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Randomized Controlled Trial
. 2024 Sep 30;25(10):1394-1404.
doi: 10.1093/ehjci/jeae132.

Longitudinal comparison of dyssynchrony correction and 'strain' improvement by conduction system pacing: LEVEL-AT trial secondary findings

Margarida Pujol-López  1   2 , Rafael Jiménez-Arjona  1 , Cora Garcia-Ribas  2 , Roger Borràs  1   2   3 , Eduard Guasch  1   2   4 , Mariona Regany-Closa  1   2 , Freddy R Graterol  1   2 , Mireia Niebla  1   2 , Esther Carro  1 , Ivo Roca-Luque  1   2   4 , J Baptiste Guichard  1   2   4 , M Ángeles Castel  1   2   4 , Elena Arbelo  1   2   4 , Andreu Porta-Sánchez  1 , Josep Brugada  1   2   4 , Marta Sitges  1   2   4 , José M Tolosana  1   2   4 , Adelina Doltra  1   2 , Lluís Mont  1   2   4
Affiliations
Randomized Controlled Trial

Longitudinal comparison of dyssynchrony correction and 'strain' improvement by conduction system pacing: LEVEL-AT trial secondary findings

Margarida Pujol-López et al. Eur Heart J Cardiovasc Imaging. .

Abstract

Aims: Longitudinal dyssynchrony correction and 'strain' improvement by comparable cardiac resynchronization therapy (CRT) techniques is unreported. Our purpose was to compare echocardiographic dyssynchrony correction and 'strain' improvement by conduction system pacing (CSP) vs. biventricular pacing (BiVP) as a marker of contractility improvement during 1-year follow-up.

Methods and results: A treatment-received analysis was performed in patients included in the LEVEL-AT trial (NCT04054895), randomized to CSP or BiVP, and evaluated at baseline (ON and OFF programming) and at 6 and 12 months (n = 69, 32% women). Analysis included intraventricular (septal flash), interventricular (difference between left and right ventricular outflow times), and atrioventricular (diastolic filling time) dyssynchrony and 'strain' parameters [septal rebound, global longitudinal 'strain' (GLS), LBBB pattern, and mechanical dispersion). Baseline left ventricular ejection fraction (LVEF) was 27.5 ± 7%, and LV end-systolic volume (LVESV) was 138 ± 77 mL, without differences between groups. Longitudinal analysis showed LVEF and LVESV improvement (P < 0.001), without between-group differences. At 12-month follow-up, adjusted mean LVEF was 46% with CSP (95% CI 42.2 and 49.3%) vs. 43% with BiVP (95% CI 39.6 and 45.8%), (P = 0.31), and LVESV was 80 mL (95% CI 55.3 and 104.5 mL) vs. 100 mL (95% CI 78.7 and 121.6 mL), respectively (P = 0.66). Longitudinal analysis showed a significant improvement of all dyssynchrony parameters and GLS over time (P < 0.001), without differences between groups. Baseline GLS significantly correlated with LVEF and LVESV at 12-month follow-up.

Conclusion: CSP and BiVP provided similar dyssynchrony and 'strain' correction over time. Baseline global longitudinal 'strain' predicted ventricular remodelling at 12-month follow-up.

Keywords: biventricular pacing; conduction system pacing; dyssynchrony; global longitudinal ‘strain’; left bundle branch pacing; resynchronization therapy; ‘strain’.

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Conflict of interest statement

Conflict of interest: M.P.-L. has received speaker honoraria from Medtronic. J.M.T. has received honoraria as a lecturer and consultant from Abbott, Boston Scientific, and Medtronic. L.M. has received unrestricted research grants, fellowship programme support, and honoraria as a lecturer and consultant from Abbott, Biotronik, Boston Scientific, Livanova, and Medtronic; he holds stock in Galgo Medical and Corify. I.R.-L. has received honoraria as a lecturer and consultant from Abbott and Biosense Webster. M.S. has received consultant fees and speaker honoraria from Abbott, Medtronic, General Electric, and Edwards Lifesciences. M.A.C. has received speaker honoraria from Boston Scientific, Abbott, and Microport. E.A. has received speaker honoraria from Biosense Webster and Bayer. A.P.-S. has received honoraria as a lecturer and consultant from Biosense Webster, Abbott, and Boston Scientific. All remaining authors have declared no conflicts of interest.

Figures

Graphical Abstract
Graphical Abstract
Conduction system pacing (CSP) and biventricular pacing (BiVP) provided a similar dyssynchrony and ‘strain’ correction over time in patients who successfully received the device (treatment-received analysis). LVESV, left ventricular end-systolic volume.
Figure 1
Figure 1
Study flowchart. BiVP, biventricular pacing; CSP, conduction system pacing.
Figure 2
Figure 2
Methodology: echocardiographic dyssynchrony assessment. Analysis of cardiac dyssynchrony using standard techniques and techniques derived from myocardial deformation analysis. (A) AV dyssynchrony assessment based on the relationship between transmitral filling time (b) and the R–R interval (a). (B) Measurement of VV dyssynchrony based on the difference between pulmonary and aortic pre-ejection times, defined as the time from the beginning of the QRS complex to the onset of ejection determined from pulsed Doppler register of the outflow tracts. (C) Quantification of SF as a marker of left intraventricular dyssynchrony using an M-mode register passing through the VV septum, measuring the distance between the maximum protosystolic excursion of the septum and its baseline position. (D) Analysis of septal rebound stretch (arrow) as a marker of intraventricular dyssynchrony, defined as the presence of myocardial stretch prior to aortic valve closure (positive deflection, marked as *) preceded by shortening (negative deflection) in septal segments. (E) Longitudinal ‘strain’ curves showing a typical pattern of LBBB, with early shortening followed by stretching of a septal segment (arrow) and early stretching with a post-systolic peak of contraction in a lateral segment (arrowheads).
Figure 3
Figure 3
Correction of dyssynchrony with CSP and BiVP over time. Longitudinal analyses showed that the improvement of all echocardiographic dyssynchrony parameters (A-F) over time was significant (P < 0.001) but without differences between groups. LBBB, left bundle branch block.
Figure 4
Figure 4
Left ventricular remodelling and ‘strain’ improvement with CSP and BiVP. Longitudinal analyses showed a significant improvement of LVEF, LVESV, and GLS over time (P < 0.001), but not different between groups (P = 0.31, P = 0.66, and P = 0.55, respectively) (A, B, C).
Figure 5
Figure 5
Baseline GLS predicting LVEF improvement and response at 12-month follow-up. (A) Baseline GLS significantly correlated with LVEF at 12 months of follow-up (r = 0.54, P < 0.001). (B) The area under the ROC curve was calculated for GLS; the value of baseline GLS of the ROC curve with the best sensitivity and specificity to discriminate between those patients who will present an echocardiographic response (LVEF > 5%) was GLS −7.1%.
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References

    1. Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IMet al. . 2021 ESC guidelines on cardiac pacing and cardiac resynchronization therapy. EP Europace 2022;24:71–164. - PubMed
    1. Chung MK, Patton KK, Lau CP, Dal Forno ARJ, Al-Khatib SM, Arora Vet al. . 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm 2023;20:e17–91. - PMC - PubMed
    1. Ezzeddine FM, Pistiolis SM, Pujol-Lopez M, Lavelle M, Wan EY, Patton KKet al. . Outcomes of conduction system pacing for cardiac resynchronization therapy in patients with heart failure: a multicenter experience. Heart Rhythm 2023;20:863–71. - PMC - PubMed
    1. Jastrzębski M, Kiełbasa G, Cano O, Curila K, Heckman L, De Pooter Jet al. . Left bundle branch area pacing outcomes: the multicentre European MELOS study. Eur Heart J 2022;43:4161–73. - PMC - PubMed
    1. Vijayaraman P, Sharma PS, Cano Ó, Ponnusamy SS, Herweg B, Zanon Fet al. . Comparison of left bundle branch area pacing and biventricular pacing in candidates for resynchronization therapy. J Am Coll Cardiol 2023;82:228–41. - PubMed

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