Background
Atrioventricular nodal ablation (AVNA) combined with biventricular pacing (BVP) improves
outcomes in patients with persistent atrial fibrillation (AF), adequate rate control,
and reduced left ventricular ejection fraction (LVEF). His-bundle pacing (HBP) delivers
physiological ventricular activation and is a promising alternative to BVP.
Objective
The purpose of this trial was to compare HBP with BVP following AVNA.
Methods
In this multicenter, prospective, randomized crossover trial, we recruited patients
with persistent AF and reduced LVEF (≤40%). All patients underwent AVNA and received
both HBP and BVP. Patients were randomized to either HBP or BVP for 9 months (phase
1), then were switched to the alternative pacing modality for the next 9 months (phase
2). The primary endpoint was change in LVEF.
Results
Fifty patients (age 64.3 ± 10.3 years; ventricular rate 93.1 ± 19.9 bpm; 72% male)
were enrolled. Thirty-eight patients completed the 2 phases and were included in the
crossover analysis. A significant improvement in LVEF was observed with HBP compared
to BVP (phase 1: ΔLVEFHBP 21.3% and ΔLVEFBVP 16.7%; phase 2: ΔLVEFHBP 3.5% and ΔLVEFBVP –2.4%; Pgeneralized additive model = 0.015). Significant improvements in left ventricular end-diastolic diameter, New
York Heart Association functional class, and B-type natriuretic peptide level were
observed with both pacing modalities compared with baseline, whereas no significant
differences were observed between HBP and BVP.
Conclusion
HBP delivers a modest but significant improvement in LVEF in patients with persistent
AF, impaired ventricular function, and narrow QRS duration post-AVNA compared with
BVP. Larger long-term trials are required to confirm the additional improvements in
function with HBP.
Graphical abstract
Graphical Abstract
Keywords
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Article info
Publication history
Published online: July 13, 2022
Footnotes
Funding Sources: This work was supported by Key Research and Development Program of Zhejiang, China (2019C03012).
Disclosures: Dr Whinnett reports consultant and speaker fees from Medtronic; serving as a consultant for Boston Scientific; and serving on the advisory board of Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. ClinicalTrials.gov Identifier: NCT02805465.
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Copyright
© 2022 Published by Elsevier Inc. on behalf of Heart Rhythm Society.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Advancing alternatives for atrial fibrillation in heart failure: Ablate and pace is backHeart RhythmVol. 19Issue 12
- PreviewThe physiological pacing movement continues its rapid evolution, perhaps faster than any other advances in the field of electrophysiology over the past 5 years. While stimulation and recruitment of the intrinsic conduction system is intuitive, teleological, and physiologically compelling, the mounting evidence still lags behind the enthusiasm that is driving widespread clinical adoption. Single-arm feasibility registries populate the literature, and comparative studies between His bundle pacing (HBP) and conventional biventricular pacing (BiV) are few to date.
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