Left Bundle Branch Pacemaker vs. Traditional Biventricular Pacemaker

hmmm

by Tracey_E - 2024-08-28 13:00:31

You can absolutely refuse to be part of a trial!!!! Just say no. If he gives you pushback, find another doctor. Honestly, I'd be finding another doctor based on him saying you'll be fine either way. If that's true, what's the point of the study?? 

Do you mean HIS pacing? I'm not sure what you mean by LBB pacing. Does he mean the third lead?

More doctors do HIS pacing now. It's a different way of placing the leads so that it's easier on the heart and closer to our natural conduction system. If he's offering this, then you want it. 

Bi-vent is totally different from two lead. It has a third lead so that it paces both ventricles and forces them to stay in sync. There are a very few doctors who give them for heart block as a preventative for pacing induce heart failure. Most doctors wait to see signs before adding the extra hardware. If ejection fraction (how they measure heart function) drops, they can switch us to bi-vent (also called CRT) in order to bring EF back up.

I asked my ep about it after my previous ep asked me if I wanted one when I had my last replacement. That turned me off, I'm not the one who went to medical school, tell me what you think is best! My current ep is an adult congenital specialist so sees a lot of us who are paced young and for a lifetime. He said heart failure from pacing happens well under 10% of the time and he believes it does not prevent heart failure, that if it's going happen it's going to happen regardless. That's just his opinion, but he has more long term paced patients that most ep's so I trust him. 

More hardware is more places for things to go wrong, so for me, I don't want it unless someone gives me a compelling reason why I need it. YMMV, of course. 

LBBAP, HBP vs CRT-P - We're Still Learning

by DoingMyBest - 2024-08-28 15:43:51

I believe David is talking about CRT-P (three-lead biventricular) vs. LBBAP (two-lead with left bundle branch area pacing in the right ventricle).

I am one year into my standard dual-lead pacemaker with LBBAP lead placement. My EP initially said I'd get a three-lead, biventricular CRT-P setup, but then changed his mind the morning of my surgery.

Research I've seen favors LBBAP over HBP (HIS bundle pacing). Apparently HBP is difficult to position correctly and tends to have a higher capture threshold leading to reduced battery life. LBBAP seems to have equivalent beneficial results without the problems. The downside being that there is lack of long-term studies. And LBBAP physiologic pacing seems to have advantages over "traditional" non-physiologic CRT pacing for some if not all patients.

I can see why they would desire trials to compare outcomes between "traditional" CRT pacing and LBBAP.

I think it is very much dependent on the nature of the conduction blocks a particular patient has. What is best for one is not necessarily best for all. CRT devices seem to be much more configurable, allowing excellent fine-tuning of ventricular synchronization, while LBBAP is simpler but dependent on the heart's natural conduction to still be working well to achieve proper ventricular synchronization.

Conductive pacing

by Amyelynn - 2024-08-28 17:07:48

Hi

I am geting four leads extracted in Nov as well as two new leads and new generator placed (I have a duel lead pacer as well)

my EP is not doing the procedure yet she knows my case well and insisted I ask for left bundle pacemaker (conduction system pacing) she said the way I have it now is old technology and I believe because I am 💯 paced in my ventricle and now 85% paced in atrial this gives me a better chance of hopefully not needing a CRT or dealing with low LVEF numbers (heart failure) I believe the left bundle pacing placement from what I am reading makes your heart beat more in synchrony than the traditional placement.

i have complete heart block not sure what you have and what the percentages of pacing you are doing in your atrial and ventricles?

after reading I 💯 want the left bundle placement and plan to reach out to the cardiac surgeon about it prior to my procedure to request he do it (if he is familiar with it as it's tricker placement than the trading placement) if not I am going to request than an EP who does a lot of LBB placement also be in the room for the procedure to handle the lead placement. 
 

Amy

Clinical Trial participation

by Rch - 2024-08-28 17:39:59

Hi

I have a Boston Scientific dual chamber Accolade implanted 2 years ago for symptomatic Mobitz Type 2 (2:1). Prior to the implantation , I was so uncomortable with my symptoms of  'thuds' every other beat, that I really didn't care nor had the energy to research into the various lead placement sites. Also, I already had to wait for 48 hours for the Apixaban to wash out of the system, and that seemed like for ever ! I just trusted my Intervention Cardiologist. After the implantation, in the recovery area, I just checked my rhythm on the Kadia and I saw positive deflections of the QRS complexes in Leads1 and 2, which was not the usual polarity I am used to in the literature. So, my V lead must have been placed some where in the LBB area. My EF in the TTE had been good. 

I don't know whether HIS or LBBAP sites have been unequivoally shown to be better sites than the apical sites, but the present trend sems to be moving that direction. That said, I would rather have my EP place the leads where  he is comfortable placing than trying to learn on the job to place elsewhere.

Just a note aside, one of the advantages of being in a randomized trial is that you get periodic follow up and closer monitoring. But that siad, it really doesnot mean much if you are not too happy with the location. Pacemakers last for 10-12 years these days and you have to be really satisfied with what you are getting. So, I would encourage you to have a frank discussion with your Provider as to his experiences with different sites and come to a mutually acceptable plan. I wish you well!!  

Rch - " I just checked my rhythm on the Kadia....."

by sgmfish - 2024-08-28 20:14:41

Rch, this caught my eye. I too have a Kardia (2 lead only) which I use a lot. It was my understanding that the Kardia can NOT "see" PM generated pulses, and that has certainly been my experience. I get a nice QRS wave in the Karida trace if the RV beat is sensed, but just a few squiggles in place of a QRS if the RV beat is paced.

Can you say more about the kind of data the Kardia gives you when you are paced?  Thanks

P.S. I have a standard dual-lead pacemaker with RV apex lead placement

Kardia mobile 1 and 6 lead

by Rch - 2024-08-28 23:46:55

Hi sgm

 In both Kardia 1 ( lead I) and 6, lead devices, I get very good Vs and Vp waveforms in all the leads, and I believe most users do. However, as to pacemaker spikes, I saw some weird looking spikes only first 2-3 days after the implantation, and then they disappeared!!! 

Decline

by Penguin - 2024-08-29 02:56:26

David, you've had some really informative replies on this thread and I can't add to them as I don't know enough about the newer placement (LBBAP) option.  DoingMyBest's comment about a lack of long term trials strikes me as important and so does your own attitude to risk. You clearly say that you don't want to be part of a trial and that you just want advice as to the best kind of lead placement for your situation.Your EP should be able to offer this to you rather than asking you to accept one of two alternatives and not knowing which you will receive. 

You may be a great candidate for the trial and you may receive impressive levels of follow up, but when the trial ends none of that will matter as you will have the lead placement in place that was randomly selected for you and you may or may not regret that. My leads have been in place over 15 years and sometimes people keep the same leads for a great deal longer than that. Although lead extraction is performed a great deal now and I understand it can be easier when leads haven't been in place for a long time, it is quite likely that lead extraction hasn't been performed that often from these newer positionings and that's something I'd want to talk through with your EP. How easy would it be to extract the leads if the placement didn't suit for example? It may be straightforward, but I'd want to know.

A decision about lead placement is an important one.  

I'd consider the information on this thread from a number of experienced individuals and follow up on some of the issues raised. You've received some useful tips IMO. 

Further Comments

by DoingMyBest - 2024-08-29 08:57:44

As to David's original question, in your shoes, I was offered CRT-P one moment, LBBP the next. I didn't know the difference. So far I am happy with LBBP. My expectation based on what I've read is that the heart will respond well compared to CRT-P. Maybe somewhat better, maybe somewhat worse. I am happy that CRT-P is available as a Plan B if my LBBP placement fails to perform as expected. A slight benefit of LBBP is that the dual-lead PM is smaller than the three-lead CRT-P and battery life should be somewhat better.

At one year post-implant, I am doing well and don't have complaints about the PM. I'll have another echocardiogram in a couple months and we'll see where things stand.

Actually the trial sounds somewhat enticing. I'd have no qualms about receiving either LBBP or CRT-P and the extra attention you get could be a nice benefit.

Thanks All!

by David K - 2024-09-05 15:20:56

So much great (and smart!) feedback to my initial post.  I really appreciative everyone's advice and info.