Abstract
Left bundle branch area pacing (LBBAP) has shown potential to be an alternative to biventricular pacing (BiVP) in patients with indications for cardiac resynchronization therapy (CRT). However, few studies focused on the long-term clinical outcomes of LBBAP versus BiVP. This prospective observational study aimed to compare long-term clinical outcomes and complications between LBBAP and BiVP. Consecutive patients with left ventricular ejection fraction (LVEF) <50% and CRT indications were enrolled and prospectively followed up at device clinic if they received successful LBBAP or BiVP from Jan. 2019 to Dec. 2020 at two centers. The primary endpoint was the composite outcomes of all-cause death or heart failure hospitalization (HFH). Secondary endpoints included the occurrence of death, or HFH, or malignant ventricular arrhythmias (VAs). The safety endpoints were device-related complications. Pacing parameters and cardiac function were routinely tracked. A total of 259 patients (mean age 63 ± 11 years, male 65.6%, LVEF 30.4% ± 6.9%) were enrolled, including 106 cases with LBBAP and 153 with BiVP. The paced QRS duration of LBBAP was significantly shorter than that of BiVP (137.3 ± 27.8 ms vs. 148.8 ± 22.1 ms, p<0.001). During the median follow-up of 27 months, LBBAP achieved a higher LVEF improvement from baseline (12.8 ± 12.3% vs. 9.81 ± 12.7%, p=0.043) and similar echo response or super response as compared with BiVP. The risk of the primary endpoint was significantly decreased by 42% in patients with LBBAP than those with BiVP [21.7% vs. 41.2%, adjusted hazard ratio (aHR) 0.58; 95% confidence interval (CI) 0.35–0.98; p=0.041], which was primarily driven by significantly reduced events of HFH after LBBAP treatment [16.0% vs. 36.6%, aHR (95%CI): 0.49 (0.28, 0.85), p=0.012]. The events of all-cause death or malignant VAs were comparable between two groups. Subgroup analysis revealed that patients with left bundle branch block (LBBB) benefited more from LBBAP [aHR (95%CI): 0.35 (0.17, 0.73), p=0.005] than those with non-LBBB or narrow QRS (p for interaction=0.005). The device-related complications were lower in the LBBAP than BiVP group (3.8% vs. 13.1%, p=0.005), mainly due to lead-related complications (1.9% vs. 11.1%, p<0.001). The long-term clinical outcomes of LBBAP for HF treatment might be superior to BiVP with reduced HFH events and lead-related complications in patients with indications for CRT.
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