His-bundle and left bundle pacing with optimized atrioventricular delay achieve superior electrical synchrony over endocardial and epicardial pacing in left bundle branch block patients

doi:10.1016/j.hrthm.2020.06.028

Heart Rhythm

Volume 17, Issue 11, November 2020, Pages 1922-1929

https://doi.org/10.1016/j.hrthm.2020.06.028 Get rights and content

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Background

His-bundle pacing (HBP) and left bundle pacing (LBP) are emerging as novel delivery methods for cardiac resynchronization therapy (CRT) in heart failure patients with left bundle branch block (LBBB). HBP and LBP have never been compared to biventricular endocardial (BiV-endo) pacing. Furthermore, there are indications of negative effects of LBP on right ventricular (RV) activation times (ATs), but these effects have not been quantified.

Objective

The purpose of this study was to compare changes in ventricular activation induced by HBP, LBP, left ventricular (LV) septal pacing, BiV-endo, and biventricular epicardial (BiV-epi) pacing using computer simulations.

Methods

We simulated ventricular activation on 24 four-chamber heart meshes inclusive of the His-Purkinje network in the presence of LBBB. We simulated BiV-epi pacing, BiV-endo pacing with left ventricular (LV) lead at the lateral wall, BiV-endo pacing with LV lead at the LV septum, HBP, and LBP.

Results

HBP was superior to BiV-endo and BiV-epi in terms of reduction in LV ATs and interventricular dyssynchrony (P <.05). LBP reduced LV ATs but not interventricular dyssynchrony compared to BiV-epi and BiV-endo pacing. RV latest AT was higher with LBP than with HBP (141.3 ± 10.0 ms vs 111.8 ± 10.4 ms). Optimizing AV delay during LBP reduced RV latest AT (104.7 ± 8.7 ms) and led to comparable response to HBP. In case of complete AV block, BiV-endo septal pacing was equivalent to LBP.

Conclusion

HBP is superior to BiV-epi and BiV-endo. To achieve comparable response to HBP, AV delay optimization during LBP is required in order to reduce RV ATs.

Keywords

Cardiac resynchronization therapy

Heart failure

His-bundle pacing

Left bundle branch block

Left bundle pacing

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: Funding sources: This study received support from the UK Engineering and Physical Sciences Research Council (EP/M012492/1, NS/A000049/1, EP/L015226/1, and EP/P01268X/1), the Wellcome EPSRC Centre for Medical Engineering https://gtr.ukri.org/projects?ref=NS/A000049/1 (NS/A000049/1and WT 203148/Z/16/Z), the British Heart Foundation (PG/15/91/31812 and PG/13/37/30280), and King’s Health Partners London National Institute for Health Research (NIHR) Biomedical Research Centre. Disclosures: Drs Vigmond, Bouyssier, and Dr Plank were supported by the ERA-Net ERACoSysMed Co-Fund 2015 (ANR 15 CMED–0003 01). Drs Vigmond and Dr Bouyssier were supported by the “Investments of the Future” program managed by the National Research Agency (ANR), Grant reference ANR-10-IAHU-04. Miss Marina Strocchi was supported by an unrestricted Abbott educational grant through the Centre for Doctoral Training in Medical Imaging at King’s College London. Dr Neic is employed by NumeriCor GmbH, Graz, Austria. All other authors have reported that they have no conflicts relevant to the contents of this paper to disclose.