- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03614169
Direct HIS-pacing as an Alternative to BiV-pacing in Symptomatic HFrEF Patients With True LBBB (HISalternative)
Direct HIS-pacing as an Alternative to Biventricular Pacing in Symptomatic Heart Failure Patients With Severely Reduced LVEF and a True Left Bundle Branch Block
Study Overview
Status
Intervention / Treatment
Detailed Description
Biventricular (BiV) pacing is an established treatment of symptomatic heart failure patients with severely reduced left ventricular ejection fraction (HFrEF) and wide QRS due to bundle branch block (BBB) on a 12-lead ECG. BiV pacing is normally achieved with an endocardial pacing lead in the right ventricle and an epicardial lead over the left ventricle situated in a coronary vein. BiV pacing does not correct the BBB but corrects the mechanical dyssynchrony that is a consequence of the BBB. It has been shown to work best on patients with "true" left bundle branch block (LBBB) where the block is due to disease within the conduction system (and not for example left ventricular hypertrophy or scars). Even if the patient is an ideal candidate for BiV pacing it can sometimes be difficult to achieve the best mechanical resynchronization because of anatomic difficulties, high pacing thresholds or phrenic nerve capture.
In recent years it has been demonstrated that the level of block in true LBBB is often within the bundle of HIS and it is possible in many cases to place a pacing lead distally to the site of block and get capture of both right and left bundles thereby "correcting" the BBB and achieve a normal or near-normal QRS complex. If the conduction system is intact distal to the block this mode of pacing leads to complete resynchronization of the ventricles. HIS-pacing can be achieved as either selective HIS-capture where it is only the conduction system that is paced leading to a narrow QRS complex. However, mostly it is achieved with non-selective HIS-capture where both the septal myocardium close to the pacing site and the His-bundle is captured. This leads to a QRS resembling the QRS achieved by selective HIS-capture but preceded by a delta-wave-like deflection which broadens the QRS complex. Since it is only a small part of the septum that is captured early this does not influence the resynchronization of the heart. In some patients HIS-pacing cannot be achieved due to anatomical difficulties that hinders reaching the HIS bundle with the present tools available. In others it is not possible to come distal to the block and recruiting both the left and the right bundle branch.
There is to date no randomized studies between HIS-bundle pacing and BiV pacing in HFrEF patients with LBBB but there are several case reports and retrospective data on successful HIS-bundle pacing in these patients. The present study will randomize 50 patients in a single centre to HIS-pacing or BiV pacing to determine to which extent it is possible to achieve normalization or near-normalization of the QRS with HIS-bundle pacing and what this translates to with regard to symptom relieve, walking distance, echocardiographic measures and N-terminal pro B-type natriuretic peptide (NT-proBNP) levels as compared to BiV pacing.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
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Hovedstaden
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Copenhagen, Hovedstaden, Denmark, 2100
- Rigshospitalet
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Patients with ischaemic or non-ischaemic cardiomyopathy
- LVEF ≤ 35 % as assessed by echocardiography
- New York Heart Association (NYHA) class II-IV despite optimal medical therapy
- Either found eligible for cardiac resynchronization therapy (CRT-P or CRT-D) because of sinus rhythm and "true" LBBB according to Strauss criteria on a 12-lead ECG
- or found eligible for upgrade of an existing pacing system to cardiac resynchronization therapy (CRT-P or CRT-D) because of sinus rhythm and "true" LBBB according to Strauss criteria on a 12-lead ECG or at least 90 % right ventricular pacing in the preceding two months.
- Signed informed consent
Exclusion Criteria:
- Existing biventricular pacing system
- Permanent atrial fibrillation
- Severe kidney failure (eGFR < 30 ml/min)
- Acute myocardial infarction or Coronary By-pass Grafting within the preceding three months
- unwillingness to participate
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Double
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Direct HIS-pacing
In this arm a right ventricular (RV) lead or implantable cardioverter defibrillator (ICD) lead is placed first and then implantation of a HIS-pacing lead is attempted.
If it is not possible to find and pace HIS or it is not possible to correct the LBBB, a left ventricular (LV) lead is implanted instead.
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This intervention is attempted first
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Active Comparator: Biventricular pacing
In this arm an RV-lead or ICD-lead is placed first and then implantation of a LV-pacing lead is attempted.
If this is not possible due to anatomical difficulties (no coronary sinus (CS) access, no available branches other than v cordis anterior or v cordis media) or electrical difficulties (no capture below 4 V at 1.0 msec or phrenic nerve stimulation < 2x pacing threshold)
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This intervention is attempted first
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Success rate of obtaining capture of HIS-bundle with narrowing of the QRS-duration
Time Frame: 6 months
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What is the success rate of implanting a pacing lead to the HIS bundle with narrowing of the QRS duration and maintaining this effect during the course of the study
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6 months
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Fall in end-systolic volume > 15%
Time Frame: 6 months
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How many HIS-paced patients as opposed to BiV paced patients have a fall in end-systolic volume > 15 % of the initial value?
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6 months
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Collaborators and Investigators
Sponsor
Publications and helpful links
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- HIS-alternative
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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Tomsk National Research Medical Center of the Russian...RecruitingHeart Failure | Left Bundle-Branch Block | Ischemic Cardiomyopathy | Left Ventricular Dysfunction | Left Ventricular Dyssynchrony | Non-ischemic Dilated Cardiomyopathy | Left Ventricle RemodelingRussian Federation
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