Jin, Chengyue

AbstractIntroductionLeft bundle branch area pacing (LBBP) is a novel conduction system pacing method to achieve effective physiological pacing and an alternative to cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) for patients with heart failure with reduced ejection fraction (HFrEF). We conduted this meta‐analysis and systemic review to review current data comparing BVP and LBBP in patients with HFrEF and indications for CRT.MethodsWe searched PubMed/Medline, Web of Science, and Cochrane Library from the inception of the database to November 2022. All studies that compared LBBP with BVP in patients with HFrEF and indications for CRT were included. Two reviewers performed study selection, data abstraction, and risk of bias assessment. We calculated risk ratios (RRs) with the Mantel–Haenszel method and mean difference (MD) with inverse variance using random effect models. We assessed heterogeneity using the I2 index, with I2 > 50% indicating significant heterogeneity.ResultsTen studies (9 observational studies and 1 randomized controlled trial; 616 patients; 15 centers) published between 2020 and 2022 were included. We observed a shorter fluoroscopy time (MD: 9.68, 95% confidence interval [CI]: 4.49–14.87, I2 = 95%, p < .01, minutes) as well as a shorter procedural time (MD 33.68, 95% CI: 17.80–49.55, I2 = 73%, p < .01, minutes) during the implantation of LBBP CRT compared to conventional BVP CRT. LBBP was shown to have a greater reduction in QRS duration (MD 25.13, 95% CI: 20.06–30.20, I2 = 51%, p < .01, milliseconds), a greater left ventricular ejection fraction improvement (MD: 5.80, 95% CI: 4.81–6.78, I2 = 0%, p < .01, percentage), and a greater left ventricular end‐diastolic diameter reduction (MD: 2.11, 95% CI: 0.12–4.10, I2 = 18%, p = .04, millimeter). There was a greater improvement in New York Heart Association function class with LBBP (MD: 0.37, 95% CI: 0.05–0.68, I2 = 61%, p = .02). LBBP was also associated with a lower risk of a composite of heart failure hospitalizations (HFH) and all‐cause mortality (RR: 0.48, 95% CI: 0.25–0.90, I2 = 0%, p = .02) driven by reduced HFH (RR: 0.39, 95% CI: 0.19–0.82, I2 = 0%, p = .01). However, all‐cause mortality rates were low in both groups (1.52% vs. 1.13%) and similar (RR: 0.98, 95% CI: 0.21–4.68, I2 = 0%, p = .87).ConclusionThis meta‐analysis of primarily nonrandomized studies suggests that LBBP is associated with a greater improvement in left ventricular systolic function and a lower rate of HFH compared to BVP. There was uniformity of these findings in all of the included studies. However, it would be premature to conclude based solely on the current meta‐analysis alone, given the limitations stated. Dedicated, well‐designed, randomized controlled trials and observational studies are needed to elucidate better the comparative long‐term efficacy and safety of LBBP CRT versus BIV CRT.

Background: Left bundle area branch pacing (LBBP) is a novel conduction system pacing method to achieve effective physiological pacing and an alternative to cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) for patients with heart failure and reduced ejection fraction (HFrEF). Objective: To review current data comparing BVP and LBBP in patients with HFrEF and indication CRT. Methods: We searched PubMed/Medline, Web of Science, and Cochrane Library from the inception of the database to November 2022. All studies that compared LBBP with BVP in patients with HFrEF and indications of CRT were included. Two reviewers performed the study selection, data abstraction, and risk of bias assessment. We calculated risk ratios with the Mantel-Haenszel method and mean difference with inverse variance using random effect models. We assessed heterogeneity using the I 2 index, with I 2 > 50% indicating significant heterogeneity. Results: Ten studies (9 observational studies and 1 randomized controlled trial; 616 patients; 15 centers) published between 2020 and 2022 were included. We observed a shorter fluoroscopy time [mean difference (MD) 9.68, 95% CI 4.49-14.87, I 2 =95%, P<0.01, minutes] as well as a shorter procedure time (MD 33.68, 95% CI 17.80-49.55, I 2 =73%, P<0.01, minutes) during implantation of LBBP CRT compared to conventional BVP CRT. LBBP was shown to have a greater reduction in QRSd (MD 25.13, 95%CI 20.06-30.20, I 2 = 51%, P<0.01, milliseconds) a greater left ventricular ejection fraction (LVEF) improvement (MD 5.80, 95% CI 4.81-6.78, I 2 =0%, P<0.01, percentage) and a greater ventricular end-diastolic diameter (LVEDD) reduction (MD 2.11, 95% CI 0.12-4.10, I 2 =18%, P=0.04, millimeter). There was a greater improvement in New York Heart Association function (NYHA) class with LBBP (MD 0.37, 95% CI 0.05-0.68, I 2 =61%, P=0.02).LBBP was also associated with a lower risk of a composite of heart failure hospitalizations and all-cause mortality [Risk ratio (RR) 0.48, 95% CI 0.25-0.90, I 2 =0%, p=0.02] driven by reduced heart failure hospitalizations (RR 0.39, 95% CI 0.19-0.82, I 2 =0%, p=0.01). However, all-cause mortality rates were low in both groups (1.52% vs. 1.13%) and similar (RR 0.98, 95%CI 0.21-4.68, I 2 =0%, p=0.87). Conclusion: Compared to BVP, LBBP is associated with, a greater improvement in LV systolic function, and a lower rate of heart failure-related hospitalization. Dedicated randomized controlled trials and larger patient populations are needed to further elucidate the long-term safety and efficacy of LBBP CRT.

AbstractIntroductionData on utilization, major complications, and in‐hospital mortality of catheter ablation (CA) for sarcoidosis‐related ventricular tachycardia (VT) are limited. We sought to determine the outcomes of sarcoidosis‐related VT, and incidence and predictors of complications associated with the CA procedure.MethodsWe queried the 2002–2018 National Inpatient Sample database to identify patients aged ≥18 years with sarcoidosis admitted with VT. A 1:3 propensity score‐matched (PSM) analysis was used to compare patient outcomes between CA and medically managed groups. Multivariable regression was performed to determine independent predictors of in‐hospital mortality and procedural complications associated with the CA procedure.ResultsOf 3220 sarcoidosis patients with VT, 132 (4.1%) underwent CA. Patients who underwent CA were younger, male predominant, more likely Caucasian, had differences in baseline comorbidities including more likely to have heart failure, less likely to have prior myocardial infarction, COPD, or severe renal disease, had a higher mean household income, and more likely admitted to a larger/urban teaching hospital. After PSM, we examined 106 CA cases and 318 medically managed cases. There was a trend toward a lower in‐hospital mortality rate in the CA group when compared to the medically managed group (1.9% vs. 6.6%, p = 0.08). The most common complications were pericardial drainage (5.3%), postoperative hemorrhage (3.8%), accidental puncture periprocedure (3.0%), and cardiac tamponade (2.3%). Independent predictors of in‐hospital mortality and procedural complications among the CA group included congestive heart failure (odds ratio [OR], 13.2; 95% confidence interval [CI], 1.7–104.2) and mild to moderate renal disease (OR, 3.9; 95% CI, 1.1–13.3).ConclusionsCompared to patients with sarcoidosis‐related VT who received medical therapy alone, those who underwent CA have a trend for a lower mortality rate despite procedure‐related complications occurring as high as 9.1%. Additional studies are recommended to better evaluate the benefits and risks of VT ablation in this group.