Key result
Conduction system pacing reduced the composite of death or heart failure hospitalization compared to biventricular pacing.
Why the study?
Although conduction system pacing is a safe and physiologic alternative to biventricular pacing, comparative clinical outcome data in patients with LVEF <50% undergoing CRT were needed.
Does conduction system pacing reduce the composite of death or heart failure hospitalization compared to biventricular pacing in patients with LVEF <50% requiring cardiac resynchronization therapy?
Observational (n=2,956)
Yes
Does conduction system pacing reduce the composite of death or heart failure hospitalization compared to biventricular pacing in patients with LVEF <50% requiring cardiac resynchronization therapy?
Conduction system pacing is associated with a significantly lower risk of death or heart failure hospitalization compared to traditional biventricular pacing in patients with LVEF <50% requiring CRT.
Answers are grounded in this paper and cite their sources.
CSP associated with lower events in large observational cohort; supports consensus on physiologic pacing but leaves open need for RCTs.
Introduction Cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) is a guideline-recommended therapy in patients with mid-range (LVEF 36-50%) and severely reduced left ventricular ejection fraction (LVEF ≤35%), heart failure and wide QRS or indication for pacing. Conduction system pacing (CSP) utilizing left bundle branch area pacing (LBBAP) or His bundle pacing (HBP) has been shown to be a safe and physiologic alternative to BVP. The aim of this study was to compare the clinical outcomes between BVP and CSP among patients with LVEF<50% undergoing CRT. Methods This observational registry included consecutive patients who underwent BVP or CSP in patients with LVEF<50% between Jan 2018 to June 2023 at 18 international centers. Patient demographics, echocardiographic outcomes, heart failure hospitalization (HFH), mortality and lead complications were assessed. The primary outcome was the composite endpoint of time to death or HFH. Secondary endpoints included individual endpoints of death and HFH. Results A total of 2956 patients met inclusion criteria: BVP 1118, CSP 1838 (HBP 377; LBBAP 1461). Mean age was 71±13 yrs, female 32%, HTN 67%, DM 38%, CAD 38%, LBBB 49%, QRSd 154±30 and LVEF 32±9%. Paced QRSd in CSP was significantly narrower compared to BVP (129±20 vs 143±22, p<0.001). LVEF improved during f/u in both groups. On multivariate analysis, CSP was associated with significant reduction in the primary endpoint of time to death or HFH compared to BVP (23.5% vs 29.5%; HR 0.83; 95%CI 0.0.72-0.96; p=0.017) (Figure). Secondary outcomes of time to HFH was significantly reduced with CSP compared to BVP (13.9% vs 20.8%; HR 0.69; 95%CI 0.57-0.83; p<0.001) while there was no difference in mortality. Conclusions CSP was associated with better clinical outcomes compared to BVP in patients with LVEF<50% requiring CRT. Our findings support the hypothesis that targeting the conduction system may result in superior electrical resynchronization leading to better clinical outcomes.
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Vijayaraman et al. (2025) conducted an observational in Heart failure with LVEF <50% requiring cardiac resynchronization therapy (n=2,956). Conduction system pacing vs. Biventricular pacing was evaluated on Composite of time to death or heart failure hospitalization (HR 0.83, 95% CI 0.72-0.96, p=0.017). Conduction system pacing reduced the composite of death or heart failure hospitalization compared to biventricular pacing.
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