Left bundle branch area pacing prevails over His bundle pacing for heart failure patients undergoing atrioventricular node ablation in permanent atrial fibrillation: a network meta-analysis

Jingwen Ding; Yu-Ang Jiang; Qiuting Wang; Chungang Guo; Jianhui Yao; JingChen; Huaisheng Ding

doi:10.1007/s10840-025-02034-7

April 3, 2025Journal of Interventional Cardiac ElectrophysiologyOpen Access

Left bundle branch area pacing prevails over His bundle pacing for heart failure patients undergoing atrioventricular node ablation in permanent atrial fibrillation: a network meta-analysis

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Why the study?

Atrioventricular node ablation and pacemaker implantation enhance prognosis in heart failure patients with rapid ventricular response due to atrial fibrillation, but the clinical benefits of various pacing modalities following ablation needed assessment.

Do conduction system pacing modalities (LBBAP or HBP) improve QRS duration and clinical outcomes compared to conventional ventricular pacing in heart failure patients with permanent atrial fibrillation undergoing atrioventricular node ablation?

Structured PICO

Do conduction system pacing modalities (LBBAP or HBP) improve QRS duration and clinical outcomes compared to conventional ventricular pacing in heart failure patients with permanent atrial fibrillation undergoing atrioventricular node ablation?

P

Population

13 studies (6 RCTs and 7 observational studies) pooling n=1,257 patients with heart failure and permanent atrial fibrillation undergoing atrioventricular node ablation (AVNA).

I

Intervention

Conduction system pacing modalities, specifically left bundle branch area pacing (LBBAP) and His bundle pacing (HBP), following atrioventricular node ablation.

C

Comparator

Conventional ventricular pacing strategies including biventricular pacing (BVP), right ventricular pacing (RVP), and left ventricular pacing (LVP).

O

Outcome

QRS duration (electrophysiological endpoint).surrogate

In patients with heart failure and permanent atrial fibrillation undergoing AV node ablation, conduction system pacing (LBBAP and HBP) significantly narrows QRS duration and improves LVEF compared to conventional ventricular pacing, with LBBAP also demonstrating lower pacing thresholds and reduced all-cause mortality.

Limitations

Insufficient data availability for different groups hindered ability to analyze effects on NYHA class improvement.
Limited number of studies directly comparing different pacing strategies may result in inconsistencies in sub-analysis findings compared to SUCRA values.

Implication

LBBAP may warrant consideration post-AVNA in HF with permanent AF; leaves open superiority over HBP pending randomized confirmation.

Abstract

BACKGROUND: Atrioventricular node ablation (AVNA) and pacemaker implantation enhance prognosis in heart failure patients experiencing rapid ventricular response due to atrial fibrillation. This meta-analysis assessed the clinical benefits of various pacing modalities following AVNA. METHODS: The electrophysiological endpoint was defined as QRS duration, while the echocardiographic endpoint was the change in left ventricular ejection fraction. Secondary endpoints included pacing threshold, mortality rates, and improvements in the 6-min walk test. RESULTS: This meta-analysis of 13 studies involving 1257 patients suggested that His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) conferred an advantage in narrowing QRS duration compared to biventricular pacing (BVP) (HBP vs BVP OR = - 59.05, 95%CI = - 73.12 to - 44.97; LBBAP vs BVP OR = - 48.64, 95%CI = - 64.05 to - 33.24). The findings of echocardiographic endpoints suggested that LBBAP and HBP emerged as the optimal strategies over RVP (vs HBP OR = - 7.59, 95%CI = - 11.85 to - 3.32; vs LBBAP OR = - 6.58, 95%CI = - 12.08 to - 1.07). LBBAP reduced all-cause mortality compared to BVP (OR = 0.10, 95%CI = 0.01-0.78); however, no significant differences in all-cause mortality were observed between LBBAP and HBP. The pacing threshold of LBBAP was significantly lower than HBP (OR = - 0.40, 95%CI = - 0.57 to - 0.23). CONCLUSION: LBBAP not only demonstrated superior clinical outcomes regarding mortality compared to ventricular pacing strategies, but also was associated with a lower pacing threshold than HBP, thereby indicating its potential advantage over HBP in patients undergoing AVNA and subsequent pacemaker implantation.