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. 2022 Dec 14:13:1049214.
doi: 10.3389/fphys.2022.1049214. eCollection 2022.

Leadless biventricular left bundle and endocardial lateral wall pacing versus left bundle only pacing in left bundle branch block patients

Marina Strocchi  1 , Nadeev Wijesuriya  1   2 , Mark K Elliott  1   2 , Karli Gillette  3   4 , Aurel Neic  5 , Vishal Mehta  1   2 , Edward J Vigmond  6   7 , Gernot Plank  3   4 , Christopher A Rinaldi  1   2 , Steven A Niederer  1
Affiliations

Leadless biventricular left bundle and endocardial lateral wall pacing versus left bundle only pacing in left bundle branch block patients

Marina Strocchi et al. Front Physiol. .

Abstract

Biventricular endocardial (BIV-endo) pacing and left bundle pacing (LBP) are novel delivery methods for cardiac resynchronization therapy (CRT). Both pacing methods can be delivered through leadless pacing, to avoid risks associated with endocardial or transvenous leads. We used computational modelling to quantify synchrony induced by BIV-endo pacing and LBP through a leadless pacing system, and to investigate how the right-left ventricle (RV-LV) delay, RV lead location and type of left bundle capture affect response. We simulated ventricular activation on twenty-four four-chamber heart meshes inclusive of His-Purkinje networks with left bundle branch block (LBBB). Leadless biventricular (BIV) pacing was simulated by adding an RV apical stimulus and an LV lateral wall stimulus (BIV-endo lateral) or targeting the left bundle (BIV-LBP), with an RV-LV delay set to 5 ms. To test effect of prolonged RV-LV delays and RV pacing location, the RV-LV delay was increased to 35 ms and/or the RV stimulus was moved to the RV septum. BIV-endo lateral pacing was less sensitive to increased RV-LV delays, while RV septal pacing worsened response compared to RV apical pacing, especially for long RV-LV delays. To investigate how left bundle capture affects response, we computed 90% BIV activation times (BIVAT-90) during BIV-LBP with selective and non-selective capture, and left bundle branch area pacing (LBBAP), simulated by pacing 1 cm below the left bundle. Non-selective LBP was comparable to selective LBP. LBBAP was worse than selective LBP (BIVAT-90: 54.2 ± 5.7 ms vs. 62.7 ± 6.5, p < 0.01), but it still significantly reduced activation times from baseline. Finally, we compared leadless LBP with RV pacing against optimal LBP delivery through a standard lead system by simulating BIV-LBP and selective LBP alone with and without optimized atrioventricular delay (AVD). Although LBP alone with optimized AVD was better than BIV-LBP, when AVD optimization was not possible BIV-LBP outperformed LBP alone, because the RV pacing stimulus shortened RV activation (BIVAT-90: 54.2 ± 5.7 ms vs. 66.9 ± 5.1 ms, p < 0.01). BIV-endo lateral pacing or LBP delivered through a leadless system could potentially become an alternative to standard CRT. RV-LV delay, RV lead location and type of left bundle capture affect leadless pacing efficacy and should be considered in future trial designs.

Keywords: cardiac resynchronization therapy; conduction system pacing; dyssynchrony; endocardial pacing; leadless pacing; left bundle branch block; left bundle pacing.

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Conflict of interest statement

AN is employed by NumeriCor GmbH, Graz, Austria. The remaining authors declare that the research was conducted in the absence of any commercial of financial relationships that could be construed as a potential conflict of interest.

Figures

FIGURE 1
FIGURE 1
Schematic representation of pacing simulations. The red cross shows the proximal LBBB introduced along the His. The green diamonds and the purple stars represent the pacing locations through a standard lead and a leadless electrode, respectively.
FIGURE 2
FIGURE 2
(A) Simulated activation times: Red and blue areas represent early and late activated regions, respectively. We show simulations during LBBB baseline, selective LBP (S-LBP) with and without AV delay optimization, leadless S-LBP (BIV-LBP, e.g., with an additional RV apical stimulus) and BIV-endo pacing with the LV lead in the lateral wall (BIV-endo lat). (B) Response metrics: BLVAT-95, LVDI, BIVAT-90 and BIVDI are shown for baseline and pacing. The bar plot represents the mean while the black segments represent ±standard deviation.
FIGURE 3
FIGURE 3
The effect of RV-LV delay and RV pacing location on response. (A) Mean LVAT-95, LVDI, BIVAT-90 and BIVDI achieved with BIV-endo lateral pacing or BIV-LBP with RV apical or septal pacing for different RV-LV delays. (B) Simulated activation times during baseline and pacing for maximum RV-LV delay (35 ms). (C) Response metrics (mean ± standard deviation) simulated during baseline and pacing.
FIGURE 4
FIGURE 4
The effect of suboptimal LBP delivery. Response metrics (mean ± standard deviation) simulated during baseline and LBP pacing simulated through the WiSE-CRT system with selective capture, non-selective capture and LBBAP (pacing 1 cm below the left bundle). All pacing simulations were performed with RV apical pacing and 5 ms RV-LV delay.
See this image and copyright information in PMC

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