Left bundle branch area pacing as a first line pacing strategy, which patients should we consider?

A higher right ventricular (RV) pacing burden in those with permanent pacemakers results in accelerated pacing induced cardiomyopathy, in addition to increased incidence of heart failure and mortality [1–3]. This process may necessitate upgrade to a biventricular system in time, as the cardiomyopathy progresses. Physiological conduction system pacing targets such as His-bundle pacing (HBP) or Left Bundle Branch Area Pacing (LBBAP) have been shown to generate comparatively narrower QRS complexes and thus mitigate this cardiomyopathy development [4,5].

The 2021 ESC guidelines have a class 2b indication for consideration of HBP as an alternative to RV pacing in those with AV block and left ventricular ejection fraction >40%, who are anticipated to have >20% ventricular pacing burden [6].

To retrospectively identify ECG, echocardiographic, permanent pacemaker (PPM) setting and patient factors associated with high RV pacing burden that may aid selection of those who may benefit from conduction system pacing (CSP).

We retrospectively identified 300 consecutive patients who underwent cardiac implantable electronic device insertion in our Electrophysiology Lab from the years 2017–2018. We excluded patients who underwent generator replacements, in addition to those who had biventricular devices or implantable cardioverter defibrillators inserted. We collated ECG, echo, past medical history and pacing data for each patient over a three-year follow up period.

Data were analysed using SPSS v.26.

160 patients met inclusion criteria. Those with an RV pacing burden >20% were categorised group one (n=85) and those with <20% in group two (n=75). Baseline characteristics of these two groups are compared in Table 1 and Table 2.

Our analysis showed that significant differences between these groups included a lower mean HR (Table 1) (55.1±17.8 vs 57.63±17.4) with a more prolonged PR interval (225.7ms ± 8.34 vs. 188.6ms ± 6.62) or atrial fibrillation/flutter (AF/AFL) on admission ECG. There were more males with a greater mean age (High Ventricular Paced (VP) = 76.6 years ± 8.4 vs Low VP = 71.23 years ± 12.3) in the higher VP group, and they demonstrated more incidence of dilated RA/RV on echo (Enlarged RA = 30.5%; Enlarged RV = 23.6% vs 10% and 8.4% respectively).

There were significant differences in PPM indications and setting between groups (Table 2), with the higher VP groups having PPM inserted for persistent high-grade AV block (CHB = 31.5% vs 4.9% and Mobitz 2 = 9.6% vs 0%) and had less MVP mode activated (Mode switch algorithm = 13.3% vs 71%).

Our data suggests that those with persistent high grade AV block such as Mobitz 2 or CHB should be considered for CSP. Other considerations include older age, male sex, dilated RV/RA, prolonged PR, lower intrinsic HR or AF/AFL on admission ECG. PPM mode switching settings to reduce RV pacing burden should be utilised where possible.

Type of funding sources: None.