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Improved all-cause mortality with left bundle branch area pacing compared to biventricular pacing in cardiac resynchronization therapy: a meta-analysis

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Abstract

Background

Left bundle branch area pacing (LBBAP) has emerged as a physiological alternative pacing strategy to biventricular pacing (BIVP) in cardiac resynchronization therapy (CRT). We aimed to assess the impact of LBBAP vs. BIVP on all-cause mortality and heart failure (HF)-related hospitalization in patients undergoing CRT.

Methods

Studies comparing LBBAP and BIVP for CRT in patients with HF with reduced left ventricular ejection fraction (LVEF) were included. The coprimary outcomes were all-cause mortality and HF-related hospitalization. Secondary outcomes included procedural and fluoroscopy time, change in QRS duration, and change in LVEF.

Results

Thirteen studies (12 observational and 1 RCT, n = 3239; LBBAP = 1338 and BIVP = 1901) with a mean follow-up duration of 25.8 months were included. Compared to BIVP, LBBAP was associated with a significant absolute risk reduction of 3.2% in all-cause mortality (9.3% vs 12.5%, RR 0.7, 95% CI 0.57–0.86, p < 0.001) and an 8.2% reduction in HF-related hospitalization (11.3% vs 19.5%, RR 0.6, 95% CI 0.5–0.71, p < 0.00001). LBBAP also resulted in reductions in procedural time (mean weighted difference− 23.2 min, 95% CI − 42.9 to − 3.6, p = 0.02) and fluoroscopy time (− 8.6 min, 95% CI − 12.5 to − 4.7, p < 0.001) as well as a significant reduction in QRS duration (mean weighted difference:− 25.3 ms, 95% CI − 30.9 to − 19.8, p < 0.00001) and a greater improvement in LVEF of 5.1% (95% CI 4.4–5.8, p < 0.001) compared to BIVP in the studies that reported these outcomes.

Conclusion

In this meta-analysis, LBBAP was associated with a significant reduction in all-cause mortality as well as HF-related hospitalization when compared to BIVP. Additional data from large RCTs is warranted to corroborate these promising findings.

Graphical abstract

LBBP, left bundle branch area pacing; BIVP, biventricular pacing; RRR, relative risk reduction; ARR, absolute risk reduction; ms, milliseconds; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; min, minutes

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Abbreviations

ARR:

Absolute risk reduction

BIVP:

Biventricular pacing

CRT:

Cardiac resynchronization therapy

CSP:

Conduction system pacing

HF:

Heart failure

HR:

Hazard ratio

NICM:

Non-ischemic cardiomyopathy

IQR:

Interquartile range

LBBAP:

Left bundle branch area pacing

LBBB:

Left bundle branch block

LV:

Left ventricle/left ventricular

LVAT:

Left ventricular activation time

LVEF:

Left ventricular ejection fraction

NYHA:

New York Heart Association

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Authors and Affiliations

  1. Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Clinica Las Vegas, Universidad CES Medical School, Medellin, Colombia

    Juan Carlos Diaz

  2. Cardiac Arrhythmia Service, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA

    Mohamed Gabr, Usha B. Tedrow, Bruce A. Koplan, Carolina Hoyos, Carlos D. Matos, Daniela Hincapie, Isabella Alviz, Nathaniel A. Steiger, Sunil Kapur, Thomas M. Tadros, Paul C. Zei, William H. Sauer & Jorge E. Romero

  3. Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Hospital San Vicente Fundacion, Rionegro, Colombia

    Mauricio Duque & Julian Aristizabal

  4. Cardiac Arrhythmia and Electrophysiology Service, Department of Medicine, Division of Cardiology, Clinica Las Americas, Medellin, Colombia

    Jorge Marin

  5. Cardiac Arrhythmia and Electrophysiology Service, Clinica SOMER, Rionegro, Colombia

    Cesar Niño

  6. Cardiac Arrhythmia and Electrophysiology Service, Hospital Pablo Tobon Uribe, Medellin, Colombia

    Oriana Bastidas

  7. Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Kevin Pacheco-Barrios

  8. Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación Para La Generación y Síntesis de Evidencias en Salud, Lima, Peru

    Kevin Pacheco-Barrios

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Correspondence to Jorge E. Romero.

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Dr. Diaz has received speaker honoraria and is a proctor for Medtronic for left bundle branch area pacing. The remaining authors report no conflicts of interest.

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Juan Carlos Diaz and Mohamed Gabr contributed equally to the manuscript.

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Diaz, J.C., Gabr, M., Tedrow, U.B. et al. Improved all-cause mortality with left bundle branch area pacing compared to biventricular pacing in cardiac resynchronization therapy: a meta-analysis. J Interv Card Electrophysiol (2024). https://doi.org/10.1007/s10840-024-01785-z

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