Dr Pugazhendi Vijayaraman (Geisinger Heart Institute, Wilkes-Barre, Pennsylvania, US) joins us from HRS 2022 to discuss the real-world data from an international study assessing the outcomes of rescue LBBAP in patients with coronary sinus lead failure, or those who did not respond to BIV-CRT.
1. Importance of this study
2. Patient cohort, study design and endpoints
3. Key findings
4. Take-home messages
Recorded onsite at HRS 2022, San Francisco.
– Hi, I’m Pugal Vijayaraman from Geisinger Health System in Pennsylvania. The topic of our study is that the rescue left bundle branch area pacing in patients who failed coronary vein lead placement for biventricular pacing and in those patients who did not respond to biventricular pacing. And this is an international multi-center study involving 16 centres across eight countries.
Importance of this study
Yeah, this is important study in the sense that for those patients who failed biventricular pacing in the past, the choices were somewhat limited and the choice were also somewhat drastic in the sense that simple transvenous procedure now needs surgical placement of a lead, which increases morbidity. There are some newer alternative implantation of a complex device called EBR system where you implant a transventricular endocardial LV, placement with additional devices to perform resynchronization. But the study shows that left bundle branch area pacing, which is similar to biventricular pacing transvenous lead placement and can be performed at the same time as performing a biventricular pacing that can rescue in cases where you fail biventricular lead placement. So it has huge implications for the patient and the cost for the health system.
Patient cohort, study design and endpoints
In this international multicenter study involving 16 centres we collected retrospectively on patients who had failed prior biventricular pacing implantation and then who went on to undergo left bundle branch area pacing. And we looked at the reasons for why they failed biventricular pacing and also looked at patients who failed to respond to a successful biventricular pacing. So overall we had about 212 patients. We were successful in 200 patients with a 94% success rate in this population. And 156 of them were lead failure patient and 44 patients with non-responders. What we found was that the success rate and the outcomes of this group was significantly improved, both clinically in terms of reducing heart failure hospitalisation, improving functional class, and more importantly, improving left ventricular ejection fraction in a significant percentage of the population. Overall, when we looked at the two groups, both the non-responders and the lead failure group we were able to show that the lead failure groups performed significantly better. About 70% of them had clinical and echocardiographic response, while the non-responders had slightly under 50% response rates suggesting that those patients are much sicker group of patients. And looking at the outcome of death or time to first heart failure hospitalisation, the patients who had lead failure subsequent to left bundle branch area pacing did significantly better. There was a 13% incidence compared to 30% in patients who had non-response to biventricular pacing.
Yeah. So what we learned from this study is that most patients who fail biventricular pacing we have a very easy, simple, and even better option to provide them cardiac resynchronization therapy. So in our centre and most of the participating centres, none of our patients go for surgical epicardial lead placement anymore because we have a simpler, easier solution for the problem.
Yeah. So one thing we learned is a non-responder group. So this is a small population, but in the study, but there’s a large group of patients who don’t respond to biventricular pacing. So looking at these small subset of patient we should be able to gleam and identify which of these patients will benefit from an additional intervention with left bundle branch area pacing. So identifying those patients and providing them with this new therapy, we can improve the response rate in patients who fail biventricular pacing. And we need a prospective study to assess these outcomes.