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Usefulness of His Bundle Pacing to Achieve Electrical Resynchronization in Patients With Complete Left Bundle Branch Block and the Relation Between Native QRS Axis, Duration, and Normalization.

ABSTRACT: His Bundle pacing (HBP) restores electrical synchronization in left bundle branch block (LBBB); however, the underlying mechanisms are poorly understood. We examined the relation between native QRS axis in LBBB, a potential indicator of the site of block, and QRS normalization in patients with LBBB. Data from patients (n = 41) undergoing HBP at 3 sites were studied (68 ± 13 years, 13 women). Study criteria included strictly defined complete LBBB and successful implantation of a permanent HBP lead. Preprocedure and postprocedure electrocardiograms were reviewed independently by 2 blinded readers. QRS axis and duration were measured to the nearest 10° and 10 ms, respectively. QRS narrowing or normalization was the primary end point. Of 29 patients meeting study criteria, 9 had frontal plane QRS axes between -60° and -80°, 10 from -40° to 0°, and 10 from +1° to +90°. QRS narrowing occurred in 24 patients (83%, 44 ± 34 ms, p <0.05). Percent QRS narrowing by axis were 26 ± 19%, 29 ± 25%, and 28 ± 23%, respectively. No correlation between prepacing QRS axis and postpacing narrowing was identified (r(2) = 0.001, p = 0.9). In patients with or without QRS normalization after HBP, mean QRS duration was 155 ± 21 vs 171 ± 8 ms, respectively, p = 0.014. HBP induces significant QRS narrowing in most patients and normalization in patients with shorter baseline QRS duration. In conclusion, the lack of correlation between native QRS axis and narrowing suggests that proximal His-Purkinje block causes most cases of LBBB, or that additional mechanisms underlie HBP efficacy. Further studies are needed to better understand how to predict those patients in whom HBP will normalize LBBB.

SUBMITTER: Teng AE

PROVIDER: S-EPMC4976011 | biostudies-other | 2016 Aug

REPOSITORIES: biostudies-other

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Project description:Cardiac dyssynchrony is the proposed mechanism for pacemaker-induced cardiomyopathy, which can be prevented by biventricular pacing. Left bundle branch pacing and His bundle pacing are novel interventions that imitate the natural conduction of the heart with, theoretically, less interventricular dyssynchrony. One of the surrogate markers of interventricular synchrony is QRS duration. Our study aimed to compare the change of QRS duration before and after implantation between types of cardiac implantable electronic devices (CIEDs): left bundle branch pacing versus His bundle pacing versus biventricular pacing and conventional right ventricular pacing. A literature search for studies that reported an interval change of QRS duration after CIED implantation was conducted utilizing the MEDLINE, EMBASE, and Cochrane databases. All relevant works from database inception through November 2020 were included in this analysis. A random-effects model, Bayesian network meta-analysis was used to analyze QRS duration changes (eg, electrical cardiac synchronization) across different CIED implantations. The mean study sample size, from 14 included studies, was 185 subjects. The search found 707 articles. After exclusions, 14 articles remained with 2,054 patients. The His bundle pacing intervention resulted in the most dramatic decline in QRS duration (mean difference, - 53 ms; 95% CI - 67, - 39), followed by left bundle branch pacing (mean difference, - 46 ms; 95% CI - 60, - 33), and biventricular pacing (mean difference, - 19 ms; 95% CI - 37, - 1.8), when compared to conventional right ventricle apical pacing. When compared between LBBP and HBP, showed no statistically significant wider QRS duration in LBBP with mean different 6.5 ms. (95% CI - 6.7, 21). Our network meta-analysis found that physiologic pacing has the greatest effect on QRS duration after implantation. Thus, HBP and LBBP showed no significant difference between QRS duration after implantation. Physiologic pacing interventions result in improved electrocardiography markers of cardiac synchrony, narrower QRS duration, and might lower electromechanical dyssynchrony.

Project description:BackgroundAlthough right ventricular pacing (RVP) is recommended by most of the guidelines for atrioventricular block, it can cause electrical and mechanical desynchrony, impair left ventricular function, and increase the risk of atrial fibrillation. Recently, the His-Purkinje system pacing, including His bundle pacing (HBP) and left bundle branch pacing (LBBP), has emerged as a physiological pacing modality. However, few studies have compared their efficacy and safety in atrioventricular block (AVB).Methods and resultsThe PubMed, Web of Science, Cochrane Library, and ScienceDirect databases were searched for observational studies and randomized trials of patients with atrioventricular block requiring permanent pacing, from database inception until 10 January 2022. The primary outcomes were complications and heart failure hospitalization. The secondary outcomes included changes in left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter (LVEDD), pacing parameters, procedure duration, and success rate. After extracting the data at baseline and the longest follow-up duration available, a pairwise meta-analysis and a Bayesian random-effects network meta-analysis were performed. Odds ratios (ORs) with 95% confidence intervals (CIs) or 95% credible intervals (CrIs) were calculated for dichotomous outcomes, whereas mean differences (MDs) with 95% CIs or 95% CrIs were calculated for continuous outcomes. Seven studies and 1,069 patients were included. Overall, 43.4% underwent LBBP, 33.5% HBP, and 23.1% RVP. Compared with RVP, LBBP and HBP were associated with a shorter paced QRS duration and a more preserved LVEF. HBP significantly increased the pacing threshold and reduced the R-wave amplitude. There was no difference in the risk of complications or the implant success rate. The pacing threshold remained stable during follow-up for the three pacing modalities. The pacing impedance was significantly reduced in HBP, while a numerical but non-significant pacing impedance decrease was observed in both LBBP and RVP. LBBP was associated with an increased R-wave amplitude during follow-up.ConclusionIn this systematic review and network meta-analysis, HBP and LBBP were superior to RVP in paced QRS duration and preservation of LVEF for patients with atrioventricular block. LBBP was associated with a lower pacing threshold and a greater R-wave amplitude than HBP. However, the stability of the pacing output of LBBP may be a concern. Further investigation of the long-term efficacy in left ventricular function and the risk of heart failure hospitalization is needed.Systematic review registration[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=315046], identifier [CRD42022315046].

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Usefulness of His Bundle Pacing to Achieve Electrical Resynchronization in Patients With Complete Left Bundle Branch Block and the Relation Between Native QRS Axis, Duration, and Normalization.

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