Citations

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.

Abstract Background Alzheimer’s disease (AD) is a progressive neurological disorder with no specific curative medications. Sophisticated clinical skills are crucial to optimize treatment regimens given the multiple coexisting comorbidities in the patient population. Objective Here, we propose a study to leverage reinforcement learning (RL) to learn the clinicians’ decisions for AD patients based on the longitude data from electronic health records. Methods In this study, we selected 1736 patients from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) database. We focused on the two most frequent concomitant diseases—depression, and hypertension, thus creating 5 data cohorts (ie, Whole Data, AD, AD-Hypertension, AD-Depression, and AD-Depression-Hypertension). We modeled the treatment learning into an RL problem by defining states, actions, and rewards. We built a regression model and decision tree to generate multiple states, used six combinations of medications (ie, cholinesterase inhibitors, memantine, memantine-cholinesterase inhibitors, hypertension drugs, supplements, or no drugs) as actions, and Mini-Mental State Exam (MMSE) scores as rewards. Results Given the proper dataset, the RL model can generate an optimal policy (regimen plan) that outperforms the clinician’s treatment regimen. Optimal policies (ie, policy iteration and Q-learning) had lower rewards than the clinician’s policy (mean −3.03 and −2.93 vs. −2.93, respectively) for smaller datasets but had higher rewards for larger datasets (mean −4.68 and −2.82 vs. −4.57, respectively). Conclusions Our results highlight the potential of using RL to generate the optimal treatment based on the patients’ longitude records. Our work can lead the path towards developing RL-based decision support systems that could help manage AD with comorbidities.

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.