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Frontiers in Cardiovascular Medicine 2022As a novel physiological pacing technique, left bundle branch pacing (LBBP) can preserve the left ventricular (LV) electrical and mechanical synchronization by directly... (Review)
Review
BACKGROUND
As a novel physiological pacing technique, left bundle branch pacing (LBBP) can preserve the left ventricular (LV) electrical and mechanical synchronization by directly capturing left bundle branch (LBB). Approximately 60-90% of LBBP were confirmed to have captured LBB during implantation, implying that up to one-third of LBBP is actually left ventricular septal pacing (LVSP). LBB capture is critical for distinguishing LBBP from LVSP.
METHODS AND RESULTS
A total of 15 articles were included in the analysis by searching PubMed, EMBASE, Web of Science, and the Cochrane Library database till August 2022. Comparisons of paced QRS duration between LVSP and LBBP have not been uniformly concluded, but the stimulus artifact to LV activation time in lead V5 or V6 (Stim-LVAT) was shorter in LBBP than LVSP in all studies. Stim-LVAT was used to determine LBB capture with a sensitivity of 76-95.2% and specificity of 78.8-100%, which varied across patient populations.
CONCLUSION
The output-dependent QRS transition from non-selective LBBP to selective LBBP or LVSP is direct evidence of LBB capture. LBB potential combined with short Stim-LVAT can predict LBB capture better. Personalized criteria rather than a fixed value of Stim-LVAT are necessary to confirm LBB capture in different populations, especially in patients with LBB block or heart failure.
PubMed: 36247445
DOI: 10.3389/fcvm.2022.1006966 -
CJC Open Oct 2021Real-world data on the use of left bundle branch area pacing (LBBAP) as an alternative novel pacing strategy to biventricular pacing (BVP) for cardiac resynchronization... (Review)
Review
BACKGROUND
Real-world data on the use of left bundle branch area pacing (LBBAP) as an alternative novel pacing strategy to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT) remains scarce. We aimed to investigate the outcomes of LBBAP as an alternative to BVP as a method of CRT.
METHODS
Electronic databases were searched for studies on the use of LBBAP as CRT and studies that compared LBBAP with BVP. The main outcomes examined were changes in New York Heart Association classification, left ventricular end-diastolic diameter, left ventricular ejection fraction, and paced QRS duration post CRT device implantation.
RESULTS
Our meta-analysis included 8 nonrandomized studies with a total of 527 patients who underwent LBBAP as CRT. In studies with a BVP comparison group, patients with LBBAP had a greater reduction in paced QRS (mean difference [MD], 27.91 msec; 95% confidence interval [CI], 22.33-33.50), and a greater improvement in New York Heart Association class (MD, 0.59; 95% CI, 0.28-0.90) and left ventricular ejection fraction (MD, 6.77%; 95% CI, 3.84-9.71). Patients with underlying left bundle branch block appeared to benefit the most from LBBAP compared with patients without underlying left bundle branch block.
CONCLUSIONS
LBBAP might be a reasonable option for patients who meet indications for CRT, particularly in those who have limited anatomy or do not benefit from CRT. Randomized trials are needed to compare LBBAP with BVP for CRT and to identify which populations might benefit the most from LBBAP.
PubMed: 34888508
DOI: 10.1016/j.cjco.2021.05.019 -
Heart Rhythm O2 Nov 2023Left bundle branch area pacing (LBBAP) may offer greater physiological benefits than traditional biventricular pacing (BiVP). However, there are limited data comparing...
BACKGROUND
Left bundle branch area pacing (LBBAP) may offer greater physiological benefits than traditional biventricular pacing (BiVP). However, there are limited data comparing the efficacy of LBBAP vs BiVP in patients with systolic heart failure (HF).
OBJECTIVE
The purpose of this meta-analysis was to compare the feasibility and electromechanical and clinical outcomes of both LBBAP and BiVP.
METHODS
We conducted a systematic review of studies retrieved from various databases including PubMed, Embase, Google Scholar, Scopus, and Cochrane Central Register of Control Trials (CENTRAL) published up to May 22, 2023. The risk ratio (RR) and standardized mean difference (SMD) with corresponding 95% confidence intervals (CIs) were calculated for dichotomous and continuous outcomes, respectively.
RESULTS
We included 12 studies with a total of 3004 patients (LBBAP = 1242, BiVP = 1762). Pooled results showed that LBBAP resulted in a significant increase in left ventricular ejection fraction (SMD 0.40, 95% CI 0.25, 0.54, .00001), echocardiographic response (RR 1.19, 95% CI 1.10 to 1.29, .0001), improvement in New York Heart Association functional class (SMD -0.44, 95% CI -0.65 to -0.23, .0001), QRS duration reduction (SMD -0.90, 95% CI -1.14 to -0.66, .00001), left ventricular end-diastolic diameter reduction (SMD -0.31, 95% CI -0.57 to -0.05, .02), fewer HF hospitalizations (RR 0.72, 95% CI 0.62, 0.85, .0001), and improved survival (RR 0.73, 95% CI 0.58, 0.92, .007). In addition, LBBAP was associated with shorter fluoroscopy time (SMD -0.94, 95% CI -1.42 to -0.47, .0001) and lower pacing threshold at implantation (SMD -1.03, 95% CI -1.32 to -0.74, .00001) and at 6 months (SMD -1.44, 95% CI -2.11 to -0.77, .0001) as compared with BiVP.
CONCLUSION
Compared with BiVP, LBBAP was associated with better electromechanical and clinical outcomes, including left ventricular ejection fraction, QRS duration, echocardiographic response, New York Heart Association functional class, HF hospitalization, and all-cause mortality in patients with systolic HF.
PubMed: 38034886
DOI: 10.1016/j.hroo.2023.06.011 -
Frontiers in Medicine 2022To evaluate the evidence regarding the prevalence and risk of bundle branch block (BBB), atrioventricular block (AVB) and pacemaker implantation (PMI) in patients with...
OBJECTIVE
To evaluate the evidence regarding the prevalence and risk of bundle branch block (BBB), atrioventricular block (AVB) and pacemaker implantation (PMI) in patients with spondyloarthritis compared to a control group without spondyloarthritis.
METHODS
A systematic review of the literature was performed using Pubmed (Medline), EMBASE (Elsevier) and Cochrane Library (Wiley) databases until December 2021. The prevalence and risk for AVB, BBB and PMI were analyzed. Cohort, case control and cross-sectional studies in patients ≥18 years meeting the classification criteria for spondyloarthritis were included. The Odds ratio (OR), risk ratio (RR), or Hazard ratio (HR) and prevalence difference were considered as outcomes. Data was synthesized in a previously defined extraction form which included a risk of bias assessment using the Newcastle-Ottawa Scale.
RESULTS
In total, eight out of 374 studies were included. None of the studies provided results regarding the risk of low grade AVB and BBB in SpA patients. Only indirect results comparing prevalences from low to medium quality studies were found. According to population based registries, the sex and age adjusted HR of AVB was 2.3 (95% CI 1.6-3.3) in ankylosing spondylitis, 2.9 (95% CI 1.8-4.7) in undifferentiated spondyloarthritis and 1.5 (95% CI 1.1 a 1.9) in psoriatic arthritis. The absolute risk for AVB was 0.4% (moderate to high; 95% CI 0.34%-0.69%) for AS, 0.33% (moderate to high; 95% CI 0.21%-0.53%) for uSpA and 0.34% (moderate to high; 95% CI 0.26%-0.45%) for PsA.The RR for PMI in AS patients was 1.3 (95% CI 1.16-1.46) for groups aged between 65 and 69 years, 1.33 (95% CI 1.22-1.44) for 70-75 years, 1.24 (95% CI 1.55-1.33) for 75-79 years and 1.11 (95% CI 1.06-1.17) for groups older than 80 years. The absolute risk for PMI in AS patients was 0.7% (moderate to high risk; 95% CI 0.6-0.8%) for groups aged between 65-69, 1.44% (high risk; 95% CI 1.33-1.6%) for 70-75 years, 2.09% (high risk; 95% CI 2.0-2.2%) for 75-79 years and 4.15% (high risk; 95% CI 4.0-4.3%) for groups older than 80 years.
CONCLUSIONS
Very few cases of low grade AVB and BBB were observed in observational studies. No study evaluated association measures for low grade AVB and BBB but the differences of prevalence were similar in SpA and control groups even though studies lacked the power to detect statistical differences. According to population based registries there was an approximately two fold-increased risk of high grade AVB in SpA patients. RR for PMI was higher in younger age groups.
PubMed: 35402464
DOI: 10.3389/fmed.2022.851483 -
Frontiers in Cardiovascular Medicine 2022Although right ventricular pacing (RVP) is recommended by most of the guidelines for atrioventricular block, it can cause electrical and mechanical desynchrony, impair...
A systematic review and Bayesian network meta-analysis comparing left bundle branch pacing, his bundle branch pacing, and right ventricular pacing for atrioventricular block.
BACKGROUND
Although right ventricular pacing (RVP) is recommended by most of the guidelines for atrioventricular block, it can cause electrical and mechanical desynchrony, impair left ventricular function, and increase the risk of atrial fibrillation. Recently, the His-Purkinje system pacing, including His bundle pacing (HBP) and left bundle branch pacing (LBBP), has emerged as a physiological pacing modality. However, few studies have compared their efficacy and safety in atrioventricular block (AVB).
METHODS AND RESULTS
The PubMed, Web of Science, Cochrane Library, and ScienceDirect databases were searched for observational studies and randomized trials of patients with atrioventricular block requiring permanent pacing, from database inception until 10 January 2022. The primary outcomes were complications and heart failure hospitalization. The secondary outcomes included changes in left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter (LVEDD), pacing parameters, procedure duration, and success rate. After extracting the data at baseline and the longest follow-up duration available, a pairwise meta-analysis and a Bayesian random-effects network meta-analysis were performed. Odds ratios (ORs) with 95% confidence intervals (CIs) or 95% credible intervals (CrIs) were calculated for dichotomous outcomes, whereas mean differences (MDs) with 95% CIs or 95% CrIs were calculated for continuous outcomes. Seven studies and 1,069 patients were included. Overall, 43.4% underwent LBBP, 33.5% HBP, and 23.1% RVP. Compared with RVP, LBBP and HBP were associated with a shorter paced QRS duration and a more preserved LVEF. HBP significantly increased the pacing threshold and reduced the R-wave amplitude. There was no difference in the risk of complications or the implant success rate. The pacing threshold remained stable during follow-up for the three pacing modalities. The pacing impedance was significantly reduced in HBP, while a numerical but non-significant pacing impedance decrease was observed in both LBBP and RVP. LBBP was associated with an increased R-wave amplitude during follow-up.
CONCLUSION
In this systematic review and network meta-analysis, HBP and LBBP were superior to RVP in paced QRS duration and preservation of LVEF for patients with atrioventricular block. LBBP was associated with a lower pacing threshold and a greater R-wave amplitude than HBP. However, the stability of the pacing output of LBBP may be a concern. Further investigation of the long-term efficacy in left ventricular function and the risk of heart failure hospitalization is needed.
SYSTEMATIC REVIEW REGISTRATION
[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=315046], identifier [CRD42022315046].
PubMed: 36386361
DOI: 10.3389/fcvm.2022.939850 -
Medicine Jul 2021Right ventricular pacing (RVP) has been widely accepted as a traditional pacing strategy, but long-term RVP has detrimental impact on ventricular synchrony. However,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Right ventricular pacing (RVP) has been widely accepted as a traditional pacing strategy, but long-term RVP has detrimental impact on ventricular synchrony. However, left bundle branch pacing (LBBP) that evolved from His-bundle pacing could maintain ventricular synchrony and overcome its clinical deficiencies such as difficulty of lead implantation, His bundle damage, and high and unstable thresholds. This analysis aimed to appraise the clinical safety and efficacy of LBBP.
METHODS
The Medline, PubMed, Embase, and the Cochrane Library databases from inception to November 2020 were searched for studies comparing LBBP and RVP.
RESULTS
Seven trials with 451 patients (221 patients underwent LBBP and 230 patients underwent RVP) were included in the analysis. Pooled analyses verified that the paced QRS duration (QRSd) and left ventricular mechanical synchronization parameters of the LBBP capture were similar with the native-conduction mode (P > .7),but LBBP showed shorter QRS duration (weighted mean difference [WMD]: -33.32; 95% confidence interval [CI], -40.44 to -26.19, P < .001), better left ventricular mechanical synchrony (standard mean differences: -1.5; 95% CI: -1.85 to -1.14, P < .001) compared with RVP. No significant differences in Pacing threshold (WMD: 0.01; 95% CI: -0.08 to 0.09, P < .001), R wave amplitude (WMD: 0.04; 95% CI: -1.12 to 1.19, P = .95) were noted between LBBP and RVP. Ventricular impedance of LBBP was higher than that of RVP originally (WMD: 19.34; 95% CI: 3.13-35.56, P = .02), and there was no difference between the 2 groups after follow-up (WMD: 11.78; 95% CI: -24.48 to 48.04, P = .52). And follow-up pacing threshold of LBBP kept stability (WMD: 0.08; 95% CI: -0.09 to 0.25, P = .36). However, no statistical difference existed in ejection fraction between the 2 groups (WMD: 1.41; 95% CI: -1.72 to 4.54, P = .38).
CONCLUSIONS
The safety and efficacy of LBBP was firstly verified by meta-analysis to date. LBBP markedly preserve ventricular electrical and mechanical synchrony compared with RVP. Meanwhile, LBBP had stable and excellent pacing parameters. However, LBBP could not be significant difference in ejection fraction between RVP during short- term follow-up.
Topics: Bundle of His; Bundle-Branch Block; Cardiac Pacing, Artificial; Electrocardiography; Heart Rate; Heart Ventricles; Humans; Treatment Outcome; Ventricular Function, Left
PubMed: 34232199
DOI: 10.1097/MD.0000000000026560 -
Frontiers in Cardiovascular Medicine 2022Left bundle branch block (LBBB) is a common complication of the transcatheter aortic valve replacement (TAVR), and its impact on prognosis is controversial.
Prognostic Outcome of New-Onset Left Bundle Branch Block After Transcatheter Aortic Valve Replacement in Patients With Aortic Stenosis: A Systematic Review and Meta-Analysis.
BACKGROUND
Left bundle branch block (LBBB) is a common complication of the transcatheter aortic valve replacement (TAVR), and its impact on prognosis is controversial.
METHODS
A comprehensive electronic search was conducted in databases (PubMed, Embase, Cochrane Library, and The Web of Science), from the date of database establishment till March 2021, to screen for studies on new-onset LBBB after TAVR. We next performed a meta-analysis to evaluate the effect of new-onset LBBB after TAVR on patient prognosis, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.
RESULTS
A total of 17 studies, including 9205 patients, were eligible for our analysis. Patients with new-onset LBBB had elevated all-cause mortality risk verses patients without new-onset LBBB, during all follow ups. The relevant data are as follows: 30-day (RR:1.71; 95%CI:1.27-2.29; < 0.001), 1-year (RR:1.31; 95%CI:1.12-1.52; < 0.001), and 2-year (RR:1.31; 95%CI:1.09-1.56; = 0.003) follow ups. Likewise, new-onset LBBB patients also experienced increased cardiovascular mortality, compared to non-new-onset LBBB patients, but only in the 1-year follow up (RR:1.49; 95%CI:1.23-1.82; < 0.001). Hospitalization for heart failure was dramatically elevated in patients with new-onset LBBB verses non-new-onset LBBB, in all follow ups. The relevant data are as follows: 30-day (RR:1.56; 95%CI:1.13-2.12; = 0.007), 1-year (RR:1.35; 95%CI:1.08-1.68; = 0.007), and 2-year (RR:1.49; 95%CI:1.21-1.84; < 0.001). Similarly, new-onset LBBB patients had higher PPI risk than non-new-onset LBBB patients, in all follow ups. The relevant data are as follows: 30-day (RR:3.05; 95%CI:1.49-6.22; = 0.002), 1-year (RR:2.15; 95%CI:1.52-3.03; < 0.001), and 2-year (RR:2.52; 95%CI:1.68-3.78; < 0.001).
CONCLUSION
Patients with new-onset LBBB have worse prognosis after TAVR than those without new-onset LBBB. Recognition of the adverse effects of post-TAVR new-onset LBBB can lead to the development of new strategies that enhance clinical outcomes.
SYSTEMATIC TRIAL REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197224, identifier: 19722.
PubMed: 35463780
DOI: 10.3389/fcvm.2022.842929 -
Medical Science Monitor : International... Mar 2016The aim of the current meta-analysis was to assess the effect of right bundle branch block (RBBB) on mortality outcome in patients with acute myocardial infarction (AMI). (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The aim of the current meta-analysis was to assess the effect of right bundle branch block (RBBB) on mortality outcome in patients with acute myocardial infarction (AMI).
MATERIAL/METHODS
Embase, PubMed, and Cochrane databases were searched through January 2015 using the keywords "RBBB", "mortality", "AMI", "Coronary Heart Disease", and "cardiovascular". An odds ratio (OR) of RBBB on mortality endpoints was calculated using random-effects models.
RESULTS
RBBB was associated with significantly increased overall mortality in patients with AMI. The OR of RBBB for deaths was 1.56 [95% confidence interval (CI), 1.44 to 1.68, p<0.001]. Moreover, RBBB showed a considerable effect on both in-hospital mortality (OR: 1.94, 95% CI: 1.60 to 2.37, p=0.002) and long-term mortality (OR: 1.49, 95% CI: 1.37 to 1.62, p<0.001).
CONCLUSIONS
RBBB is associated with an increased risk of all-cause mortality and indicates a poorer prognosis in patients with AMI.
Topics: Bundle-Branch Block; Confidence Intervals; Humans; Myocardial Infarction; Prognosis; Publication Bias; Risk Factors
PubMed: 27017617
DOI: 10.12659/msm.895687 -
Scientific Reports Jun 2021Cardiac dyssynchrony is the proposed mechanism for pacemaker-induced cardiomyopathy, which can be prevented by biventricular pacing. Left bundle branch pacing and His... (Meta-Analysis)
Meta-Analysis
A network meta-analysis and systematic review of change in QRS duration after left bundle branch pacing, His bundle pacing, biventricular pacing, or right ventricular pacing in patients requiring permanent pacemaker.
Cardiac dyssynchrony is the proposed mechanism for pacemaker-induced cardiomyopathy, which can be prevented by biventricular pacing. Left bundle branch pacing and His bundle pacing are novel interventions that imitate the natural conduction of the heart with, theoretically, less interventricular dyssynchrony. One of the surrogate markers of interventricular synchrony is QRS duration. Our study aimed to compare the change of QRS duration before and after implantation between types of cardiac implantable electronic devices (CIEDs): left bundle branch pacing versus His bundle pacing versus biventricular pacing and conventional right ventricular pacing. A literature search for studies that reported an interval change of QRS duration after CIED implantation was conducted utilizing the MEDLINE, EMBASE, and Cochrane databases. All relevant works from database inception through November 2020 were included in this analysis. A random-effects model, Bayesian network meta-analysis was used to analyze QRS duration changes (eg, electrical cardiac synchronization) across different CIED implantations. The mean study sample size, from 14 included studies, was 185 subjects. The search found 707 articles. After exclusions, 14 articles remained with 2,054 patients. The His bundle pacing intervention resulted in the most dramatic decline in QRS duration (mean difference, - 53 ms; 95% CI - 67, - 39), followed by left bundle branch pacing (mean difference, - 46 ms; 95% CI - 60, - 33), and biventricular pacing (mean difference, - 19 ms; 95% CI - 37, - 1.8), when compared to conventional right ventricle apical pacing. When compared between LBBP and HBP, showed no statistically significant wider QRS duration in LBBP with mean different 6.5 ms. (95% CI - 6.7, 21). Our network meta-analysis found that physiologic pacing has the greatest effect on QRS duration after implantation. Thus, HBP and LBBP showed no significant difference between QRS duration after implantation. Physiologic pacing interventions result in improved electrocardiography markers of cardiac synchrony, narrower QRS duration, and might lower electromechanical dyssynchrony.
Topics: Bayes Theorem; Bundle of His; Bundle-Branch Block; Cardiac Resynchronization Therapy; Electrocardiography; Heart Failure; Heart Ventricles; Humans; Network Meta-Analysis; Pacemaker, Artificial; Treatment Outcome
PubMed: 34108548
DOI: 10.1038/s41598-021-91610-8 -
CJC Open Dec 2023Electrocardiographic (ECG) criteria to detect left ventricular hypertrophy (LVH) in patients with left bundle branch block (LBBB) remain under debate. We conducted a... (Review)
Review
BACKGROUND
Electrocardiographic (ECG) criteria to detect left ventricular hypertrophy (LVH) in patients with left bundle branch block (LBBB) remain under debate. We conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of different ECG criteria for diagnosing LVH in patients with LBBB.
METHODS
We searched PubMed, Embase, Cochrane, and LILACS for articles evaluating the diagnostic accuracy of ECG criteria for LVH in patients with LBBB published between 1984 and 2023. Echocardiogram, magnetic resonance imaging, or autopsy were used as the reference standard for diagnosis of LVH. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. The co-primary outcomes were sensitivity, specificity, the diagnostic odds ratio, and likelihood ratios, estimated using a bivariate generalized linear mixed model for each ECG criterion. The prespecified protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO).
RESULTS
We included 12 studies with a total of 1023 patients. We analyzed 10 criteria for LVH on ECG, including the Sokolow-Lyon criterion, the Cornell criterion, the RaVL (R wave in aVL) criterion, the Gubner-Ungerleider criterion, and the Dálfo criterion, among others. The Dalfó criterion was used for 487 patients and had the highest pooled sensitivity of 86% (95% confidence interval [CI] 57%-97%). All the other criteria had poor sensitivities. The Gubner-Ungerleider criterion and the RV5 or RV6 > 25 mm criterion had the highest specificities, with the former being used for 805 patients, obtaining a specificity of 99% (95% CI 80%-100%) and the latter being used for 355 patients, obtaining a specificity of 99% (95% CI 94%-100%).
CONCLUSIONS
In patients with LBBB, the use of ECG criteria had poor performance for ruling out LVH, mostly due to low sensitivities. None of the criteria analyzed demonstrated a balanced tradeoff between sensitivity and specificity, suggesting that ECG should not be used routinely to screen for LVH.
PubMed: 38204852
DOI: 10.1016/j.cjco.2023.08.010