiographic imaging of His bundle, left bundle branch, epicardial, and endocardial left ventricular pacing to achieve cardiac resynchronization therapy

Cited by 11 publications

References 15 publications

Comparison of Depolarization and Repolarization Parameters in Left vs. Right Ventricular Septal Pacing—An Intraprocedural Electrocardiographic Study

Comparison of Depolarization and Repolarization Parameters in Left vs. Right Ventricular Septal Pacing—An Intraprocedural Electrocardiographic Study

Left Bundle Branch Area Pacing vs. Biventricular Pacing for Cardiac Resynchronization Therapy: A Meta-Analysis

Leadless Left Bundle Branch Area Pacing in Cardiac Resynchronisation Therapy: Advances, Challenges and Future Directions

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