CSP Versus BiVP for Heart Failure Patients With RVP Upgraded to Cardiac Resynchronization Therapy

Heart Failure Clinical Trial

— CSP-UPGRADE  

Official title:

Conduction System Pacing Versus Biventricular Pacing for Heart Failure Patients With Right Ventricular Pacing Upgraded to Cardiac Resynchronization Therapy: a Prospective Multicenter Non-inferiority Randomized Controlled Study

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT06241651
• Other study ID #: 2023-SR-811
• Status: Recruiting
• Phase: N/A
• Start date: January 1, 2024
• Est. completion date: March 1, 2026

Study information

• Verified date: January 2024
• Source: The First Affiliated Hospital with Nanjing Medical University
• Contact: Jiangang Zou
• Phone: 86-13605191407
• Email: jgzou[@]njmu.edu.cn
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The present study is a prospective, multicenter, non-inferiority, randomized controlled trail. It aims to investigate whether the efficacy of conduction system pacing (CSP) is non-inferior to biventricular pacing (BiVP) in patients with heart failure and right ventricular pacing (RVP) requiring upgrading to cardiac resynchronization therapy (CRT).

Description:

RVP is a standardized treatment strategy for severe bradyarrhythmia. However, RVP can result in electrical and mechanical dyssynchrony of the heart, which will adversely affect cardiac function. Until now, many studies have shown that RVP can promote the progression of heart failure, especially in patients with high ventricular pacing percentage. For these heart failure patients, upgrading to CRT is a feasible and effective therapy.

BiVP is a traditional method to achieve CRT, which can improve cardiac synchrony and provide great clinical outcomes for heart failure patients upgraded from RVP. CSP contains left bundle branch pacing (LBBP) and His bundle pacing (HBP), which is able to activate native His-Purkinje conduction system and solve the problems caused by RVP. Although HBP has high technical requirements, lower sense value and higher threshold, it is the pacing modality closest to physiological conditions so far. Since first reported by Huang et al. in 2017, LBBP has been carried out boomingly all over the world. LBBP has been reported to offer higher success rate with higher sense value and lower pacing thresholds compared with HBP, which can also achieve similar electrical and mechanical resynchronization as well as HBP.

However, no randomized controlled studies have been reported to compare the efficacy of CSP and BiVP in patients with heart failure and RVP requiring upgrading to CRT. CSP-UPGRADE is a non-inferiority study, and the purpose of which is to investigate whether the efficacy of CSP is not inferior to BiVP in such patients. Eligible patients will be 1:1 randomized to two groups. The primary outcome is change in LVEF between baseline and six months after device implantation assessed by echocardiography. According to BUDAPEST-CRT Upgrade trial, half of lower limit of the 95% confidence interval for difference in mean ΔLVEF between the CRTD and ICD group is about 3.8%, which is used as non-inferiority margin in the present study. Based on previous studies and cases, it is assumed that the mean ΔLVEF values in patients upgraded to CSP and BiVP are equal and the standard deviations are both 5%. With power as 80%, alpha as 0.025, rate of lost-of-follow-up as 10%, the final sample size was estimated as 66 by using PASS Version 21.0.3 (33 patients for each group). If the non-inferiority test reaches positive results, then we will further verify whether CSP is superior to BiVP in such patients.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 66
• Est. completion date: March 1, 2026
• Est. primary completion date: March 1, 2026
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 80 Years

Eligibility

Inclusion Criteria:

1. Patients with symptomatic heart failure (LVEF <50%) after right ventricular pacing for at least 3 months;

2. NYHA class II-IV;

3. NT-proBNP >125pg/mL in patients with sinus rhythm, NT-proBNP >250pg/mL in patients with atrial fibrillation;

4. Right ventricular pacing percentage >40%;

5. Adult patients aged 18-80;

6. With informed consent signed.

Exclusion Criteria:

1. History of acute myocardial infarction within 3 months before enrollment;

2. Frequent premature ventricular contraction (>15%) or malignant ventricular arrhythmia which is difficult to control;

3. History of valvular heart disease intervention within 3 months before enrollment;

4. After mechanical tricuspid valve replacement;

5. Ventricular septal hypertrophy (=15mm during diastole);

6. Complex congenital heart disease;

7. History of heart transplantation;

8. Enrollment in any other study;

9. Pregnant or with child-bearing plan;

10. A life expectancy of less than 12 months.

Related Conditions & MeSH terms

• Cardiac Resynchronization Therapy
• Conduction System Pacing
• Heart Failure
• Right Ventricular Pacing

Intervention

Device:
• Conduction system pacing
Firstly, we will attempt LBBP if the patient is allocated to the experimental group. If we can not achieve LBBP successfully, then we will turn to attempt HBP.
• Biventricular pacing
Implantation of RA lead, RV lead and LV lead are attempted using the standard-of-care technique.

Locations

Country	Name	City	State
China	The First Affiliated Hospital with Nanjing Medical University	Nanjing	Jiangsu

Sponsors (14)

Lead Sponsor

Collaborator

The First Affiliated Hospital with Nanjing Medical University

First Affiliated Hospital, Sun Yat-Sen University, Huizhou Third People's Hospital, Guangzhou Medical University, Meizhou People's Hospital, Nanfang Hospital, Southern Medical University, Rugao People's Hospital, Shantou Central Hospital, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, The Affiliated Hospital of Xuzhou Medical University, The Affiliated Zhangjiagang Hospital of Soochow University, The First Affiliated Hospital of Soochow University, The Third Affiliated Hospital of Soochow University, Third Affiliated Hospital, Sun Yat-Sen University

Country where clinical trial is conducted

China, 

References & Publications (8)

Chung MK, Patton KK, Lau CP, Dal Forno ARJ, Al-Khatib SM, Arora V, Birgersdotter-Green UM, Cha YM, Chung EH, Cronin EM, Curtis AB, Cygankiewicz I, Dandamudi G, Dubin AM, Ensch DP, Glotzer TV, Gold MR, Goldberger ZD, Gopinathannair R, Gorodeski EZ, Gutierrez A, Guzman JC, Huang W, Imrey PB, Indik JH, Karim S, Karpawich PP, Khaykin Y, Kiehl EL, Kron J, Kutyifa V, Link MS, Marine JE, Mullens W, Park SJ, Parkash R, Patete MF, Pathak RK, Perona CA, Rickard J, Schoenfeld MH, Seow SC, Shen WK, Shoda M, Singh JP, Slotwiner DJ, Sridhar ARM, Srivatsa UN, Stecker EC, Tanawuttiwat T, Tang WHW, Tapias CA, Tracy CM, Upadhyay GA, Varma N, Vernooy K, Vijayaraman P, Worsnick SA, Zareba W, Zeitler EP. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm. 2023 Sep;20(9):e17-e91. doi: 10.1016/j.hrthm.2023.03.1538. Epub 2023 May 20. — View Citation

Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabes JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylen I, Tolosana JM; ESC Scientific Document Group. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021 Sep 14;42(35):3427-3520. doi: 10.1093/eurheartj/ehab364. No abstract available. Erratum In: Eur Heart J. 2022 May 1;43(17):1651. — View Citation

Kaye GC, Linker NJ, Marwick TH, Pollock L, Graham L, Pouliot E, Poloniecki J, Gammage M; Protect-Pace trial investigators. Effect of right ventricular pacing lead site on left ventricular function in patients with high-grade atrioventricular block: results of the Protect-Pace study. Eur Heart J. 2015 Apr 7;36(14):856-62. doi: 10.1093/eurheartj/ehu304. Epub 2014 Sep 4. — View Citation

Khurshid S, Obeng-Gyimah E, Supple GE, Schaller R, Lin D, Owens AT, Epstein AE, Dixit S, Marchlinski FE, Frankel DS. Reversal of Pacing-Induced Cardiomyopathy Following Cardiac Resynchronization Therapy. JACC Clin Electrophysiol. 2018 Feb;4(2):168-177. doi: 10.1016/j.jacep.2017.10.002. Epub 2017 Nov 15. — View Citation

Merkely B, Hatala R, Wranicz JK, Duray G, Foldesi C, Som Z, Nemeth M, Goscinska-Bis K, Geller L, Zima E, Osztheimer I, Molnar L, Karady J, Hindricks G, Goldenberg I, Klein H, Szigeti M, Solomon SD, Kutyifa V, Kovacs A, Kosztin A. Upgrade of right ventricular pacing to cardiac resynchronization therapy in heart failure: a randomized trial. Eur Heart J. 2023 Oct 21;44(40):4259-4269. doi: 10.1093/eurheartj/ehad591. — View Citation

Qian Z, Wang Y, Hou X, Qiu Y, Wu H, Zhou W, Zou J. Efficacy of upgrading to left bundle branch pacing in patients with heart failure after right ventricular pacing. Pacing Clin Electrophysiol. 2021 Mar;44(3):472-480. doi: 10.1111/pace.14147. Epub 2021 Jan 31. — View Citation

Shan P, Su L, Zhou X, Wu S, Xu L, Xiao F, Zhou X, Ellenbogen KA, Huang W. Beneficial effects of upgrading to His bundle pacing in chronically paced patients with left ventricular ejection fraction <50. Heart Rhythm. 2018 Mar;15(3):405-412. doi: 10.1016/j.hrthm.2017.10.031. Epub 2017 Nov 16. — View Citation

Tops LF, Schalij MJ, Bax JJ. The effects of right ventricular apical pacing on ventricular function and dyssynchrony implications for therapy. J Am Coll Cardiol. 2009 Aug 25;54(9):764-76. doi: 10.1016/j.jacc.2009.06.006. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	?LVEF	Change in LVEF between baseline and six months after device implantation	Baseline; 6-month follow-up
Secondary	?LVEDD	Change in LVEDD between baseline and follow-up	Baseline; 3-month follow-up; 6-month follow-up
Secondary	?LVEDV	Change in LVEDV between baseline and follow-up	Baseline; 3-month follow-up; 6-month follow-up
Secondary	?LVESV	Change in LVESV between baseline and follow-up	Baseline; 3-month follow-up; 6-month follow-up
Secondary	Paced QRS duration	Paced QRS duration is evaluated before discharge and follow-up	1 day before discharge; 1-month follow-up; 3-month follow-up; 6-month follow-up
Secondary	Echocardiographic response rate	The percentage of patients responding to CRT upgrade assessed by echocardiography	Baseline; 6-month follow-up
Secondary	Changes in NT-proBNP	The changes of NT-proBNP between baseline and follow-up	Baseline; 3-month follow-up; 6-month follow-up
Secondary	Changes in New York Heart Association Heart Function Classification	The higher the classification, the more severe the heart failure symptoms (four levels: I, II, III and IV)	Baseline; 1-month follow-up; 3-month follow-up; 6-month follow-up
Secondary	Changes in 6-minute Walk Distance	Distance that a participant walk within 6 minutes	Baseline; 3-month, 6-month follow-up
Secondary	Change in Quality Of Life Questionnaire score	Reflect the effect of heart failure on quality of life, and higher scores represent a worse outcome	Baseline; 3-month follow-up; 6-month follow-up
Secondary	Incidence of clinical adverse events	Including all-cause mortality, cardiovascular mortality, heart failure hospitalization and malignant ventricular arrhythmia	1 day before discharge; 1-month follow-up; 3-month follow-up; 6-month follow-up
Secondary	Procedure-related costs	Costs related to device implantation	1 day before discharge
Secondary	Estimated longevity of the device	The longevity of the device will be estimated during pacemaker test	1 day before discharge; 1-month follow-up; 3-month follow-up; 6-month follow-up
Secondary	Pacing parameters	Number of atrial fibrillation and NSVT/VT	1 day before discharge; 1-month follow-up; 3-month follow-up; 6-month follow-up
Secondary	Pacemaker related complications	Including but not limited to hemorrhage, pneumothorax, pericardial effusion, device-related infection and lead displacement	1 day before discharge; 1-month follow-up; 3-month follow-up; 6-month follow-up