Evaluation of cardiac synchrony in left bundle branch pacing: Insights from echocardiographic research

Binni Cai, Xinyi Huang, Linlin Li, Jincun Guo, Simei Chen, Fanqi Meng, Huimin Wang, Biqin Lin, Maolong Su, Binni Cai, Xinyi Huang, Linlin Li, Jincun Guo, Simei Chen, Fanqi Meng, Huimin Wang, Biqin Lin, Maolong Su

Abstract

Aim: The aim of this study is to assess if left bundle branch pacing (LBBP) can preserve physiological cardiac synchrony and deliver favorable hemodynamic effects.

Methods: Consecutive patients undergoing dual chamber pacemaker implantation for sick sinus syndrome (SSS) and a normal cardiac function with a narrow QRS complex were recruited for the study. Electrocardiogram and echocardiographic examinations were performed during ventricular pacing-on and native-conduction modes. The QRS duration (QRSd), systolic dyssynchrony index (SDI), and the standard deviation of time-to-peak contraction velocity in left ventricular (LV) 12 segments (Tsd-12-LV) were measured to evaluate LV synchrony. The stroke volume (SV) and the degree of atrioventricular valvular regurgitation were also assessed.

Results: A total of 40 patients underwent LBBP, while another 38 patients underwent right ventricular septum pacing (RVSP) as control group. Baseline characteristics were similar between the two groups. With LBBP, the paced QRSd was slightly wider than the intrinsic QRSd (101.03 ± 8.79 ms vs 91.06 ± 14.17 ms, P < .0001) while the LV mechanical synchrony during LBBP pacing mode was similar to that of native-conduction mode (SDI, 3.14 ± 2.49 vs 2.70 ± 1.68, P = 0.129; Tsd-12-LV, 26.43 ± 15.55 vs 25.61 ± 16.07, P = .671) in the LBBP group. The LV synchrony in the LBBP group was superior to the RVSP group significantly. No significant differences in SV (64.08 ± 16.97 mL vs 65.45 ± 18.68 mL, P = .241) or the degree of atrioventricular valvular regurgitation were noted between LBBP capture and native-conduction modes.

Conclusion: LBBP could preserve satisfactory LV synchrony and result in favorable hemodynamic effects.

Keywords: cardiac mechanical synchrony; echocardiography; hemodynamic effects; left bundle branch pacing; physiological pacing; right ventricular septum pacing; sick sinus syndrome.

© 2020 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals, Inc.

Figures

Figure 1
Figure 1
Flow chart of patients diagnosed with SSS who accepted pacing therapy in our study. 1 Reasons for exclusion: pacemaker replacements (n = 8), single chamber pacemaker implantations (n = 8) 2 ; Reasons for exclusion: intrinsic QRS > 120 ms, or were accordant with our exclusive criterions, or the patients refused to take part in the study (n = 42). LBBP, left bundle branch pacing; RVSP, right ventricular septum pacing; SSS, sick sinus syndrome
Figure 2
Figure 2
Comparison of QRSd of RVSP, LBBP with normal axis, and LBBP with left axis deviation. The 12‐lead surface ECGs of RVSP, LBBP with normal axis, and LBBP with left axis deviation in three patients. QRSd of RVSP mode was obvious wider than that in native‐conduction mode (A). QRSd of LBBP with normal axis (B) or with left axis deviation (C) was slightly wider than that in native‐conduction mode. ECG, electrocardiography; LBBP, left bundle branch pacing; QRSd, QRS durations; RVSP, right ventricular septum pacing; Stim‐LVAT, the interval from the pacing stimulus to the peak of the R‐wave
Figure 3
Figure 3
Comparison of LV mechanical synchrony between LBBP and RVSP groups. LV mechanical synchronization parameters (SDI or Tsd‐12‐LV) in LBBP capture were significantly shorter compared with RVSP capture mode (A). Similar LV synchrony was showed in native‐conduction (B, left) and LBBP capture modes (B, right) by color coded bull's eye maps in a patient with SSS. Poorer synchrony was showed in RVSP capture mode (C, right) compared with native‐conduction mode (C, left) in another patient with SSS. TDI showed that the time of peak myocardial contraction velocity in the LV segments was relatively concentrated in one LBBP patient (D, left) but was discrete in the other RVSP patient (D, right). LBBP, left bundle branch pacing; LV, left ventricular; RVSP, right ventricular septum pacing; SDI, systolic dyssynchrony index; SSS, sick sinus syndrome; Tsd‐12‐LV, the standard deviation of the time‐to‐peak contraction velocity in the 12 segments
Figure 4
Figure 4
The Stim‐LVAT of tip‐paced ECGs in patients with LBBP with and without LBB potential. One patient without LBB potential (A, left), had Stim‐LVAT of 68 ms (A, right). The other patient recorded with LBB potential (B, left), had Stim‐LVAT of 67 ms (B, right). ECG, echocardiography; LBB, left bundle branch; Stim‐LVAT, the interval from the pacing stimulus to the peak of the R‐wave
Figure 5
Figure 5
Comparison of QRSd (A) and Stim‐LVAT (B) between subgroups divided by paced QRS axis and LBB potential in LBBP group. LBBP, left bundle branch pacing; QRSd, QRS duration; Stim‐LVAT, the interval from the pacing stimulus to the peak of the R‐wave
Figure 6
Figure 6
Comparison of LV mechanical synchrony between subgroups divided by paced QRS axis and LBB potential in LBBP group. Subgroup of left axis deviation had slightly greater SDI and Tsd‐12‐LV than the normal axis subgroup, but without statistically significance (A,B).There were no differences in SDI or Tsd‐12‐LV between the potential+ and potential− subgroups (C,D). ECG, echocardiography; LBB, left bundle branch; LBBP, left bundle branch pacing; LV, left ventricle; SDI, systolic dyssynchrony index; Tsd‐12‐LV, the standard deviation of time‐to‐peak contraction velocity in LV 12 segments

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