Multicenter Hemodynamic Assessment of the LOT-CRT Strategy: When Does Combining Left Bundle Branch Pacing and Coronary Venous Pacing Enhance Resynchronization?: Primary Results of the CSPOT Study.

IF 9.1 1区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Circulation. Arrhythmia and electrophysiology Pub Date : 2024-11-01 Epub Date: 2024-10-23 DOI:10.1161/CIRCEP.124.013059

Marek Jastrzębski, Paul Foley, Badrinathan Chandrasekaran, Zachary Whinnett, Pugazhendhi Vijayaraman, Gaurav A Upadhyay, Robert D Schaller, Rafał Gardas, Travis Richardson, D'Anne Kudlik, Robert W Stadler, Patrick Zimmerman, James Burrell, Robert Waxman, Richard N Cornelussen, Jonathan Lyne, Bengt Herweg

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Abstract

Background: Left bundle branch area pacing (LBBAP) may be an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT). We sought to compare the acute hemodynamic and ECG effects of LBBAP, BVP, and left bundle-optimized therapy CRT (LOT-CRT) in CRT candidates with advanced conduction disease.

Methods: In this multicenter study, 48 patients with either nonspecific interventricular conduction delay (n=29) or left bundle branch block (n=19) underwent acute hemodynamic testing to determine the change in left ventricular pressure maximal first derivative (LV dP/dt_max) from baseline atrial pacing to BVP, LBBAP, or LOT-CRT.

Results: Atrioventricular-optimized increases in LV dP/dt_max for LOT-CRT (mean, 25.8% [95% CI, 20.9%-30.7%]) and BVP (26.4% [95% CI, 20.2%-32.6%]) were greater than unipolar LBBAP (19.3% [95% CI, 15.0%-23.7%]) or bipolar LBBAP (16.4% [95% CI, 12.7%-20.0%]; P≤0.005). QRS shortening was greater in LOT-CRT (29.5 [95% CI, 23.4-35.6] ms) than unipolar LBBAP (11.9 [95% CI, 6.1-17.7] ms), bipolar LBBAP (11.7 ms [95% CI, 6.4-17.0]), or BVP (18.5 [95% CI, 11.0-25.9] ms), all P≤0.005. Compared with patients with left bundle branch block, patients with interventricular conduction delay experienced less QRS reduction (P=0.026) but similar improvements in LV dP/dt_max (P=0.29). Bipolar LBBAP caused anodal capture in 54% of patients and resulted in less LV dP/dt_max improvement than unipolar LBBAP (18.6% versus 23.7%; P<0.001). Subclassification of LBBAP capture (European Heart Rhythm Association criteria) indicated LBBAP or LV septal pacing in 27 patients (56%) and deep septal pacing in 21 patients (44%). The hemodynamic benefit of adding left ventricular coronary vein pacing to LBBAP depended on baseline QRS duration (P=0.031) and success of LBBAP (P<0.004): LOT-CRT provided 14.5% (5.0%-24.1%) greater LV dP/dt_max improvement and 20.8 (12.8-28.8) ms greater QRS shortening than LBBAP in subjects with QRS ≥171 ms and deep septal pacing capture type.

Conclusions: In a CRT cohort with advanced conduction disease, LOT-CRT and BVP provided greater acute hemodynamic benefit than LBBAP. Subjects with wider QRS or deep septal pacing are more likely to benefit from the addition of a left ventricular coronary vein lead to implement LOT-CRT.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04905290.

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LOT-CRT 策略的多中心血液动力学评估：联合左束支起搏和冠状静脉起搏何时可增强再同步？CSPOT 研究的初步结果。

背景：左束支区起搏（LBBAP）可替代双心室起搏（BVP）用于心脏再同步化治疗（CRT）。我们试图比较 LBBAP、BVP 和左束优化治疗 CRT（LOT-CRT）对患有晚期传导疾病的 CRT 候选者的急性血流动力学和心电图影响：在这项多中心研究中，48 名患有非特异性室间传导延迟（29 人）或左束支传导阻滞（19 人）的患者接受了急性血液动力学测试，以确定从基线心房起搏到 BVP、LBBAP 或 LOT-CRT 期间左心室压力最大一阶导数（LV dP/dtmax）的变化：结果： LOT-CRT（平均值为 25.8% [95% CI, 20.9%-30.7%] ）和 BVP（26.4% [95% CI, 20.2%-32.6%] ）的房室优化 LV dP/dtmax 增幅高于单极 LBBAP（19.3% [95% CI, 15.0%-23.7%] ）或双极 LBBAP（16.4% [95% CI, 12.7%-20.0%]; P≤0.005）。与单极 LBBAP（11.9 [95% CI, 6.1-17.7] ms）、双极 LBBAP（11.7 ms [95% CI, 6.4-17.0] ms）或 BVP（18.5 [95% CI, 11.0-25.9] ms）相比，LOT-CRT 的 QRS 缩短幅度更大（29.5 [95% CI, 23.4-35.6] ms），所有 P 均≤0.005。与左束支传导阻滞患者相比，室间传导延迟患者的 QRS 降低幅度较小（P=0.026），但 LV dP/dtmax 的改善幅度相似（P=0.29）。双极 LBBAP 在 54% 的患者中引起了阳极捕获，与单极 LBBAP 相比，双极 LBBAP 的 LV dP/dtmax 改善较少（18.6% 对 23.7%；PP=0.031），而 LBBAP 的成功率（PP/dtmax 改善和 QRS ≥171 ms 及深室间隔起搏捕获类型受试者的 QRS 缩短比 LBBAP 大 20.8 (12.8-28.8) ms）则更高：结论：在患有晚期传导疾病的 CRT 队列中，LOT-CRT 和 BVP 比 LBBAP 提供了更大的急性血流动力学益处。QRS较宽或室间隔起搏较深的受试者更有可能从添加左心室冠状静脉导联以实施LOT-CRT中获益：URL: https://www.clinicaltrials.gov; Unique identifier：NCT04905290。

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来源期刊

Circulation. Arrhythmia and electrophysiology 医学-心血管系统

CiteScore

13.70

自引率

4.80%

发文量

187

审稿时长

4-8 weeks

期刊介绍： Circulation: Arrhythmia and Electrophysiology is a journal dedicated to the study and application of clinical cardiac electrophysiology. It covers a wide range of topics including the diagnosis and treatment of cardiac arrhythmias, as well as research in this field. The journal accepts various types of studies, including observational research, clinical trials, epidemiological studies, and advancements in translational research.