Conduction-system pacing could be poised to reshape standard care for atrioventricular (AV) block patients after the randomized CSPACE trial demonstrated its significant benefits over traditional right ventricular septal pacing.
- Conduction-system pacing includes His-bundle, left bundle branch, and LV septal pacing techniques that preserve the heart’s natural electrical pathways.
- However, current guidelines only provide class 2 recommendations for conduction-system pacing in AV block patients.
Taking a closer look at CSP’s potential, the CSPACE trial enrolled 202 patients with AV block at two Australian hospitals, randomizing them to conduction-system pacing or conventional RV septal pacing plus standard care and found that…
- CSP achieved a 65% reduction in the composite primary outcome of pacing-induced cardiomyopathy, CRT upgrade need, heart failure hospitalization, or mortality.
- The benefit was driven by dramatic reductions in pacing-induced cardiomyopathy (69% reduction) and elimination of CRT upgrade requirements.
- However, lead revisions were far more common with conduction-system pacing (7.9% vs. 1.0%), though all cases were manageable with successful revision.
Even without detailed mechanistic data, the clinical outcomes could be used to upgrade current guideline recommendations from class 2 to class 1.
- If guidelines are revised, conduction-system pacing would join a select group of evidence-based first-line pacing strategies, potentially replacing conventional RV pacing.
- The technique already shows promise beyond AV block, with ongoing research exploring applications across broader pacing populations.
Given the significant clinical benefits and potential to prevent heart failure complications, conduction-system pacing represents both a patient care advance and health economic opportunity.
- Beyond individual patient benefits, preventing pacing-induced cardiomyopathy and CRT upgrades could yield substantial healthcare cost savings.
- The 5-year extended follow-up planned for CSPACE patients will provide crucial long-term lead durability and safety data.
The Takeaway
CSPACE provides the first randomized evidence that conduction-system pacing delivers superior clinical outcomes compared to conventional RV pacing in AV block patients. With results like these, there’s a good chance we could see CSP become a first-line treatment in the coming years so long as long-term results hold up.
