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Conduction System Pacing vs Biventricular Pacing in Heart Failure and Wide QRS Patients
Why the study?
Does conduction system pacing improve cardiac resynchronization, ventricular reverse remodeling, and clinical outcomes in heart failure patients with wide QRS compared to biventricular pacing?
Key Points
- To evaluate the efficacy of conduction system pacing compared with conventional biventricular pacing in patients with heart failure and wide QRS duration.
- Conducted a clinical trial (LEVEL-AT; NCT04054895) evaluating left ventricular activation time shortening.
- Assessed conduction system pacing (CSP) versus traditional biventricular pacing (BiVP) in patients with heart failure and wide QRS complexes.
- Conduction system pacing achieved cardiac resynchronization and ventricular reverse remodeling to a degree equivalent to biventricular pacing.
- Clinical outcomes were comparable between both pacing groups, establishing conduction system pacing as a feasible alternative intervention.
Structured PICO
Does conduction system pacing improve cardiac resynchronization, ventricular reverse remodeling, and clinical outcomes in heart failure patients with wide QRS compared to biventricular pacing?
P
Population
Heart failure patients with wide QRS
I
Intervention
Conduction system pacing (CSP)
C
Comparator
Biventricular pacing (BiVP)
O
Outcome
Cardiac resynchronization, ventricular reverse remodeling, and clinical outcomes
Conduction system pacing is a feasible alternative to biventricular pacing in heart failure patients with wide QRS, achieving similar resynchronization and clinical outcomes.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The results of this trial show that ventricular synchronization achieved with conduction system pacing is noninferior to conventional BiV pacing among eligible patients. Conduction system pacing included His-bundle pacing but was primarily via LBB pacing. This approach appears promising and will need to be tested in future trials. There appears to be a high rate of crossover to BiV pacing; in the current trial, nearly 1 in 4-5 patients required crossover.”
VSVishal S. MehtaCardiologist, Guy's and St Thomas' NHS Foundation Trust
“Only four randomized controlled trials (RCTs) have been performed to date involving CSP: His-Sync (41 patients), His-Alternative (50 patients), LEVEL-AT (70 patients), and LBBP-RESYNC (40 patients). These are small numbers compared with MADIT CRT, which enrolled 1,820 patients alone. Nevertheless, pooled meta-analyses, including both randomized and non-randomized studies comparing CSP with BVP, have been undertaken... only four were randomized and the results suggested CSP is associated with shortened QRS duration and an improved LVEF and NYHA class. Pooling study designs in such a way is fraught with challenges in interpretation and these findings suggest cautious optimism.”
Implication
CSP serves as a viable alternative to BiVP in wide-QRS HF; extends RCT evidence for conduction system pacing.
Abstract
Similar degrees of cardiac resynchronization, ventricular reverse remodeling, and clinical outcomes were attained by CSP as compared to BiVP. CSP could be a feasible alternative to BiVP. (LEVEL-AT [Left Ventricular Activation Time Shortening With Conduction System Pacing vs Biventricular Resynchronization Therapy]; NCT04054895).
Discussion
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Cite This Study
Pujol‐López et al. (2022) studied this question.