AIMS: Permanent transseptal left bundle branch area pacing (LBBAP) is a promising new pacing method for both bradyarrhythmia and heart failure indications. However, data regarding safety, feasibility and capture type are limited to relatively small, usually single centre studies. In this large multicentre international collaboration, outcomes of LBBAP were evaluated. METHODS AND RESULTS: This is a registry-based observational study that included patients in whom LBBAP device implantation was attempted at 14 European centres, for any indication. The study comprised 2533 patients (mean age 73.9 years, female 57.6%, heart failure 27.5%). LBBAP lead implantation success rate for bradyarrhythmia and heart failure indications was 92.4% and 82.2%, respectively. The learning curve was steepest for the initial 110 cases and plateaued after 250 cases. Independent predictors of LBBAP lead implantation failure were heart failure, broad baseline QRS and left ventricular end-diastolic diameter. The predominant LBBAP capture type was left bundle fascicular capture (69.5%), followed by left ventricular septal capture (21.5%) and proximal left bundle branch capture (9%). Capture threshold (0.77 V) and sensing (10.6 mV) were stable during mean follow-up of 6.4 months. The complication rate was 11.7%. Complications specific to the ventricular transseptal route of the pacing lead occurred in 209 patients (8.3%). CONCLUSIONS: LBBAP is feasible as a primary pacing technique for both bradyarrhythmia and heart failure indications. Success rate in heart failure patients and safety need to be improved. For wider use of LBBAP, randomized trials are necessary to assess clinical outcomes.
- MeSH
- Bundle-Branch Block therapy etiology MeSH
- Bradycardia therapy etiology MeSH
- Electrocardiography methods MeSH
- Bundle of His * MeSH
- Cardiac Pacing, Artificial adverse effects methods MeSH
- Humans MeSH
- Aged MeSH
- Heart Failure * MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
- Observational Study MeSH
BACKGROUND: Nonselective His-bundle pacing (nsHBp), nonselective left bundle branch pacing (nsLBBp), and left ventricular septal myocardial pacing (LVSP) are recognized as physiological pacing techniques. OBJECTIVE: The purpose of this study was to compare differences in ventricular depolarization between these techniques using ultra-high-frequency electrocardiography (UHF-ECG). METHODS: In patients with bradycardia, nsHBp, nsLBBp (confirmed concomitant left bundle branch [LBB] and myocardial capture), and LVSP (pacing in left ventricular [LV] septal position without proven LBB capture) were performed. Timings of ventricular activations in precordial leads were displayed using UHF-ECG, and electrical dyssynchrony (e-DYS) was calculated as the difference between the first and last activation. Duration of local depolarization (Vd) was determined as width of the UHF-QRS complex at 50% of its amplitude. RESULTS: In 68 patients, data were collected during nsLBBp (35), LVSP (96), and nsHBp (55). nsLBBp resulted in larger e-DYS than did LVSP and nsHBp [- 24 ms (-28;-19) vs -12 ms (-16;-9) vs 10 ms (7;14), respectively; P <.001]. nsLBBp produced similar values of Vd in leads V5-V8 (36-43 ms vs 38-43 ms; P = NS in all leads) but longer Vd in leads V1-V4 (47-59 ms vs 41-44 ms; P <.05) as nsHBp. LVSP caused prolonged Vd in leads V1-V8 compared to nsHBp and longer Vd in leads V5-V8 compared to nsLBBp (44-51 ms vs 36-43 ms; P <.05) regardless of R-wave peak time in lead V5 or QRS morphology in lead V1 present during LVSP. CONCLUSION: nslbbp preserves physiological LV depolarization but increases interventricular electrical dyssynchrony. LV lateral wall depolarization during LVSP is prolonged, but interventricular synchrony is preserved.
- MeSH
- Bundle-Branch Block physiopathology therapy MeSH
- Electrocardiography methods MeSH
- Ventricular Function, Left physiology MeSH
- Bundle of His physiopathology MeSH
- Cardiac Pacing, Artificial methods MeSH
- Humans MeSH
- Ventricular Septum physiopathology MeSH
- Follow-Up Studies MeSH
- Prospective Studies MeSH
- Aged MeSH
- Heart Ventricles physiopathology MeSH
- Check Tag
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Research Support, Non-U.S. Gov't MeSH
- Comparative Study MeSH
Souhrn: Stimulace oblasti levého Tawarova raménka (LBBAP) je nový způsob stimulace u nemocných s bradykardií či indikací k resynchronizační terapii (CRT). Údajů o peroperačních a pooperačních výsledcích této metody je nedostatek. Metody: Do registru byli zařazeni všichni nemocní s bradykardií nebo indikací k CRT, u kterých byla v období 11/2018-5/2021 v průběhu operačního zákroku prováděna LBBAP v Kardiocentru FNKV a 3. LF UK. Většina pacientů byla do registru zařazena prospektivně a vybrané ukazatele byly doplňovány retrospektivně. Ke shromáždění základních klinických, peroperačních a pooperačních ukazatelů byly použity údaje z elektronického nemocničního infomačního systému a elektrofyziologického zařízení používaného v průběhu operačních zákroků. Výsledky: LBBAP byla prováděna u 329 pacientů, z toho se jednalo o 237 nemocných s bradykardií a 92 nemocných se CRT indikací. Stimulační prahy k dosažení LBBAP byly průměrně 0,6 ± 0,5V na 0,5 ms a při průměrné délce sledování 5 ± 5 měsíců byly stabilní (0,7 ± 0,3V na 0,4 ms). Komplikace byly pozorovány u 26 pacientů (8 %), z toho se u 15 z nich jednalo o komplikace specifické pro LBBAP (12× peroperační penetrace elektrody do dutiny LKS, 1× bolest na hrudi a 1× bolest na hrudi s elevacemi ST úseků po fixaci elektrody), které však odezněly bez následků ještě v průběhu zákroku. Celková úspěšnost LBBAP byla 89 % a byla signifikantně vyšší u pacientů s bradykardií, než u pacientů se CRT indikací (92 % vs. 83 %, p = 0,02). Byl pozorován významný vliv počtu provedených zákroků na úspěšnost LBBAP a výskyt některých komplikací. Závěr: LBBAP je možnou alternativou trvalé kardiostimulace u pacientů s bradykardií a indikací k CRT. Vyskytují se u ní některé specifické komplikace, jejichž význam je potřeba posoudit v kontextu benefitu metody v randomizovaných studiích.
Summary: Left bundle branch area pacing (LBBAP) is a new method of pacing in patients who have bradycardia or are indicated to receive cardiac resynchronization therapy (CRT). Data on intraoperative and postoperative outcomes of this method are lacking. Methods: All patients with bradycardia or an indication for CRT, who underwent LBBAP during a surgical procedure at the Heart Centre of the Kralovske Vinohrady University Hospital and the Third Faculty of Medicine of Charles University in the period from 11/2018 to 05/2021, were included in the registry. Most patients were included in the registry in a prospective manner, and selected parameters were added retrospectively. To obtain basic clinical, intraoperative, and postoperative parameters, data from the electronic hospital information system and the electrophysiological device employed during the course of surgical procedures were used. Results: LBBAP was performed in 329 patients, of which 237 had bradycardia and 92 were indicated to receive CRT. The pacing thresholds for achieving LBBAP were 0.6 ± 0.5 V per 0.5 ms on average, and were stable with a mean follow-up duration of 5 ± 5 months (0.7 ± 0.3 V per 0.4 ms). Complications were seen in 26 patients (8%), of which 15 were specific complications related to LBBAP (12 cases of intraoperative lead penetration into the right ventricle, 1 case of chest pain, and 1 case of chest pain with ST segment elevation after lead placement) which, however, resolved without sequelae during the course of the procedure. The overall success rate of LBBAP was 89% and was significantly higher in patients with bradycardia than in those indicated to receive CRT (92% vs 83%, p = 0.02). A significant effect of the number of procedures performed on the success rate of LBBAP and the rate of some complications was observed. Conclusion: LBBAP is a possible alternative to permanent cardiac pacing in patients who have bradycardia or are indicated to receive CRT. It is associated with certain specific complications, whose significance requires evaluation in terms of the method's benefit in randomized trials.
- MeSH
- Bradycardia therapy MeSH
- Bundle of His * MeSH
- Electrodes, Implanted MeSH
- Humans MeSH
- Postoperative Complications MeSH
- Registries MeSH
- Retrospective Studies MeSH
- Cardiac Resynchronization Therapy * methods MeSH
- Check Tag
- Humans MeSH
- Publication type
- Research Support, Non-U.S. Gov't MeSH
- Comparative Study MeSH
INTRODUCTION: Left bundle branch area pacing (LBBAP) comprises pacing at the left ventricular septum (LVSP) or left bundle branch (LBBP). The aim of the present study was to investigate the differences in ventricular electrical heterogeneity between LVSP, LBBP, right ventricular pacing (RVP) and intrinsic conduction with different dyssynchrony measures using the ECG, vectorcardiograpy, ECG belt, and Ultrahigh frequency (UHF-)ECG. METHODS: Thirty-seven patients with a pacemaker indication for bradycardia or cardiac resynchronization therapy underwent LBBAP implantation. ECG, vectorcardiogram, ECG belt and UHF-ECG signals were recorded during RVP, LVSP and LBBP, and intrinsic activation. QRS duration (QRSd) was measured from the ECG, QRS area was calculated from the vectorcardiogram, LV activation time (LVAT) and standard deviation of activation time (SDAT) from ECG belt and electrical dyssynchrony (e-DYS16) from UHF-ECG. RESULTS: Both LVSP and LBBP significantly reduced ventricular electrical heterogeneity as compared to underlying LBBB and RV pacing in terms of QRS area (p < .001), SDAT (p < .001), LVAT (p < .001) and e-DYS16 (p < .001). QRSd was only reduced as compared to RV pacing(p < .001). QRS area was similar during LBBP and normal intrinsic conduction, e-DYS16 was similar during LVSP and normal intrinsic conduction, whereas SDAT was similar for LVSP, LBBP and normal intrinsic conduction. For all these variables there was no significant difference between LVSP and LBBP. CONCLUSION: Both LVSP and LBBP resulted in a more synchronous LV activation than LBBB and RVP. Especially LBBP resulted in levels of LV synchrony comparable to normal intrinsic conduction.
- MeSH
- Action Potentials * MeSH
- Bundle-Branch Block physiopathology therapy diagnosis MeSH
- Bradycardia physiopathology therapy diagnosis MeSH
- Time Factors MeSH
- Electrophysiologic Techniques, Cardiac MeSH
- Electrocardiography MeSH
- Ventricular Function, Left * MeSH
- Bundle of His * physiopathology MeSH
- Cardiac Pacing, Artificial * MeSH
- Middle Aged MeSH
- Humans MeSH
- Ventricular Septum * physiopathology MeSH
- Predictive Value of Tests * MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Heart Rate * MeSH
- Cardiac Resynchronization Therapy MeSH
- Vectorcardiography * methods MeSH
- Treatment Outcome MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Comparative Study MeSH
BACKGROUND: Cardiac resynchronization therapy (CRT) using biventricular pacing (BVP) is effective in patients with heart failure, left bundle branch block (LBBB), and reduced left ventricular function. Left bundle branch area pacing (LBBAP) has been reported as an alternative option for CRT. OBJECTIVE: The purpose of this study was to assess the feasibility and outcomes of LBBAP in patients who failed conventional BVP because of coronary venous (CV) lead complications or who were nonresponders to BVP. METHODS: At 16 international centers, LBBAP was attempted in patients with conventional CRT indication who failed BVP because of CV lead complications or lack of therapeutic response to BVP. Heart failure hospitalization (HFH) and death, echocardiographic outcomes, procedural data, pacing parameters, and lead complications including CV lead failure are reported. RESULTS: LBBAP was successfully performed in 200 patients (CV lead failures 156; nonresponders 44) (age 68 ± 11 years; female 35%; LBBB 55%; right ventricular pacing 23%; ischemic cardiomyopathy 28%; nonischemic cardiomyopathy 63%; left ventricular ejection fraction [LVEF] ≤35% in 80%). Procedural duration was 119.5 ± 59.6 minutes, and fluoroscopy duration was 25.7 ± 18.5 minutes. LBBAP threshold and R-wave amplitudes were 0.68 ± 0.35 V @ 0.45 ms and 10.4 ± 5 mV at implant, respectively, and remained stable during mean follow-up of 12 ± 10.1 months. LBBAP resulted in significant QRS narrowing from 170 ± 28 ms to 139 ± 25 ms (P <.001) with V6 R-wave peak times of 85 ± 17 ms. LVEF improved from 29% ± 10% at baseline to 40% ± 12% (P <.001) during follow-up. The risk of death or HFH was lower in those with CV lead failure than in nonresponders (hazard ratio 0.357; 95% confidence interval 0.168-0.756; P = .007) CONCLUSION: LBBAP is a viable alternative to CRT in patients who failed conventional BVP due to CV lead failure or who were nonresponders.
- MeSH
- Bundle-Branch Block diagnosis etiology therapy MeSH
- Electrocardiography methods MeSH
- Ventricular Function, Left physiology MeSH
- Bundle of His MeSH
- Cardiac Pacing, Artificial methods MeSH
- Middle Aged MeSH
- Humans MeSH
- Aged MeSH
- Arrhythmias, Cardiac therapy MeSH
- Cardiac Resynchronization Therapy * methods MeSH
- Heart Failure * diagnosis etiology therapy MeSH
- Stroke Volume MeSH
- Treatment Outcome MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- MeSH
- Electrocardiography MeSH
- Ventricular Function, Left MeSH
- Bundle of His MeSH
- Cardiac Pacing, Artificial MeSH
- Humans MeSH
- Heart Conduction System * MeSH
- Heart Ventricles diagnostic imaging MeSH
- Cardiac Resynchronization Therapy * MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
BACKGROUND: Left bundle branch area pacing (LBBAP) is an emerging technique to achieve cardiac resynchronization therapy (CRT), but its feasibility and safety in elderly patients with heart failure with reduced ejection fraction and left bundle branch block is hardly investigated. METHODS: We enrolled consecutive patients with an indication for CRT comparing pacing parameters and complication rates of LBBAP-CRT in elderly patients (≥ 75 years) versus younger patients (< 75 years) over a 6-month follow-up. RESULTS: LBBAP was successful in 55/60 enrolled patients (92%), among which 25(45%) were elderly. In both groups, LBBAP significantly reduced the QRS duration (elderly group: 168 ± 15 ms to 136 ± 12 ms, p < 0.0001; younger group: 166 ± 14 ms to 134 ± 11 ms, p < 0.0001) and improved LVEF (elderly group: 28 ± 5% to 40 ± 7%, p < 0.0001; younger group: 29 ± 5% to 41 ± 8%, p < 0.0001). The pacing threshold was 0.9 ± 0.8 V in the elderly group vs. 0.7 ± 0.5 V in the younger group (p = 0.350). The R wave was 9.5 ± 3.9 mV in elderly patients vs. 10.7 ± 2.7 mV in younger patients (p = 0.341). The fluoroscopic (elderly: 13 ± 7 min vs. younger: 11 ± 7 min, p = 0.153) and procedural time (elderly: 80 ± 20 min vs. younger: 78 ± 16 min, p = 0.749) were comparable between groups. Lead dislodgement occurred in 2(4%) patients, 1 in each group (p = 1.000). Intraprocedural septal perforation occurred in three patients (5%), 2(8%) in the elderly group (p = 0.585). One patient (2%) in the elderly group had a pocket infection. CONCLUSIONS: LBBAP is a feasible and safe technique for delivering physiological pacing in elderly patients who are candidates for CRT with suitable pacing parameters and low complication rates.
- MeSH
- Electrocardiography methods MeSH
- Bundle of His MeSH
- Cardiac Pacing, Artificial adverse effects methods MeSH
- Humans MeSH
- Aged MeSH
- Cardiac Resynchronization Therapy * methods MeSH
- Feasibility Studies MeSH
- Stroke Volume MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Aged MeSH
- Publication type
- Journal Article MeSH
Pacienti s blokádou pravého Tawarova raménka (RBBB) a se srdečním selháním nejsou ve velkých randomizovaných klinických studiích hodnotících účinnost srdeční resynchronizační léčby (SRL) dostatečně zastoupeni, protože jsou do těchto projektů zařazováni hlavně pacienti s blokádou levého Tawarova raménka. Ve shodě s výsledky nedávno publikované metaanalýzy naše studie se 14 pacienty s RBBB a srdečním selháním léčenými klasickou SRL (biventrikulární stimulací) prokázala, že žádný z nich neodpovídá na léčbu, jde tedy o „non-respondéry“. Alternativou v případě neúspěšné biventrikulární stimulace je v současnosti bifokální stimulace, speciální metoda simultánní stimulace pomocí elektrod implantovaných do pravé komory. Na základě výsledků studie BRIGHT byla na naší kardiologické klinice provedena u 25 pacientů se srdečním selháním a s neúspěšnou biventrikulární stimulací provedena implantace bifokálního stimulátoru do pravé komory. Během 12měsíčního sledování došlo ke zlepšení funkční třídy NYHA a zvýšení ejekční frakce levé komory (dvouleté přežití 77 %). Bifokální stimulace pravé komory by u pacientů s RBBB a pokročilým srdečním selháním mohla představovat přijatelnou alternativu klasické biventrikulární stimulace, protože zajišťuje racionálnější elektrickou „resynchronizaci“, i když hemodynamický a funkční přínos bifokální stimulace je teprve nutno prokázat.
Patients with right bundle branch block (RBBB) and heart failure (HF) are not well represented in large randomized clinical trials evaluating the efficacy of cardiac resynchronization therapy (CRT), which included mainly left bundle branch block morphology. According to a recent meta-analysis, in our series we have 14 patients with RBBB and HF treated with conventional CRT (biventricular pacing), all of them turned out to be “non-responders”. Bifocal pacing, a particular modality of simultaneous pacing with two leads implanted in the right ventricle, is a current option in case of unsuccessful biventricular pacing. In accordance with the results of the BRIGHT study, 25 patients with heart failure and unsuccessful biventricular pacing underwent right ventricular bifocal pacing implantation in our Cardiology Department, with significant improvements of NYHA functional class and left ventricular ejection fraction at 12-month follow-up (survival rate 77% after 2 years). Right ventricular bifocal pacing could be an alternative to conventional biventricular pacing in patients with RBBB and advanced HF, ensuring a more rational electric “resynchronization”, even if hemodynamic and functional benefit remains to be demonstrated.
- Keywords
- bifokální stimulace pravé komory,
- MeSH
- Bundle-Branch Block * surgery complications mortality therapy MeSH
- Cardiac Pacing, Artificial * statistics & numerical data MeSH
- Humans MeSH
- Prospective Studies MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Cardiac Resynchronization Therapy statistics & numerical data MeSH
- Heart Failure * surgery complications mortality therapy MeSH
- Check Tag
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
BACKGROUND: Adoption and outcomes for conduction system pacing (CSP), which includes His bundle pacing (HBP) or left bundle branch area pacing (LBBAP), in real-world settings are incompletely understood. We sought to describe real-world adoption of CSP lead implantation and subsequent outcomes. METHODS: We performed an online cross-sectional survey on the implantation and outcomes associated with CSP, between November 15, 2020, and February 15, 2021. We described survey responses and reported HBP and LBBAP outcomes for bradycardia pacing and cardiac resynchronization CRT indications, separately. RESULTS: The analysis cohort included 140 institutions, located on 5 continents, who contributed data to the worldwide survey on CSP. Of these, 127 institutions (90.7%) reported experience implanting CSP leads. CSP and overall device implantation volumes were reported by 84 institutions. In 2019, the median proportion of device implants with CSP, HBP, and/or LBBAP leads attempted were 4.4% (interquartile range [IQR], 1.9-12.5%; range, 0.4-100%), 3.3% (IQR, 1.3-7.1%; range, 0.2-87.0%), and 2.5% (IQR, 0.5-24.0%; range, 0.1-55.6%), respectively. For bradycardia pacing indications, HBP leads, as compared to LBBAP leads, had higher reported implant threshold (median [IQR]: 1.5 V [1.3-2.0 V] vs 0.8 V [0.6-1.0 V], p = 0.0008) and lower ventricular sensing (median [IQR]: 4.0 mV [3.0-5.0 mV] vs. 10.0 mV [7.0-12.0 mV], p < 0.0001). CONCLUSION: In conclusion, CSP lead implantation has been broadly adopted but has yet to become the default approach at most surveyed institutions. As the indications and data for CSP continue to evolve, strategies to educate and promote CSP lead implantation at institutions without CSP lead implantation experience would be necessary.
- MeSH
- Bradycardia * therapy MeSH
- Electrocardiography MeSH
- Bundle of His * MeSH
- Cardiac Pacing, Artificial MeSH
- Humans MeSH
- Cardiac Conduction System Disease MeSH
- Heart Conduction System MeSH
- Cross-Sectional Studies MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
BACKGROUND: Targets for right-sided conduction system pacing (CSP) include His bundle and right bundle branch. Electrocardiographic patterns, diagnostic criteria, and outcomes of right bundle branch pacing (RBBP) are not known. OBJECTIVE: Our aims were to delineate electrocardiographic and electrophysiological characteristics of RBBP and to compare outcomes between RBBP and His bundle pacing (HBP). METHODS: Patients with confirmed right CSP were divided according to the conduction system potential to QRS complex interval at the pacing lead implantation site. Six hypothesized RBBP criteria as well as pacing parameters, echocardiographic outcomes, and all-cause mortality were analyzed. RESULTS: All analyzed criteria discriminated between HBP and RBBP: double QRS complex transition during the threshold test, selective paced QRS complex different from conducted QRS complex, stimulus to selective-QRS complex > potential-QRS complex, small increase in V6 R-wave peak time (V6RWPT) during QRS complex transition, equal capture thresholds of CSP and myocardium, and stimulus-V6RWPT > potential-V6RWPT (adopted as the diagnostic standard). According to the last criterion, RBBP was observed in 19.2% of patients (64 of 326) who had been targeted for HBP, present mainly among patients with potential to QRS complex interval <35 ms (90.6% [48 of 53]) and occasionally among the remaining patients (5.6% [16 of 273]). RBBP was characterized by longer QRS complex (by 10.5 ms), longer V6RWPT (by 11.6 ms), and better sensing (by 2.6 mV) compared with HBP. During a median follow-up duration of 29 months, no differences in capture threshold, echocardiographic outcomes, or mortality were found. CONCLUSION: RBBP has distinct features that separate it from HBP and is observed in approximately a fifth of patients in whom HBP is intended.
