This prospective, randomized controlled trial aims to evaluate the effect of left bundle branch pacing (LBBP) compared with conventional right ventricular (RV) pacing on the cumulative duration (total time) of atrial high-rate episodes (AHREs) in patients with preserved left ventricular ejection fraction (LVEF) who are expected to require frequent ventricular pacing.
Atrial High-Rate Episodes (AHREs) are defined as episodes of atrial tachyarrhythmia that are automatically recorded by device diagnostics and detected by implanted cardiac devices. These episodes usually have an atrial rate ≥170 beats per minute and a duration ≥6 minutes. AHREs are linked to a higher risk of thromboembolic events and clinical atrial fibrillation (AF), and they may indicate subclinical AF or other atrial tachyarrhythmias.
Chronic RV pacing has been linked to mechanical and electrical dyssynchrony, which may encourage atrial remodeling and the development of AF. LBBP provides a more physiological ventricular activation and may reduce atrial tachyarrhythmia time (AHRE time).
Patients with LVEF \>50% and atrioventricular (AV) conduction disorders requiring a dual-chamber pacemaker will be randomized to either conventional RV septal pacing or LBBP.
Age ≥ 18 years
Documented preserved LVEF (≥50%)
Sinus rhythm at baseline
Ability to provide written informed consent
History of paroxysmal, persistent, or permanent atrial fibrillation
Previous atrial fibrillation ablation (catheter-based or surgical)
LVEF < 50%
Sinus node disease
Parallel
Right Ventricular Pacing
DeviceImplantation of a dual-chamber pacemaker with the ventricular lead placed in the RV septum. At follow-up, the ventricular pacing percentage and pacing configuration will be noted. All devices used in this study are commercially available in the European Union and carry a valid CE mark.
Left Bundle Branch Pacing
DeviceImplantation of a dual-chamber pacemaker with the ventricular lead placed at the left bundle branch area. Physiological pacing will be programmed into the devices and, at follow-up, the percentage of spontaneous pacing will be noted. All devices used in this study are commercially available in the European Union and carry a valid CE mark.
Total cumulative AHRE time for device-detected episodes lasting >6 minutes
Sum of the durations of all device-detected AHREs with individual episode duration \>6 minutes (atrial rate threshold per device diagnostics, typically ≥170 bpm), expressed as total time (minutes/hours). Total analyzable monitoring time will be defined as the interval from implantation to the last successful device interrogation/remote transmission, excluding periods of missing device data.
Total cumulative time in AHRE episodes with individual episode duration 0 to 6 minutes.
Total cumulative time in AHRE episodes with individual episode duration 6 minutes to 6 hours.
Total cumulative time in AHRE episodes with individual episode duration 6 hours to 24 hours.
Total cumulative time in AHRE episodes with individual episode duration >24 hours.
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