Three-dimensional-mapping-guided permanent conduction system pacing in paediatric patients with congenitally corrected transposition of the great arteries

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Congenitally corrected transposition of the great arteries (CCTGA) with complete or advanced atrioventricular block (n=7). Intervention: Three-dimensional-electroanatomic mapping (3D-EAM)-guided left ventricular conduction system pacing (LVCSP) vs. Baseline pre-implantation status (each patient serving as their own control; 4 with prior epicardial pacing and 3 without prior pacing). Primary outcome: Systemic right ventricular fractional area change (FAC %) and global longitudinal strain (GLS %) at 1-year follow-up (p=0.04).

Q: What does this research mean for the field?

Three-dimensional-electroanatomic mapping-guided left ventricular conduction system pacing preserves systemic right ventricular systolic function and significantly improves fractional area change and global longitudinal strain at one-year follow-up in pediatric patients with congenitally corrected transposition of the great arteries and atrioventricular block. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Massimo Stefano Silvetti; Carla Favoccia; Fabio Anselmo Saputo; Ilaria Tamburri; Chiara Mizzon; Marta Campisi; Fabrizio Gimigliano; Gabriele Rinelli; Lucilla Ravà; Fabrizio Drago

doi:10.1093/europace/euad026

February 16, 2023EP EuropaceOpen Access

Three-dimensional-mapping-guided permanent conduction system pacing in paediatric patients with congenitally corrected transposition of the great arteries

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Key result

3D-EAM-guided LV conduction system pacing is linked to ~7-point higher systemic RV fractional area change in CCTGA.

P=0.04
n=7

Figures

Graphical abstract published by EP Europace — Graphical abstract · Published by EP Europace · CC BY-NC

Why the study?

In CCTGA, permanent pacing of the subpulmonary LV may worsen systemic RV dysfunction, prompting investigation into whether 3D-EAM-guided LVCSP can preserve RV systolic function in paediatric patients with AVB.

Does 3D-electroanatomic mapping-guided left ventricular conduction system pacing preserve or improve systemic right ventricular systolic function at 1 year in paediatric patients with congenitally corrected transposition of the great arteries and atrioventricular block?

Key Points

To determine whether left ventricular conduction system pacing guided by three-dimensional electroanatomic mapping systems can preserve right ventricular systolic function in paediatric patients with congenitally corrected transposition of the great arteries and atrioventricular block.
Retrospective analysis of consecutive paediatric patients (N=7; median age 15 [9–17] years) with congenitally corrected transposition of the great arteries and complete or advanced atrioventricular block (4 with prior epicardial pacing).
Patients underwent left ventricular conduction system pacing guided by three-dimensional electroanatomic mapping (5 DDD, 2 VVIR) to target ventricular septal sites exhibiting narrower paced QRS complexes.
Electrocardiograms, lead performance parameters, and echocardiographic measures of right ventricular function (fractional area change, global longitudinal strain, and 3D ejection fraction) were evaluated pre-implantation and at 1-year follow-up.
Systemic right ventricular systolic function improved significantly at 1-year follow-up, with fractional area change increasing from 33% (30–43) to 40% (40–45) (P=0.04) and global longitudinal strain improving from -13% (-14 to -11) to -17% (-20 to -15) (P=0.03).
Right ventricular ejection fraction shifted from 48% (30–50) to 52% (50–56) (P=0.09), with all 7 patients presenting normal right ventricular ejection fraction (>45%) at 1 year.
Overall QRS duration remained stable compared with baseline (120 [80–130] ms vs. 120 [100–125] ms, P=0.9), ventricular pacing was >90%, and no acute or chronic complications occurred.

Study Design

Type

Cohort (n=7)

Multicenter

No

Structured PICO

Does 3D-electroanatomic mapping-guided left ventricular conduction system pacing preserve or improve systemic right ventricular systolic function at 1 year in paediatric patients with congenitally corrected transposition of the great arteries and atrioventricular block?

P

Population

7 paediatric patients (median age 15 years, range 2-17, 57.1% female) with congenitally corrected transposition of the great arteries and complete or advanced atrioventricular block undergoing 3D-electroanatomic mapping-guided left ventricular conduction system pacing, followed for 1 year.

E

Exposure

Permanent transvenous left ventricular conduction system pacing (LVCSP) guided by three-dimensional electroanatomic mapping (3D-EAM; EnSite Velocity/Precision) using stylet-directed active fixation bipolar screw-in leads (Medtronic 4076 or Biotronik Solia S60) implanted in the LV septum (His-bundle area, mid septum, or low septum; 5 DDD and 2 VVIR pacemakers) over 12 months.

C

Comparator

Baseline pre-implantation status (patients served as their own controls comparing pre-implantation baseline vs 12-month follow-up; subgroups of 4 pre-paced epicardial patients vs 3 non-paced patients were also compared).

O

Outcome

Systemic right ventricular (RV) systolic function evaluated by 3D echocardiographic ejection fraction (EF), fractional area change (FAC %), and speckle-tracking RV global longitudinal strain (GLS %) at 1-year (12 months) follow-up.surrogate

Main Result

Absolute Event Rate: 40% vs 33%

p-value: p=0.04

This first report of 3D-electroanatomic mapping-guided left ventricular conduction system pacing in paediatric patients with CCTGA and AV block demonstrates that the technique is feasible, safe, and preserves or improves systemic right ventricular systolic function at 1-year follow-up.

Limitations

Small number of patients (n=7)
Patient heterogeneity (mix of patients with prior epicardial pacing and without prior pacing)
Single-centre study
Retrospective analysis
Short duration of follow-up (1 year) with unknown long-term outcomes
Heterogeneity of the cohort (inclusion of both patients with prior biventricular or LV epicardial pacing and patients without prior pacing)
Single-centre study design

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Implication

May support 3D-EAM-guided LV pacing to preserve systemic RV function in paediatric CCTGA; leaves open need for randomized confirmation.

Abstract

AIMS: In congenitally corrected transposition of the great arteries (CCTGA) the right ventricle (RV) is systemic. Atrioventricular block (AVB) and systolic dysfunction are frequently observed. Permanent pacing of the subpulmonary left ventricle (LV) may worsen RV dysfunction. The aim of this study was to seek out if LV conduction system pacing (LVCSP) guided by three-dimensional-electroanatomic mapping systems (3D-EAMs) can preserve RV systolic function in paediatric CCTGA patients with AVB. METHODS AND RESULTS: Retrospective analysis of CCTGA patients who underwent 3D-EAM-guided LVCSP. Three-dimensional-pacing map guided lead implantation towards septal sites with narrower paced QRS. Electrocardiograms (ECGs), echocardiograms, and lead parameters (threshold, sensing, and impedance) were compared at baseline (pre-implantation) and at 1-year follow-up. Right ventricle function was evaluated by 3D ejection fraction (EF), fractional area change (FAC), RV global longitudinal strain (GLS). Data are reported as median (25th-75th centiles). Seven CCTGA patients aged 15 (9-17) years, with complete/advanced AVB (4 with prior epicardial pacing), underwent 3D-guided LVCSP (5 DDD, 2 VVIR). Baseline echocardiographic parameters were impaired in most patients. No acute/chronic complications occurred. Ventricular pacing was >90%. At 1-year follow-up QRS duration showed no significant changes compared with baseline; however, QRS duration shortened in comparison with prior epicardial pacing. Lead parameters remained acceptable despite ventricular threshold increased. Systemic RV function was preserved: FAC and GLS improved significantly, and all patients showed normal RV EF (>45%). CONCLUSION: Three-dimensional-EAM-guided LVCSP preserved RV systolic function in paediatric patients with CCTGA and AVB after short-term follow-up.

Discussion

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Cite This Study

Silvetti et al. (2023) conducted a cohort in Congenitally corrected transposition of the great arteries (CCTGA) with complete or advanced atrioventricular block (n=7). Three-dimensional-electroanatomic mapping (3D-EAM)-guided left ventricular conduction system pacing (LVCSP) vs. Baseline pre-implantation status (each patient serving as their own control; 4 with prior epicardial pacing and 3 without prior pacing) was evaluated on Systemic right ventricular fractional area change (FAC %) and global longitudinal strain (GLS %) at 1-year follow-up (p=0.04). 3D-EAM-guided LV conduction system pacing improved systemic RV fractional area change and global longitudinal strain at 1 year in CCTGA.

synapsesocial.com/papers/6a86eec224dcec08efbef9fd https://doi.org/10.1093/europace/euad026

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Three-dimensional-mapping-guided permanent conduction system pacing in paediatric patients with congenitally corrected transposition of the great arteries

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Three-dimensional-mapping-guided permanent conduction system pacing in paediatric patients with congenitally corrected transposition of the great arteries

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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