A Randomized Controlled Trial of LOT-CRT Versus conventionaL BiVP in Heart Failure Patients With NICD

The First Affiliated Hospital with Nanjing Medical University86 enrolled

Overview

BATTLE study has been designed as a prospective, multi-center, randomized, controlled trial. This study will enroll 83 patients with chronic heart failure accompanied by intraventricular block (NICD) over an estimated recruitment period of 3 years. An LOT-CRT group will be compared with a group of conventional BiVP in the follow-up of at least 6 months. The study aimed to compare the curative effect of LOT-CRT in preserving LV systolic function with traditional BiVP in chronic heart failure patients with NICD.

Cardiac resynchronization therapy is a standardized treatment strategy for patients with chronic heart failure complicated by wide QRS waves. With the continuous development of physiological pacing technology, traditional cardiac resynchronization therapy, namely biventricular pacing technology, is constantly challenged. Left bundle branch area pacing (LBBAP), as the main method of physiological pacing technology, is currently increasingly widely used in clinical practice. In recent years, research has mainly focused on heart failure patients with wide QRS waves such as non ischemic cardiomyopathy and typical left bundle branch block (LBBB). The recently published LBBP-RESYNC study was a randomized controlled study comparing left bundle branch pacing (LBBP) and biventricular pacing. The results showed that LBBP can achieve better improvement in left ventricular function compared to traditional biventricular pacing. Compared with patients with typical LBBB, traditional biventricular pacing synchronized treatment is less effective in chronic heart failure patients accompanied by intraventricular block (NICD), which is closely related to the electrophysiological mechanism of LBBB. The blocking site of typical LBBB is generally located within the His bundle to the proximal end of the left bundle branch, while the distal end of the left bundle branch is relatively healthy. Therefore, LBBP can completely correct this type of LBBB and significantly narrow the QRS wave; The electrophysiological mechanism of NICD is relatively complex, and there may be multiple blocking sites, and LBBP cannot be completely corrected. How to improve the treatment efficacy and clinical prognosis of chronic heart failure patients with NICD is an important scientific issue that urgently needs to be solved. It is unclear whether left bundle branch pacing technology can provide support for cardiac function in such patients. Traditional biventricular pacing combines right ventricular and left epicardial pacing; LBBAP combined with left ventricular epicardial pacing, also known as LOT-CRT, is an innovative pacing method. This study aims to explore the application value of LBBAP in patients with chronic heart failure and NICD.

Interventions

LOT-CRT groupPROCEDURE

In addition to the leads implanted in BiVP group, it is also necessary to implant the left bundle branch area pacing(LBBAP) leads LBBAP includes LBBP and LVSP. LBBP is defined if fulfilling criterion 1 and at least one in criteria 2: 1. Paced morphology of RBBD in surface lead V1 (QR, Qr, rSr', rSR' or Qrs); 2. One of the following should be met, while the pacing threshold ≤ 1.5V/0.5ms: 1. Selective LBBP capture pattern appears, with an iso-electrical window between the pacing spike and QRS onset; 2. When reducing the output voltage, the LVAT undergoes a sudden change of\>10ms; If criterion 1 is fulfilled but none in criteria 2 is met, the procedure is considered to be left ventricular septal pacing (LVSP).

BiVP groupPROCEDURE

Implantation of a LV pacing lead is attempted using the standard-of-care technique first.

Eligibility

Sex: ALLMin age: 18 YearsMax age: 80 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. Ischemic or non ischemic cardiomyopathy 2. Optimal medical therapy for at lest 3 months 3. NYHA class II-IV 4. LVEF≤35% as assessed by echocardiography 5. Sinus rhythm (may have paroxysmal atrial fibrillation) 6. QRS duration ≥ 150ms 7. Intraventricular block (NICD), QRS morphology is neither LBBB nor RBBB Exclusion Criteria: 1. Valvular heart disease that requires or has undergone surgical intervention 2. After mechanical tricuspid valve replacement 3. Persistent or permanent atrial fibrillation or atrial flutter 4. Second or third degree atrioventricular block 5. Have a history of acute myocardial infarction within 3 months prior to enrollment 6. Patient's expected survival time is less than 12 months 7. Pregnant or planned to conceive 8. Ventricular septal hypertrophy (ventricular septal thickness exceeds 15mm at the end of diastole) 9. Patients with simple and persistent left superior vena cava 10. Patients with existing pacemaker implantation

Outcomes

Primary Outcomes

Left ventricular ejection fraction(LVEF)

Changes from baseline LVEF(unit: %) assessed by echocardiography at follow-up

Time frame: Baseline; 6-month follow-up

Secondary Outcomes

Paced QRS duration

Paced QRS duration is evaluated postoperative day 1 and 1 months, 3 months and 6 months after implantation.

Time frame: Postoperative day 1; 1-month,3-month and 6-month follow-up

A combined clinical endpoint of all-cause mortality and heart failure hospitalization,

Including date and number of all-cause mortalityand heart failure hospitalization,

Time frame: 6-month follow-up

Left ventricular end systolic volume(LVESV)

Changes from baseline LVESV(unit: mL) assessed by echocardiography at follow-up