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• W4226002934 abstract "HomeCirculation: Arrhythmia and ElectrophysiologyVol. 15, No. 4New-Onset Atrial Fibrillation in Left Bundle Branch Area Pacing Compared With Right Ventricular Pacing Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBNew-Onset Atrial Fibrillation in Left Bundle Branch Area Pacing Compared With Right Ventricular Pacing Venkatesh Ravi, MD, Parikshit S. Sharma, MD, MPH, Neil R. Patel, MD, MPH, Sujitraj Dommaraju, MD, Dipen V. Zalavadia, MD, Varun Garg, MD, Timothy R. Larsen, DO, Angela M. Naperkowski, RN, Jeremiah Wasserlauf, MD, MS, Kousik Krishnan, MD, Wilson Young, MD, PhD, Parash Pokharel, MD, Jess W. Oren, MD, Randle H. Storm, MD, Richard G. Trohman, MD, MBA, Henry D. Huang, MD, Faiz A. Subzposh, MD and Pugazhendhi Vijayaraman, MD Venkatesh RaviVenkatesh Ravi https://orcid.org/0000-0001-6826-9231 Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, IL (V.R., P.S.S., V.G., T.R.L., J.W., K.K., R.G.T., H.G.H.). Search for more papers by this author , Parikshit S. SharmaParikshit S. Sharma https://orcid.org/0000-0002-7999-476X Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, IL (V.R., P.S.S., V.G., T.R.L., J.W., K.K., R.G.T., H.G.H.). Search for more papers by this author , Neil R. PatelNeil R. Patel https://orcid.org/0000-0002-1420-1503 Wright Center for GME, Scranton, PA (N.R.P., S.D.). Search for more papers by this author , Sujitraj DommarajuSujitraj Dommaraju https://orcid.org/0000-0001-9745-783X Wright Center for GME, Scranton, PA (N.R.P., S.D.). Search for more papers by this author , Dipen V. ZalavadiaDipen V. Zalavadia https://orcid.org/0000-0001-7913-5191 Geisinger Heart Institute, Wilkes Barre, PA (D.V.Z., A.M.N., F.A.S., P.V.). Search for more papers by this author , Varun GargVarun Garg https://orcid.org/0000-0002-4617-997X Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, IL (V.R., P.S.S., V.G., T.R.L., J.W., K.K., R.G.T., H.G.H.). Search for more papers by this author , Timothy R. LarsenTimothy R. Larsen Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, IL (V.R., P.S.S., V.G., T.R.L., J.W., K.K., R.G.T., H.G.H.). Search for more papers by this author , Angela M. NaperkowskiAngela M. Naperkowski https://orcid.org/0000-0003-3208-8337 Geisinger Heart Institute, Wilkes Barre, PA (D.V.Z., A.M.N., F.A.S., P.V.). Search for more papers by this author , Jeremiah WasserlaufJeremiah Wasserlauf https://orcid.org/0000-0002-4497-3520 Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, IL (V.R., P.S.S., V.G., T.R.L., J.W., K.K., R.G.T., H.G.H.). Search for more papers by this author , Kousik KrishnanKousik Krishnan https://orcid.org/0000-0002-9534-349X Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, IL (V.R., P.S.S., V.G., T.R.L., J.W., K.K., R.G.T., H.G.H.). Search for more papers by this author , Wilson YoungWilson Young https://orcid.org/0000-0002-1602-5910 Geisinger Heart Institute, Scranton, PA (W.Y.). Search for more papers by this author , Parash PokharelParash Pokharel https://orcid.org/0000-0003-0658-1443 Geisinger Heart Institute, Danville, PA (P.P., J.W.O., R.H.S.). Search for more papers by this author , Jess W. OrenJess W. Oren Geisinger Heart Institute, Danville, PA (P.P., J.W.O., R.H.S.). Search for more papers by this author , Randle H. StormRandle H. Storm Geisinger Heart Institute, Danville, PA (P.P., J.W.O., R.H.S.). Search for more papers by this author , Richard G. TrohmanRichard G. Trohman https://orcid.org/0000-0003-0889-411X Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, IL (V.R., P.S.S., V.G., T.R.L., J.W., K.K., R.G.T., H.G.H.). Search for more papers by this author , Henry D. HuangHenry D. Huang https://orcid.org/0000-0002-4103-4317 Division of Cardiac Electrophysiology, Rush University Medical Center, Chicago, IL (V.R., P.S.S., V.G., T.R.L., J.W., K.K., R.G.T., H.G.H.). Search for more papers by this author , Faiz A. SubzposhFaiz A. Subzposh https://orcid.org/0000-0003-0103-0255 Geisinger Heart Institute, Wilkes Barre, PA (D.V.Z., A.M.N., F.A.S., P.V.). Search for more papers by this author and Pugazhendhi VijayaramanPugazhendhi Vijayaraman Correspondence to: Pugazhendhi Vijayaraman, MD, Geisinger Heart Institute, Geisinger Wyoming Valley Medical Center, MC 36-10, 1000 E Mountain Blvd, Wilkes-Barre, PA 18711. Email E-mail Address: [email protected] https://orcid.org/0000-0003-2230-100X Geisinger Heart Institute, Wilkes Barre, PA (D.V.Z., A.M.N., F.A.S., P.V.). Search for more papers by this author Originally published25 Mar 2022https://doi.org/10.1161/CIRCEP.121.010710Circulation: Arrhythmia and Electrophysiology. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 25, 2022: Ahead of Print Conventional right ventricular pacing (RVP) results in ventricular dyssynchrony and is associated with an increased risk of cardiomyopathy and the development of atrial fibrillation (AF), especially in patients with a high ventricular pacing burden.1 His bundle pacing has been shown to decrease or reverse the adverse clinical outcomes associated with RVP.2 We hypothesized that in patients with dual-chamber pacemakers, left bundle branch area pacing (LBBAP) would also be associated with a lower risk of new-onset AF than RVP.All patients with an age ≥18 years, referred to Geisinger Health System, Pennsylvania, and Rush University Medical Center, Illinois, for permanent pacemaker implantation with RVP and LBBAP, between April 2018 and October 2020 were included in this retrospective cohort study. Patients with <6 months of follow-up, left ventricular ejection fraction ≤35%, and known history of AF at initial implant, were excluded. The data that support the findings of this study are available from the corresponding author upon reasonable request. The study protocol was approved by the institutional review committee at each site. The primary outcome was new-onset AF episode ≥30 seconds detected on scheduled device follow-up performed in-person and remotely. The secondary outcome was new-onset AF episode ≥6 minutes. Subgroup analysis based on ventricular pacing burden ≥20% was also planned a priori. Kaplan-Meier curves, univariable and multivariable Cox proportional hazard models were used to estimate survival probability for the primary outcome and secondary outcomes in LBBAP and RVP groups. A 2-tailed P value of <0.05 was considered statistically significant.A total of 410 patients were included in the analysis, with 173 in the LBBAP group and 237 in the RVP group (Figure [A]). There were no significant differences in the baseline characteristics between the 2 groups. The average follow-up duration among all patients was 600±278 days. A new diagnosis of AF ≥30 s was noted in 9 (5.2%) patients in the LBBAP group and 43 (18.1%) patients in the RVP group. Multivariable analysis adjusted for confounders of congestive heart failure status and use of angiotensin-converting enzyme inhibitor/angiotensin-receptor-blocker drugs demonstrated that LBBAP was associated with a significantly lower risk of a new diagnosis of AF ≥30 s (hazard ratio [HR], 0.327 [95% CI, 0.158–0.673]; P=0.002) as shown in Figure (B). LBBAP was also associated with a significantly lower risk of a new diagnosis of AF ≥6 minutes (HR, 0.409 [95% CI, 0.178–0.940]; P=0.035). In the subgroup of ventricular pacing burden ≥20% (136 in LBBAP versus 145 in RVP), LBBAP demonstrated significant reduction in new-onset AF ≥30 s (HR, 0.274 [95% CI, 0.119–0.633]; P=0.002) as well as new-onset AF ≥6 min (HR, 0.380 [95% CI, 0.150–0.963]; P=0.041). In patients with ventricular pacing burden <20% (37 in LBBAP versus 92 in RVP), there was no difference in the primary outcome (P=0.342) or the secondary outcome (PP=0.419) between the 2 groups.Download figureDownload PowerPointFigure. Flowchart and survival curves of patients included in the study. A, Flowchart demonstrating the patients included in the study. B, Kaplan-Meier survival curves and analysis for the primary outcome of atrial fibrillation (AF) ≥30 s and secondary outcome of AF ≥6 min among all patients in the study demonstrated a statistically significant reduction in AF with left bundle branch area pacing (LBBAP) when compared to right ventricular pacing (RVP). HR indicates hazard ratio; and V pacing, ventricular pacing.In this study, we evaluated the differences between LBBAP and traditional RVP on development of new-onset AF and demonstrated a lower incidence of a new-onset AF with LBBAP. LBBAP was associated with a 67% relative risk reduction and 13% absolute risk reduction of new-onset AF ≥30 s, compared with RVP. The mechanism by which RVP promotes AF development is unclear, but left atrial dysfunction induced by LV dyssynchrony and reduced LV compliance is a probable culprit.3 LBBAP generates physiological electromechanical activation of the LV without LV intraventricular and minimal interventricular dyssynchrony, potentially explaining the lower incidence of AF seen in our study.4The clinical significance of a new diagnosis of an episode of AF ≥30 s may be unclear. However given the progressive nature of AF, this might herald an increase in burden over time. When AF episodes ≥6 minutes were analyzed there was a 59% relative risk reduction as well as a 9% absolute risk reduction with LBBAP. In a prior study, atrial high rate episodes ≥6 minutes were associated with a significantly higher risk of stroke during follow-up of 2.5 years, although the difference was mainly driven by longer duration of atrial high rate episodes >17.7 hours.5In our study, LBBAP demonstrated a similar pacing threshold to RVP at implant (P=0.334) and 1-year follow-up (P=0.260). The R waves on 1-year follow-up were better than RVP (17 versus 12 mV, P<0.001) with no difference in lead revisions (P=0.92). The procedure duration for LBBAP was still significantly longer when compared to RVP (95 versus 68 minutes, P<0.001).In conclusion, LBBAP was associated with a lower risk of new-onset AF compared to conventional RVP. Patients with higher burdens of ventricular pacing are more likely to benefit from LBBAP. These findings should be further evaluated in multicenter randomized trials with larger sample sizes and longer follow-ups.Article InformationAcknowledgmentsAll authors were involved in the design, acquisition, analysis, and drafting of the article. All authors have reviewed the final article, approved, and agreed to be accountable for all aspects of work ensuring integrity and accuracy.Sources of FundingNone.Nonstandard Abbreviations and AcronymsAFatrial fibrillationLBBAPleft bundle branch area pacingRVPright ventricular pacingDisclosures Dr Sharma has received honoraria from Medtronic and has been consultant for Medtronic, Abbott, Biotronik, Boston Scientific. Dr Krishnan is a consultant for Abbott/St. Jude Medical, Cardiva, Zoll and has received research funding from Abbott/St. Jude Medical. Dr Trohman is an advisor for Boston Scientific and has received research grants from Boston Scientific, Medtronic Inc, Abbott/ St. Jude Medical, Vitatron, and Wyeth Ayerst/Wyeth Pharmaceuticals. He is also a consultant for Biosense Webster, Alta Thera Pharmaceuticals, and Newron Pharmaceuticals P.s.A. and received honoraria from Boston Scientific/Guidant CRM, Medtronic Inc, Alta Thera Pharmaceuticals, Daiichi Sankyo and Abbott/ St. Jude Medical. Dr Huang has received honoraria from Cardiofocus, Medtronic, Biotronik and is a consultant for Cardiofocus. Dr Vijayaraman has received honoraria, consultant, research, fellowship support from Medtronic. He is also a, consultant for Abbott, Biotronik, Eaglepoint LLC and has a patent for His bundle pacing (HBP) delivery tool. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 266Correspondence to: Pugazhendhi Vijayaraman, MD, Geisinger Heart Institute, Geisinger Wyoming Valley Medical Center, MC 36-10, 1000 E Mountain Blvd, Wilkes-Barre, PA 18711. Email [email protected]eduReferences1. Sweeney MO, Hellkamp AS, Ellenbogen KA, Greenspon AJ, Freedman RA, Lee KL, Lamas GA; MOde Selection Trial Investigators. Adverse 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; 107:2932–2937. doi: 10.1161/01.CIR.0000072769.17295.B1LinkGoogle Scholar2. Abdelrahman M, Subzposh FA, Beer D, Durr B, Naperkowski A, Sun H, Oren JW, Dandamudi G, Vijayaraman P. Clinical outcomes of his bundle pacing compared to right ventricular pacing.J Am Coll Cardiol. 2018; 71:2319–2330. doi: 10.1016/j.jacc.2018.02.048CrossrefMedlineGoogle Scholar3. Xie JM, Fang F, Zhang Q, Chan JY, Yip GW, Sanderson JE, Lam YY, Yan BP, Yu CM. Left atrial remodeling and reduced atrial pump function after chronic right ventricular apical pacing in patients with preserved ejection fraction.Int J Cardiol. 2012; 157:364–369. doi: 10.1016/j.ijcard.2010.12.075CrossrefMedlineGoogle Scholar4. Cai B, Huang X, Li L, Guo J, Chen S, Meng F, Wang H, Lin B, Su M. Evaluation of cardiac synchrony in left bundle branch pacing: insights from echocardiographic research.J Cardiovasc Electrophysiol. 2020; 31:560–569. doi: 10.1111/jce.14342CrossrefMedlineGoogle Scholar5. Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, Lau CP, Fain E, Yang S, Bailleul C, et al..; ASSERT Investigators. Subclinical atrial fibrillation and the risk of stroke.N Engl J Med. 2012; 366:120–129. doi: 10.1056/NEJMoa1105575CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails April 2022Vol 15, Issue 4 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.121.010710PMID: 35333096 Originally publishedMarch 25, 2022 Keywordspatientscardiomyopathiespacemakersatrial fibrillationriskartificialPDF download Advertisement SubjectsArrhythmiasAtrial FibrillationPacemaker" @default.
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