Conduction system pacing versus biventricular pacing for cardiac resynchronization: the CSP-SYNC randomized single center study

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Abstract
Background: There are limited prospective randomized studies comparing left bundle branch area pacing (LBBAP) and biventricular (BiV) pacing for cardiac resynchronization therapy (CRT). Aim: The study tested whether LBBAP is noninferior to BiV pacing in patients with Class I indication for CRT. Methods: The CSP-SYNC study is an investigator-initiated, randomized, single-center study. Sixty-two patients were randomized 1:1 to LBBAP or BiV. The primary study endpoint was change in left ventricular ejection fraction (LVEF) at 6 months. Secondary endpoints included changes in echo and clinical parameters after 6 months and 12 months. Results: Thirty-one patients were randomized to each arm. Most patients were males (71%), and 32 % had ischemic cardiomyopathy. At 6 months, similar improvement of LVEF was observed in the LBBAP group compared to the BiV group (14.0% (95% CI: 11.2-16.8) in LBBAP vs. 8.5% (95% CI: 5.6-11.2) in BiV) with mean intergroup difference of 5.6% (95% CI: 1.6-9.5; P<0.001 for noninferiority). Both groups showed comparable decrease in LVESV (-64 ml (95% CI: -78 to -50) vs -40 ml (95% CI: -54 to -25) respectively, mean difference -24 ml (CI 95%: -44 to -4); P<0.001 for noninferiority), changes in 6-minute walk test (P<0.001 for noninferiority) and NYHA class (P=0.011 for noninferiority). Temporal trends of LV remodelling and heart failure hospitalization rates were also comparable. Conclusions: In patients with a Class I indication for CRT, LBBAP was noninferior to BiV pacing in improving LVEF and provided similar structural and electrical remodelling.

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