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Left bundle branch–optimized cardiac resynchronization therapy (LOT-CRT): Results from an international LBBAP collaborative study group

      Background

      Cardiac resynchronization therapy (CRT) based on the conventional biventricular pacing (BiV-CRT) technique sometimes results in broad QRS complex and suboptimal response.

      Objective

      We aimed to assess the feasibility and outcomes of CRT based on left bundle branch area pacing (LBBAP, in lieu of the right ventricular lead) combined with coronary venous left ventricular pacing in an international multicenter study.

      Methods

      LBBAP-optimized CRT (LOT-CRT) was attempted in nonconsecutive patients with CRT indications. Addition of the LBBA (or coronary venous) lead was at the discretion of the implanting physician, who was guided by suboptimal paced QRS complex, and/or on clinical grounds.

      Results

      LOT-CRT was successful in 91 of 112 patients (81%). The baseline characteristics were as follows: mean age 70 ± 11 years, female 22 (20%), left ventricular ejection fraction 28.7% ± 9.8%, left ventricular end-diastolic diameter 62 ± 9 mm, N-terminal pro–B-type natriuretic peptide level 5821 ± 8193 pg/mL, left bundle branch block 47 (42%), nonspecific intraventricular conduction delay 25 (22%), right ventricular pacing 26 (23%), and right bundle branch block 14 (12%). The procedure characteristics were as follows: mean fluoroscopy time 27.3 ± 22 minutes, LBBAP capture threshold 0.8 ± 0.5 V @ 0.5 ms, and R-wave amplitude 10 mV. LOT-CRT resulted in significantly greater narrowing of QRS complex from 182 ± 25 ms at baseline to 144 ± 22 ms (P < .0001) than did BiV-CRT (170 ± 30 ms; P < .0001) and LBBAP (162 ± 23 ms; P < .0001). At follow-up of ≥3 months, the ejection fraction improved to 37% ± 12%, left ventricular end-diastolic diameter decreased to 59 ± 9 mm, N-terminal pro–B-type natriuretic peptide level decreased to 2514 ± 3537 pg/mL, pacing parameters were stable, and clinical improvement was noted in 76% of patients (New York Heart Association class 2.9 vs 1.9).

      Conclusion

      LOT-CRT is feasible and safe and provides greater electrical resynchronization as compared with BiV-CRT and could be an alternative, especially when only suboptimal electrical resynchronization is obtained with BiV-CRT. Randomized controlled trials comparing LOT-CRT and BiV-CRT are needed.

      Graphical abstract

      Keywords

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      References

        • Huang W.
        • Su L.
        • Wu S.
        • et al.
        A novel pacing strategy with low and stable output: pacing the left bundle branch immediately beyond the conduction block.
        Can J Cardiol. 2017; 33: 1736
        • Huang W.
        • Chen X.
        • Su L.
        • Wu S.
        • Xia X.
        • Vijayaraman P.
        A beginner’s guide to permanent left bundle branch pacing.
        Heart Rhythm. 2019; 16: 1791-1796
        • Ponnusamy S.S.
        • Arora V.
        • Namboodiri N.
        • Kumar V.
        • Kapoor A.
        • Vijayaraman P.
        Left bundle branch pacing: a comprehensive review.
        J Cardiovasc Electrophysiol. 2020; 31: 2462-2473
        • Vijayaraman P.
        • Ponnusamy S.
        • Cano O.
        • et al.
        Left bundle branch area pacing for cardiac resynchronization therapy: results from the International LBBAP Collaborative Study Group.
        JACC Clin Electrophysiol. 2021; 7: 135-147
        • Herweg B.
        • Ilercil A.
        • Madramootoo C.
        • et al.
        Latency during left ventricular pacing from the lateral cardiac veins: a cause of ineffectual biventricular pacing.
        Pacing Clin Electrophysiol. 2006; 29: 574-581
        • Jastrzebski M.
        • Wilinski J.
        • Fijorek K.
        • Sondej T.
        • Czarnecka D.
        Mortality and morbidity in cardiac resynchronization patients: impact of lead position, paced left ventricular QRS morphology and other characteristics on long-term outcome.
        Europace. 2013; 15: 258-265
      1. Vijayaraman P. Left bundle branch pacing optimized cardiac resynchronization therapy: a novel approach [published online ahead of print July 21, 2021]. JACC Clin Electrophysiol. https://doi.org/10.1016/j.jacep.2021.04.005.

        • Jastrzebski M.
        • Moskal P.
        • Holda M.K.
        • et al.
        Deep septal deployment of a thin, lumenless pacing lead: a translational cadaver simulation study.
        Europace. 2020; 22: 156-161
        • Jastrzebski M.
        • Kielbasa G.
        • Moskal P.
        • et al.
        Fixation beats: a novel marker for reaching the left bundle branch area during deep septal lead implantation.
        Heart Rhythm. 2021; 18: 562-569
        • Ponnusamy S.S.
        • Ganesan V.
        • Syed T.
        • Balasubramanian S.
        • Vijayaraman P.
        Template beat: a novel marker for left bundle branch capture during physiological pacing.
        Circ Arrhythm Electrophysiol. 2021; 14e009677
        • Jastrzebski M.
        • Moskal P.
        Reaching the left bundle branch pacing area within 36 heartbeats.
        Kardiol Pol. 2021; 79: 587-588
        • Jastrzebski M.
        ECG and pacing criteria for differentiating conduction system pacing from myocardial pacing.
        Arrhythm Electrophysiol Rev. 2021; (In press)
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        J Am Soc Echocardiogr. 2015; 28: 1-39
        • Abraham W.T.
        • Fisher W.G.
        • Smith A.L.
        • et al.
        Cardiac resynchronization in chronic heart failure.
        N Engl J Med. 2002; 346: 1845-1853
        • Gold M.R.
        • Thebault C.
        • Linde C.
        • et al.
        Effect of QRS duration and morphology on cardiac resynchronization therapy outcomes in mild heart failure: results from the Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction (REVERSE) study.
        Circulation. 2012; 126: 822-829
        • Sweeney M.O.
        • van Bommel R.J.
        • Schalij M.J.
        • Borleffs C.J.
        • Hellkamp A.S.
        • Bax J.J.
        Analysis of ventricular activation using surface electrocardiography to predict left ventricular reverse volumetric remodeling during cardiac resynchronization therapy.
        Circulation. 2010; 121: 626-634
        • Vijayaraman P.
        • Herweg B.
        • Ellenbogen K.A.
        • Gajek J.
        His-optimized cardiac resynchronization therapy to maximize electrical resynchronization: a feasibility study.
        Circ Arrhythm Electrophysiol. 2019; 12e006934
        • Reddy V.Y.
        • Miller M.A.
        • Neuzil P.
        • et al.
        Cardiac resynchronization therapy with wireless left ventricular endocardial pacing: the SELECT-LV study.
        J Am Coll Cardiol. 2017; 69: 2119-2129
        • Deshmukh A.
        • Sattur S.
        • Bechtol T.
        • Heckman L.I.B.
        • Prinzen F.W.
        • Deshmukh P.
        Sequential His bundle and left ventricular pacing for cardiac resynchronization.
        J Cardiovasc Electrophysiol. 2020; 31: 2448-2454
        • Jastrzebski M.
        • Baranchuk A.
        • Fijorek K.
        • et al.
        Cardiac resynchronization therapy-induced acute shortening of QRS duration predicts long-term mortality only in patients with left bundle branch block.
        Europace. 2021; 21: 281-289
        • Kronborg M.B.
        • Nielsen J.C.
        • Mortensen P.T.
        Electrocardiographic patterns and long-term clinical outcome in cardiac resynchronization therapy.
        Europace. 2010; 12: 216-222
        • Sweeney M.O.
        • Hellkamp A.S.
        • van Bommel R.J.
        • Schalij M.J.
        • Borleffs C.J.
        • Bax J.J.
        QRS fusion complex analysis using wave interference to predict reverse remodeling during cardiac resynchronization therapy.
        Heart Rhythm. 2014; 11: 806-813
        • Huang W.
        • Wu S.
        • Vijayaraman P.
        • et al.
        Cardiac resynchronization therapy in patients with nonischemic cardiomyopathy using left bundle branch pacing.
        JACC Clin Electrophysiol. 2020; 6: 849-858
        • Upadhyay G.A.
        • Cherian T.
        • Shatz D.Y.
        • et al.
        Intracardiac delineation of septal conduction in left bundle branch block patterns: mechanistic evidence of left intra-hisian block circumvented by His pacing.
        Circulation. 2019; 139: 1876-1888
        • Jastrzebski M.
        • Kielbasa G.
        • Curila K.
        • et al.
        Physiology-based electrocardiographic criteria for left bundle branch capture.
        Heart Rhythm. 2021; 18: 935-943