Comparison of Tricuspid Regurgitation in Cardiac Resynchronization Therapy- Defibrillator Implants Using Left Bundle Branch Area Pacing Versus Biventricular Pacing

Comparison of Tricuspid Regurgitation in Cardiac Resynchronization Therapy- Defibrillator Implants Using Left Bundle Branch Area Pacing Versus Biventricular Pacing | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Tricuspid Regurgitation in Cardiac Resynchronization Therapy- Defibrillator Implants Using Left Bundle Branch Area Pacing Versus Biventricular Pacing Kevin Lee, Karlie Sample, Sahil Attawala, Hany Demo, Westby Fisher, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9510233/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Left bundle branch area pacing (LBBAP) has emerged as an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT). In patients who require a defibrillator in addition to CRT (CRT-D), LBBAP traditionally places two right ventricular leads across the tricuspid valve as opposed to a single lead with CSP. There are limited data on the impact of BVP versus LBBAP on tricuspid regurgitation. Objective: The objective of this study is to determine if there is a significant difference in severity of TR in patients receiving CRT-D with LBBAP with two right ventricular leadas versus BVP. Methods: Consecutive patients receiving CRT-D with either LBBAP or BVP between January 2022 and November 2024 were identified through chart review at a multicenter health system. TR severity was evaluated based on transthoracic echocardiography and classified as 0 (none or trivial), 1 (mild), 2 (moderate), or 3 (severe) within 12 months before and after CRT-D implantation. The primary endpoint was the change in TR, defined as the difference between the pre- and post-implant TR, with positive values representing a worsening of TR and negative values representing an improvement in TR. Secondary endpoints including incidence of worsening TR, HF hospitalization, and all-cause mortality were also identified. Results: 262 patients received CRT-D (mean age 73 ± 10 years, 27% female), of whom 51 (19.5%) received LBBAP while 211 (80.5%) received BVP. After excluding patients with missing TR data, 41 patients who received LBBAP and 144 patients who received BVP were included for the final analysis. The mean TR change in patients with LBBAP was 0.76 ± 0.27, while the mean TR change in patients with BVP was 0.04 ± 0.14 ( p < 0.05). Conclusions: In this retrospective study, patients receiving CRT-D with LBBAP had significant worsening of echocardiographic TR severity when compared to BVP. Figures Figure 1 Figure 2 Introduction Left bundle branch area pacing (LBBAP) provides ventricular pacing using a lead penetrated into the interventricular septum via the right ventricle to capture the left bundle branch area. LBBAP is increasingly utilized to treat patients with a ventricular pacing indication for bradycardia, as well as an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT). When there is a concurrent indication for implantable cardioverter defibrillator functionality with CRT (CRT-D), this can be performed with either BVP or LBBAP. In both cases, a right ventricular ICD lead is placed. However, a coronary sinus lead is placed in the case of BVP, whereas in patients receiving LBBAP, there has traditionally been two leads crossing the tricuspid valve. 1 , 2 It has been previously described that tricuspid regurgitation (TR) may be more likely to occur based on the site of lead fixation in LBBAP. 2 – 4 However, there are limited data comparing severity of TR when there are two leads traversing the tricuspid valve in CRT-D with LBBAP as opposed to one with BVP. This aim of this study was to compare incidence and severity of TR in CRT-D using BVP versus LBBAP. Methods Study Population Via retrospective study, consecutive patients receiving CRT-D with either LBBAP or BVP between January 2022 and November 2024 were identified at Endeavor Health, a multicenter health system. Baseline patient characteristics, pertinent medical comorbidities, medications, baseline QRS morphology, and post-implantation pacing percentages were documented via chart review. TR severity within 12 months before and after CRT-D implantation was evaluated based on transthoracic echocardiography following the American Society of Echocardiography guidelines and classified by assigning a numeric system to correlate with severity, represented as 0 (none or trivial), 1 (mild), 2 (moderate), or 3 (severe) via echocardiographic analysis by an independent reader. The primary endpoint was the change in TR, defined as the difference between the post- and pre-implant TR, with positive values representing a worsening of TR and negative values representing an improvement in TR. Secondary endpoints including incidence of worsening TR, HF hospitalization, and all-cause mortality were also identified. This study was approved by the institutional review board of Endeavor Health. The research adhered to ethical guidelines outlined in the Declaration of Helsinki. Written informed consent was waived by the IRB due to the use of retrospective and de-identified data. Statistical Methods Baseline and medical history were compared between patients receiving LBBAP and those receiving a BVP system using either the Fisher Exact test (categorical variables) or t-tests or the Wilcoxon rank-sum test (continuous variables). Propensity score matching was performed to reduce selection bias due to baseline differences between groups. The propensity score for patients receiving LBBAP versus BVP was estimated using a multivariable logistic regression model including age (< 65 vs ≥ 65 years), sex, comorbidities (hypertension, diabetes, ischemic heart disease, atrial fibrillation, baseline ejection fraction, chronic kidney disease), and medical therapy (beta blockers, ACEi/ARB/ARNi, mineralocorticoid receptor antagonists, diuretics, and SGLT2 inhibitors). One-to-one nearest neighbor matching without replacement was performed using a caliper width of 0.2 of the standard deviation of the logit of the propensity score. Covariate balance before and after matching was assessed using standized mean differences (SMD) with values < 0.10 indicating adequate balance. After propensity score matching, differences in tricuspid regurgitation (TR) change between groups were assessed using weighted linear regression models accounting for matching weights. Logistic regression was used to determine univariate and multivariable predictors of worsening TR. Specifically, candidate variables with a univariate association with worsening TR at the P < 0.15 level were entered into a multivariable model. The final model which included all variables in the multivariable model significant at the < 0.05 level was used to predict the rate of worsening TR for each patient in the study cohort. All analyses were performed using SAS 9.4 (SAS Institute Cary, NC) or R ( www.r-project.org ). Results A total of 262 patients receiving CRT-D (mean age 73 ± 10 years, 27% female) were identified from medical records, of whom 51 (19.5%) received LBBAP while 211 (80.5%) received BVP. After excluding patients who did not have an echocardiogram within 12 months prior to the procedure and within 12 months after CRT-D implantation, 185 patients were included for analysis, 41 (22%) of whom received LBBAP and 144 (78%) patients of whom received BVP. Mean follow up was 180 days for the LBBAP group and 161 days for the BVP group. Table 1 displays baseline characteristics for the patients included in the analysis cohort. There was no significant difference in baseline characteristics between the two groups. The mean TR change in patients with LBBAP was 0.76 ± 0.27, while the mean TR change in patients with BVP was 0.04 ± 0.14 (P < 0.01; Table 2 and Fig. 1 ). The incidence of any amount of worsening TR was 45% in those receiving LBBAP and 20% in those receiving BVP (P < 0.01; Table 2 ). There was no significant difference between the two groups in heart failure hospitalization or all-cause mortality (P = 0.88 and P = 0.61, respectively; Table 2 ). Given differences in the number of patients per group, propensity score matching was performed to reduce selection bias due to baseline differences between groups. The SMD prior to adjustment was 0.51, while the SMD after adjustment was 0.01 (Fig. 2 ). In the propensity-score matched cohort, LBBAP was still associated with a significantly greater increase in TR change compared with BVP (OR 8.57, 95% CI 2.2–39.6, P = 0.009). Table 3 displays the multivariable associations with worsening tricuspid regurgitation. In a multivariable model including sex, baseline QRS morphology, percentage RV and LV pacing, pre-implant TR severity, and type of CRT-D, only severity of pre-implant TR and use of LBBAP were associated with worsening severity of post-implant TR. Discussion In the present study, a significant difference in rate of worsening TR after LBBAP was identified compared to BVP. LBBAP resulted in a worsening of approximately one stage of TR, while BVP did not show any change in TR. The incidence of worsening TR was significantly higher in patients receiving LBBAP (45%) compared to those receiving BVP (20%). In a propensity-score matched cohort, LBBAP was associated with eight-fold higher odds of worsening TR compared with BVP. There have been various proposed mechanisms of tricuspid regurgitation due to leads traversing the tricuspid valve. These include impingement of the leaflets, disruption of the sub-valvular apparatus including chordal injury, and mechanical interference with the tricuspid annulus. 1 ,24, 5 Specific to LBBAP is the sharper angulation of the lead required for implantation in the left bundle branch area compared to the RV apex which increases the risk of TR. 2,6 Bednarek, et al. and Karwiky, et al. both note that shorter distance between the tricuspid annulus and lead implantation site were predictors of worsening TR in patients, which is often required for LBBAP. These studies however, excluded patients with two leads traversing the tricuspid valve, as is the case in CRT-D with LBBAP. For patients receiving CRT-D, this study additionally notes in a multivariable analysis that both pre-implant TR severity and receiving LBBAP rather than BVP increase the risk of worsening TR, with odds ratios of 2.36 and 8.56 respectively. While this study addresses the risk of worsening tricuspid regurgitation after CRT-D, this may be balanced against the overall improvement in biventricular function which is found with cardiac resynchronization therapy, where recent studies have shown improved echocardiographic outcomes with LBBAP when compared to BVP. 7 , 8 The I-CLAS study has also shown a reduction in heart failure hospitalization with LBBAP compared to BVP in patients with LVEF ≤ 50%, though it is important to note that there were significantly more patients who underwent defibrillator implantation in the BVP group (71% to 65%). 9 Further study will be needed to determine the clinical significance of the worsened tricuspid regurgitation in patients with LBBAP compared to BVP in CRT-D. Additionally, a new lumenless defibrillation lead (OmniaSecure, Medtronic, Minneapolis, USA) has recently become commercially available which may improve this issue as it consolidates the LBBAP and defibrillation leads into a single lead. However, the findings of this current study will still inform select cases, such as in patients who are receiving CRT upgrade with a prior defibrillation lead. There are several limitations of the present study. This a single center retrospective analysis, which limits generalizability as well as overall sample size. The choice of pacing modality was non-randomized and carried out at the discretion of the operator. There was also incomplete follow up in a minority of patients who did not have a pre-implant and/or post-implant echocardiogram. Conclusion This study reports the incidence and change in tricuspid regurgitation for patients receiving CRT-D with LBBAP compared to BVP. There was a mean worsening of 0.76 stages of TR for LBBAP with an incidence of 45%, compared to worsening of 0.03 stages of TR for BVP with an incidence of 20%. Risk factors for the development of worsening TR by multivariable logistical regression included worse pre-implant TR and LBBAP. The results may specifically help inform the choice of CRT upgrade in patients with chronic ICD leads. Further studies are needed to place these specific findings regarding TR in context of other outcomes of CRT-D procedures. Declarations Author Contribution K.L. wrote the main manuscript text and prepared all tables and figures with the assistance of K.S. and J.W. All authors reviewed the manuscript. References Russo AM, Desai MY, Do MM, et al. ACC/AHA/ASE/HFSA/HRS/SCAI/SCCT/SCMR 2025 Appropriate Use Criteria for Implantable Cardioverter-Defibrillators, Cardiac Resynchronization Therapy, and Pacing. JACC . 2025;85(11):1213-1285. doi:10.1016/j.jacc.2024.11.023 Karwiky G, Kamarullah W, Pranata R, Achmad C, Iqbal M. A meta-analysis of the distance between lead-implanted site and tricuspid valve annulus with postoperative tricuspid regurgitation deterioration in patients with left bundle branch area pacing. Journal of Cardiovascular Electrophysiology . 2024;35(11):2220-2229. doi:10.1111/jce.16444 Addetia K, Maffessanti F, Mediratta A, et al. Impact of Implantable Transvenous Device Lead Location on Severity of Tricuspid Regurgitation. Journal of the American Society of Echocardiography . 2014;27(11):1164-1175. doi:10.1016/j.echo.2014.07.004 Hu Q, You H, Chen K, et al. Distance between the lead-implanted site and tricuspid valve annulus in patients with left bundle branch pacing: Effects on postoperative tricuspid regurgitation deterioration. Heart Rhythm . 2023;20(2):217-223. doi:10.1016/j.hrthm.2022.10.027 Stassen J, Galloo X, Hirasawa K, et al. Tricuspid regurgitation after cardiac resynchronization therapy: evolution and prognostic significance. Europace . 2022;24(8):1291-1299. doi:10.1093/europace/euac034 Bednarek A, Kiełbasa G, Moskal P, et al. Left bundle branch area pacing improves right ventricular function and synchrony. Heart Rhythm . 2024;21(11):2234-2241. doi:10.1016/j.hrthm.2024.05.019 Vijayaraman P, Ponnusamy S, Cano Ó, et al. Left Bundle Branch Area Pacing for Cardiac Resynchronization Therapy: Results From the International LBBAP Collaborative Study Group. JACC Clin Electrophysiol . 2021;7(2):135-147. doi:10.1016/j.jacep.2020.08.015 Vijayaraman P, Sharma PS, Cano Ó, et al. Comparison of Left Bundle Branch Area Pacing and Biventricular Pacing in Candidates for Resynchronization Therapy. JACC . 2023;82(3):228-241. doi:10.1016/j.jacc.2023.05.006 Morcos R, Vijayaraman P, Cano Ó, et al. Left bundle branch area pacing compared with biventricular pacing for cardiac resynchronization therapy in patients with left ventricular ejection fraction ≤50%: Results from the International Collaborative LBBAP Study (I-CLAS). Heart Rhythm . 2025;22(8):2028-2037. doi:10.1016/j.hrthm.2025.04.005 Tables Table 1. Baseline and Medical History Characteristics Patient Characteristics LBBAP (N=41) BVP (N=144) P-value Age (mean, SD) 73.1 (8.9) 74.2 (9.1) 0.77 Female 41% 25% 0.13 Comorbidities HTN 69% 70% 0.79 DM 19% 30% 0.21 Ischemic Heart Disease 36% 48% 0.22 AF 39% 40% 0.99 EF <= 35% 64% 65% 0.86 CKD 28% 29% 0.99 Medications BB 79% 81% 0.51 ACEI/ARB/ARNI 69% 82% 0.11 MRA 39% 51% 0.10 Diuretic 48% 60% 0.23 SGLT2I 40% 52% 0.19 Baseline QRS Morphology 0.23 LBBB 52% 55% RBBB 4% 10% Other 45% 32% Pacing % RV (median, IQR) 91% (57% - 99%) 93% (35% - 99%) 0.22 LV (median, IQR) 98% (91% - 99%) 98% (95% - 99%) 0.25 Table 2. Primary and Secondary Outcomes LBBAP (N=41) BVP (N=144) P-value Primary Outcome Change in TR 0.76 (0.27) 0.04 (0.14) < 0.01 Secondary Outcomes Change in TR ≥ 1 45% (18/41) 20% (29/144) < 0.01 Change in TR ≥ 2 14% (6/41) 6% (9/144) 0.10 HF Hospitalization 7% (3/41) 3% (5/144) 0.88 All-Cause Mortality 5% (2/41) 4% (6/144) 0.61 Table 3. Propensity Score Matched Characteristics. Characteristic Overall (N = 64) BVP (N = 32) LBBAP (N = 32) P-value Age 0.5 0.9 DM 26 (41%) 15 (47%) 11 (34%) 0.3 Ischemic Heart Disease 37 (58%) 20 (63%) 17 (53%) 0.4 AF 24 (38%) 10 (31%) 14 (44%) 0.3 EF <= 35% 41 (64%) 19 (59%) 22 (69%) 0.4 CKD 20 (31%) 11 (34%) 9 (28%) 0.6 Medications BB 56 (88%) 27 (84%) 29 (91%) 0.7 ACEI/ARB/ARNI 0.8 ACEI 6 (9.4%) 3 (9.4%) 3 (9.4%) ARB 14 (22%) 8 (25%) 6 (19%) ARNI 20 (31%) 8 (25%) 12 (38%) none 24 (38%) 13 (41%) 11 (34%) MRA 30 (47%) 15 (47%) 15 (47%) >0.9 Diuretic 35 (55%) 17 (53%) 18 (56%) 0.8 SGLT2I 28 (44%) 13 (41%) 15 (47%) 0.6 Table 4. Multivariate Predictors of Worsening Tricuspid Regurgitation Characteristic Odds Ratio (95% CI) P-value Female 4.20 (0.66 – 26.91) 0.13 QRS Morphology 1.37 (0.69 – 2.72) 0.37 %RV Pacing 1.19 (0.42 – 3.40) 0.74 %LV Pacing 0.83 (0.14 – 4.77) 0.83 Pre-Implant TR 2.36 (1.29 – 4.31) 0.01 LBBAP 8.56 (3.20 – 22.90) < 0.001 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9510233","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633738627,"identity":"dc0a7cec-7a00-49c1-a775-4f3019e171a9","order_by":0,"name":"Kevin 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Institute","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Metzl","suffix":""},{"id":633738642,"identity":"875cbef4-7af7-4f27-a4a3-6de3f68b2b90","order_by":11,"name":"Jeremiah Wasserlauf","email":"","orcid":"","institution":"Endeavor Health Cardiovascular Institute","correspondingAuthor":false,"prefix":"","firstName":"Jeremiah","middleName":"","lastName":"Wasserlauf","suffix":""}],"badges":[],"createdAt":"2026-04-23 20:08:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9510233/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9510233/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108944251,"identity":"10de95ef-f062-4b76-9325-8f9eccb9aea4","added_by":"auto","created_at":"2026-05-11 05:58:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23412,"visible":true,"origin":"","legend":"\u003cp\u003eLBBAP = Left bundle branch area pacing. BVP = Biventricular pacing. TR = tricuspid regurgitation. CRT-D = Cardiac resynchronization therapy with defibrillator.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9510233/v1/d4dcd108cdb2c1168ec06dc3.png"},{"id":108944296,"identity":"a5ddd654-ce1f-4365-a5ee-d6c238903b4b","added_by":"auto","created_at":"2026-05-11 05:58:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":127634,"visible":true,"origin":"","legend":"\u003cp\u003eLove Plot for Propensity Score Matching.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9510233/v1/14bf4c9656feac50566520ee.png"},{"id":108944450,"identity":"49738c52-fc3e-4dcd-a8ca-2f18a32143eb","added_by":"auto","created_at":"2026-05-11 05:59:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":435051,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9510233/v1/d5151041-1466-436d-8bab-be3f8605d196.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of Tricuspid Regurgitation in Cardiac Resynchronization Therapy- Defibrillator Implants Using Left Bundle Branch Area Pacing Versus Biventricular Pacing","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLeft bundle branch area pacing (LBBAP) provides ventricular pacing using a lead penetrated into the interventricular septum via the right ventricle to capture the left bundle branch area. LBBAP is increasingly utilized to treat patients with a ventricular pacing indication for bradycardia, as well as an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT).\u003c/p\u003e \u003cp\u003eWhen there is a concurrent indication for implantable cardioverter defibrillator functionality with CRT (CRT-D), this can be performed with either BVP or LBBAP. In both cases, a right ventricular ICD lead is placed. However, a coronary sinus lead is placed in the case of BVP, whereas in patients receiving LBBAP, there has traditionally been two leads crossing the tricuspid valve.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e It has been previously described that tricuspid regurgitation (TR) may be more likely to occur based on the site of lead fixation in LBBAP.\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, there are limited data comparing severity of TR when there are two leads traversing the tricuspid valve in CRT-D with LBBAP as opposed to one with BVP. This aim of this study was to compare incidence and severity of TR in CRT-D using BVP versus LBBAP.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Population\u003c/p\u003e\n\u003cp\u003eVia retrospective study, consecutive patients receiving CRT-D with either LBBAP or BVP between January 2022 and November 2024 were identified at Endeavor Health, a multicenter health system. Baseline patient characteristics, pertinent medical comorbidities, medications, baseline QRS morphology, and post-implantation pacing percentages were documented via chart review. TR severity within 12 months before and after CRT-D implantation was evaluated based on transthoracic echocardiography following the American Society of Echocardiography guidelines and classified by assigning a numeric system to correlate with severity, represented as 0 (none or trivial), 1 (mild), 2 (moderate), or 3 (severe) via echocardiographic analysis by an independent reader. The primary endpoint was the change in TR, defined as the difference between the post- and pre-implant TR, with positive values representing a worsening of TR and negative values representing an improvement in TR. Secondary endpoints including incidence of worsening TR, HF hospitalization, and all-cause mortality were also identified.\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional review board of Endeavor Health. The research adhered to ethical guidelines outlined in the Declaration of Helsinki. Written informed consent was waived by the IRB due to the use of retrospective and de-identified data.\u003c/p\u003e\n\u003cp\u003eStatistical Methods\u003c/p\u003e\n\u003cp\u003eBaseline and medical history were compared between patients receiving LBBAP and those receiving a BVP system using either the Fisher Exact test (categorical variables) or t-tests or the Wilcoxon rank-sum test (continuous variables). Propensity score matching was performed to reduce selection bias due to baseline differences between groups. The propensity score for patients receiving LBBAP versus BVP was estimated using a multivariable logistic regression model including age (\u0026lt;\u0026thinsp;65 vs\u0026thinsp;\u0026ge;\u0026thinsp;65 years), sex, comorbidities (hypertension, diabetes, ischemic heart disease, atrial fibrillation, baseline ejection fraction, chronic kidney disease), and medical therapy (beta blockers, ACEi/ARB/ARNi, mineralocorticoid receptor antagonists, diuretics, and SGLT2 inhibitors). One-to-one nearest neighbor matching without replacement was performed using a caliper width of 0.2 of the standard deviation of the logit of the propensity score. Covariate balance before and after matching was assessed using standized mean differences (SMD) with values\u0026thinsp;\u0026lt;\u0026thinsp;0.10 indicating adequate balance. After propensity score matching, differences in tricuspid regurgitation (TR) change between groups were assessed using weighted linear regression models accounting for matching weights.\u003c/p\u003e\n\u003cp\u003eLogistic regression was used to determine univariate and multivariable predictors of worsening TR. Specifically, candidate variables with a univariate association with worsening TR at the P\u0026thinsp;\u0026lt;\u0026thinsp;0.15 level were entered into a multivariable model. The final model which included all variables in the multivariable model significant at the \u0026lt;\u0026thinsp;0.05 level was used to predict the rate of worsening TR for each patient in the study cohort.\u003c/p\u003e\n\u003cp\u003eAll analyses were performed using SAS 9.4 (SAS Institute Cary, NC) or R (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.r-project.org\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 262 patients receiving CRT-D (mean age 73\u0026thinsp;\u0026plusmn;\u0026thinsp;10 years, 27% female) were identified from medical records, of whom 51 (19.5%) received LBBAP while 211 (80.5%) received BVP. After excluding patients who did not have an echocardiogram within 12 months prior to the procedure and within 12 months after CRT-D implantation, 185 patients were included for analysis, 41 (22%) of whom received LBBAP and 144 (78%) patients of whom received BVP. Mean follow up was 180 days for the LBBAP group and 161 days for the BVP group. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays baseline characteristics for the patients included in the analysis cohort. There was no significant difference in baseline characteristics between the two groups.\u003c/p\u003e \u003cp\u003eThe mean TR change in patients with LBBAP was 0.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27, while the mean TR change in patients with BVP was 0.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The incidence of any amount of worsening TR was 45% in those receiving LBBAP and 20% in those receiving BVP (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was no significant difference between the two groups in heart failure hospitalization or all-cause mortality (P\u0026thinsp;=\u0026thinsp;0.88 and P\u0026thinsp;=\u0026thinsp;0.61, respectively; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven differences in the number of patients per group, propensity score matching was performed to reduce selection bias due to baseline differences between groups. The SMD prior to adjustment was 0.51, while the SMD after adjustment was 0.01 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the propensity-score matched cohort, LBBAP was still associated with a significantly greater increase in TR change compared with BVP (OR 8.57, 95% CI 2.2\u0026ndash;39.6, P\u0026thinsp;=\u0026thinsp;0.009).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e displays the multivariable associations with worsening tricuspid regurgitation. In a multivariable model including sex, baseline QRS morphology, percentage RV and LV pacing, pre-implant TR severity, and type of CRT-D, only severity of pre-implant TR and use of LBBAP were associated with worsening severity of post-implant TR.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, a significant difference in rate of worsening TR after LBBAP was identified compared to BVP. LBBAP resulted in a worsening of approximately one stage of TR, while BVP did not show any change in TR. The incidence of worsening TR was significantly higher in patients receiving LBBAP (45%) compared to those receiving BVP (20%). In a propensity-score matched cohort, LBBAP was associated with eight-fold higher odds of worsening TR compared with BVP.\u003c/p\u003e \u003cp\u003eThere have been various proposed mechanisms of tricuspid regurgitation due to leads traversing the tricuspid valve. These include impingement of the leaflets, disruption of the sub-valvular apparatus including chordal injury, and mechanical interference with the tricuspid annulus.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,24,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSpecific to LBBAP is the sharper angulation of the lead required for implantation in the left bundle branch area compared to the RV apex which increases the risk of TR.\u003csup\u003e2,6\u003c/sup\u003e Bednarek, et al. and Karwiky, et al. both note that shorter distance between the tricuspid annulus and lead implantation site were predictors of worsening TR in patients, which is often required for LBBAP. These studies however, excluded patients with two leads traversing the tricuspid valve, as is the case in CRT-D with LBBAP. For patients receiving CRT-D, this study additionally notes in a multivariable analysis that both pre-implant TR severity and receiving LBBAP rather than BVP increase the risk of worsening TR, with odds ratios of 2.36 and 8.56 respectively.\u003c/p\u003e \u003cp\u003eWhile this study addresses the risk of worsening tricuspid regurgitation after CRT-D, this may be balanced against the overall improvement in biventricular function which is found with cardiac resynchronization therapy, where recent studies have shown improved echocardiographic outcomes with LBBAP when compared to BVP.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The I-CLAS study has also shown a reduction in heart failure hospitalization with LBBAP compared to BVP in patients with LVEF\u0026thinsp;\u0026le;\u0026thinsp;50%, though it is important to note that there were significantly more patients who underwent defibrillator implantation in the BVP group (71% to 65%).\u003csup\u003e9\u003c/sup\u003e Further study will be needed to determine the clinical significance of the worsened tricuspid regurgitation in patients with LBBAP compared to BVP in CRT-D.\u003c/p\u003e \u003cp\u003eAdditionally, a new lumenless defibrillation lead (OmniaSecure, Medtronic, Minneapolis, USA) has recently become commercially available which may improve this issue as it consolidates the LBBAP and defibrillation leads into a single lead. However, the findings of this current study will still inform select cases, such as in patients who are receiving CRT upgrade with a prior defibrillation lead.\u003c/p\u003e \u003cp\u003eThere are several limitations of the present study. This a single center retrospective analysis, which limits generalizability as well as overall sample size. The choice of pacing modality was non-randomized and carried out at the discretion of the operator. There was also incomplete follow up in a minority of patients who did not have a pre-implant and/or post-implant echocardiogram.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study reports the incidence and change in tricuspid regurgitation for patients receiving CRT-D with LBBAP compared to BVP. There was a mean worsening of 0.76 stages of TR for LBBAP with an incidence of 45%, compared to worsening of 0.03 stages of TR for BVP with an incidence of 20%. Risk factors for the development of worsening TR by multivariable logistical regression included worse pre-implant TR and LBBAP. The results may specifically help inform the choice of CRT upgrade in patients with chronic ICD leads. Further studies are needed to place these specific findings regarding TR in context of other outcomes of CRT-D procedures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eK.L. wrote the main manuscript text and prepared all tables and figures with the assistance of K.S. and J.W. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRusso AM, Desai MY, Do MM, et al. ACC/AHA/ASE/HFSA/HRS/SCAI/SCCT/SCMR 2025 Appropriate Use Criteria for Implantable Cardioverter-Defibrillators, Cardiac Resynchronization Therapy, and Pacing. \u003cem\u003eJACC\u003c/em\u003e. 2025;85(11):1213-1285. doi:10.1016/j.jacc.2024.11.023\u003c/li\u003e\n \u003cli\u003eKarwiky G, Kamarullah W, Pranata R, Achmad C, Iqbal M. A meta-analysis of the distance between lead-implanted site and tricuspid valve annulus with postoperative tricuspid regurgitation deterioration in patients with left bundle branch area pacing. \u003cem\u003eJournal of Cardiovascular Electrophysiology\u003c/em\u003e. 2024;35(11):2220-2229. doi:10.1111/jce.16444\u003c/li\u003e\n \u003cli\u003eAddetia K, Maffessanti F, Mediratta A, et al. Impact of Implantable Transvenous Device Lead Location on Severity of Tricuspid Regurgitation. \u003cem\u003eJournal of the American Society of Echocardiography\u003c/em\u003e. 2014;27(11):1164-1175. doi:10.1016/j.echo.2014.07.004\u003c/li\u003e\n \u003cli\u003eHu Q, You H, Chen K, et al. Distance between the lead-implanted site and tricuspid valve annulus in patients with left bundle branch pacing: Effects on postoperative tricuspid regurgitation deterioration. \u003cem\u003eHeart Rhythm\u003c/em\u003e. 2023;20(2):217-223. doi:10.1016/j.hrthm.2022.10.027\u003c/li\u003e\n \u003cli\u003eStassen J, Galloo X, Hirasawa K, et al. Tricuspid regurgitation after cardiac resynchronization therapy: evolution and prognostic significance. \u003cem\u003eEuropace\u003c/em\u003e. 2022;24(8):1291-1299. doi:10.1093/europace/euac034\u003c/li\u003e\n \u003cli\u003eBednarek A, Kiełbasa G, Moskal P, et al. Left bundle branch area pacing improves right ventricular function and synchrony. \u003cem\u003eHeart Rhythm\u003c/em\u003e. 2024;21(11):2234-2241. doi:10.1016/j.hrthm.2024.05.019\u003c/li\u003e\n \u003cli\u003eVijayaraman P, Ponnusamy S, Cano \u0026Oacute;, et al. Left Bundle Branch Area Pacing for Cardiac Resynchronization Therapy: Results From the International LBBAP Collaborative Study Group. \u003cem\u003eJACC Clin Electrophysiol\u003c/em\u003e. 2021;7(2):135-147. doi:10.1016/j.jacep.2020.08.015\u003c/li\u003e\n \u003cli\u003eVijayaraman P, Sharma PS, Cano \u0026Oacute;, et al. Comparison of Left Bundle Branch Area Pacing and Biventricular Pacing in Candidates for Resynchronization Therapy. \u003cem\u003eJACC\u003c/em\u003e. 2023;82(3):228-241. doi:10.1016/j.jacc.2023.05.006\u003c/li\u003e\n \u003cli\u003eMorcos R, Vijayaraman P, Cano \u0026Oacute;, et al. Left bundle branch area pacing compared with biventricular pacing for cardiac resynchronization therapy in patients with left ventricular ejection fraction \u0026le;50%: Results from the International Collaborative LBBAP Study (I-CLAS). \u003cem\u003eHeart Rhythm\u003c/em\u003e. 2025;22(8):2028-2037. doi:10.1016/j.hrthm.2025.04.005\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Baseline and Medical History Characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLBBAP (N=41)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBVP (N=144)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (mean, SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e73.1 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e74.2 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e41%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; HTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e70%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; DM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e19%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; Ischemic Heart Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e36%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e48%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; AF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e39%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e40%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; EF \u0026lt;= 35%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e64%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; CKD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e29%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; BB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e81%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; ACEI/ARB/ARNI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e82%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; MRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e39%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e51%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; Diuretic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e48%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e60%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; SGLT2I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e40%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e52%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline QRS Morphology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; LBBB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e52%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e55%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; RBBB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e45%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e32%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePacing %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; RV (median, IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e91% (57% - 99%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e93% (35% - 99%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; LV (median, IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e98% (91% - 99%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e98% (95% - 99%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Primary and Secondary Outcomes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLBBAP (N=41)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBVP (N=144)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Outcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eChange in TR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.76 (0.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0.04 (0.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; Change in TR \u0026ge; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e45% (18/41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e20% (29/144)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; Change in TR \u0026ge; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e14% (6/41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e6% (9/144)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; HF Hospitalization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e7% (3/41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e3% (5/144)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp; All-Cause Mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e5% (2/41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e4% (6/144)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3. Propensity Score Matched Characteristics.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall (N = 64)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBVP (N = 32)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLBBAP (N = 32)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026lt;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026ge;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54 (84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26 (81%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; HTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; DM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26 (41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eIschemic Heart Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37 (58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 (63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eEF \u0026lt;= 35%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41 (64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (59%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eCKD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 (31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; BB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56 (88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27 (84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29 (91%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eACEI/ARB/ARNI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; ACEI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (9.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (9.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (9.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; ARB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; ARNI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 (31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; none\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eMRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30 (47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Diuretic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; SGLT2I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 4. Multivariate Predictors of Worsening Tricuspid Regurgitation\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio\u0026nbsp;\u003cbr\u003e\u0026nbsp;(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e4.20 (0.66 \u0026ndash; 26.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQRS Morphology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1.37 (0.69 \u0026ndash; 2.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%RV Pacing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1.19 (0.42 \u0026ndash; 3.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%LV Pacing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.83 (0.14 \u0026ndash; 4.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-Implant TR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e2.36 (1.29 \u0026ndash; 4.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLBBAP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e8.56 (3.20 \u0026ndash; 22.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9510233/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9510233/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLeft bundle branch area pacing (LBBAP) has emerged as an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT). In patients who require a defibrillator in addition to CRT (CRT-D), LBBAP traditionally places two right ventricular leads across the tricuspid valve as opposed to a single lead with CSP. There are limited data on the impact of BVP versus LBBAP on tricuspid regurgitation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe objective of this study is to determine if there is a significant difference in severity of TR in patients receiving CRT-D with LBBAP with two right ventricular leadas versus BVP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsecutive patients receiving CRT-D with either LBBAP or BVP between January 2022 and November 2024 were identified through chart review at a multicenter health system. TR severity was evaluated based on transthoracic echocardiography and classified as 0 (none or trivial), 1 (mild), 2 (moderate), or 3 (severe) within 12 months before and after CRT-D implantation. The primary endpoint was the change in TR, defined as the difference between the pre- and post-implant TR, with positive values representing a worsening of TR and negative values representing an improvement in TR. Secondary endpoints including incidence of worsening TR, HF hospitalization, and all-cause mortality were also identified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e262 patients received CRT-D (mean age 73 ± 10 years, 27% female), of whom 51 (19.5%) received LBBAP while 211 (80.5%) received BVP. After excluding patients with missing TR data, 41 patients who received LBBAP and 144 patients who received BVP were included for the final analysis. The mean TR change in patients with LBBAP was 0.76 ± 0.27, while the mean TR change in patients with BVP was 0.04 ± 0.14 (\u003cem\u003ep\u003c/em\u003e\u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospective study, patients receiving CRT-D with LBBAP had significant worsening of echocardiographic TR severity when compared to BVP.\u003c/p\u003e","manuscriptTitle":"Comparison of Tricuspid Regurgitation in Cardiac Resynchronization Therapy- Defibrillator Implants Using Left Bundle Branch Area Pacing Versus Biventricular Pacing","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 05:54:58","doi":"10.21203/rs.3.rs-9510233/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2a7ac954-e756-4b2d-a279-7c3d364853d0","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-03T22:18:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T09:27:15+00:00","index":13,"fulltext":""},{"type":"reviewerAgreed","content":"7451665309082233682758374510882608616","date":"2026-05-02T08:44:05+00:00","index":12,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T04:17:42+00:00","index":10,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T01:38:26+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 05:54:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9510233","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9510233","identity":"rs-9510233","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}