Assessment of Cardiac Function and Ventricular Mechanical Synchronization in Left Bundle Branch Area Pacing by Speckle Tracking and Three-Dimensional Echocardiography

Abstract

Real-time 3-dimensional echocardiography combined with speckle tracking was used in this study. A total of 90 patients with normal left ventricular ejection fraction were divided into 3 groups according to the pacing site: left bundle branch area pacing (LBBAP), right ventricular septal pacing (RVSP) or right ventricular apical pacing (RVAP). Procedure duration (90 ± 18 vs 61 ± 6.6 vs 58 ± 5.6 minutes, p = 0.015), Fluoroscopy duration (15.5 ± 5.4 vs 4.8 ± 2.2 vs 4 ± 1.9 minutes, p = 0.004), and ventricular capture threshold at implantation (0.8 ± 0.3 vs 0.6 ± 0.2 vs 0.6 ± 0.1 V, p = 0.002) were significantly increased in patients that received LBBAP compared with RVSP or RVAP. At 4 weeks of follow-up, brain natriuretic peptide levels were significantly lower (22 [12 to 59] vs 135 [86 to 231] vs 235 [147 to 428] pg/ml, p = 0.04), paced QRS duration was significantly shorter (115 ± 26 vs 134 ± 28 vs 157 ± 29 ms, p = 0.012), and global longitudinal strain (−19.4 ± 2.4 vs −19.3 ± 3.4 vs −17.3 ± 3.5%, p = 0.026) and systolic dyssynchrony index (2.5 ± 0.3 vs 5.9 ± 0.9 vs 7.7 ± 1.2, p = 0.001), longitudinal absolute maximum difference of time to peak strain (17 [6 to 68] vs 117 [71 to 173] vs 126 [79 to 178] ms, p <0.0001), and circumferential absolute maximum difference of time to peak strain (76 [32 to 129] vs 148 [117 to 208] vs 161 [118 to 266] ms, p = 0.005) were significantly lower in patients that received LBBAP compared with RVSP or RVAP. In conclusion, LBBAP can provide a more physiological ventricular activation pattern than RVSP or RVAP and results in good left ventricular electrical and mechanical synchronization. Real-time 3-dimensional echocardiography combined with speckle tracking was used in this study. A total of 90 patients with normal left ventricular ejection fraction were divided into 3 groups according to the pacing site: left bundle branch area pacing (LBBAP), right ventricular septal pacing (RVSP) or right ventricular apical pacing (RVAP). Procedure duration (90 ± 18 vs 61 ± 6.6 vs 58 ± 5.6 minutes, p = 0.015), Fluoroscopy duration (15.5 ± 5.4 vs 4.8 ± 2.2 vs 4 ± 1.9 minutes, p = 0.004), and ventricular capture threshold at implantation (0.8 ± 0.3 vs 0.6 ± 0.2 vs 0.6 ± 0.1 V, p = 0.002) were significantly increased in patients that received LBBAP compared with RVSP or RVAP. At 4 weeks of follow-up, brain natriuretic peptide levels were significantly lower (22 [12 to 59] vs 135 [86 to 231] vs 235 [147 to 428] pg/ml, p = 0.04), paced QRS duration was significantly shorter (115 ± 26 vs 134 ± 28 vs 157 ± 29 ms, p = 0.012), and global longitudinal strain (−19.4 ± 2.4 vs −19.3 ± 3.4 vs −17.3 ± 3.5%, p = 0.026) and systolic dyssynchrony index (2.5 ± 0.3 vs 5.9 ± 0.9 vs 7.7 ± 1.2, p = 0.001), longitudinal absolute maximum difference of time to peak strain (17 [6 to 68] vs 117 [71 to 173] vs 126 [79 to 178] ms, p <0.0001), and circumferential absolute maximum difference of time to peak strain (76 [32 to 129] vs 148 [117 to 208] vs 161 [118 to 266] ms, p = 0.005) were significantly lower in patients that received LBBAP compared with RVSP or RVAP. In conclusion, LBBAP can provide a more physiological ventricular activation pattern than RVSP or RVAP and results in good left ventricular electrical and mechanical synchronization. Traditional right ventricular (RV) apical pacing (RVAP) can cause electrical and mechanical dyssynchrony.1Sweeney MO Hellkamp AS Ellenbogen KA Greenspon AJ Freedman RA Lee KL Lamas GA MOde Selection Trial InvestigatorsAdverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction.Circulation. 2003; 107: 2932-2937Crossref PubMed Scopus (1366) Google Scholar, 2Khurshid S Epstein AE Verdino RJ Lin D Goldberg LR Marchlinski FE Frankel DS. Incidence and predictors of right ventricular pacing-induced cardiomyopathy.Heart Rhythm. 2014; 11: 1619-1625Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar, 3Kim JH Kang KW Chin JY Kim TS Park JH Choi YJ. 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Dyssynchrony, contraction efficiency and regional function with apical and non-apical RV pacing.Heart. 2015; 101: 600-608Crossref PubMed Scopus (23) Google Scholar Permanent His bundle pacing can deliver physiological pacing, but it is technically challenging because of its anatomical location and high capture threshold.5Vijayaraman P Chung MK Dandamudi G Upadhyay GA Krishnan K Crossley G K Bova Campbell Lee BK Refaat MM Saksena S Fisher JD Lakkireddy D Council ACC's Electrophysiology His bundle pacing.J Am Coll Cardiol. 2018; 72: 927-947Crossref PubMed Scopus (191) Google Scholar, 6Sharma PS Dandamudi G Naperkowski A Oren JW Storm RH Ellenbogen KA Vijayaraman P. Permanent His-bundle pacing is feasible, safe, and superior to right ventricular pacing in routine clinical practice.Heart Rhythm. 2015; 12: 305-312Abstract Full Text Full Text PDF PubMed Scopus (267) Google Scholar, 7Sharma PS Vijayaraman P Ellenbogen KA. Permanent His bundle pacing: shaping the future of physiological ventricular pacing.Nat Rev Cardiol. 2020; 17: 22-36Crossref PubMed Scopus (61) Google Scholar Left bundle branch (LBB) area pacing (LBBAP) is a novel strategy for pacing in a patient with LBB block, and heart failure with narrow-paced QRS duration (QRSd), stable low pacing output, and good R wave sensing.8Chen K Li Y Dai Y Sun Q Luo B Li C Zhang S. Comparison of electrocardiogram characteristics and pacing parameters between left bundle branch pacing and right ventricular pacing in patients receiving pacemaker therapy.Europace. 2019; 21: 673-680Crossref PubMed Scopus (131) Google Scholar, 9Su L Wang S Wu S Xu L Huang Z Chen X Zheng R Jiang L Ellenbogen KA Whinnett ZI Huang W. Long-term safety and feasibility of left bundle branch pacing in a large single-center study.Circ Arrhythm Electrophysiol. 2021; 14e009261Crossref PubMed Scopus (130) Google Scholar, 10Yuan Z Cheng L Wu Y. Meta-analysis comparing safety and efficacy of left bundle branch area pacing versus His bundle pacing.Am J Cardiol. 2022; 164: 64-72Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Two-dimensional (2D) speckle tracking strain echocardiography (STE) is a marker of LV systolic function that can detect early stages of cardiomyopathies before a change in LV ejection fraction (LVEF).11Mondillo S Galderisi M Mele D Cameli M Lomoriello VS Zacà V Ballo P D'Andrea A Muraru D Losi M Agricola E D'Errico A Buralli S Sciomer S Nistri S Badano L Echocardiography Study Group of the Italian Society of Cardiology (Rome, Italy)Speckle-tracking echocardiography: a new technique for assessing myocardial function.J Ultrasound Med. 2011; 30: 71-83Crossref PubMed Scopus (365) Google Scholar, 12Luis SA Chan J Pellikka PA. Echocardiographic assessment of left ventricular systolic function: an overview of contemporary techniques, including speckle-tracking echocardiography.Mayo Clin Proc. 2019; 94: 125-138Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 13Potter E Marwick TH. Assessment of left ventricular function by echocardiography.JACC Cardiovascular Imaging. 2018; 11: 260-274Crossref PubMed Scopus (343) Google Scholar Real-time three-dimensional echocardiography (RT-3DE) can assess regional myocardial motion without geometric assumptions of cardiac size.14Monaghan MJ. Role of real time 3D echocardiography in evaluating the left ventricle.Heart. 2006; 92: 131-136Crossref PubMed Scopus (117) Google Scholar, 15Mancuso FJN. Real-time three-dimensional echocardiography and myocardial strain: ready for use in clinical practice.Arq Bras Cardiol. 2019; 113: 946-947PubMed Google Scholar, 16Driessen MMP Kort E Cramer MJM Doevendans PA Angevaare MJ Leiner T Meijboom FJ Chamuleau SAJ Sieswerda GT. Assessment of LV ejection fraction using real-time 3D echocardiography in daily practice: direct comparison of the volumetric and speckle tracking methodologies to CMR.Neth Heart J. 2014; 22: 383-390Crossref PubMed Scopus (21) Google Scholar Evidence that LBBAP is superior to traditional RV pacing in improving cardiac function and LV electrical and mechanical synchrony is lacking. The objective of this study was to compare cardiac function and LV electrical and mechanical synchrony during short-term follow-up using 2D-STE and RT-3DE in patients that received LBBAP, RVSP, or RVAP. Patients indicated for elective permanent dual chamber pacemaker implantation according to current guidelines (class I)17Epstein AE DiMarco JP Ellenbogen KA Estes 3rd, NA Freedman RA Gettes LS Gillinov AM Gregoratos G Hammill SC Hayes DL Hlatky MA Newby LK Page RL Schoenfeld MH Silka MJ Stevenson LW Sweeney MO Tracy CM Epstein AE Darbar D DiMarco JP Dunbar SB Estes 3rd, NA Ferguson Jr, TB Hammill SC Karasik PE Link MS Marine JE Schoenfeld MH Shanker AJ Silka MJ Stevenson LW Stevenson WG Varosy PD American College of Cardiology Foundation, American Heart Association Task Force on Practice Guidelines, Heart Rhythm Society2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2013; 61: e6-e75PubMed Google Scholar who attended Beijing Anzhen Hospital between January 2021 and July 2021 were eligible for this prospective cohort study. Inclusion criteria were (1) diagnosis of sick sinus syndrome and persistent high-grade atrioventricular block; (2) age ≥18 years; and (3) normal cardiac function (LVEF >50%) at baseline. Exclusion criteria were (1) age <18 years; (2) moderate to severe valvular diseases; (3) New York Heart Association functional class III or IV; (4) myocardial infarction or coronary revascularization during the last 3 months; (5) history of cardiomyopathy; (6) persistent atrial fibrillation; (7) significant respiratory disease; (8) severe liver and or kidney dysfunction; (9) pregnancy; (10) poor acoustic window because of emphysema or other reasons; or (11) unable to attend regular follow-up at the clinic. Patients included in this study were divided into 3 groups according to the pacing site: LBBAP (patients received LBBAP), RVSP, or RVAP. Pacemaker parameters were adjusted to achieve a ventricular pacing percentage >70%. The protocol for this study was approved by the Medical Ethics committee of Beijing Anzhen Hospital (number 2021083X). The study was conducted according to the Declaration of Helsinki and ethics committee guidelines. All patients provided written informed consent before participation. The study was registered in the Chinese Clinical Trial Registry (ChiCTR2100048503). LBBAP was achieved through a transventricular septal approach in the basal ventricular septum using a select secure pacing lead (model 3830,69 cm, Medtronic Inc., Minneapolis, Minnesota), as previously described.18Zhang J Wang Z Zu L Cheng L Su R Wang X Liang Z Chen J Hang F Du J Huang W Wu Y. Simplifying physiological left bundle branch area pacing using a new nine-partition method.Can J Cardiol. 2021; 37: 329-338Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The LBBAP lead was implanted using the new nine-partition method.19Zhang JM Zhang YX Chen JR Wang ZF Zu LN Cheng LT Wang ZY Wang XL Hang F Wu YQ (Feasibility and safety of new simplified left bundle branch area pacing via nine-partition method).Zhonghua Xin Xue Guan Bing Za Zhi. 2020; 48 ([in Chinese]): 848-852PubMed Google Scholar Together, the 3830 lead and C315 sheath were rotated clockwise and taken 1.0 to 3.0 cm into the ventricular apex. The lead was screwed in by applying 8 to 10 clockwise rotations when pace mapping at the lead tip revealed a W-shaped QRS morphology in V1. The lead was fixed when paced QRS morphology showed a “QR/Qr” pattern in V1, and the pacing stimulus to LV activation time (Stim-LVAT) in V5 or V6 was <90 ms and consistent during high and low threshold was with a Medtronic to Zhang J Wang Z Zu L Cheng L Su R Wang X Liang Z Chen J Hang F Du J Huang W Wu Y. Simplifying physiological left bundle branch area pacing using a new nine-partition method.Can J Cardiol. 2021; 37: 329-338Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar a LBBAP was as (1) the of the 3830 lead was into the LBB (2) (3) duration of LBB to QRS was shorter than His to (4) stimulus to peak LV activation time in to V6 <90 (5) LBBAP revealed paced QRS morphology showed a right bundle branch pattern in V1. 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LBBAP was and over a short-term follow-up in patient LBBAP was in for of time and duration of were significantly increased in patients that received LBBAP compared with RVSP or because LBBAP is a novel approach that a At 4 weeks of follow-up, LBBAP achieved a and more stable capture threshold than RVSP and RVAP. The QRS ventricular and a QRS may a of cardiomyopathy and heart between paced QRS duration and myocardial of the left in patients with right ventricular apical pacing.J 2021; PubMed Scopus (1) Google Scholar In the at 4 weeks of follow-up, the paced was significantly shorter in patients that received LBBAP compared with RVSP or RVAP. was lower at 4 weeks of follow-up than at implantation in patients that received LBBAP, may to lead or pacemaker is a marker of LV systolic and and valvular P A F R A T J M Clinical of natriuretic peptide Heart J. 2003; PubMed Scopus Google Scholar and may cardiac function in patients who T Li and cardiac pacing: a Clin Electrophysiol. PubMed Scopus (7) Google Scholar can used as a for heart failure in the pacemaker V G V natriuretic peptide as a of heart failure in patients with permanent 135 ([in PubMed Scopus (3) Google Scholar In at 4 weeks of follow-up, levels were significantly lower in patients that received LBBAP compared with RVSP or RVAP. with at 4 weeks of follow-up, levels were lower in patients that received LBBAP but in patients that received RVSP or RVAP. cardiac function in patients that received RVSP or RVAP. synchrony is for cardiac and and cardiac can LV and the of heart 2D-STE and RT-3DE can used to assess LV mechanical M E MA M of cardiac on left ventricular and function by 3D and global longitudinal Heart J. 2021; PubMed Scopus (2) Google Scholar 2D-STE is an that myocardial strain and LV function and G S S F B J Assessment of myocardial using speckle tracking echocardiography: and clinical Am Full Text Full Text PDF PubMed Scopus Google Scholar is the current for cardiac however, LV by 2D-STE can detect LV and more for than E Marwick TH. Assessment of left ventricular function by echocardiography.JACC Cardiovascular Imaging. 2018; 11: 260-274Crossref PubMed Scopus (343) Google Scholar can to cardiac G C G K P. longitudinal strain cardiac and 2022; PubMed Scopus (2) Google Scholar In the at 4 weeks of follow-up, was significantly in patients that received LBBAP, RVSP, or however, was lower than baseline in with the in patients that received LBBAP by RVSP and RVAP. RT-3DE analysis of global ventricular and regional The as by in myocardial motion in without geometric assumptions the of the The is in the in LV and used for the of LV A E D T G E V R R of three-dimensional systolic dyssynchrony and for early left ventricular myocardial J Cardiol. 2019; 22: Google Scholar In at 4 weeks of follow-up, the was significantly lower in patients that received LBBAP compared with RVSP or LV in patients that received LBBAP the time cardiac and parameters LBBAP may a effect and achieve a more physiological cardiac activation compared with RVSP and RVAP in patients who in the of this prospective study was conducted at a with a and with follow-up to the safety and clinical of LBBAP compared with RVSP or RVAP. In conclusion, LBBAP is a and approach that can provide a more physiological ventricular activation pattern than RVSP or RVAP in patients who LBBAP high stable lead and low over short-term Long-term with LBBAP The of to

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