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Observational Study
. 2022 Oct 21;43(40):4161-4173.
doi: 10.1093/eurheartj/ehac445.

Left bundle branch area pacing outcomes: the multicentre European MELOS study

Marek Jastrzębski  1 , Grzegorz Kiełbasa  1 , Oscar Cano  2   3 , Karol Curila  4 , Luuk Heckman  5 , Jan De Pooter  6 , Milan Chovanec  7 , Leonard Rademakers  8 , Wim Huybrechts  9 , Domenico Grieco  10 , Zachary I Whinnett  11 , Stefan A J Timmer  12 , Arif Elvan  13 , Petr Stros  4 , Paweł Moskal  1 , Haran Burri  14 , Francesco Zanon  15 , Kevin Vernooy  4   16
Affiliations
Observational Study

Left bundle branch area pacing outcomes: the multicentre European MELOS study

Marek Jastrzębski et al. Eur Heart J. .

Abstract

Aims: Permanent transseptal left bundle branch area pacing (LBBAP) is a promising new pacing method for both bradyarrhythmia and heart failure indications. However, data regarding safety, feasibility and capture type are limited to relatively small, usually single centre studies. In this large multicentre international collaboration, outcomes of LBBAP were evaluated.

Methods and results: This is a registry-based observational study that included patients in whom LBBAP device implantation was attempted at 14 European centres, for any indication. The study comprised 2533 patients (mean age 73.9 years, female 57.6%, heart failure 27.5%). LBBAP lead implantation success rate for bradyarrhythmia and heart failure indications was 92.4% and 82.2%, respectively. The learning curve was steepest for the initial 110 cases and plateaued after 250 cases. Independent predictors of LBBAP lead implantation failure were heart failure, broad baseline QRS and left ventricular end-diastolic diameter. The predominant LBBAP capture type was left bundle fascicular capture (69.5%), followed by left ventricular septal capture (21.5%) and proximal left bundle branch capture (9%). Capture threshold (0.77 V) and sensing (10.6 mV) were stable during mean follow-up of 6.4 months. The complication rate was 11.7%. Complications specific to the ventricular transseptal route of the pacing lead occurred in 209 patients (8.3%).

Conclusions: LBBAP is feasible as a primary pacing technique for both bradyarrhythmia and heart failure indications. Success rate in heart failure patients and safety need to be improved. For wider use of LBBAP, randomized trials are necessary to assess clinical outcomes.

Keywords: Complications; Conduction system pacing; Distal capture; Left bundle branch pacing; Left bundle fascicular pacing; Left ventricular septal pacing.

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Conflict of interest statement

Conflict of interest: G.K., N.R., A.E, P.S.. L.H, M.C. and D.G—nothing to declare; M.J., P.M., W.H. and S.T. report speaker and consultancy fees from Medtronic; K.V. reports consultancy for Biosense Webster, Philips, Medtronic, Abbott, reports speaker fees from Microport and K.V.'s institution has received research and educational grants from Philips, Abbott, Medtronic, Biosense Webster; O.C. reports consulting fees from Biotronik, Medtronic and Boston Scientific and speaker’s fees from Medtronic and Boston Scientific; F.Z. reported speaker fees from Abbott, Biotronik, Boston Scientific, Medtronic and Microport; A.E.’s institution received speaker and advisory fees from Boston Scientific and Medtronic; H.B. reports speaker and/or consultancy fees (minor) from Abbott, Biotronik, Boston Scientific, Medtronic and Microport; Z.W. reports advisor and speaker fees from Medtronic, Boston Scientific advisor and Abbott Advisory board member; J. De P. reports speaker fees and honoraria from Medtronic, Boston Scientific and Biotronik. K.C. reports speaker and consultant fees for Medtronic and Biotronik.

Figures

Structured graphical abstract
Structured graphical abstract
LBBP, left bundle branch pacing; LBFP, left bundle fascicular pacing; LVSP, left ventricular septal pacing; LBBAP, left bundle branch area pacing; OR, odds ratio.
Figure 1
Figure 1
Examples of paced electrocardiogram patterns and endocardial electrograms during left bundle branch area pacing, characterized by left bundle branch potential to QRS interval of 34–25 ms and lead tip position approximately 1.5 cm from the His bundle. LBFP, left bundle fascicular pacing—characterized by potential to QRS of 24–0 ms and lead tip position approximately 1.5–4.5 cm from His bundle. Left bundle fascicular pacing includes: left posterior fascicle pacing; left anterior fascicle pacing; left septal fascicle pacing. LVSP: diagnosed when left bundle branch capture criteria are not met, any distance from His bundle. Heart drawing based on work by Patrick J. Lynch and C. Carl Jaffe, MD/CC-BY 2.5, https://commons.m.wikimedia.org/wiki/File:Heart_anterior_view_coronal_section.jpg.
Figure 2
Figure 2
Learning curves for the left bundle branch area pacing technique based on the number of procedures performed by the operators. (A) Probability of success of left bundle branch area pacing lead implantation slowly increases until 270 cases (P < 0.001). (B) Decrease in fluoroscopy time over the initial 110 cases (P < 0.001). (C) Despite increase in experience the proportion of left ventricular septal pacing does not decrease (P = 0.5) but remain stable. (D) Decrease of paced V6 R-wave peak time is present over the initial 110 cases (P < 0.001). Curves on (A), (B), and (C) were based on 1809 cases performed by 14 mid-high volume operators, while (D) curve was based on 860 cases performed by 3 high-volume operators—see Methods section.
Figure 3
Figure 3
Distribution of left bundle branch/Purkinje potential to QRS intervals—attesting to the variety of lead positions and wide target area on the interventricular septum. During proximal left bundle branch pacing, probably already including proximal parts of the major fascicles, the potential to QRS interval is likely in the range of 34–25 ms, this would correspond the main LBB length of 1.5–2.0 cm. Anterior, posterior and septal fascicular pacing is characterized by potential to QRS interval of 24–0 ms, with the values <10 ms indicating pacing of very distal arborization of the left conduction system, close to the Purkinje fibres to myocytes interface.
Figure 4
Figure 4
Illustrations of the complications of the transseptal route of the left bundle branch area pacing lead. (A) Coronary venous fistula (arrow points to contrast in great cardiac vein). (B) Coronary artery fistula (arrow points to the blood jet near the lead entry site). (C) Acute ST-segment elevation in leads II, III, aVF and V3-V6 with concomitant chest pain during left bundle branch area pacing lead deployment. (D) Late lead perforation into left ventricular cavity (initial lead position superimposed, arrow indicates leftward displacement from the perforation site). (E) Helix entrapment with subsequent lead break during attempts to unscrew/remove (arrow points to the helix, broken and entrapped in the endocardium). Figure in (B) reproduced with permission from De Pooter J, Calle S, Demulier L et al. Septal coronary artery fistula following left bundle branch area pacing. JACC Clin Elecrtrophysiol. 2020; 6: 1337–1338.
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References

    1. Mafi-Rad M, Luermans JG, Blaauw Y, Janssen M, Crijns HJ, Prinzen FW, et al. Feasibility and acute hemodynamic effect of left ventricular septal pacing by transvenous approach through the interventricular septum. Circ Arrhythm Electrophysiol 2016;9:e003344. - PubMed
    1. Huang W, Su L, Wu S, Xu L, Xiao F, Zhou X, et al. A novel pacing strategy with low and stable output: pacing the left bundle branch immediately beyond the conduction block. Can J Cardiol 2017;33:1736.e1–1736.e3. - PubMed
    1. Jastrzebski M, Kielbasa G, Curila K, Moskal P, Bednarek A, Rajzer M, et al. Physiology-based electrocardiographic criteria for left bundle branch capture. Heart Rhythm 2021;18:935–943. - PubMed
    1. Jastrzebski M, Moskal P. Reaching the left bundle branch pacing area within 36 heartbeats. Kardiol Pol 2021;79:587–588. - PubMed
    1. Vijayaraman P, Ponnusamy S, Cano O, Sharma PS, Naperkowski A, Subsposh FA, et al. Left bundle branch area pacing for cardiac resynchronization therapy: results from the international LBBAP collaborative study group. JACC Clin Electrophysiol 2021;7:135–147. - PubMed

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