CONGRESS ABSTRACT

Introduction Cardiac resynchronization therapy defibrillator (CRT-D) via epicardial pacing (EP) is the standard treatment for heart failure (HF) patients with left ventricular dyssynchrony. However, reimplantation of EP following transvenous lead extraction (TLE) can be technically challenging due to venous occlusions and unfavorable coronary sinus anatomy. Left bundle branch area pacing defibrillator (LBBAP-D) has emerged as a promising alternative, but evidence regarding its long-term outcomes is lacking. The aim of this study is to evaluate the long-term clinical effects of LBBAP-D versus CRT-D reimplantation in patients undergoing CRT-D extraction. Materials and Methods From July 2022 to January 2024, we prospectively enrolled 38 patients with indication to CRT-D extraction and reimplantation. TLE was performed following a standardized stepwise approach. The decision between EP and LBBAP strategy was related to the presence of visible posterolateral coronary sinus branches at post-TLE coronary sinus venography. The primary procedural endpoint was successful procedure including complete TLE and device reimplantation without device-related complications. The primary efficacy endpoint was changing in LVEF, indexed LVEDV/BSA, NT-proBNP, NYHA functional class and HF therapy at follow-up compared to pre inhospital admission. Results The study cohort included 38 patients (mean age 71.8±9.9 years, 11% females). Reasons for TLE included pocket infection (n=11, 29%), lead malfunction (n=19, 50%), and endocarditis (n=8, 21%). Overall, 17 patients underwent LBBAP. The primary procedural endpoint was achieved in 92% of cases. One patient died during in hospital stay for septic shock. At a mean follow up of 13±5 months, LVEF slight improved in the LBBAP-D group (37.5±8.3% to 41.8±8.1%), without changes in the CRT-D group (36.0±7.1% to 36.3±7.4%, p=0.03). No significant changes were observed in LVEDV/BSA (93.2±36.6 to 94.3±38.2, p=0.71). Baseline levels of NT-proBNP reduced at follow-up in both groups (LBBAP-D 1403.1±1011.8 to 1128.4±856.7 pg/ml, CRT-D 2317.0±1343.6 to 1814±1202.1 pg/ml, p=0.56). NYHA Class improved slightly in both groups (LBBAP-D median 2, IQR 1.5 to 2±1, CRT-D 2±1 to 2±0.5, p=0.12).  Therapy up-titration occurred at a similar rate in both groups (46% in LBBAP-D vs 42% in CRT-D p=0.78). Conclusion LBBAP-D showed to be a safe and effective alternative to CRT-D in patients undergoing CRT-D extraction with concurrent anatomical constraints.