Comparison of Left Bundle Branch Area Pacing and Biventricular Pacing in Candidates for Resynchronization Therapy

Authors, Journal, Affiliations, Type, DOI

• Authors: Pugazhendhi Vijayaraman, Parikshit S. Sharma, Óscar Cano, Shunmuga Sundaram Ponnusamy, Bengt Herweg, Francesco Zanon, Marek Jastrzebski, Jiangang Zou, Mihail G. Chelu, Kevin Vernooy, Zachary I. Whinnett, Girish M. Nair, Manuel Molina-Lerma, Karol Curila, Dipen Zalavadia, Abdul Haseeb, Cicely Dye, Sharath C. Vipparthy, Ryan Brunetti, Pawel Moskal, Alexandra Ross, Antonius van Stipdonk, Jerin George, Yusuf K. Qadeer, Mishal Mumtaz, Jeffrey Kolominsky, Syeda A. Zahra, Mehrdad Golian, Lina Marcantoni, Faiz A. Subzposh, Kenneth A. Ellenbogen
• Journal: Journal of the American College of Cardiology 2023;82(3):228–241
• Affiliations: 15 international centres in North America, Asia and Europe, including Geisinger Heart Institute, Rush University, Hospital Universitari i Politècnic La Fe, Velammal Medical College, USF Morsani, Santa Maria della Misericordia, Jagiellonian University, Nanjing Medical University, Baylor College of Medicine/Texas Heart Institute, Maastricht UMC, Imperial College, University of Ottawa Heart Institute, Hospital Universitario Virgen de las Nieves, Charles University, University Hospital in Krakow, VCU Medical Center
• Type: Retrospective, multicentre, observational case-control study
• DOI: 10.1016/j.jacc.2023.05.006

Overview

This is the foundational large observational comparison of LBBAP and BVP in 1,778 patients with LVEF ≤35% and a CRT indication, treated at 15 centres between 2018 and 2022. LBBAP was associated with a significant reduction in the composite of death or heart failure hospitalisation (21% vs 28%; adjusted HR 1.495 for BVP vs LBBAP), driven by fewer heart failure hospitalisations, with no significant mortality difference after adjustment. LBBAP produced narrower paced QRS (128 vs 144 ms), greater LVEF improvement (+13% vs +10%), higher echocardiographic response (73.9% vs 65.4%) and hyper-response (33.9% vs 25.1%) rates, and fewer procedural complications (3.8% vs 7.5%). In the LBBB subgroup the HFH benefit was larger (9% vs 19%; HR 2.158). The paper supplied the LVEF <35% cohort later combined with the HFmrEF cohort in the I-CLAS ≤50% analysis.

Keywords

Biventricular pacing, cardiac resynchronization therapy, heart failure hospitalization, left bundle branch area pacing, mortality

Key Takeaways

Population

• 1,778 patients: BVP 981, LBBAP 797; January 2018–June 2022.
• Inclusion: NYHA II–IV, LVEF ≤35%, CRT indication or expected ventricular pacing >40%.
• Mean age 69 ± 12 years; 32% women; mean LVEF 27% ± 6%; mean QRS 160 ± 26 ms; LBBB (Strauss) 61%.
• Ischaemic cardiomyopathy 36%, non-ischaemic 58%, mixed 6%.
• Baseline imbalance: BVP group had more ischaemic cardiomyopathy and more LBBB; otherwise well matched.
• Among LBBAP patients, 144 (18%) also received a coronary sinus lead — 69 (8.6%) as LOT-CRT and 75 (9.4%) as a back-up LV lead.
• Mean follow-up 33 ± 16 months.

Procedural outcomes

• Procedure duration longer with LBBAP: 142 ± 55 vs 124 ± 48 min (P < .001); fluoroscopy similar (17 ± 15 vs 16 ± 12 min).
• Paced QRS narrower with LBBAP: 128 ± 19 vs 144 ± 23 ms (P < .001).
• Capture threshold lower with LBBAP: 0.72 ± 0.4 V vs 1.15 ± 0.7 V at implant (P < .001).
• Threshold rise ≥1 V: 1.6% LBBAP vs 7.3% BVP (P < .001).
• Lead revision: 3.6% vs 4.9% (P = .20).
• Procedural complications: 3.8% LBBAP vs 7.5% BVP (P < .001).
• More LBBAP patients received pacemakers (33% vs 15%) and fewer received ICDs (67% vs 85%).

Clinical outcomes

• Primary composite (death or HFH): 21% LBBAP (166/797) vs 28% BVP (275/981); multivariable HR 1.495 for BVP vs LBBAP (95% CI 1.213–1.842), P < .001.
• HFH: 12% vs 19%; HR 1.494 (95% CI 1.159–1.927), P = .002; competing-risk analysis confirmed the benefit (HR 1.49).
• All-cause mortality: 12% vs 17%; adjusted HR 1.144 (95% CI 0.881–1.485), P = .313 — not significant.
• In LBBB (n = 1,073): composite 17% vs 26%; HR 1.543 (95% CI 1.150–2.071), P = .004.
• In LBBB, HFH 9% vs 19%; HR 2.158 (95% CI 1.487–3.132), P < .001; mortality 10% vs 14% (P = .41).
• NYHA improvement ≥1 class: 64% LBBAP vs 47% BVP (P < .001).
• Excluding the 69 LOT-CRT patients did not change the primary or secondary results.

Echocardiographic outcomes

• Echo follow-up available in 1,424 patients (80%).
• LVEF: LBBAP 27.5% ± 6.2% → 40.4% ± 13.3%; BVP 26.6% ± 6.4% → 36.6% ± 12.5% (both P < .001 vs baseline).
• Change in LVEF: +13% ± 12% vs +10% ± 12% (P < .001).
• In LBBB: +15.3% ± 12.0% vs +10.8% ± 12.0% (P < .001).
• Echocardiographic response (≥5% LVEF gain): 73.9% vs 65.4%; adjusted OR 1.604 (P < .001); in LBBB 81.7% vs 68.2% (OR 1.932).
• Hyper-response (LVEF ≥50% or ≥20-point gain): 33.9% vs 25.1% (OR 1.678); in LBBB 42.1% vs 28.5% (OR 1.771).

Limitations of the document

• Retrospective, non-randomised, on-treatment analysis. Treatment was assigned by operator/institution; the true success rates of each strategy were not analysed.
• Baseline differences — more ischaemic cardiomyopathy and LBBB in the BVP group; residual confounding is possible despite multivariable adjustment.
• Centre-level clustering — 6 centres used BVP first, 5 used LBBAP first, and 4 varied by operator, so results may reflect institutional expertise.
• Echocardiography was not blinded or core-laboratory adjudicated.
• The composite benefit is driven by HFH, not mortality; the adjusted mortality HR was non-significant.
• 18% of LBBAP patients also received a coronary sinus lead, so the LBBAP arm is not a pure single-lead strategy.
• Observational follow-up (mean 33 months) with censoring at a fixed date.
• Industry conflicts are extensive, including Medtronic honoraria, consultancy and research support for multiple authors; one author holds a His-bundle pacing delivery-tool patent.

Key Concepts Mentioned

• concepts/Left-Bundle-Branch-Area-Pacing — the intervention
• concepts/Cardiac-Resynchronization-Therapy — the clinical context
• concepts/Cardiac-Resynchronization-Therapy — the comparator
• entities/Heart-Failure — the population
• concepts/LOT-CRT — the hybrid strategy used in a subset
• concepts/Cardiac-Resynchronization-Therapy — the response metric

Key Entities Mentioned

• International LBBAP Collaborative Study Group — the multicentre consortium
• Geisinger Heart Institute — coordinating centre
• Medtronic, Abbott, Boston Scientific, Biotronik — device manufacturers

Wiki Pages Updated

• Created: wiki/sources/lbbap-crt-jacc-2023.md
• Updated: wiki/concepts/Left-Bundle-Branch-Area-Pacing.md
• Updated: wiki/concepts/Cardiac-Resynchronization-Therapy.md
• Updated: wiki/entities/CRT.md
• Updated: wiki/sourceindex.md
• Updated: log.md