Feasibility and safety of upgrade to Left Bundle Branch Area Pacing (LBBAP) in patients with Pacemaker-induced Cardiomyopathy (PMiCMP): a single-center experience

Background: High burden of right ventricular (RV) pacing after pacemaker (PM) implantation can lead to pacemaker-induced cardiomyopathy (PMiCMP). Left bundle branch area pacing (LBBAP) offers a more physiological alternative and is endorsed by current guidelines. However, data on its feasibility, safety, and short-term outcomes in this population remains limited.

Objective:  We report on our single-center experience as part of a non-randomized prospective registry, focusing on the feasibility, safety, short-term efficacy, and potential short-term clinical benefits of LBBAP.

Methods and Results: A total of 45 patients with PMiCMP underwent an upgrade from single- or dual-chamber PM or ICD devices via LBBAP in the Heart and Vascular Center of Bad Segeberg in Germany, and were enrolled in our prospective registry between November 2023 and December 2024. 

Our small cohort consisted of 34 (75.6 %) male patients with a median age of 77 (73, 84) years and with a median LVEF of 30 (24, 34), who presented with a mean NYHA Class of 2.90.5 (Table 1).

A stylet-driven pacemaker lead (Biotronik Solia S60) was implanted for LBBAP using a 3-dimensional delivery catheter (Biotronik Selectra 3D) in every procedure. All procedures were performed under deep sedation and under continuous 12-lead ECG monitoring to ensure LBBAP. We report on the first LBBAP upgrade procedures performed in our center and by our operators.

The 45 upgraded devices consisted of 7 single-chamber (2 single-chamber ICDs and 5 single-chamber PMs) and 38 dual-chamber devices (8 dual-chamber ICDs and 30 dual-chamber PMs). There were no system changes from ICD to pacemaker or vice versa (upgrade or downgrade). All patients received a new LBBAP electrode as part of the system upgrade.

Of all upgrade procedures, 44 (98%) were successfully performed with a low periprocedural complication rate of 2%. One complication occurred—a pneumothorax resulting from an unsuccessful subclavian vein puncture due to total venous occlusion. The patient was successfully treated with a chest tube. As the upgrade via the left subclavian vein was not feasible, a new dual-chamber system with LBBAP was implanted from the contralateral side 9 days later.

The median procedure time was 49 (Q1=44, Q3=47) minutes, fluoroscopy time was
7.1 (Q1=5.3, Q3=20.9) minutes and median dose area product was 540 (Q1=287, Q3=1129) cGy·cm², all comparable to conventional biventricular CRT upgrades, as described in the literature. A significant QRS width reduction of 34% (from 186 ms to 122 ms) was achieved after the upgrade procedure due to LBBAP.

Three-month follow-up data was available of 66% of patients. It showed an increase of the median LVEF (from 30 to 40%).

Conclusions:  Upgrade to LBBAP in patients with PMiCMP was feasible and safe, with a high success rate, low periprocedural complication rate, and significant QRS narrowing with improvement of LVEF after 3-months.

 

Table 1:

Baseline characteristics
Number of patients	45
Male gender	34 (75.6%)
Age (y)	77 (73, 84)
Dual chamber devices (PM, ICD)	38 (30, 8)
Single chamber devices (PM, ICD)	7 (5, 2)
Baseline ntproBNP (pg/ml)	2301 (1192, 3242)
Baseline QRS width (ms)	186+/-22
NYHA class	2.9+/-0.5
LVEF(%)	30 (24, 34)
Procedural data
Procedure time (min)	49 (44, 47)
Fluoroscopy time (min)	7.1 (5.3, 20.9)
Area dose product (cGy·cm2)	540 (287, 1129)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Categorical data are summarized as n (%).Continuous data are summarized as medians (1. and 3. quartiles) or means+/-SD.