Clinical Outcomes of Conduction System Pacing vs Right Ventricular Septal Pacing in Atrioventricular Block: The CSPACE Randomized Controlled Trial.

IF 22.3 1区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

Journal of the American College of Cardiology Pub Date : 2025-08-26 DOI:10.1016/j.jacc.2025.06.043

Chee Loong Dominic Chow, Chiew Wong, Nigel Sutherland, Manoj Niranjan Obeyesekere, Geoffrey R Wong, Charles M Eastwood, Julie Abduloska, Christian M Davey, Amandeep Singh Bhutani, Victoria Tran, Fari Asari, Aakaash D Patel, Muhtasim Rahman Zahin, Amarpal Karamjit Singh, Mark A Tacey, William J van Gaal, Pugazhendhi Vijayaraman, Han S Lim, Uwais Mohamed

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引用次数: 0

Abstract

Background: Patients with atrioventricular (AV) block receiving right ventricular (RV) pacing are at risk of pacing-induced cardiomyopathy (PICM), need for upgrade to biventricular cardiac resynchronization therapy (CRT), heart failure hospitalization (HFH), and mortality. Conduction system pacing (CSP) is a promising pacing strategy to mitigate these adverse outcomes.

Objectives: The aim of this study was to compare the clinical outcomes between RV septal pacing (RVsP) and CSP.

Methods: A randomized controlled trial (RCT) was performed in 202 consecutive patients with pacing indication for AV block without CRT indication, with a 1:1 randomization allocation ratio between RVsP and CSP. The primary outcome was a composite endpoint of PICM, upgrade to biventricular CRT, HFH, and all-cause mortality. This trial was registered with the Australian New Zealand Clinical Trials Registry.

Results: CSP was successful in 89 of 101 patients (88.1%). After a mean follow-up period of 25.2 ± 11.8 months, CSP was associated with lower composite endpoint (7.17 vs 20.69 events per 100 person-years; HR: 0.35; 95% CI: 0.19-0.64; P < 0.001) primarily driven by lower PICM (CSP 4.58 vs RVsP 14.69 events per 100-person-years; HR: 0.31; 95% CI: 0.15-0.67; P = 0.002) and need for CRT upgrade (0 vs 1.92 events per 100-person-years; HR: 1.65e^-9; 95% CI: 0-∞; P = 0.043). There was no difference in HFH (CSP 0.48 vs RVsP 2.92 events per 100-person years; HR: 0.16; 95% CI: 0.02-1.37, P = 0.057) or all-cause mortality (CSP 2.86 vs RVsP 4.72 events per 100-person-years; HR: 0.61; 95% CI: 0.22-1.69; P = 0.337). Lead revision occurred more with CSP (8 patients [7.9%] vs 1 patient [1.0%]; P = 0.017).

Conclusions: This RCT demonstrates the superiority of CSP over RVsP in achieving improved clinical outcomes and supports the indication of CSP as an upfront pacing technique for patients with AV block. (CSPACE: A Randomised Controlled Trial Comparing Right Ventricular Pacing with Conduction System Pacing; ACTRN12619001613190).

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传导系统起搏与右室间隔起搏在房室传导阻滞中的临床效果：CSPACE随机对照试验

背景：房室（AV）传导阻滞接受右心室（RV）起搏的患者存在起搏诱发性心肌病（PICM）的风险，需要升级到双心室心脏再同步化治疗（CRT），心力衰竭住院（HFH）和死亡率。传导系统起搏（CSP）是一种很有希望减轻这些不良后果的起搏策略。目的：本研究的目的是比较右心室间隔起搏（RVsP）和CSP的临床结果。方法：采用随机对照试验（RCT），连续202例无CRT指征的起搏指征房室传导阻滞患者，RVsP与CSP随机分配比例为1:1。主要终点是PICM、升级到双心室CRT、HFH和全因死亡率的复合终点。该试验已在澳大利亚新西兰临床试验登记处注册。结果：101例患者中89例（88.1%）CSP成功。在平均随访25.2±11.8个月后，CSP与较低的综合终点相关（7.17 vs 20.69事件/ 100人年；HR: 0.35; 95% CI: 0.19-0.64; P < 0.001），主要由较低的PICM （CSP 4.58 vs RVsP 14.69事件/ 100人年；HR: 0.31; 95% CI: 0.15-0.67; P = 0.002）和CRT升级需求（0 vs 1.92事件/ 100人年；HR: 1.65e-9; 95% CI: 0-∞;P = 0.043）驱动。HFH （CSP 0.48 vs RVsP 2.92事件/ 100人年；HR: 0.16; 95% CI: 0.02-1.37, P = 0.057）或全因死亡率（CSP 2.86 vs RVsP 4.72事件/ 100人年；HR: 0.61; 95% CI: 0.22-1.69; P = 0.337）无差异。CSP的导联翻修发生率更高（8例[7.9%]vs 1例[1.0%];P = 0.017）。结论：该随机对照试验表明，CSP优于RVsP，可以改善临床结果，并支持CSP作为房室传导阻滞患者的前期起搏技术的适应症。（CSPACE：一项比较右心室起搏与传导系统起搏的随机对照试验；ACTRN12619001613190）。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Journal of the American College of Cardiology 医学-心血管系统

CiteScore

42.70

自引率

3.30%

发文量

5097

审稿时长

2-4 weeks

期刊介绍： The Journal of the American College of Cardiology (JACC) publishes peer-reviewed articles highlighting all aspects of cardiovascular disease, including original clinical studies, experimental investigations with clear clinical relevance, state-of-the-art papers and viewpoints. Content Profile: -Original Investigations -JACC State-of-the-Art Reviews -JACC Review Topics of the Week -Guidelines & Clinical Documents -JACC Guideline Comparisons -JACC Scientific Expert Panels -Cardiovascular Medicine & Society -Editorial Comments (accompanying every Original Investigation) -Research Letters -Fellows-in-Training/Early Career Professional Pages -Editor’s Pages from the Editor-in-Chief or other invited thought leaders