Editorial
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Apr 26, 2024; 16(4): 186-190
Published online Apr 26, 2024. doi: 10.4330/wjc.v16.i4.186
Left bundle branch pacing set to outshine biventricular pacing for cardiac resynchronization therapy?
Akash Batta, Juniali Hatwal
Akash Batta, Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana 141001, India
Juniali Hatwal, Department of Internal Medicine, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Chandigarh 160012, India
Author contributions: Batta A contributed to the conception and design, did analysis and interpretation, collected the data, finally approved the manuscript, and took overall responsibility; Batta A and Hatwal J wrote and critically revised the manuscript. All authors have read and approved of the final version of the manuscript.
Conflict-of-interest statement: The authors declare no conflict-of-interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Akash Batta, MD, DM, Assistant Professor, Senior Scientist, Department of Cardiology, Dayanand Medical College and Hospital, Tagore Nagar, Civil Lines, Ludhiana 141001, India. akashbatta02@gmail.com
Received: January 19, 2024
Peer-review started: January 19, 2024
First decision: February 3, 2024
Revised: February 9, 2024
Accepted: March 18, 2024
Article in press: March 18, 2024
Published online: April 26, 2024
Processing time: 95 Days and 2.2 Hours
Abstract

The deleterious effects of long-term right ventricular pacing necessitated the search for alternative pacing sites which could prevent or alleviate pacing-induced cardiomyopathy. Until recently, biventricular pacing (BiVP) was the only modality which could mitigate or prevent pacing induced dysfunction. Further, BiVP could resynchronize the baseline electromechanical dssynchrony in heart failure and improve outcomes. However, the high non-response rate of around 20%-30% remains a major limitation. This non-response has been largely attributable to the direct non-physiological stimulation of the left ventricular myocardium bypassing the conduction system. To overcome this limitation, the concept of conduction system pacing (CSP) came up. Despite initial success of the first CSP via His bundle pacing (HBP), certain drawbacks including lead instability and dislodgements, steep learning curve and rapid battery depletion on many occasions prevented its widespread use for cardiac resynchronization therapy (CRT). Subsequently, CSP via left bundle branch-area pacing (LBBP) was developed in 2018, which over the last few years has shown efficacy comparable to BiVP-CRT in small observational studies. Further, its safety has also been well established and is largely free of the pitfalls of the HBP-CRT. In the recent metanalysis by Yasmin et al, comprising of 6 studies with 389 participants, LBBP-CRT was superior to BiVP-CRT in terms of QRS duration, left ventricular ejection fraction, cardiac chamber dimensions, lead thresholds, and functional status amongst heart failure patients with left bundle branch block. However, there are important limitations of the study including the small overall numbers, inclusion of only a single small randomized controlled trial (RCT) and a small follow-up duration. Further, the entire study population analyzed was from China which makes generalizability a concern. Despite the concerns, the meta-analysis adds to the growing body of evidence demonstrating the efficacy of LBBP-CRT. At this stage, one must acknowledge that the fact that still our opinions on this technique are largely based on observational data and there is a dire need for larger RCTs to ascertain the position of LBBP-CRT in management of heart failure patients with left bundle branch block.

Keywords: Biventricular pacing; Cardiac resynchronization therapy; Conduction system pacing; Left bundle branch-area pacing; Left bundle branch block; Electromechanical dssynchrony

Core Tip: The deleterious effects of long-term right ventricular pacing necessitated the search for alternative pacing sites which could prevent or alleviate pacing-induced cardiomyopathy. Until recently, biventricular pacing (BiVP) was the only modality which could mitigate or prevent pacing induced dysfunction. Left bundle branch-area pacing (LBBP) was developed in 2018, which over the last few years has shown efficacy comparable to BiVP-cardiac resynchronization therapy (CRT) in small observational studies. However, as of now our opinion is largely based on observational data which are inherently prone to selection biases. Hence, there is an urgent need for larger randomized controlled trials which will ascertain the role of LBBP-CRT in the future.