His Resynchronization Versus Biventricular Pacing in Patients With Heart Failure and Left Bundle Branch Block
Key result
His resynchronization provides better ventricular resynchronization and hemodynamics than BiV pacing in HF with LBBB.
- MD -18.6 ms
- 95% CI -31.6 to -5.7
- P=0.007
- n=23
Figures
Why the study?
His bundle pacing is a new method for delivering CRT, but its comparative effects on ventricular activation and acute hemodynamic function versus conventional biventricular pacing were not established.
Does His bundle pacing improve ventricular resynchronization and acute hemodynamic function compared to biventricular pacing in patients with heart failure and left bundle branch block?
Structured PICO
Does His bundle pacing improve ventricular resynchronization and acute hemodynamic function compared to biventricular pacing in patients with heart failure and left bundle branch block?
P
Population
23 patients with heart failure and left bundle branch block referred for conventional biventricular CRT undergoing acute crossover comparison.
I
Intervention
His bundle pacing
C
Comparator
Conventional biventricular pacing
O
Outcome
Ventricular activation (QRS duration, left ventricular activation time, left ventricular dyssynchrony index) and acute hemodynamic functionsurrogate
Main Result
Mean Difference: -18.6 (95% CI -31.6–-5.7)
p-value: p=0.007
His bundle pacing provides superior acute electrical resynchronization and hemodynamic improvement compared to conventional biventricular pacing in patients with heart failure and LBBB.
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“There has been tremendous enthusiasm in His bundle pacing. It has been shown to correct QRS duration across bundle block patterns. However, the prior work has focused primarily on His corrective pacing as a bailout strategy for failed biventricular pacing, and in limited feasibility studies as first-line therapy.”
“His-CRT was not suitable as a first-line strategy in an unselected CRT population.”
“This technique using either pacing from the His bundle or more distally in the left bundle holds promise in trying to then more physiologically activate the ventricles. And there are surrogate markers such as ejection fraction that seem to be better, while we are waiting for harder clinical outcomes that will impact the patients.”
Implication
His resynchronization may improve acute synchrony and hemodynamics vs BiV pacing; leaves open long-term outcomes in HF-LBBB.
Abstract
BACKGROUND: His bundle pacing is a new method for delivering cardiac resynchronization therapy (CRT). OBJECTIVES: The authors performed a head-to-head, high-precision, acute crossover comparison between His bundle pacing and conventional biventricular CRT, measuring effects on ventricular activation and acute hemodynamic function. METHODS: Patients with heart failure and left bundle branch block referred for conventional biventricular CRT were recruited. Using noninvasive epicardial electrocardiographic imaging, the authors identified patients in whom His bundle pacing shortened left ventricular activation time. In these patients, the authors compared the hemodynamic effects of His bundle pacing against biventricular pacing using a high-multiple repeated alternation protocol to minimize the effect of noise, as well as comparing effects on ventricular activation. RESULTS: In 18 of 23 patients, left ventricular activation time was significantly shortened by His bundle pacing. Seventeen patients had a complete electromechanical dataset. In them, His bundle pacing was more effective at delivering ventricular resynchronization than biventricular pacing: greater reduction in QRS duration (-18.6 ms; 95% confidence interval [CI]: -31.6 to -5.7 ms; p = 0.007), left ventricular activation time (-26 ms; 95% CI: -41 to -21 ms; p = 0.002), and left ventricular dyssynchrony index (-11.2 ms; 95% CI: -16.8 to -5.6 ms; p < 0.001). His bundle pacing also produced a greater acute hemodynamic response (4.6 mm Hg; 95% CI: 0.2 to 9.1 mm Hg; p = 0.04). The incremental activation time reduction with His bundle pacing over biventricular pacing correlated with the incremental hemodynamic improvement with His bundle pacing over biventricular pacing (R = 0.70; p = 0.04). CONCLUSIONS: His resynchronization delivers better ventricular resynchronization, and greater improvement in hemodynamic parameters, than biventricular pacing.
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Cite This Study
Arnold et al. (2018) studied Heart failure and left bundle branch block (n=23). His bundle pacing vs. Biventricular pacing was evaluated on Reduction in QRS duration (MD -18.6 ms, 95% CI -31.6 to -5.7, p=0.007). His bundle pacing delivered better ventricular resynchronization, including a greater reduction in QRS duration (MD -18.6 ms; 95% CI -31.6 to -5.7; p=0.007), than biventricular pacing.