Left Bundle Branch Pacing Versus Biventricular Pacing for Acute Cardiac Resynchronization in Patients With Heart Failure

Yixiu Liang, Jingfeng Wang, Xue Gong, Hongyang Lu, Ziqing Yu, Lei Zhang, Minghui Li, Lei Pan, Xueying Chen, Jie Cui, Weiwei Zhang, Ruogu Li, Xiaohong Zhou, Weijian Huang, Yangang Su, Junbo Ge, Yixiu Liang, Jingfeng Wang, Xue Gong, Hongyang Lu, Ziqing Yu, Lei Zhang, Minghui Li, Lei Pan, Xueying Chen, Jie Cui, Weiwei Zhang, Ruogu Li, Xiaohong Zhou, Weijian Huang, Yangang Su, Junbo Ge

Abstract

Background: Left bundle branch pacing (LBBP) has emerged as an alternative to biventricular pacing (BVP) for delivering cardiac resynchronization therapy. We sought to compare the acute improvement of electrical and mechanical synchrony, and hemodynamics between LBBP and BVP in patients with heart failure and left bundle branch block.

Methods: LBBP and BVP were performed and compared in a crossover fashion in patients with heart failure and left bundle branch block undergoing cardiac resynchronization therapy implantation. Electrical synchrony was assessed by QRS duration and area, mechanical synchrony by the SD of time to peak velocity of 12 left ventricular segments (Ts-SD) and interventricular mechanical delay, and hemodynamics by the maximum rate of left ventricular pressure rise (dP/dtmax).

Results: Twenty-one patient with heart failure and left bundle branch block (mean age 67±10 years, 48% male, and 90% nonischemic cause) were included. Both LBBP and BVP provided significant improvements in electrical and mechanical synchrony, and hemodynamics compared to the baseline. Compared with BVP, LBBP achieved a larger reduction in QRS duration (-11 ms [95% CI, -17 to -4 ms]; P=0.003) and QRS area (-85 µVs [95% CI, -113 to -56 µVs]; P<0.001); LBBP achieved a greater decrease in Ts-SD (-14 ms [95% CI, -21 to -7 ms]; P=0.001), with no significant difference in interventricular mechanical delay (-2 ms [95% CI, -13 to 8 ms]; P=0.63). The increase in dP/dtmax from LBBP was significantly higher than that from BVP (6% [95% CI, 2%-9%]; P=0.002).

Conclusions: LBBP delivers greater acute electrical and mechanical resynchronization and hemodynamic improvement than BVP in predominantly nonischemic heart failure patients with left bundle branch block.

Registration: URL: https://www.

Clinicaltrials: gov; Unique identifier: NCT04505384.

Keywords: biventricular pacing; cardiac resynchronization therapy; heart failure; hemodynamics; left bundle branch pacing.

Figures

Figure 1.
Figure 1.
Representative electrocardiograms and fluoroscopy during implantation. A, Intrinsic QRS with His potential mapped (His-ventricular interval of 56 ms). B, Left bundle branch (LBB) pacing (LBBP) at the threshold output of 1.0V@0.48 ms with stimulus to peak left ventricular (LV) activation time of 75 ms, demonstrating selective LBBP. C, LBBP at an output of 3.0V@0.48 ms with stimulus to peak LV activation time of 75 ms, demonstrating non-selective LBBP. D, LBBP at a high output of 10.0V@0.48 ms with stimulus to peak LV activation time of 75 ms, demonstrating non-selective LBBP. E, An LBB potential recorded during an escape beat with a potential-ventricular interval of 18 ms (red arrow). F, Fluoroscopy during cardiac resynchronization therapy (CRT)-defibrillator implantation with LBBP lead in place. G, Fluoroscopy during CRT-pacemaker implantation with LBBP lead in place. A right ventricular (RV) pacing lead was temporarily placed at the RV apex to implement biventricular pacing (BVP) and would be extracted after hemodynamic data acquisition.
Figure 2.
Figure 2.
Paced QRS complex and increase in dP/dtmax during atrioventricular (AV) delay programming. A, An example of baseline, paced QRS complex by biventricular pacing (BVP), and paced QRS complex by left bundle branch pacing (LBBP) during AV delay programming. B, The mean and 95% CI are calculated for each atrioventricular (AV) delay for BVP and LBBP. A quadratic curve was fitted from the mean value of each AV delay for estimation of the increase in dP/dtmax during AV delay programming for BVP and LBBP, respectively.
Figure 3.
Figure 3.
Assessment of electrical synchrony. A, An example of ECGs and vectorcardiograms (VCGs) during baseline, biventricular pacing (BVP), and left bundle branch pacing (LBBP) with corresponding QRS duration and QRS area. B, Comparison of QRS duration among baseline, BVP, and LBBP. C, Comparison of QRS area among baseline, BVP, and LBBP. *P<0.05 versus baseline; †P<0.05 LBBP versus BVP.
Figure 4.
Figure 4.
Echocardiographic assessment of intra-ventricular and interventricular mechanical synchrony. A, (left) An example of Ts-SD as calculated with longitudinal velocity from apical 4-chamber, 2-chamber, and long-axis views of tissue Doppler images with time to peak velocity from basal and midventricular sites, of baseline, biventricular pacing (BVP) and left bundle branch pacing (LBBP). (right) Comparison of Ts-SD among baseline, BVP, and LBBP. B, (left) An example of interventricular mechanical delay (IVMD) as calculated as the difference between RV ejection (left) and LV ejection (right; white arrow), of baseline, BVP and LBBP. (right) Comparison of IVMD among baseline, BVP, and LBBP. *P<0.05 versus baseline; †P<0.05 LBBP versus BVP.
Figure 5.
Figure 5.
Assessment of hemodynamics. A, An example of increase in dP/dtmax over baseline during biventricular pacing (BVP; top) and left bundle branch pacing (LBBP; bottom), with the first 2 of the total 8 transitions demonstrated. B, Comparison of increase in dP/dtmax between BVP and LBBP. * the increase of dP/ dtmax was 27% during BVP, and 46% during LBBP. †P<0.05 LBBP versus BVP.

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