Comparison between conduction system pacing and cardiac resynchronization therapy in right bundle branch block patients
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Key result
In simulated heart failure models with right bundle branch block, His bundle pacing significantly shortened biventricular activation time compared to baseline (42.6 vs 66.9 ms, p<0.01), whereas standard CRT was ineffective.
Why the study?
Many RBBB patients receive CRT despite lacking evidence of benefit, and the effects of HBP and LBP on RBBB remain understudied.
Does His bundle pacing or left bundle pacing improve electrical synchrony compared to standard CRT in simulated right bundle branch block?
Structured PICO
Does His bundle pacing or left bundle pacing improve electrical synchrony compared to standard CRT in simulated right bundle branch block?
P
Population
24 computational four-chamber heart models derived from heart failure patients (mean age 67, 4.2% female) with simulated right bundle branch block and various conduction disturbances.
I
Intervention
His bundle pacing (HBP) and left bundle pacing (LBP) (selective, non-selective, and with/without RV septum anodal capture) simulated in an Eikonal electrophysiology model.
C
Comparator
Baseline (unpaced RBBB) and standard cardiac resynchronization therapy (CRT) (simulated by stimulating the RV at the apex and the LV at the latest activated region in the LV epicardium, with RV-LV delay set to 0 ms).
O
Outcome
Electrical synchrony measured by the shortest interval to activate 90% of the ventricles (BIVAT-90).surrogate
Main Result
Absolute Event Rate: 42.6% vs 66.9%
p-value: p=<0.01
In computational models of RBBB, His bundle pacing effectively improves electrical synchrony, whereas standard CRT and left bundle pacing are largely ineffective unless LBP is combined with RV septum anodal capture.
Limitations
- Assumes acute electrical response implies long-term benefits.
- Does not account for mechanical synchrony induced by pacing.
- Assumes perfect correction of RBBB through selective capture during HBP, which may overestimate electrical synchrony.
- Models include synthetically generated His-Purkinje systems that did not replicate the conduction system of a specific patient.
- Only simulated ventricular activation times without propagation of the electrical activation in the torso, so no simulated surface ECGs were provided.
Authors
Discussion
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Implication
HBP may improve modeled synchrony in RBBB; hypothesis-generating and leaves clinical translation versus CRT open.
Cite This Study
Strocchi et al. (2022) studied Heart failure with right bundle branch block (n=24). His bundle pacing vs. Baseline (unpaced) was evaluated on 90% of biventricular activation time (BIVAT-90) (p=<0.01). In simulated heart failure models with right bundle branch block, His bundle pacing significantly shortened biventricular activation time compared to baseline (42.6 vs 66.9 ms, p<0.01), whereas standard CRT was ineffective.
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