AV‐optimized conduction system pacing for treatment of AV dromotropathy: A randomized, cross‐over study

Abstract Background Severe first‐degree atrioventricular (AV) block may produce symptoms similar to heart failure due to AV dyssynchrony, a syndrome termed AV dromotropathy. According to guidelines, it should be considered for permanent pacemaker implantation, yet evidence supporting this treatment is scarce. Objectives This study aimed to determine the impact of AV‐optimized conduction system pacing (CSP) in patients with symptomatic severe first‐degree AV block and echocardiographic signs of AV dyssynchrony. Methods Patients with symptomatic first‐degree AV block (PR > 250 ms), preserved left ventricular ejection fraction, narrow QRS, and AV dyssynchrony were included in the study. In a single‐blind cross‐over design, patients were randomized to AV sequential CSP or backup VVI pacing with a base rate of 40 bpm. We compared exercise capacity, echocardiographic parameters, and symptom occurrence at the end of 3 months of each period. Results Fourteen patients completed the study. During the AV‐optimized CSP compared to the backup pacing period, patients achieved a higher workload on exercise test (147.2 ± 50.9 vs. 140.7 ± 55.8 W; p = .032), with a trend towards higher peak VO2 (23.3 ± 7.1 vs. 22.8 ± 7.1 mL/min/kg; p = .224), and higher left ventricular stroke volume (LVSV 74.5 ± 13.8 vs. 66.4 ± 12.5 mL; p < .001). Symptomatic improvement was recorded, with fewer patients reporting general tiredness and 71% of patients preferring the AV‐optimized CSP ( p = .008). Conclusions AV‐optimized CSP could improve symptoms, exercise capacity and LVSV in patients with severe first‐degree AV block.