Abstract 13774: Comparison of His Bundle Pacing and Bi-Ventricular Pacing in Heart Failure Patients With Atrial Fibrillation Who Need Atrial-Ventricular Node Ablation: The ALTERNATIVE Study

Abstract

Introduction: Cardiac resynchronization therapy typically is attempted with biventricular pacing (BVP). As an alternative to BVP, his bundle pacing (HBP) can maintain electrical and mechanical synchrony in patients with atrial fibrillation (AF) and atrioventricular node ablation (AVNA). However, there is still a lack of prospective randomized studies to compare BVP and HBP. Hypothesis: For patients with heart failure (HF) and AF who need AVNA, HBP is not inferior to traditional BVP. Methods: ALTERNATIVE is a prospective multicenter randomized single blind crossover study. Fifty consecutive AF patients who received BVP or HBP in conjunction with AVNA between March 2016 and February 2019 were enrolled in 6 centers. Patients were implanted with a right apical pacing lead, left ventricular lead, and HBP lead. After successful implant, patients were randomized in single patient-blinded fashion to either HBP or BVP. After 9 months, patients were crossed over to the other pacing modality and followed for another 9 months. Pacing parameters, echocardiographic measurements were obtained at baseline and at each follow-up. Results: Fifty patients were enrolled from 6 centers in this study. 25 received BVP and 25 HBP at first stage. Thirty-eight patients completed the crossover analysis at 18 months. LVEF were significantly improved for both pacing modes compared with baseline (30.93±7.27% vs. 51.29±10.79%, p<0.001 in HBP; 33.43±9.40% vs. 51.94±10.97%, p<0.001 in BVP). HBP was superior to BVP in terms of post-implant QRS duration (103.33±12.00 ms vs. 132.42±15.25 ms). Moreover, HBP can lead to greater improvement in cardiac function than BVP (p<0.001 in LVEDd; p<0.001 in LVEF). Conclusions: HBP can be used as a favorable alternative to BVP in patients with HF and AF after AVNA whose QRS complex is less than 120 ms. Further long-term and large studies are warranted to compare the outcomes between HBP and BVP.