His-bundle pacing versus biventricular pacing in cardiac resynchronization therapy patients: A crossover design comparison

Daniel L Lustgarten; Eric M Crespo; Irina Arkhipova-Jenkins; Robert Lobel; Joseph Winget; Jodi Koehler; Evan Liberman; Todd Sheldon

doi:10.1016/j.hrthm.2015.03.048

His-bundle pacing versus biventricular pacing in cardiac resynchronization therapy patients: A crossover design comparison

Heart Rhythm. 2015 Jul;12(7):1548-57. doi: 10.1016/j.hrthm.2015.03.048. Epub 2015 Mar 28.

Authors

Daniel L Lustgarten¹, Eric M Crespo², Irina Arkhipova-Jenkins³, Robert Lobel⁴, Joseph Winget⁴, Jodi Koehler³, Evan Liberman³, Todd Sheldon³

Affiliations

¹ Department of Medicine at the University of Vermont School of Medicine and Fletcher Allen Health Care, Burlington, Vermont; The Cardiovascular Research Institute, Burlington, Vermont. Electronic address: daniel.lustgarten@vtmednet.org.
² Division of Cardiology, Hartford Hospital, Hartford, Connecticut.
³ Medtronic Inc., Mounds View, Minnesota.
⁴ Department of Medicine at the University of Vermont School of Medicine and Fletcher Allen Health Care, Burlington, Vermont.

PMID: 25828601
DOI: 10.1016/j.hrthm.2015.03.048

Abstract

Background: Cardiac resynchronization therapy (CRT) typically is attempted with biventricular pacing (BiVP). One-third of patients are nonresponders. His-bundle pacing (HBP) has been evaluated as an alternative means of effecting CRT because it generates truly physiologic ventricular activation, as evidenced in part by the morphologic identity between normally conducted and paced QRS complexes.

Objective: The purpose of this study was to assess the feasibility of, and clinical response to, permanent HBP as an alternative to BiVP in CRT-indicated patients.

Methods: Patients were implanted with a right atrial pacing lead, defibrillation lead, left ventricular (LV) lead via the coronary sinus, and HBP lead. His and LV leads were plugged into the LV port via a Y-adapter. After successful implant, patients were randomized in single patient-blinded fashion to either HBP or BiVP. After 6 months, patients were crossed over to the other pacing modality and followed for another 6 months. Quality-of-life assessments, echocardiographic measurements, New York Heart Association classification, and 6-minute hall walk test were obtained at baseline and at each 6-month follow-up.

Results: Twenty-nine patients were enrolled; 21 (72%) demonstrated electrical resynchronization (QRS narrowing) at implant. Twelve patients completed the crossover analysis at 1 year. Clinical outcomes (quality of life, New York Heart Association functional class, 6-minute hall walk test, LV ejection fraction) were significantly improved for both pacing modes compared with baseline measures.

Conclusion: In this crossover comparison between HBP and BiVP, HBP was found to effect an equivalent CRT response. QRS narrowing was observed in 21 of 29 patients, suggesting this approach may be feasible in more patients with left bundle branch block than previously assumed.

Keywords: Bundle branch block; Cardiac resynchronization therapy; Congestive heart failure; Electrical resynchronization; His-bundle pacing; Longitudinal dissociation.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Bundle of His / physiopathology
Bundle-Branch Block* / diagnosis
Bundle-Branch Block* / physiopathology
Bundle-Branch Block* / therapy
Cardiac Resynchronization Therapy / methods*
Cross-Over Studies
Echocardiography / methods
Electrocardiography / methods
Female
Heart Failure* / diagnosis
Heart Failure* / physiopathology
Heart Failure* / psychology
Heart Failure* / therapy
Heart Ventricles / physiopathology*
Humans
Male
Middle Aged
Myocardial Contraction
Quality of Life*
Stroke Volume
Treatment Outcome
Ventricular Function, Left