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Comparative Study
. 2024 Nov;17(11):e013059.
doi: 10.1161/CIRCEP.124.013059. Epub 2024 Oct 23.

Multicenter Hemodynamic Assessment of the LOT-CRT Strategy: When Does Combining Left Bundle Branch Pacing and Coronary Venous Pacing Enhance Resynchronization?: Primary Results of the CSPOT Study

Marek Jastrzębski  1 , Paul Foley  2 , Badrinathan Chandrasekaran  2 , Zachary Whinnett  3 , Pugazhendhi Vijayaraman  4 , Gaurav A Upadhyay  5 , Robert D Schaller  6 , Rafał Gardas  7 , Travis Richardson  8 , D'Anne Kudlik  9 , Robert W Stadler  9 , Patrick Zimmerman  9 , James Burrell  9 , Robert Waxman  9 , Richard N Cornelussen  10 , Jonathan Lyne  11 , Bengt Herweg  12
Affiliations
Comparative Study

Multicenter Hemodynamic Assessment of the LOT-CRT Strategy: When Does Combining Left Bundle Branch Pacing and Coronary Venous Pacing Enhance Resynchronization?: Primary Results of the CSPOT Study

Marek Jastrzębski et al. Circ Arrhythm Electrophysiol. 2024 Nov.

Abstract

Background: Left bundle branch area pacing (LBBAP) may be an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT). We sought to compare the acute hemodynamic and ECG effects of LBBAP, BVP, and left bundle-optimized therapy CRT (LOT-CRT) in CRT candidates with advanced conduction disease.

Methods: In this multicenter study, 48 patients with either nonspecific interventricular conduction delay (n=29) or left bundle branch block (n=19) underwent acute hemodynamic testing to determine the change in left ventricular pressure maximal first derivative (LV dP/dtmax) from baseline atrial pacing to BVP, LBBAP, or LOT-CRT.

Results: Atrioventricular-optimized increases in LV dP/dtmax for LOT-CRT (mean, 25.8% [95% CI, 20.9%-30.7%]) and BVP (26.4% [95% CI, 20.2%-32.6%]) were greater than unipolar LBBAP (19.3% [95% CI, 15.0%-23.7%]) or bipolar LBBAP (16.4% [95% CI, 12.7%-20.0%]; P≤0.005). QRS shortening was greater in LOT-CRT (29.5 [95% CI, 23.4-35.6] ms) than unipolar LBBAP (11.9 [95% CI, 6.1-17.7] ms), bipolar LBBAP (11.7 ms [95% CI, 6.4-17.0]), or BVP (18.5 [95% CI, 11.0-25.9] ms), all P≤0.005. Compared with patients with left bundle branch block, patients with interventricular conduction delay experienced less QRS reduction (P=0.026) but similar improvements in LV dP/dtmax (P=0.29). Bipolar LBBAP caused anodal capture in 54% of patients and resulted in less LV dP/dtmax improvement than unipolar LBBAP (18.6% versus 23.7%; P<0.001). Subclassification of LBBAP capture (European Heart Rhythm Association criteria) indicated LBBAP or LV septal pacing in 27 patients (56%) and deep septal pacing in 21 patients (44%). The hemodynamic benefit of adding left ventricular coronary vein pacing to LBBAP depended on baseline QRS duration (P=0.031) and success of LBBAP (P<0.004): LOT-CRT provided 14.5% (5.0%-24.1%) greater LV dP/dtmax improvement and 20.8 (12.8-28.8) ms greater QRS shortening than LBBAP in subjects with QRS ≥171 ms and deep septal pacing capture type.

Conclusions: In a CRT cohort with advanced conduction disease, LOT-CRT and BVP provided greater acute hemodynamic benefit than LBBAP. Subjects with wider QRS or deep septal pacing are more likely to benefit from the addition of a left ventricular coronary vein lead to implement LOT-CRT.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04905290.

Keywords: bundle-branch block; cardiac resynchronization therapy; electrocardiography; hemodynamics; pacemaker.

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Conflict of interest statement

Dr Jastrzębski: speaker/consultant honoraria from Abbott, Biotronik, Boston Scientific, and Medtronic. Dr Foley: consultant to Medtronic, proctor for Medtronic. Dr Chandrasekaran: honoraria, consultancy fees and funding support from Medtronic, Biotronik, and Abbot. Dr Whinnett: speaker honoraria, consulting fees, and institutional fellowship/research support from Abbot, Boston Scientific, and Medtronic. Dr Vijayaraman: Medtronic: honoraria, consultant, research and fellowship support Abbott: honoraria, consultant Boston Scientific/Biotronik: honoraria; patent: HBP delivery tool. Dr Upadhyay: consulting and speaker honoraria from Abbott, Biotronik, Boston Scientific, GE Healthcare, Medtronic, Philips, Rhythm Science, and Zoll Medical. R.D. Schaller: speaking honoraria for Medtronic. Dr Richardson: consulting and speaking honoraria from Medtronic, Inc. Dr Herweg: fellowship support from Medtronic, speaker for Medtronic and Abbott. Dr Stadler, D. Kudlik, R. Waxman, Dr Zimmerman, J. Burrell, and Dr Cornelussen are Medtronic employees. The other authors report no conflicts

Figures

Figure 1.
Figure 1.
Comparison of acute responses from different pacing configurations. A. Left ventricular pressure maximal first derivative (LV dP/dtmax) increase; B. QRS-duration shortening. Displayed are means±95% CIs. *P≤0.005. Left bundle branch area pacing (LBBAP), including deep septal pacing. BVP, biventricular pacing; and LOT-CRT, left bundle branch-optimized cardiac resynchronization therapy.
Figure 2.
Figure 2.
Subgroup analysis according to conduction disease: intraventricular conduction disease (IVCD; red) or left bundle branch block (LBBB; blue). A, Left ventricular pressure maximal first derivative (LV dP/dtmax) increase (mean and 95% CIs), comparison between groups: P=0.29, comparison of relative effects of pacing configurations: P=0.79 and B, QRS-duration shortening (absolute decrease from baseline), comparison between groups: P=0.026, comparison of relative effects of pacing configurations: P=0.21. Left bundle branch area pacing (LBBAP), including deep septal pacing. BVP, biventricular pacing; IVCD, intraventricular conduction delay; and LOT-CRT, left bundle branch-optimized cardiac resynchronization therapy.
Figure 3.
Figure 3.
Classification of capture types: Deep septal pacing (DSP) and successful left bundle branch area pacing (LBBAP). DSP (left panel), LBBAP (right panel). AAI indicates AAI mode; and EGM, electrogram.
Figure 4.
Figure 4.
Subclassification according to successful left bundle branch area pacing (LBBAP; red) or deep septal pacing (DSP; blue). A, Left ventricular pressure maximal first derivative (LV dP/dtmax) increase (mean and 95% CIs), comparison between groups: P=0.40, comparison of relative effects of pacing configurations: P<0.005 and B, QRS-duration shortening, comparison between groups: P=0.53, comparison of relative effects of pacing configurations: P=0.80. BVP, biventricular pacing; and LOT-CRT, left bundle branch-optimized cardiac resynchronization therapy.
Figure 5.
Figure 5.
Subclassification according to baseline QRS <171 ms (red) or ≥171 ms (blue). A, Left ventricular pressure maximal first derivative (LV dP/dtmax) increase (mean and 95% CIs), comparison between groups: P=0.12, comparison of relative effects of pacing configurations: P=0.031 and B, QRS-duration shortening, comparison between groups: P=0.014, comparison of relative effects of pacing configurations: P=0.47. Left bundle branch area pacing (LBBAP), including deep septal pacing. BVP includes biventricular pacing; and LOT-CRT, left bundle branch-optimized cardiac resynchronization therapy.
Figure 6.
Figure 6.
Acute hemodynamic benefit of adding a left ventricular coronary vein lead to unipolar left bundle branch area pacing (LBBAP) pacing in 4 subgroups. Each bar represents the left ventricular pressure maximal first derivative (%LV dP/dtmax) improvement (mean and 95% CIs) between left bundle branch-optimized cardiac resynchronization therapy and unipolar LBBAP. DSP includes deep septal pacing.
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