Key result
Biventricular endocardial pacing and left bundle branch area pacing achieved superior acute LV resynchronization (LVAT-95: ~49 ms vs 79.2 ms; P=0.001) compared to biventricular epicardial pacing.
Why the study?
BiV-endo shows superior resynchronization to BiV-epi and LBBAP may also achieve effective CRT, but their acute electrical and hemodynamic effects and the influence of myocardial scar remained unclear.
Do biventricular endocardial pacing and left bundle branch area pacing improve acute electrical and hemodynamic resynchronization compared to conventional biventricular epicardial pacing in patients with heart failure?
Do biventricular endocardial pacing and left bundle branch area pacing improve acute electrical and hemodynamic resynchronization compared to conventional biventricular epicardial pacing in patients with heart failure?
Absolute Event Rate: 48.5% vs 79.2%
p-value: p=.001
Biventricular endocardial pacing and left bundle branch area pacing provide superior acute electrical resynchronization and a higher proportion of acute hemodynamic responders compared to conventional biventricular epicardial pacing, though septal scar may attenuate the benefits of LBBAP.
May support alternative pacing in select HF patients needing acute resynchronization; leaves open long-term outcomes and requires randomized confirmation.
BACKGROUND: Biventricular endocardial pacing (BiV-endo) has demonstrated superior cardiac resynchronization compared to conventional biventricular epicardial pacing (BiV-epi). Left bundle branch area pacing (LBBAP) may also achieve effective cardiac resynchronization therapy (CRT). OBJECTIVE: The purpose of this study was to compare the acute electrical and hemodynamic effects of BiV-epi, BiV-endo, and LBBAP delivered from the LV endocardium and to assess how myocardial scar affects response. METHODS: Eleven patients with heart failure and indications for CRT underwent a temporary pacing study with electrocardiographic imaging (ECGi) and hemodynamic assessment. BiV-endo was delivered by stimulation of the left ventricular (LV) lateral wall, and LBBAP was delivered by stimulation of the LV septum, at the site of a Purkinje potential. LV activation time (LVAT-95), LV dyssynchrony index (LVDI), biventricular activation time (BIVAT-90), and biventricular dyssynchrony index (BIVDI) were calculated. Myocardial scar was assessed using magnetic resonance imaging (MRI). RESULTS: The protocol was completed in 10 patients. Compared to BiV-epi (LVAT-95: 79.2 ± 13.1 ms; LVDI: 26.6 ± 3.4 ms) LV resynchronization was superior during BiV-endo (LVAT-95: 48.5 ± 14.9 ms; P = .001; LVDI: 16.6 ± 6.4 ms; P = .002) and LBBAP (LVAT-95: 48.9 ± 12.5 ms; P = .001; LVDI: 15.3 ± 3.4 ms; P = .001). Biventricular resynchronization was similarly superior during BiV-endo and LBBAP vs BiV-epi (BIVAT-90 and BIVDI; P <.05). The rate of acute hemodynamic responders was higher during BiV-endo (90%) and LBBAP (70%) vs BiV-epi (50%). The benefits of LBBAP (but not BiV-endo) on LV resynchronization were attenuated when septal scar was present in a subset of 8 patients who underwent MRI. CONCLUSION: Our findings suggest superior electrical resynchronization and a higher proportion of acute hemodynamic responders during BiV-endo and LBBAP compared to BiV-epi. Electrical resynchronization was similar between BiV-endo and LBBAP; however, septal scar seemed to attenuate response to LBBAP.
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Elliott et al. (2022) studied Heart failure with indications for CRT (n=11). Biventricular endocardial pacing (BiV-endo) and left bundle branch area pacing (LBBAP) vs. Biventricular epicardial pacing (BiV-epi) was evaluated on LV activation time (LVAT-95) (p=.001). Biventricular endocardial pacing and left bundle branch area pacing achieved superior acute LV resynchronization (LVAT-95: ~49 ms vs 79.2 ms; P=0.001) compared to biventricular epicardial pacing.
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