Comparison of Left Ventricular Function after His Bundle Pacing vs Left Bundle Branch Area Pacing Implantation

Comparison of Left Ventricular Function after His Bundle Pacing vs Left Bundle Branch Area Pacing Implantation | 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 Left Ventricular Function after His Bundle Pacing vs Left Bundle Branch Area Pacing Implantation Kurniawan Prakoso, Kevin Wibawa, Giky Karwiky, Mohammad Rizki Akbar, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4572835/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 Right ventricular pacing may lead to deterioration of left ventricular (LV) function. Recent guideline suggests the use of conduction system pacing (CSP) with either his bundle pacing (HBP) or left bundle branch area pacing (LBBAP). This study aimed to investigate the difference of LV function between HBP and LBBAP. Methods This is a prospective cohort study enrolling patients age > 18 years requiring CSP implantation from June 2020 to January 2024 in Hasan Sadikin General Hospital, Bandung. Data regarding QRS duration and several echocardiography parameters were obtained at baseline and during follow up within 1 year after CSP implantation. Results From 66 patients, 35 were included in the HBP group. There was no difference in QRS duration at baseline between both groups with higher left ventricular ejection fraction (LVEF) in HBP group (51.17 ± 13.87% vs 45.58 ± 11.08%, p = 0.078). During follow up, HBP group showed narrower QRS duration (113.40 ± 17.06ms vs 120.81 ± 12.12ms, p = 0.029). LV function was preserved in HBP group while there was a trend of LV function improvement in LBBAP group (53.11 ± 11.67% in LBBAP vs 53.93 ± 11.45% in HBP group, p = 0.536). Further analysis in 33 patients with LV dysfunction showed a trend of LVEF improvement in both groups (35.31 ± 7.86% to 44.54 ± 11.28% in HBP and 38.75 ± 6.95% to 51.35 ± 13.14% in LBBAP group). Conclusion HBP resulted in narrower QRS complex. However, both HBP and LBBAP showed a trend of LV function improvement in patients with LV dysfunction. conduction system pacing (CSP) his bundle pacing (HBP) left bundle branch area pacing (LBBAP) left ventricular (LV) function Figures Figure 1 Figure 2 Figure 3 Background Permanent pacemaker (PPM) implantation is indicated in patients with symptomatic bradycardia or other conditions such as heart failure (HF), certain types of cardiomyopathies, and other rare diseases. 1 Conventional right ventricular pacing (RVP) may lead to deterioration of left ventricular (LV) function as it may induced cardiomyopathy due to electrical dyssynchrony, especially in patients anticipated to have a substantial right ventricular pacing. 2 – 4 Conduction system pacing (CSP), a more physiologic type of pacing, aims to directly or indirectly stimulate the His-Purkinje cardiac conduction system, consisting of His bundle pacing (HBP), left bundle branch area pacing (LBBAP), and pacing of the surrounding conduction system tissues, including right ventricular septal pacing (RVSP), left ventricular septal pacing (LVSP), and mid-septal pacing. 5 Studies reported that both HBP and LBBAP resulted in a narrower QRS complex, a higher left ventricular ejection fraction (LVEF), and a lower heart failure hospitalization during follow up compared with RVP. 6 – 8 Although previous recommendations of using CSP are limited, recent guideline suggests the use of either cardiac resynchronization therapy (CRT) with biventricular (BiV) pacing or CSP (HBP or LBBAP) in all patients requiring PPM regardless of patient’s left ventricular (LV) function to mitigate the occurrence of HF. 4 Pacing of the His bundle are thought to be more physiologic and has a lower rate of tricuspid regurgitation (TR), however it requires a more difficult procedural techniques for implantation, resulting in a longer procedure duration and fluoroscopy time. 10 – 12 It also has a higher capture threshold during follow up compared to RVP and LBBAP. 10 Furthermore, it may not be able to correct a preexisting bundle branch block. 13 Left bundle branch area pacing was introduced much later in 2017. 14 It is easier to implant with several advantages such as lower and more stable capture threshold, lower CSP-related complication, and have a possibility of correcting a preexisting bundle branch block. 10 , 15 – 17 Despite the clear superiority of LBBAP compared to HBP especially in terms of pacing parameters, procedure duration, and pacemaker related complications, the recommendations of using HBP are more common in the existing guidelines. 1 , 18 – 20 Furthermore, the data about head-to-head comparison regarding the LV function after pacemaker implantation between LBBAP and HBP is limited. Therefore, this study aimed to investigate the difference of left ventricular function following HBP and LBBAP implantation. Methods Patient selection This is a prospective cohort study enrolling consecutive patients age > 18 years old requiring CSP implantation due to symptomatic bradycardia or as a resynchronization therapy in heart failure patients with reduced ejection fraction (HFrEF) in Hasan Sadikin General Hospital, Bandung, Indonesia, from June 2020 to January 2024. From 79 patients undergoing CSP implantation, 13 patients were excluded due to incomplete echocardiography data or loss to follow up. His bundle pacing was initially attempted in 49 patients, however, cross over to LBBAP group occurred in 14 patients due to several reasons such as inability to visualize the His region, failure to capture of the His signal, presence of a high His bundle capture threshold, or if the HBP is unable to correct a wide QRS complex (Fig. 1 ). Pacemaker Implantation CSP implantations were carried out using local anesthesia. Venous accesses were obtained through cephalic and axillary veins. For HBP implantation, the tip of active bipolar SelectSecure 3930 Medtronic lead was placed on the His region after visualization with contrast injection at the membranous septum at the level of tricuspid annulus. After obtaining the His bundle potential, pacing was attempted to achieve optimal pacing parameters as explained by Ezzeddine et al. 21 A selective his bundle pacing was defined as an equal duration of an interval between stimulus-ventricle interval (S-V) and the intrinsic His-ventricle (H-V), along with an identical paced QRS morphology to the intrinsic QRS complex. A nonselective his bundle pacing was defined as a shorter S-V compared to the intrinsic H-V along with a local fusion of both the His bundle and septal myocardium signals. 22 In LBBAP, pacing lead was placed 1.5-2 cm distal to the His bundle. 21 The presence of a paced QS morphology in lead V1, a QRS discordance in the inferior leads, and a QRS discordance in lead aVR/aVL were the marker for optimal sites for LBBAP implantation. Once this pacing morphology is obtained, the intraventricular septum is penetrated with a depth of 1.4 ± 0.23 cm. 23 A nonselective LBBAP is characterized by a prolonged peak left ventricular activation time (pLVAT) when there is a change in output from high to low, a longer stimulus-His interval, and a longer stimulus-right atrial interval. 24 Assessment of LV function Echocardiographic parameters were obtained before and within 1 year after pacemaker implantation using Vivid S70 or Vivid iq (GE Vingmend Ultrasound, Horten Norway) evaluating the left atrial anteroposterior diameter using M-mode (mm), left atrial volume index (LAVI), left ventricular end diastolic-diameter (LVEDD), left ventricular ejection fraction (LVEF) using Simpson Biplane technique, degree of valvular regurgitation (mitral and tricuspid), and degree of probability of pulmonary hypertension as recommended by the guidelines. 25 Left atrial dilatation was defined based on left atrial anteroposterior diameter of > 4.0 cm in male or > 3.8 cm in female, or if LAVI is ≥ 35 ml/m2. Left ventricular dilatation was defined as LVEDD divided by body surface area (BSA) of ≥ 3.1 cm/m2 in male or ≥ 3.2 cm/m2 in female. Left ventricular dysfunction was defined as LVEF < 50%. Left ventricular function improvement was defined as those who initially have left ventricular dysfunction with a final LVEF of ≥ 50% during follow up. Data collection and follow-up The baseline clinical data analysed in this study included history of pacemaker implantation (temporary or permanent pacemaker) and QRS complex duration (ms) obtained from 12 lead ECG. For patients with LV dysfunction, additional data regarding doses of guideline directed medical including angiotensin converting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB), angiotensin receptor/neprilysin inhibitor (ARNI), beta blocker (BB), mineralocorticoid receptor antagonist (MRA), and sodium-glucose cotransporter 2 (SGLT-2) inhibitor were collected. Statistical analysis Descriptive statistics were used to summarize the data. Categorical data were presented as frequencies and percentages. The normality test using Kolmogorov-Smirnov test was performed to continuous data. Normally distributed data were presented as mean and standard deviation. Otherwise, the data were presented in median and interquartile range. Continuous data were compared with 2-tailed Student’s t-test, while categorical data were analysed using Chi-square (χ2) test. A p value of < 0.05 was considered statistically significant. The statistical analysis was conducted using SPSS 29.0 software (SPSS, Inc., Chicago, Illinois). Results Baseline clinical characteristics From the final 66 patients, 35 patient (53%) had HBP implantation, while the other 31 (47%) patients had LBBAP implantation (Table 1). There was no significant age difference between both groups, and only 2 patient (5.7%) from HBP group underwent the procedure as a resynchronization therapy for heart failure. More than half of the patients from each group had dual chamber pacemaker. A considerable number of patients from LBBAP group had a history of previous pacemaker implantation (67.7%, p=0.197). Both groups had a wide QRS complex duration at baseline (124.63 ± 33.36 ms in HBP vs. 121.94 ± 32.91 ms in LBBAP group, p=0.981). Table 1. Baseline Characteristics Baseline HBP n = 35 LBBAP n = 31 p Value Age (years) 57.00 ± 16.15 57.68 ± 17.45 0.404 Gender 0.047* Male 21 (60.0%) 11 (35.5%) Female 14 (40.0%) 20 (64.5%) CSP indication 0.177 Symptomatic Bradycardia Resynchronization therapy 33 (94.3%) 2 (5.7%) 31 (100%) 0 (0%) Pacemaker chambers 0.258 Single 9 (25.7%) 12 (38.7%) Dual 26 (74.3%) 19 (61.3%) History of pacemaker 0.197 No history of pacemaker 19 (54.3%) 10 (32.3%) Temporary Pacemaker 12 (34.3%) 16 (51.6%) Permanent Pacemaker 4 (11.4%) 5 (16.1%) QRS duration (ms) 124.63 ± 33.36 121.94 ± 32.91 0.981 CSP = conduction system pacing *P value <0.05 Baseline echocardiography parameters From the baseline data of echocardiography parameters measured before PPM implantation, majority of patients in either HBP or LBBAP group had a normal LA and LV size, with a higher mean of LVEF in HBP group (51.17 ± 13.87% vs. 45.58 ± 11.08%, p=0.078) (Table 2). Most patients had normal or mild degree of mitral regurgitation or tricuspid valves regurgitation along with low or intermediate probability of pulmonary hypertension. QRS duration and echocardiographic parameters after pacemaker implantation After pacemaker implantation, HBP group had a shorter mean QRS duration compared to LBBAP group (113.40 ± 17.06 ms vs 120.81 ± 12.12 ms, p=0.029) (Figure 2). Table 2. Baseline Echocardiographic Parameters Echocardiographic parameters HBP n = 35 LBBAP n = 31 p Value LA Size (mm) 38.86 ± 8.44 36.13 ± 10.07 0.236 LAVI (ml/m2) 41.63 ± 34.32 34.29 ± 20.27 0.302 LVEDd (mm) 48.54 ± 7.43 49.55 ± 9.09 0.623 LV dilatation 0.691 Yes 13 (37.1%) 13 (41.9%) No 22 (62.9%) 18 (58.1%) LA dilatation 0.805 Yes 17 (48.6%) 16 (51.6%) No 18 (51.4%) 15 (48.4%) LVEF (%) 51.17 ± 13.87 45.58 ± 11.08 0.078 EF 0.026* Preserved EF 22 (62.9%) 11 (35.5%) Reduced EF 13 (37.1%) 20 (64.5%) Mitral regurgitation 0.739 No 23 (65.7%) 24 (77.4%) Mild 9 (25.7%) 5 (16.1%) Moderate 2 (5.7%) 1 (3.2%) Severe 1 (2.9%) 1 (3.2%) Tricuspid regurgitation 0.803 No 22 (62.9%) 21 (67.7%) Mild 8 (22.9%) 7 (22.6%) Moderate 4 (11.4%) 3 (9.7%) Severe 1 (2.9%) 0 (0%) Probability of pulmonary hypertension 0.962 Low 23 (65.7%) 20 (64.5%) Intermediate 7 (20.0%) 7 (22.6%) High 5 (14.3%) 4 (12.9%) EF = ejection fraction; LAVI = left atrial volume index; LA = left atrium; LV = left ventricle; LVEDd = left ventricular end diastolic dimension; LVEF = left ventricular ejection fraction Compared with baseline, the mean LVEDD in both groups were similar, while the mean of LAVI in HBP group was reduced (41.63 ± 34.32 ml/m2 to 37.11 ± 24.82 ml/m2, p=0.815) with a relatively similar value in LBBAP group (Table 3). Table 3. QRS Duration and Echocardiographic Parameters after Pacemaker Implantation Echocardiographic parameters HBP n = 35 LBBAP n = 31 p Value Mean follow up (months) 6.33 4.81 0.316 QRS duration (ms) 113.40 ± 17.06 120.81 ± 12.12 0.029* Pacing selectivity Selective Nonselective 18 (51.4%) 17 (48.6%) 25 (80.6%) 6 (19.4%) 0.013* LA Size (mm) 36.20 ± 7.02 37.29 ± 8.62 0.574 LAVI (ml/m2) 37.11 ± 24.82 35.87 ± 16.71 0.815 LVEDD (mm) 47.31 ± 7.86 47.55 ± 7.52 0.902 LV dilatation 0.579 Yes 6 (17.1%) 7 (22.6%) No 29 (82.9%) 24 (77.4%) LA dilatation 0.782 Yes 17 (48.6%) 14 (45.2%) No 18 (51.4%) 17 (54.8%) LVEF 53.93 ± 11.45 53.11 ± 11.67 0.536 Ejection fraction 0.558 Preserved EF 26 (74.3%) 21 (67.7%) Reduced EF 9 (25.7%) 10 (32.3%) Mitral regurgitation 0.472 No 27 (77.1%) 21 (67.7%) Mild 7 (20.0%) 7 (22.6%) Moderate 0 (0.0%) 2 (6.5%) Severe 1 (2.9%) 1 (3.2%) Tricuspid regurgitation 0.406 No 28 (80.0%) 21 (67.7%) Mild 5 (14.3%) 9 (29.0%) Moderate 1 (2.9%) 1 (3.2%) Severe 1 (2.9%) 0 (0%) Probability of pulmonary hypertension 0.248 Low 30 (85.7%) 29 (93.5%) Intermediate 3 (8.6%) 0 (0%) High 2 (5.7%) 2 (6.5%) EF = ejection fraction; LAVI = left atrial volume index; LA = left atrium; LV = left ventricle; LVEDd = left ventricular end diastolic dimension; LVEF = left ventricular ejection fraction Compared with baseline, the mean LVEF was increased in LBBAP group (45.58 ± 11.08% to 53.11% ± 11.67%, p = 0.536), while in the HBP group the mean LVEF was remain preserved (51.17 ± 13.87% to 53.93 ± 11.45%) (Figure 3). Patients with left ventricular dysfunction Subgroup analysis was performed for patient with LV dysfunction. Majority of patients receiving HBP had no history of previous pacemaker implantation (69.2%), while only 25% patients in LBBAP group had neither history of temporary nor permanent pacemaker implantation, respectively. There was a reduction in QRS duration in the HBP group, while in the LBBAP group the QRS duration was relatively similar. At the end of follow up, 38.5% of patients in HBP group and 50% in LBBAP group had LVEF improvement (p=0.515). Table 4. Subgroup Analysis on Patient with Left Ventricular Dysfunction Pre PPM p Value Post PPM p Value HBP n = 13 LBBAP n = 20 HBP n = 13 LBBAP n = 20 Mean follow up (months) 5.00 ± 4.45 6.50 ± 4.16 0.332 Age 64.08 ± 8.98 63.35 ± 11.90 0.852 Chambers pacing 0.963 Single Dual 4 (30.8%) 9 (69.2%) 6 (30.0%) 14 (70.0%) Pacing selectivity Selective Nonselective 7 (53.8%) 6 (46.2%) 16 (80.0%) 4 (20.0%) 0.110 Previous pacemaker No 9 (69.2%) 5 (25.0%) 0.053 TPM 4 (30.8%) 11 (55.0%) PPM 0 (0%) 4 (20.0%) QRS duration 128.15 ± 41.04 129.05 ± 33.84 0.946 113.23 ± 19.50 123.35 ± 11.68 0.071 LVEF 35.31 ± 7.86 38.75 ± 6.95 0.197 44.54 ± 11.28 51.35 ± 13.14 0.135 LA dilatation No 10 (76.9%) 9 (45.0%) 0.070 12 (92.3%) 8 (40.0%) 0.003* Yes 3 (23.1%) 11 (55.0%) 1 (7.7%) 12 (60.0%) LV dilatation No 3 (23.1%) 9 (45.0%) 0.201 8 (61.5%) 14 (70.0%) 0.614 Yes 10 (76.9%) 11 (55.0%) 5 (38.5%) 6 (30.0%) LVEDD 52.46 ± 7.63 52.45 ± 7.61 0.997 49.92 ± 9.55 48.65 ± 7.94 0.681 Mitral regurgitation No 6 (46.2%) 16 (80.0%) 0.130 8 (61.5%) 14 (70.0%) 0.547 Mild 5 (38.5%) 3 (15.0%) 5 (38.5%) 5 (25.0%) Moderate 2 (15.4%) 1 (5%) 0 (0%) 1 (5.0%) Severe 0 (0%) 0 (0%) 0 (0%) 0 (0%) Tricuspid regurgitation No 5 (38.5%) 16 (80.0%) 0.081 9 (69.2%) 13 (65.0%) 0.503 Mild 4 (30.8%) 3 (15.0%) 2 (15.4%) 6 (30.0%) Moderate 3 (23.1%) 1 (5.0%) 1 (7.7%) 1 (5.0%) Severe 1 (7.7%) 0 (0%) 1 (7.7%) 0 (0%) Probability of PH Low 4 (30.8%) 14 (70.0%) 0.046* 10 (76.9%) 18 (90.0%) 0.194 Intermediate 5 (38.5%) 5 (25.0%) 2 (15.4%) 0 (0%) High 4 (30.8%) 1 (5.0%) 1 (7.7%) 2 (10.0%) Reduced EF Yes 8 (61.5%) 10 (50.0%) 0.515 Improved LVEF Yes 5 (38.5%) 10 (50.0%) 0.515 EF = ejection fraction; LAVI = left atrial volume index; LA = left atrium; LV = left ventricle; LVEDd = left ventricular end diastolic dimension; LVEF = left ventricular ejection fraction; PH = pulmonary hypertension PPM = permanent pacemaker; TPM = temporary pacemaker; *P value <0.05 Majority of patients in the HBP group receive no or less than 50% of recommended dose of the guideline medical therapies, while in the LBBAP group, more patients received adequate dose of renin-angiotensin-aldosterone system (RAAS) blockers (ACE-I, ARB, or ARNI) and MRA. Table 5. Guideline Medical Therapy in Patients with Left Ventricular Dysfunction Medication HBP n = 13 LBBAP n = 20 p Value No ACE-I/ARB 7 (53.8%) 7 (35.0%) 0.035* ACE-I/ARB <50% target dose 5 (38.5%) 3 (15.0%) ACE-I/ARB ≥50% target dose 1 (7.7%) 10 (50.0%) No ARNI 11 (84.6%) 18 (90.0%) 0.898 ARNI <50% target dose 1 (7.7%) 1 (5.0%) ARNI ≥50% target dose 1 (7.7%) 1 (5.0%) No beta blocker 7 (53.8%) 7 (35.0%) 0.412 Beta blocker <50% target dose 2 (15.4%) 7 (35.0%) Beta blocker ≥50% target dose 4 (30.8%) 6 (30.0%) No MRA 8 (61.5%) 7 (35.0%) 0.275 MRA <50% target dose 0 (0%) 1 (5%) MRA ≥50% target dose 5 (38.5%) 12 (60.0%) SGLT2 inhibitor (no) 11 (84.6%) 19 (95.0%) 0.311 SGLT2 inhibitor (yes) 2 (15.4%) 1 (5.0%) ACE-I = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor blocker; ARNI = angiotensin receptor neprilysin inhibitor; MRA = mineralocorticoid receptor antagonist Discussion CSP recently has become the main option for type of PPM especially to prevent the occurrence of pacemaker induced cardiomyopathy in patients anticipated to have substantial right ventricular pacing. 2 – 4 Despite the absence of a clear head-to-head comparison between HBP and LBBAP implantation in term of LV function, more guidelines tend to recommend the use of HBP implantation instead of LBBAP. 1 , 18 – 20 This study involved 66 patients undergoing CSP implantation for symptomatic bradycardia or as a resynchronization therapy in HFrEF. From 35 patients in the HBP group (53%) and 31 patients in the LBBAP group (47%), there was no significant difference in term of age with most of them had dual chamber pacemaker implantation (74.3% in HBP vs 61.3% in LBBAP, p = 0.258). Both groups also have a similarly wide baseline QRS complex (124.63 ± 33.36ms in HBP vs 121.94 ± 32.91ms, p = 0.981) (Table 1 ). For the baseline echocardiography data, HBP group has a relatively higher mean of LVEF compare to LBBAP group (51.17 ± 13.87% vs 45.58 ± 11.08%, p = 0.078) due to a higher number of patients having LV dysfunction in the LBBAP group (64.5% in LBBAP vs 37.1% in HBP, p = 0.026). Despite having a lower mean LVEF baseline in the LBBAP group, most of the patients in this group have a normal LV dimension as well as normal or mild abnormalities of the mitral and tricuspid valves (Table 2 ), reflecting the possibility of acute LV dysfunction due electrical dyssynchrony resulted from a wide baseline QRS complex before CSP implantation. As showed by previous study, a wide QRS complex, especially in patients with LBBB morphology, delayed regional electrical activation at the left posterobasal region of the left ventricle will result in loss of energy of the intraventricular septum for the late-developing lateral forces, leading to a reduction in cardiac output. 26 Evaluation after HBP implantation showed a marked reduction in the QRS duration (113.40 ± 17.06 ms) with a relatively similar QRS duration in the LBBAP group compared to baseline (120.81 ± 12.12, p = 0.029) (Fig. 2 ). This result is slightly different with data from a recent meta-analysis by Abidin et al. involving 9 studies which showed a slightly decreased QRS duration in the paced rhythm compared to baseline in both HBP and LBBA group. 27 However if analyzed separately in the meta-analysis, only studies with a very wide QRS complex (≥ 140 ms) have a significant reduction in the QRS duration after CSP implantation, while baseline QRS duration of both HBP and LBBAP groups in this study are ± 120ms. 27 Furthermore, in our study, patients who were initially attempted to have HBP implantation but failed to correct the wide QRS complex would switch to LBBAP implantation in the hope of correcting a more distal conduction abnormalities, resulting in a wide paced rhythm QRS duration in the LBBAP group. However, despite a persistent wide QRS duration even after LBBAP implantation, there was a trend of LVEF improvement in the LBBAP group compared to baseline (45.58 ± 11.08% to 53.11 ± 11.67) (Fig. 1 ). This result may be explained by previous studies stating that not all wide QRS complex lead to a reduction in cardiac output, and in this situation, resynchronization therapy would result in an improvement of LV function, even in patients with mechanical dyssynchrony despite having a narrow baseline QRS complex. 26 , 28 – 29 Further analysis was carried out for patients with LV dysfunction. This subgroup has a higher mean of age (64.08 ± 8.98 years in HBP and 63.35 ± 11.090 years in LBBAP, p = 0.852) compared with the overall mean age in this study (57.00 ± 16.15 years in HBP and 57.68 ± 17.45 years in LBBAP, p = 0.404) (Table 4 ). In this subgroup analysis, similar results of a trend of QRS duration reduction in the HBP group (128.15 ± 43.02ms to 112.00 ± 21.10ms) with persistently wide QRS complex in the LBBAP group (125.13 ± 32.82ms to 122.07 ± 11.61ms) were found. These results were accompanied with a trend of LVEF improvement in both groups (35.31 ± 7.86% to 44.54 ± 11.28% in HBP group vs 44.54 ± 11.28% to 51.35 ± 13.14% in LBBAP group) with at least 50% of patients had LVEF improvement by the end of follow up (Table 4 ). Several reasons may explain the more dramatic LVEF improvement in the LBBAP group of this subgroup analysis compared to HBP group. First, there were 2 patients in the HBP group underwent HBP implantation as a form of resynchronization therapy. These patients were known to have significant coronary artery disease with several non-viable myocardial regions as assessed by imaging testing. Therefore, narrowing of the QRS duration may not lead to an LVEF improvement in these patients. Second, despite a lower baseline of LVEF in the HBP group, more patients received less adequate dose of guideline directed medical therapy compared with LBBAP group (Table 5 ). Third, this subgroup analysis may be underpower to truly show a significant improvement of LVEF in the HBP group due to a relatively small subjects in the HBP group compared to the LBBAP group. Lastly, previous meta-analysis stated that CSP may induce LVEF improvement after 6 months or even 12 months of follow up, however in this subgroup analysis, the mean of follow up in the HBP group of this subgroup analysis was only 5.00 ± 4.45 months, p = 0.332 group, therefore LVEF improvement may not occurred yet in all subjects of this group. 30 – 31 Limitation This study is a prospective cohort study with a small sample size and a relatively short duration of follow up. A larger study with longer follow up duration may be needed to demonstrate a statistically significant difference of LV function after HBP and LBBAP implantation. This study also did not evaluate echocardiographic parameters for inter- and intraventricular dyssynchrony, which might be able to explain the trend of LVEF improvement in spite of a persistently wide QRS complex after LBBAP implantation. Even though it might be underpowered, this is the first study trying to further analyze the difference of LV function following HBP and LBBAP implantation in subgroup of patients with underlying LV dysfunction. The findings from this study provided additional information that LBBAP was comparable to HBP in regard to improving and preserving LV function. Conclusion In this study, HBP resulted in a narrower QRS complex duration compared to LBBAP. However, both HBP and LBBAP groups showed a trend of LV function improvement in patients with preexisting LV dysfunction. Declarations Author Contribution K.P, G.K, and M.I.Q conceived and designed the study. K.P and G.K performed study selection. K.P performed data extraction and interpreted the data. K.P, G.K, and M.I.Q performed extensive search of relevant topics. K.P performed statistical analysis. K.W, G.K, M.R.A, J.W.M and M.I.Q performed review and extensive editing of the manuscript. All authors contributed significantly to the writing of the manuscript. All authors approved the final manuscript. Approval of the research protocols This study was approved by the Medical Research Ethics Committee of Dr. Hasan Sadikin General Hospital, West Java, Indonesia Funding N/A Conflict of interests N/A Data availability Data are available on reasonable request Informed consent Patients provided a written informed consent Animal studies N/A Clinical trial registration N/A References Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés 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, Thylén 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. Erratum in: Eur Heart J. 2022 May 1;43(17):1651. PMID: 34455430. Khurshid S, Epstein AE, Verdino RJ, Lin D, Goldberg LR, Marchlinski FE, Frankel DS. Incidence and predictors of right ventricular pacing-induced cardiomyopathy. Heart Rhythm. 2014 Sep;11(9):1619-25. doi: 10.1016/j.hrthm.2014.05.040. Epub 2014 Jun 2. PMID: 24893122. Kiehl EL, Makki T, Kumar R, Gumber D, Kwon DH, Rickard JW, Kanj M, Wazni OM, Saliba WI, Varma N, Wilkoff BL, Cantillon DJ. Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function. Heart Rhythm. 2016 Dec;13(12):2272-2278. doi: 10.1016/j.hrthm.2016.09.027. PMID: 27855853. 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. PMID: 37283271. Arnold AD, Whinnett ZI, Vijayaraman P. His-Purkinje Conduction System Pacing: State of the Art in 2020. Arrhythm Electrophysiol Rev. 2020 Nov;9(3):136-145. doi: 10.15420/aer.2020.14. PMID: 33240509; PMCID: PMC7675135. Zhuang L, Mao Y, Wu L, Niu W, Chen K. Effects of right ventricular septum or His-bundle pacing versus right ventricular apical pacing on cardiac function: A systematic review and meta-analysis of randomized controlled trials. J Int Med Res. 2018 Sep;46(9):3848-3860. doi: 10.1177/0300060518781415. Epub 2018 Jul 1. PMID: 29962274; PMCID: PMC6136004. Abdin A, Aktaa S, Vukadinović D, Arbelo E, Burri H, Glikson M, Meyer C, Munyombwe T, Nielsen JC, Ukena C, Vernooy K, Gale CP. Outcomes of conduction system pacing compared to right ventricular pacing as a primary strategy for treating bradyarrhythmia: systematic review and meta-analysis. Clin Res Cardiol. 2022 Nov;111(11):1198-1209. doi: 10.1007/s00392-021-01927-7. Epub 2021 Aug 19. PMID: 34410461; PMCID: PMC9622534. Ravi V, Hanifin JL, Larsen T, Huang HD, Trohman RG, Sharma PS. Pros and Cons of Left Bundle Branch Pacing: A Single-Center Experience. Circ Arrhythm Electrophysiol. 2020 Dec;13(12):e008874. doi: 10.1161/CIRCEP.120.008874. Epub 2020 Nov 16. PMID: 33198496. Deshmukh P, Casavant DA, Romanyshyn M, Anderson K. Permanent, direct His-bundle pacing: a novel approach to cardiac pacing in patients with normal His-Purkinje activation. Circulation. 2000 Feb 29;101(8):869-77. doi: 10.1161/01.cir.101.8.869. PMID: 10694526. Hua W, Fan X, Li X, Niu H, Gu M, Ning X, Hu Y, Gold MR, Zhang S. Comparison of Left Bundle Branch and His Bundle Pacing in Bradycardia Patients. JACC Clin Electrophysiol. 2020 Oct;6(10):1291-1299. doi: 10.1016/j.jacep.2020.05.008. Epub 2020 Aug 12. PMID: 33092757. Lewis AJM, Foley P, Whinnett Z, Keene D, Chandrasekaran B. His Bundle Pacing: A New Strategy for Physiological Ventricular Activation. J Am Heart Assoc. 2019 Mar 19;8(6):e010972. doi: 10.1161/JAHA.118.010972. Erratum in: J Am Heart Assoc. 2019 Jun 4;8(11):e002310. PMID: 30854911; PMCID: PMC6475060. Thosani AJ, Liu E, Shaw G, Belden W, Chenarides J. Rapid reversal of right ventricular pacing-induced cardiomyopathy by His bundle pacing. HeartRhythm Case Rep. 2017 Jan 24;3(3):189-191. doi: 10.1016/j.hrcr.2017.01.004. PMID: 28791212; PMCID: PMC5532750. Vijayaraman P, Naperkowski A, Subzposh FA, Abdelrahman M, Sharma PS, Oren JW, Dandamudi G, Ellenbogen KA. Permanent His-bundle pacing: Long-term lead performance and clinical outcomes. Heart Rhythm. 2018 May;15(5):696-702. doi: 10.1016/j.hrthm.2017.12.022. Epub 2017 Dec 20. PMID: 29274474. Huang W, Su L, Wu S, Xu L, Xiao F, Zhou X, Ellenbogen KA. A Novel Pacing Strategy With Low and Stable Output: Pacing the Left Bundle Branch Immediately Beyond the Conduction Block. Can J Cardiol. 2017 Dec;33(12):1736.e1-1736.e3. doi: 10.1016/j.cjca.2017.09.013. Epub 2017 Sep 22. PMID: 29173611. Vijayaraman P, Subzposh FA, Naperkowski A, Panikkath R, John K, Mascarenhas V, Bauch TD, Huang W. Prospective evaluation of feasibility and electrophysiologic and echocardiographic characteristics of left bundle branch area pacing. Heart Rhythm. 2019 Dec;16(12):1774-1782. doi: 10.1016/j.hrthm.2019.05.011. Epub 2019 May 25. PMID: 31136869. Li X, Li H, Ma W, Ning X, Liang E, Pang K, Yao Y, Hua W, Zhang S, Fan X. Permanent left bundle branch area pacing for atrioventricular block: Feasibility, safety, and acute effect. Heart Rhythm. 2019 Dec;16(12):1766-1773. doi: 10.1016/j.hrthm.2019.04.043. Epub 2019 Apr 29. PMID: 31048065. Tan ESJ, Soh R, Boey E, Lee JY, de Leon J, Chan SP, Gan HH, Seow SC, Kojodjojo P. Comparison of Pacing Performance and Clinical Outcomes Between Left Bundle Branch and His Bundle Pacing. JACC Clin Electrophysiol. 2023 Aug;9(8 Pt 1):1393-1403. doi: 10.1016/j.jacep.2022.12.022. Epub 2023 Feb 22. PMID: 37558292. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. doi: 10.1093/eurheartj/ehaa612. Erratum in: Eur Heart J. 2021 Feb 1;42(5):507. Erratum in: Eur Heart J. 2021 Feb 1;42(5):546-547. Erratum in: Eur Heart J. 2021 Oct 21;42(40):4194. PMID: 32860505. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A; ESC Scientific Document Group. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-3726. doi: 10.1093/eurheartj/ehab368. Erratum in: Eur Heart J. 2021 Oct 14;: PMID: 34447992. Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Aug 20;74(7):932-987. doi: 10.1016/j.jacc.2018.10.043. Epub 2018 Nov 6. Erratum in: J Am Coll Cardiol. 2019 Aug 20;74(7):1014-1016. PMID: 30412710. Ezzeddine FM, Leon IG, Cha YM. Cardiac Resynchronisation with Conduction System Pacing. Arrhythm Electrophysiol Rev. 2023 Aug 11;12:e22. doi: 10.15420/aer.2023.03. PMID: 37654672; PMCID: PMC10466271. Devabhaktuni S, Mar PL, Shirazi J, Dandamudi G. How to Perform His Bundle Pacing: Tools and Techniques. Card Electrophysiol Clin. 2018 Sep;10(3):495-502. doi: 10.1016/j.ccep.2018.05.008. PMID: 30172286. Vijayaraman P, Subzposh FA, Naperkowski A, et al. Prospective evaluation of feasibility and electrophysiologic and echocardiographic characteristics of left bundle branch area pacing. Heart Rhythm 2019;16:1774–82. Sundaram S, Vijayaraman P. Left bundle branch pacing. Herzschrittmacherther Elektrophysiol 2020;31:124–34. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015 Jan;28(1):1-39.e14. doi: 10.1016/j.echo.2014.10.003. PMID: 25559473. Cheng A, Helm RH, Abraham TP. Pathophysiological mechanisms underlying ventricular dyssynchrony. Europace. 2009 Nov;11 Suppl 5:v10-14. doi: 10.1093/europace/eup272. PMID: 19861385. Abdin A, Werner C, Burri H, Merino JL, Vukadinović D, Sawan N, Gajek J, Böhm M, Ukena C. Outcomes of left bundle branch area pacing compared to His bundle pacing as a primary pacing strategy: Systematic review and meta-analysis. Pacing Clin Electrophysiol. 2023 Nov;46(11):1315-1324. doi: 10.1111/pace.14836. Epub 2023 Oct 9. PMID: 37812167. Byrne MJ, Helm RH, Daya S, Osman NF, Halperin HR, Berger RD, Kass DA, Lardo AC. Diminished left ventricular dyssynchrony and impact of resynchronization in failing hearts with right versus left bundle branch block. J Am Coll Cardiol. 2007 Oct 9;50(15):1484-90. doi: 10.1016/j.jacc.2007.07.011. Epub 2007 Sep 24. PMID: 17919569. Tanaka H, Tanabe M, Simon MA, Starling RC, Markham D, Thohan V, Mather P, McNamara DM, Gorcsan J 3rd. Left ventricular mechanical dyssynchrony in acute onset cardiomyopathy: association of its resolution with improvements in ventricular function. JACC Cardiovasc Imaging. 2011 May;4(5):445-56. doi: 10.1016/j.jcmg.2011.02.012. PMID: 21565730. Kronborg MB, Mortensen PT, Poulsen SH, Gerdes JC, Jensen HK, Nielsen JC. His or para-His pacing preserves left ventricular function in atrioventricular block: a double-blind, randomized, crossover study. Europace. 2014 Aug;16(8):1189-96. doi: 10.1093/europace/euu011. Epub 2014 Feb 7. PMID: 24509688. Weizong W, Zhongsu W, Yujiao Z, Mei G, Jiangrong W, Yong Z, Xinxing X, Yinglong H. Effects of right ventricular nonapical pacing on cardiac function: a meta-analysis of randomized controlled trials. Pacing Clin Electrophysiol. 2013 Aug;36(8):1032-51. doi: 10.1111/pace.12112. Epub 2013 Feb 25. PMID: 23438131. Additional Declarations No competing interests reported. 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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-4572835","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":325157921,"identity":"ef50cff6-0df9-4159-8072-f800f0da3b2c","order_by":0,"name":"Kurniawan Prakoso","email":"data:image/png;base64,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","orcid":"","institution":"Padjadjaran University","correspondingAuthor":true,"prefix":"","firstName":"Kurniawan","middleName":"","lastName":"Prakoso","suffix":""},{"id":325157922,"identity":"88343af4-a90a-4074-82f5-ce522001a593","order_by":1,"name":"Kevin Wibawa","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Kevin","middleName":"","lastName":"Wibawa","suffix":""},{"id":325157923,"identity":"893c7e36-ba21-4d79-b492-b98ece770ac0","order_by":2,"name":"Giky Karwiky","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Giky","middleName":"","lastName":"Karwiky","suffix":""},{"id":325157924,"identity":"302b5f35-81cb-4422-aa32-21f89cded827","order_by":3,"name":"Mohammad Rizki Akbar","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Rizki","lastName":"Akbar","suffix":""},{"id":325157925,"identity":"ebf0bef4-a715-4261-8d81-183ef9fc3599","order_by":4,"name":"Januar Wibawa Martha","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Januar","middleName":"Wibawa","lastName":"Martha","suffix":""},{"id":325157926,"identity":"7e618d75-6456-4920-b49f-1466cd8515ad","order_by":5,"name":"Mohammad Iqbal","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"","lastName":"Iqbal","suffix":""}],"badges":[],"createdAt":"2024-06-13 01:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4572835/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4572835/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60615682,"identity":"a6dd93e8-6086-4443-be0f-1e38bf1365ad","added_by":"auto","created_at":"2024-07-18 20:14:31","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70586,"visible":true,"origin":"","legend":"\u003cp\u003eStudy recruitment protocol. HFrEF = heart failure reduced ejection fraction; HBP = his bundle pacing; LBBAP = left bundle branch area pacing.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4572835/v1/e7e376999d7c1fbd47f22979.jpeg"},{"id":60615680,"identity":"38f8d1f6-4e53-46c2-9342-d0cf76200380","added_by":"auto","created_at":"2024-07-18 20:14:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":78916,"visible":true,"origin":"","legend":"\u003cp\u003eQRS duration before and after CSP implantation. HBP = His Bundle Pacing; LBBAP = Left Bundle Branch Area Pacing.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4572835/v1/278871fba86eaac319ce6034.png"},{"id":60615683,"identity":"b23628ac-5bc8-4e53-a939-f51826a0491e","added_by":"auto","created_at":"2024-07-18 20:14:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":72095,"visible":true,"origin":"","legend":"\u003cp\u003eLVEF before and after CSP implantation. HBP = His Bundle Pacing; LBBAP = Left Bundle Branch Area Pacing.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4572835/v1/1dfdf766d53deab8157fbe60.png"},{"id":62097003,"identity":"1b233953-746e-4536-b5ef-50cc0e3dd980","added_by":"auto","created_at":"2024-08-09 08:55:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":969962,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4572835/v1/5af632a0-2076-47a4-b023-a3c9aef5ec65.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of Left Ventricular Function after His Bundle Pacing vs Left Bundle Branch Area Pacing Implantation","fulltext":[{"header":"Background","content":"\u003cp\u003ePermanent pacemaker (PPM) implantation is indicated in patients with symptomatic bradycardia or other conditions such as heart failure (HF), certain types of cardiomyopathies, and other rare diseases.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Conventional right ventricular pacing (RVP) may lead to deterioration of left ventricular (LV) function as it may induced cardiomyopathy due to electrical dyssynchrony, especially in patients anticipated to have a substantial right ventricular pacing.\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\u003c/p\u003e \u003cp\u003eConduction system pacing (CSP), a more physiologic type of pacing, aims to directly or indirectly stimulate the His-Purkinje cardiac conduction system, consisting of His bundle pacing (HBP), left bundle branch area pacing (LBBAP), and pacing of the surrounding conduction system tissues, including right ventricular septal pacing (RVSP), left ventricular septal pacing (LVSP), and mid-septal pacing.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Studies reported that both HBP and LBBAP resulted in a narrower QRS complex, a higher left ventricular ejection fraction (LVEF), and a lower heart failure hospitalization during follow up compared with RVP.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Although previous recommendations of using CSP are limited, recent guideline suggests the use of either cardiac resynchronization therapy (CRT) with biventricular (BiV) pacing or CSP (HBP or LBBAP) in all patients requiring PPM regardless of patient\u0026rsquo;s left ventricular (LV) function to mitigate the occurrence of HF.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePacing of the His bundle are thought to be more physiologic and has a lower rate of tricuspid regurgitation (TR), however it requires a more difficult procedural techniques for implantation, resulting in a longer procedure duration and fluoroscopy time.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e It also has a higher capture threshold during follow up compared to RVP and LBBAP.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Furthermore, it may not be able to correct a preexisting bundle branch block.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Left bundle branch area pacing was introduced much later in 2017.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e It is easier to implant with several advantages such as lower and more stable capture threshold, lower CSP-related complication, and have a possibility of correcting a preexisting bundle branch block.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Despite the clear superiority of LBBAP compared to HBP especially in terms of pacing parameters, procedure duration, and pacemaker related complications, the recommendations of using HBP are more common in the existing guidelines.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Furthermore, the data about head-to-head comparison regarding the LV function after pacemaker implantation between LBBAP and HBP is limited. Therefore, this study aimed to investigate the difference of left ventricular function following HBP and LBBAP implantation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient selection\u003c/h2\u003e \u003cp\u003eThis is a prospective cohort study enrolling consecutive patients age\u0026thinsp;\u0026gt;\u0026thinsp;18 years old requiring CSP implantation due to symptomatic bradycardia or as a resynchronization therapy in heart failure patients with reduced ejection fraction (HFrEF) in Hasan Sadikin General Hospital, Bandung, Indonesia, from June 2020 to January 2024. From 79 patients undergoing CSP implantation, 13 patients were excluded due to incomplete echocardiography data or loss to follow up. His bundle pacing was initially attempted in 49 patients, however, cross over to LBBAP group occurred in 14 patients due to several reasons such as inability to visualize the His region, failure to capture of the His signal, presence of a high His bundle capture threshold, or if the HBP is unable to correct a wide QRS complex (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePacemaker Implantation\u003c/h2\u003e \u003cp\u003eCSP implantations were carried out using local anesthesia. Venous accesses were obtained through cephalic and axillary veins. For HBP implantation, the tip of active bipolar SelectSecure 3930 Medtronic lead was placed on the His region after visualization with contrast injection at the membranous septum at the level of tricuspid annulus. After obtaining the His bundle potential, pacing was attempted to achieve optimal pacing parameters as explained by Ezzeddine et al.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e A selective his bundle pacing was defined as an equal duration of an interval between stimulus-ventricle interval (S-V) and the intrinsic His-ventricle (H-V), along with an identical paced QRS morphology to the intrinsic QRS complex. A nonselective his bundle pacing was defined as a shorter S-V compared to the intrinsic H-V along with a local fusion of both the His bundle and septal myocardium signals.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e In LBBAP, pacing lead was placed 1.5-2 cm distal to the His bundle.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e The presence of a paced QS morphology in lead V1, a QRS discordance in the inferior leads, and a QRS discordance in lead aVR/aVL were the marker for optimal sites for LBBAP implantation. Once this pacing morphology is obtained, the intraventricular septum is penetrated with a depth of 1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23 cm.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e A nonselective LBBAP is characterized by a prolonged peak left ventricular activation time (pLVAT) when there is a change in output from high to low, a longer stimulus-His interval, and a longer stimulus-right atrial interval.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAssessment of LV function\u003c/h2\u003e \u003cp\u003eEchocardiographic parameters were obtained before and within 1 year after pacemaker implantation using Vivid S70 or Vivid iq (GE Vingmend Ultrasound, Horten Norway) evaluating the left atrial anteroposterior diameter using M-mode (mm), left atrial volume index (LAVI), left ventricular end diastolic-diameter (LVEDD), left ventricular ejection fraction (LVEF) using Simpson Biplane technique, degree of valvular regurgitation (mitral and tricuspid), and degree of probability of pulmonary hypertension as recommended by the guidelines.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Left atrial dilatation was defined based on left atrial anteroposterior diameter of \u0026gt;\u0026thinsp;4.0 cm in male or \u0026gt;\u0026thinsp;3.8 cm in female, or if LAVI is \u0026ge;\u0026thinsp;35 ml/m2. Left ventricular dilatation was defined as LVEDD divided by body surface area (BSA) of \u0026ge;\u0026thinsp;3.1 cm/m2 in male or \u0026ge;\u0026thinsp;3.2 cm/m2 in female. Left ventricular dysfunction was defined as LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50%. Left ventricular function improvement was defined as those who initially have left ventricular dysfunction with a final LVEF of \u0026ge;\u0026thinsp;50% during follow up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData collection and follow-up\u003c/h2\u003e \u003cp\u003eThe baseline clinical data analysed in this study included history of pacemaker implantation (temporary or permanent pacemaker) and QRS complex duration (ms) obtained from 12 lead ECG. For patients with LV dysfunction, additional data regarding doses of guideline directed medical including angiotensin converting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB), angiotensin receptor/neprilysin inhibitor (ARNI), beta blocker (BB), mineralocorticoid receptor antagonist (MRA), and sodium-glucose cotransporter 2 (SGLT-2) inhibitor were collected.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize the data. Categorical data were presented as frequencies and percentages. The normality test using Kolmogorov-Smirnov test was performed to continuous data. Normally distributed data were presented as mean and standard deviation. Otherwise, the data were presented in median and interquartile range. Continuous data were compared with 2-tailed Student\u0026rsquo;s t-test, while categorical data were analysed using Chi-square (χ2) test. A p value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. The statistical analysis was conducted using SPSS 29.0 software (SPSS, Inc., Chicago, Illinois).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline clinical characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom the final 66 patients, 35 patient (53%) had HBP implantation, while the other 31 (47%) patients had LBBAP implantation (Table 1). There was no significant age difference between both groups, and only 2 patient (5.7%) from HBP group underwent the procedure as a resynchronization therapy for heart failure. More than half of the patients from each group had dual chamber pacemaker. A considerable number of patients from LBBAP group had a history of previous pacemaker implantation (67.7%, p=0.197). Both groups had a wide QRS complex duration at baseline (124.63 \u0026plusmn; 33.36 ms in HBP vs. 121.94 \u0026plusmn; 32.91 ms in LBBAP group, p=0.981).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eBaseline Characteristics\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"548\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.394160583941606%\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.8978102189781%\"\u003e\n \u003cp\u003eHBP\u003c/p\u003e\n \u003cp\u003en = 35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.197080291970803%\"\u003e\n \u003cp\u003eLBBAP\u003c/p\u003e\n \u003cp\u003en = 31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.510948905109489%\"\u003e\n \u003cp\u003ep Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.394160583941606%\" valign=\"bottom\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.8978102189781%\" valign=\"bottom\"\u003e\n \u003cp\u003e57.00 \u0026plusmn; 16.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.197080291970803%\" valign=\"bottom\"\u003e\n \u003cp\u003e57.68 \u0026plusmn; 17.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.510948905109489%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.404\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"84.46069469835466%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.539305301645339%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.047*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.394160583941606%\" valign=\"bottom\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.8978102189781%\" valign=\"bottom\"\u003e\n \u003cp\u003e21 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.197080291970803%\" valign=\"bottom\"\u003e\n \u003cp\u003e11 (35.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.510948905109489%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.524838012958966%\" valign=\"bottom\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.91792656587473%\" valign=\"bottom\"\u003e\n \u003cp\u003e14 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.557235421166304%\" valign=\"bottom\"\u003e\n \u003cp\u003e20 (64.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"84.46069469835466%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eCSP indication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.539305301645339%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.177\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.394160583941606%\" valign=\"bottom\"\u003e\n \u003cp\u003eSymptomatic Bradycardia\u003c/p\u003e\n \u003cp\u003eResynchronization therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.8978102189781%\" valign=\"bottom\"\u003e\n \u003cp\u003e33 (94.3%)\u003c/p\u003e\n \u003cp\u003e2 (5.7%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.197080291970803%\" valign=\"bottom\"\u003e\n \u003cp\u003e31 (100%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.510948905109489%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"84.46069469835466%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003ePacemaker chambers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.539305301645339%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.258\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.394160583941606%\" valign=\"bottom\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.8978102189781%\" valign=\"bottom\"\u003e\n \u003cp\u003e9 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.197080291970803%\" valign=\"bottom\"\u003e\n \u003cp\u003e12 (38.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.510948905109489%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.524838012958966%\" valign=\"bottom\"\u003e\n \u003cp\u003eDual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.91792656587473%\" valign=\"bottom\"\u003e\n \u003cp\u003e26 (74.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.557235421166304%\" valign=\"bottom\"\u003e\n \u003cp\u003e19 (61.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"84.46069469835466%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eHistory of pacemaker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.539305301645339%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.197\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.394160583941606%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo history of pacemaker\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.8978102189781%\" valign=\"bottom\"\u003e\n \u003cp\u003e19 (54.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.197080291970803%\" valign=\"bottom\"\u003e\n \u003cp\u003e10 (32.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.510948905109489%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.524838012958966%\" valign=\"bottom\"\u003e\n \u003cp\u003eTemporary Pacemaker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.91792656587473%\" valign=\"bottom\"\u003e\n \u003cp\u003e12 (34.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.557235421166304%\" valign=\"bottom\"\u003e\n \u003cp\u003e16 (51.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.524838012958966%\" valign=\"bottom\"\u003e\n \u003cp\u003ePermanent Pacemaker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.91792656587473%\" valign=\"bottom\"\u003e\n \u003cp\u003e4 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.557235421166304%\" valign=\"bottom\"\u003e\n \u003cp\u003e5 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.394160583941606%\" valign=\"bottom\"\u003e\n \u003cp\u003eQRS duration (ms)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.8978102189781%\" valign=\"bottom\"\u003e\n \u003cp\u003e124.63 \u0026plusmn; 33.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.197080291970803%\" valign=\"bottom\"\u003e\n \u003cp\u003e121.94 \u0026plusmn; 32.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.510948905109489%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.981\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCSP = conduction system pacing\u003c/p\u003e\n\u003cp\u003e*P value \u0026lt;0.05\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBaseline echocardiography parameters\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom the baseline data of echocardiography parameters measured before PPM implantation, majority of patients in either HBP or LBBAP group had a normal LA and LV size, with a higher mean of LVEF in HBP group (51.17 \u0026plusmn; 13.87% vs. 45.58 \u0026plusmn; 11.08%, p=0.078) (Table 2). Most patients had normal or mild degree of mitral regurgitation or tricuspid valves regurgitation along with low or intermediate probability of pulmonary hypertension.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQRS duration and echocardiographic parameters after pacemaker implantation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter pacemaker implantation, HBP group had a shorter mean QRS duration compared to LBBAP group (113.40 \u0026plusmn; 17.06 ms vs 120.81 \u0026plusmn; 12.12 ms, p=0.029) (Figure 2). \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eBaseline Echocardiographic Parameters\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"608\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.489291598023065%\" valign=\"bottom\"\u003e\n \u003cp\u003eEchocardiographic parameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.746293245469523%\" valign=\"bottom\"\u003e\n \u003cp\u003eHBP\u003c/p\u003e\n \u003cp\u003en = 35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.4168039538715%\" valign=\"bottom\"\u003e\n \u003cp\u003eLBBAP\u003c/p\u003e\n \u003cp\u003en = 31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.347611202635914%\"\u003e\n \u003cp\u003ep Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.489291598023065%\" valign=\"bottom\"\u003e\n \u003cp\u003eLA Size (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.746293245469523%\" valign=\"bottom\"\u003e\n \u003cp\u003e38.86 \u0026plusmn; 8.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.4168039538715%\" valign=\"bottom\"\u003e\n \u003cp\u003e36.13 \u0026plusmn; 10.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.347611202635914%\"\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.489291598023065%\" valign=\"bottom\"\u003e\n \u003cp\u003eLAVI (ml/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.746293245469523%\" valign=\"bottom\"\u003e\n \u003cp\u003e41.63 \u0026plusmn; 34.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.4168039538715%\" valign=\"bottom\"\u003e\n \u003cp\u003e34.29 \u0026plusmn; 20.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.347611202635914%\"\u003e\n \u003cp\u003e0.302\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.489291598023065%\" valign=\"bottom\"\u003e\n \u003cp\u003eLVEDd (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.746293245469523%\" valign=\"bottom\"\u003e\n \u003cp\u003e48.54 \u0026plusmn; 7.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.4168039538715%\" valign=\"bottom\"\u003e\n \u003cp\u003e49.55 \u0026plusmn; 9.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.347611202635914%\"\u003e\n \u003cp\u003e0.623\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.69736842105263%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eLV dilatation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.30263157894737%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.691\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e13 (37.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e13 (41.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e22 (62.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e18 (58.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.69736842105263%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eLA dilatation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.30263157894737%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.805\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e17 (48.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e16 (51.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e18 (51.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e15 (48.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.489291598023065%\" valign=\"bottom\"\u003e\n \u003cp\u003eLVEF (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.746293245469523%\" valign=\"bottom\"\u003e\n \u003cp\u003e51.17 \u0026plusmn; 13.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.4168039538715%\" valign=\"bottom\"\u003e\n \u003cp\u003e45.58 \u0026plusmn; 11.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.347611202635914%\"\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.69736842105263%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.30263157894737%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.026*\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003ePreserved EF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e22 (62.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e11 (35.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eReduced EF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e13 (37.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e20 (64.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.69736842105263%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eMitral regurgitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.30263157894737%\" rowspan=\"5\"\u003e\n \u003cp\u003e0.739\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e23 (65.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e24 (77.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e9 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e5 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e2 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e1 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e1 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.69736842105263%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eTricuspid regurgitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.30263157894737%\" rowspan=\"5\"\u003e\n \u003cp\u003e0.803\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e22 (62.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e21 (67.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e8 (22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e7 (22.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e4 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e3 (9.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"72.69736842105263%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eProbability of pulmonary hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.30263157894737%\" rowspan=\"4\"\u003e\n \u003cp\u003e0.962\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e23 (65.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e20 (64.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eIntermediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e7 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e7 (22.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.58956916099773%\" valign=\"bottom\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.931972789115648%\" valign=\"bottom\"\u003e\n \u003cp\u003e5 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.478458049886623%\" valign=\"bottom\"\u003e\n \u003cp\u003e4 (12.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eEF = ejection fraction; LAVI = left atrial volume index; LA = left atrium; LV = left ventricle; LVEDd = left ventricular end diastolic dimension; LVEF = left ventricular ejection fraction\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompared with baseline, the mean LVEDD in both groups were similar, while the mean of LAVI in HBP group was reduced (41.63 \u0026plusmn; 34.32 ml/m2 to 37.11 \u0026plusmn; 24.82 ml/m2, p=0.815) with a relatively similar value in LBBAP group (Table 3). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e QRS Duration and Echocardiographic Parameters after Pacemaker Implantation\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"608\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eEchocardiographic parameters\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\" valign=\"bottom\"\u003e\n \u003cp\u003eHBP\u003c/p\u003e\n \u003cp\u003en = 35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\" valign=\"bottom\"\u003e\n \u003cp\u003eLBBAP\u003c/p\u003e\n \u003cp\u003en = 31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003ep Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eMean follow up (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\" valign=\"bottom\"\u003e\n \u003cp\u003e6.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\" valign=\"bottom\"\u003e\n \u003cp\u003e4.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.316\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eQRS duration (ms)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e113.40 \u0026plusmn; 17.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e120.81 \u0026plusmn; 12.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.029*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003ePacing selectivity\u003c/p\u003e\n \u003cp\u003eSelective\u003c/p\u003e\n \u003cp\u003eNonselective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 (51.4%)\u003c/p\u003e\n \u003cp\u003e17 (48.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25 (80.6%)\u003c/p\u003e\n \u003cp\u003e6 (19.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.013*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eLA Size (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e36.20 \u0026plusmn; 7.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e37.29 \u0026plusmn; 8.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.574\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eLAVI (ml/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e37.11 \u0026plusmn; 24.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e35.87 \u0026plusmn; 16.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.815\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eLVEDD (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e47.31 \u0026plusmn; 7.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e47.55 \u0026plusmn; 7.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.902\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.02631578947368%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eLV dilatation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e6 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e7 (22.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.31531531531532%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.954954954954953%\"\u003e\n \u003cp\u003e29 (82.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.72972972972973%\"\u003e\n \u003cp\u003e24 (77.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.02631578947368%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eLA dilatation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.782\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e17 (48.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e14 (45.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.31531531531532%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.954954954954953%\"\u003e\n \u003cp\u003e18 (51.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.72972972972973%\"\u003e\n \u003cp\u003e17 (54.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eLVEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e53.93 \u0026plusmn; 11.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e53.11 \u0026plusmn; 11.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.536\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.02631578947368%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eEjection fraction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.558\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003ePreserved EF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e26 (74.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e21 (67.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.31531531531532%\" valign=\"bottom\"\u003e\n \u003cp\u003eReduced EF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.954954954954953%\"\u003e\n \u003cp\u003e9 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.72972972972973%\"\u003e\n \u003cp\u003e10 (32.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.02631578947368%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eMitral regurgitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.472\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e27 (77.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e21 (67.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.31531531531532%\" valign=\"bottom\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.954954954954953%\"\u003e\n \u003cp\u003e7 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.72972972972973%\"\u003e\n \u003cp\u003e7 (22.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.31531531531532%\" valign=\"bottom\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.954954954954953%\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.72972972972973%\"\u003e\n \u003cp\u003e2 (6.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.31531531531532%\" valign=\"bottom\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.954954954954953%\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.72972972972973%\"\u003e\n \u003cp\u003e1 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.02631578947368%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eTricuspid regurgitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.406\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e28 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e21 (67.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.31531531531532%\" valign=\"bottom\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.954954954954953%\"\u003e\n \u003cp\u003e5 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.72972972972973%\"\u003e\n \u003cp\u003e9 (29.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.31531531531532%\" valign=\"bottom\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.954954954954953%\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.72972972972973%\"\u003e\n \u003cp\u003e1 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.31531531531532%\" valign=\"bottom\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.954954954954953%\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.72972972972973%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.02631578947368%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eProbability of pulmonary hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.44078947368421%\" valign=\"bottom\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e30 (85.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.710526315789473%\"\u003e\n \u003cp\u003e29 (93.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.973684210526315%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.31531531531532%\" valign=\"bottom\"\u003e\n \u003cp\u003eIntermediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.954954954954953%\"\u003e\n \u003cp\u003e3 (8.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.72972972972973%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.31531531531532%\" valign=\"bottom\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.954954954954953%\"\u003e\n \u003cp\u003e2 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.72972972972973%\"\u003e\n \u003cp\u003e2 (6.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eEF = ejection fraction; LAVI = left atrial volume index; LA = left atrium; LV = left ventricle; LVEDd = left ventricular end diastolic dimension; LVEF = left ventricular ejection fraction\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with baseline, the mean LVEF was increased in LBBAP group (45.58 \u0026plusmn; 11.08% to 53.11% \u0026plusmn; 11.67%, p = 0.536), while in the HBP group the mean LVEF was remain preserved (51.17 \u0026plusmn; 13.87% to 53.93 \u0026plusmn; 11.45%) (Figure 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients with left ventricular dysfunction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubgroup analysis was performed for patient with LV dysfunction. Majority of patients receiving HBP had no history of previous pacemaker implantation (69.2%), while only 25% patients in LBBAP group had neither history of temporary nor permanent pacemaker implantation, respectively. There was a reduction in QRS duration in the HBP group, while in the LBBAP group the QRS duration was relatively similar. At the end of follow up, 38.5% of patients in HBP group and 50% in LBBAP group had LVEF improvement (p=0.515).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eSubgroup Analysis on Patient with Left Ventricular Dysfunction\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.333333333333332%\" colspan=\"2\"\u003e\n \u003cp\u003ePre PPM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"2\"\u003e\n \u003cp\u003ep Value\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.833333333333332%\" colspan=\"2\"\u003e\n \u003cp\u003ePost PPM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9%\" rowspan=\"2\"\u003e\n \u003cp\u003ep Value\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.40449438202247%\"\u003e\n \u003cp\u003eHBP\u003c/p\u003e\n \u003cp\u003en = 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.719101123595507%\"\u003e\n \u003cp\u003eLBBAP\u003c/p\u003e\n \u003cp\u003en = 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.43820224719101%\"\u003e\n \u003cp\u003eHBP\u003c/p\u003e\n \u003cp\u003en = 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.43820224719101%\"\u003e\n \u003cp\u003eLBBAP\u003c/p\u003e\n \u003cp\u003en = 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.46089850249584%\"\u003e\n \u003cp\u003eMean follow up (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.60232945091514%\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e5.00 \u0026plusmn; 4.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e6.50 \u0026plusmn; 4.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.985024958402661%\"\u003e\n \u003cp\u003e0.332\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\"\u003e\n \u003cp\u003e64.08 \u0026plusmn; 8.98\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\"\u003e\n \u003cp\u003e63.35 \u0026plusmn; 11.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.852\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.833333333333336%\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\"\u003e\n \u003cp\u003eChambers pacing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.963\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.833333333333336%\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003cp\u003eDual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\"\u003e\n \u003cp\u003e4 (30.8%)\u003c/p\u003e\n \u003cp\u003e9 (69.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\"\u003e\n \u003cp\u003e6 (30.0%)\u003c/p\u003e\n \u003cp\u003e14 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.833333333333336%\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\"\u003e\n \u003cp\u003ePacing selectivity\u003c/p\u003e\n \u003cp\u003eSelective\u003c/p\u003e\n \u003cp\u003eNonselective\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\"\u003e\n \u003cp\u003e7 (53.8%)\u003c/p\u003e\n \u003cp\u003e6 (46.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\"\u003e\n \u003cp\u003e16 (80.0%)\u003c/p\u003e\n \u003cp\u003e4 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.110\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.833333333333336%\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"bottom\"\u003e\n \u003cp\u003ePrevious pacemaker\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\"\u003e\n \u003cp\u003e9 (69.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\"\u003e\n \u003cp\u003e5 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.833333333333336%\" colspan=\"3\" rowspan=\"3\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.65325077399381%\" valign=\"bottom\"\u003e\n \u003cp\u003eTPM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.102167182662537%\"\u003e\n \u003cp\u003e4 (30.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.24458204334365%\"\u003e\n \u003cp\u003e11 (55.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.65325077399381%\" valign=\"bottom\"\u003e\n \u003cp\u003ePPM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.102167182662537%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.24458204334365%\"\u003e\n \u003cp\u003e4 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.46089850249584%\"\u003e\n \u003cp\u003eQRS duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.640599001663894%\"\u003e\n \u003cp\u003e128.15 \u0026plusmn; 41.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.642262895174708%\"\u003e\n \u003cp\u003e129.05 \u0026plusmn; 33.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.319467554076539%\"\u003e\n \u003cp\u003e0.946\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e113.23 \u0026plusmn; 19.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e123.35 \u0026plusmn; 11.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.985024958402661%\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.46089850249584%\"\u003e\n \u003cp\u003eLVEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.640599001663894%\"\u003e\n \u003cp\u003e35.31 \u0026plusmn; 7.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.642262895174708%\"\u003e\n \u003cp\u003e38.75 \u0026plusmn; 6.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.319467554076539%\"\u003e\n \u003cp\u003e0.197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e44.54 \u0026plusmn; 11.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e51.35 \u0026plusmn; 13.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.985024958402661%\"\u003e\n \u003cp\u003e0.135\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"bottom\"\u003e\n \u003cp\u003eLA dilatation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.46089850249584%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.640599001663894%\"\u003e\n \u003cp\u003e10 (76.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.642262895174708%\"\u003e\n \u003cp\u003e9 (45.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.319467554076539%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e12 (92.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e8 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.985024958402661%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.37022132796781%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91348088531187%\"\u003e\n \u003cp\u003e3 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.706237424547282%\"\u003e\n \u003cp\u003e11 (55.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e1 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e12 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"bottom\"\u003e\n \u003cp\u003eLV dilatation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.46089850249584%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.640599001663894%\"\u003e\n \u003cp\u003e3 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.642262895174708%\"\u003e\n \u003cp\u003e9 (45.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.319467554076539%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e8 (61.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e14 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.985024958402661%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.614\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.37022132796781%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91348088531187%\"\u003e\n \u003cp\u003e10 (76.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.706237424547282%\"\u003e\n \u003cp\u003e11 (55.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e6 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.46089850249584%\"\u003e\n \u003cp\u003eLVEDD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.640599001663894%\"\u003e\n \u003cp\u003e52.46 \u0026plusmn; 7.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.642262895174708%\"\u003e\n \u003cp\u003e52.45 \u0026plusmn; 7.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.319467554076539%\"\u003e\n \u003cp\u003e0.997\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e49.92 \u0026plusmn; 9.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e48.65 \u0026plusmn; 7.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.985024958402661%\"\u003e\n \u003cp\u003e0.681\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"bottom\"\u003e\n \u003cp\u003eMitral regurgitation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.46089850249584%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.640599001663894%\"\u003e\n \u003cp\u003e6 (46.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.642262895174708%\"\u003e\n \u003cp\u003e16 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.319467554076539%\" rowspan=\"4\"\u003e\n \u003cp\u003e0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e8 (61.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e14 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.985024958402661%\" rowspan=\"4\"\u003e\n \u003cp\u003e0.547\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.37022132796781%\" valign=\"bottom\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91348088531187%\"\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.706237424547282%\"\u003e\n \u003cp\u003e3 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e5 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.37022132796781%\" valign=\"bottom\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91348088531187%\"\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.706237424547282%\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e1 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.37022132796781%\" valign=\"bottom\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91348088531187%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.706237424547282%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"bottom\"\u003e\n \u003cp\u003eTricuspid regurgitation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.46089850249584%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.640599001663894%\"\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.642262895174708%\"\u003e\n \u003cp\u003e16 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.319467554076539%\" rowspan=\"4\"\u003e\n \u003cp\u003e0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e9 (69.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e13 (65.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.985024958402661%\" rowspan=\"4\"\u003e\n \u003cp\u003e0.503\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.37022132796781%\" valign=\"bottom\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91348088531187%\"\u003e\n \u003cp\u003e4 (30.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.706237424547282%\"\u003e\n \u003cp\u003e3 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e6 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.37022132796781%\" valign=\"bottom\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91348088531187%\"\u003e\n \u003cp\u003e3 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.706237424547282%\"\u003e\n \u003cp\u003e1 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e1 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e1 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.37022132796781%\" valign=\"bottom\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91348088531187%\"\u003e\n \u003cp\u003e1 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.706237424547282%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e1 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"bottom\"\u003e\n \u003cp\u003eProbability of PH\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.46089850249584%\" valign=\"bottom\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.640599001663894%\"\u003e\n \u003cp\u003e4 (30.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.642262895174708%\"\u003e\n \u003cp\u003e14 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.319467554076539%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.046*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e10 (76.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e18 (90.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.985024958402661%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.194\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.37022132796781%\" valign=\"bottom\"\u003e\n \u003cp\u003eIntermediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91348088531187%\"\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.706237424547282%\"\u003e\n \u003cp\u003e5 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.37022132796781%\" valign=\"bottom\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.91348088531187%\"\u003e\n \u003cp\u003e4 (30.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.706237424547282%\"\u003e\n \u003cp\u003e1 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e1 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.505030181086518%\"\u003e\n \u003cp\u003e2 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"bottom\"\u003e\n \u003cp\u003eReduced EF\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.46089850249584%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.60232945091514%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e8 (61.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e10 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.985024958402661%\"\u003e\n \u003cp\u003e0.515\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"bottom\"\u003e\n \u003cp\u003eImproved LVEF\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.46089850249584%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.60232945091514%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.475873544093178%\"\u003e\n \u003cp\u003e10 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.985024958402661%\"\u003e\n \u003cp\u003e0.515\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eEF = ejection fraction; LAVI = left atrial volume index; LA = left atrium; LV = left ventricle; LVEDd = left ventricular end diastolic dimension; LVEF = left ventricular ejection fraction; PH = pulmonary hypertension PPM = permanent pacemaker; TPM = temporary pacemaker;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*P value \u0026lt;0.05\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMajority of patients in the HBP group receive no or less than 50% of recommended dose of the guideline medical therapies, while in the LBBAP group, more patients received adequate dose of renin-angiotensin-aldosterone system (RAAS) blockers (ACE-I, ARB, or ARNI) and MRA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.\u0026nbsp;\u003c/strong\u003eGuideline Medical Therapy in Patients with Left Ventricular Dysfunction\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"608\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.102141680395384%\"\u003e\n \u003cp\u003eMedication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.922570016474463%\"\u003e\n \u003cp\u003eHBP\u003c/p\u003e\n \u003cp\u003en = 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.87644151565074%\"\u003e\n \u003cp\u003eLBBAP\u003c/p\u003e\n \u003cp\u003en = 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.098846787479406%\"\u003e\n \u003cp\u003ep Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.102141680395384%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo ACE-I/ARB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.922570016474463%\"\u003e\n \u003cp\u003e7 (53.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.87644151565074%\"\u003e\n \u003cp\u003e7 (35.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.098846787479406%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.035*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.68041237113402%\" valign=\"bottom\"\u003e\n \u003cp\u003eACE-I/ARB \u0026lt;50% target dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.185567010309278%\"\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.1340206185567%\"\u003e\n \u003cp\u003e3 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.68041237113402%\" valign=\"bottom\"\u003e\n \u003cp\u003eACE-I/ARB \u0026ge;50% target dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.185567010309278%\"\u003e\n \u003cp\u003e1 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.1340206185567%\"\u003e\n \u003cp\u003e10 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.102141680395384%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo ARNI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.922570016474463%\"\u003e\n \u003cp\u003e11 (84.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.87644151565074%\"\u003e\n \u003cp\u003e18 (90.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.098846787479406%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.898\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.68041237113402%\" valign=\"bottom\"\u003e\n \u003cp\u003eARNI \u0026lt;50% target dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.185567010309278%\"\u003e\n \u003cp\u003e1 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.1340206185567%\"\u003e\n \u003cp\u003e1 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.68041237113402%\" valign=\"bottom\"\u003e\n \u003cp\u003eARNI \u0026ge;50% target dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.185567010309278%\"\u003e\n \u003cp\u003e1 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.1340206185567%\"\u003e\n \u003cp\u003e1 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.102141680395384%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo beta blocker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.922570016474463%\"\u003e\n \u003cp\u003e7 (53.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.87644151565074%\"\u003e\n \u003cp\u003e7 (35.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.098846787479406%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.412\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.68041237113402%\" valign=\"bottom\"\u003e\n \u003cp\u003eBeta blocker \u0026lt;50% target dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.185567010309278%\"\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.1340206185567%\"\u003e\n \u003cp\u003e7 (35.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.68041237113402%\" valign=\"bottom\"\u003e\n \u003cp\u003eBeta blocker \u0026ge;50% target dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.185567010309278%\"\u003e\n \u003cp\u003e4 (30.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.1340206185567%\"\u003e\n \u003cp\u003e6 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.102141680395384%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo MRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.922570016474463%\"\u003e\n \u003cp\u003e8 (61.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.87644151565074%\"\u003e\n \u003cp\u003e7 (35.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.098846787479406%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.275\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.68041237113402%\" valign=\"bottom\"\u003e\n \u003cp\u003eMRA \u0026lt;50% target dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.185567010309278%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.1340206185567%\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.68041237113402%\" valign=\"bottom\"\u003e\n \u003cp\u003eMRA \u0026ge;50% target dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.185567010309278%\"\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.1340206185567%\"\u003e\n \u003cp\u003e12 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.102141680395384%\" valign=\"bottom\"\u003e\n \u003cp\u003eSGLT2 inhibitor (no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.922570016474463%\"\u003e\n \u003cp\u003e11 (84.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.87644151565074%\"\u003e\n \u003cp\u003e19 (95.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.098846787479406%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.311\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.68041237113402%\" valign=\"bottom\"\u003e\n \u003cp\u003eSGLT2 inhibitor (yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.185567010309278%\"\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.1340206185567%\"\u003e\n \u003cp\u003e1 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eACE-I = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor blocker; ARNI = angiotensin receptor neprilysin inhibitor; MRA = mineralocorticoid receptor antagonist\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCSP recently has become the main option for type of PPM especially to prevent the occurrence of pacemaker induced cardiomyopathy in patients anticipated to have substantial right ventricular pacing.\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 Despite the absence of a clear head-to-head comparison between HBP and LBBAP implantation in term of LV function, more guidelines tend to recommend the use of HBP implantation instead of LBBAP.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e This study involved 66 patients undergoing CSP implantation for symptomatic bradycardia or as a resynchronization therapy in HFrEF. From 35 patients in the HBP group (53%) and 31 patients in the LBBAP group (47%), there was no significant difference in term of age with most of them had dual chamber pacemaker implantation (74.3% in HBP vs 61.3% in LBBAP, p\u0026thinsp;=\u0026thinsp;0.258). Both groups also have a similarly wide baseline QRS complex (124.63\u0026thinsp;\u0026plusmn;\u0026thinsp;33.36ms in HBP vs 121.94\u0026thinsp;\u0026plusmn;\u0026thinsp;32.91ms, p\u0026thinsp;=\u0026thinsp;0.981) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor the baseline echocardiography data, HBP group has a relatively higher mean of LVEF compare to LBBAP group (51.17\u0026thinsp;\u0026plusmn;\u0026thinsp;13.87% vs 45.58\u0026thinsp;\u0026plusmn;\u0026thinsp;11.08%, p\u0026thinsp;=\u0026thinsp;0.078) due to a higher number of patients having LV dysfunction in the LBBAP group (64.5% in LBBAP vs 37.1% in HBP, p\u0026thinsp;=\u0026thinsp;0.026). Despite having a lower mean LVEF baseline in the LBBAP group, most of the patients in this group have a normal LV dimension as well as normal or mild abnormalities of the mitral and tricuspid valves (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), reflecting the possibility of acute LV dysfunction due electrical dyssynchrony resulted from a wide baseline QRS complex before CSP implantation. As showed by previous study, a wide QRS complex, especially in patients with LBBB morphology, delayed regional electrical activation at the left posterobasal region of the left ventricle will result in loss of energy of the intraventricular septum for the late-developing lateral forces, leading to a reduction in cardiac output.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEvaluation after HBP implantation showed a marked reduction in the QRS duration (113.40\u0026thinsp;\u0026plusmn;\u0026thinsp;17.06 ms) with a relatively similar QRS duration in the LBBAP group compared to baseline (120.81\u0026thinsp;\u0026plusmn;\u0026thinsp;12.12, p\u0026thinsp;=\u0026thinsp;0.029) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This result is slightly different with data from a recent meta-analysis by Abidin et al. involving 9 studies which showed a slightly decreased QRS duration in the paced rhythm compared to baseline in both HBP and LBBA group.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e However if analyzed separately in the meta-analysis, only studies with a very wide QRS complex (\u0026ge;\u0026thinsp;140 ms) have a significant reduction in the QRS duration after CSP implantation, while baseline QRS duration of both HBP and LBBAP groups in this study are \u0026plusmn;\u0026thinsp;120ms.\u003csup\u003e27\u003c/sup\u003e Furthermore, in our study, patients who were initially attempted to have HBP implantation but failed to correct the wide QRS complex would switch to LBBAP implantation in the hope of correcting a more distal conduction abnormalities, resulting in a wide paced rhythm QRS duration in the LBBAP group. However, despite a persistent wide QRS duration even after LBBAP implantation, there was a trend of LVEF improvement in the LBBAP group compared to baseline (45.58\u0026thinsp;\u0026plusmn;\u0026thinsp;11.08% to 53.11\u0026thinsp;\u0026plusmn;\u0026thinsp;11.67) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This result may be explained by previous studies stating that not all wide QRS complex lead to a reduction in cardiac output, and in this situation, resynchronization therapy would result in an improvement of LV function, even in patients with mechanical dyssynchrony despite having a narrow baseline QRS complex.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFurther analysis was carried out for patients with LV dysfunction. This subgroup has a higher mean of age (64.08\u0026thinsp;\u0026plusmn;\u0026thinsp;8.98 years in HBP and 63.35\u0026thinsp;\u0026plusmn;\u0026thinsp;11.090 years in LBBAP, p\u0026thinsp;=\u0026thinsp;0.852) compared with the overall mean age in this study (57.00\u0026thinsp;\u0026plusmn;\u0026thinsp;16.15 years in HBP and 57.68\u0026thinsp;\u0026plusmn;\u0026thinsp;17.45 years in LBBAP, p\u0026thinsp;=\u0026thinsp;0.404) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In this subgroup analysis, similar results of a trend of QRS duration reduction in the HBP group (128.15\u0026thinsp;\u0026plusmn;\u0026thinsp;43.02ms to 112.00\u0026thinsp;\u0026plusmn;\u0026thinsp;21.10ms) with persistently wide QRS complex in the LBBAP group (125.13\u0026thinsp;\u0026plusmn;\u0026thinsp;32.82ms to 122.07\u0026thinsp;\u0026plusmn;\u0026thinsp;11.61ms) were found. These results were accompanied with a trend of LVEF improvement in both groups (35.31\u0026thinsp;\u0026plusmn;\u0026thinsp;7.86% to 44.54\u0026thinsp;\u0026plusmn;\u0026thinsp;11.28% in HBP group vs 44.54\u0026thinsp;\u0026plusmn;\u0026thinsp;11.28% to 51.35\u0026thinsp;\u0026plusmn;\u0026thinsp;13.14% in LBBAP group) with at least 50% of patients had LVEF improvement by the end of follow up (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Several reasons may explain the more dramatic LVEF improvement in the LBBAP group of this subgroup analysis compared to HBP group. First, there were 2 patients in the HBP group underwent HBP implantation as a form of resynchronization therapy. These patients were known to have significant coronary artery disease with several non-viable myocardial regions as assessed by imaging testing. Therefore, narrowing of the QRS duration may not lead to an LVEF improvement in these patients. Second, despite a lower baseline of LVEF in the HBP group, more patients received less adequate dose of guideline directed medical therapy compared with LBBAP group (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Third, this subgroup analysis may be underpower to truly show a significant improvement of LVEF in the HBP group due to a relatively small subjects in the HBP group compared to the LBBAP group. Lastly, previous meta-analysis stated that CSP may induce LVEF improvement after 6 months or even 12 months of follow up, however in this subgroup analysis, the mean of follow up in the HBP group of this subgroup analysis was only 5.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.45 months, p\u0026thinsp;=\u0026thinsp;0.332 group, therefore LVEF improvement may not occurred yet in all subjects of this group.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eThis study is a prospective cohort study with a small sample size and a relatively short duration of follow up. A larger study with longer follow up duration may be needed to demonstrate a statistically significant difference of LV function after HBP and LBBAP implantation. This study also did not evaluate echocardiographic parameters for inter- and intraventricular dyssynchrony, which might be able to explain the trend of LVEF improvement in spite of a persistently wide QRS complex after LBBAP implantation. Even though it might be underpowered, this is the first study trying to further analyze the difference of LV function following HBP and LBBAP implantation in subgroup of patients with underlying LV dysfunction. The findings from this study provided additional information that LBBAP was comparable to HBP in regard to improving and preserving LV function.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, HBP resulted in a narrower QRS complex duration compared to LBBAP. However, both HBP and LBBAP groups showed a trend of LV function improvement in patients with preexisting LV dysfunction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eK.P, G.K, and M.I.Q conceived and designed the study. K.P and G.K performed study selection. K.P performed data extraction and interpreted the data. K.P, G.K, and M.I.Q performed extensive search of relevant topics. K.P performed statistical analysis. K.W, G.K, M.R.A, J.W.M and M.I.Q performed review and extensive editing of the manuscript. All authors contributed significantly to the writing of the manuscript. All authors approved the final manuscript.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eApproval of the research protocols\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Medical Research Ethics Committee of Dr. Hasan Sadikin General Hospital, West Java, Indonesia\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available on reasonable request\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients provided a written informed consent\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnimal studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGlikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrab\u0026eacute;s 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, Thyl\u0026eacute;n 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. Erratum in: Eur Heart J. 2022 May 1;43(17):1651. PMID: 34455430.\u003c/li\u003e\n \u003cli\u003eKhurshid S, Epstein AE, Verdino RJ, Lin D, Goldberg LR, Marchlinski FE, Frankel DS. Incidence and predictors of right ventricular pacing-induced cardiomyopathy. Heart Rhythm. 2014 Sep;11(9):1619-25. doi: 10.1016/j.hrthm.2014.05.040. Epub 2014 Jun 2. PMID: 24893122.\u003c/li\u003e\n \u003cli\u003eKiehl EL, Makki T, Kumar R, Gumber D, Kwon DH, Rickard JW, Kanj M, Wazni OM, Saliba WI, Varma N, Wilkoff BL, Cantillon DJ. Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function. Heart Rhythm. 2016 Dec;13(12):2272-2278. doi: 10.1016/j.hrthm.2016.09.027. PMID: 27855853.\u003c/li\u003e\n \u003cli\u003eChung 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. PMID: 37283271.\u003c/li\u003e\n \u003cli\u003eArnold AD, Whinnett ZI, Vijayaraman P. His-Purkinje Conduction System Pacing: State of the Art in 2020. Arrhythm Electrophysiol Rev. 2020 Nov;9(3):136-145. doi: 10.15420/aer.2020.14. PMID: 33240509; PMCID: PMC7675135.\u003c/li\u003e\n \u003cli\u003eZhuang L, Mao Y, Wu L, Niu W, Chen K. Effects of right ventricular septum or His-bundle pacing versus right ventricular apical pacing on cardiac function: A systematic review and meta-analysis of randomized controlled trials. J Int Med Res. 2018 Sep;46(9):3848-3860. doi: 10.1177/0300060518781415. Epub 2018 Jul 1. PMID: 29962274; PMCID: PMC6136004.\u003c/li\u003e\n \u003cli\u003eAbdin A, Aktaa S, Vukadinović D, Arbelo E, Burri H, Glikson M, Meyer C, Munyombwe T, Nielsen JC, Ukena C, Vernooy K, Gale CP. Outcomes of conduction system pacing compared to right ventricular pacing as a primary strategy for treating bradyarrhythmia: systematic review and meta-analysis. Clin Res Cardiol. 2022 Nov;111(11):1198-1209. doi: 10.1007/s00392-021-01927-7. Epub 2021 Aug 19. PMID: 34410461; PMCID: PMC9622534.\u003c/li\u003e\n \u003cli\u003eRavi V, Hanifin JL, Larsen T, Huang HD, Trohman RG, Sharma PS. Pros and Cons of Left Bundle Branch Pacing: A Single-Center Experience. Circ Arrhythm Electrophysiol. 2020 Dec;13(12):e008874. doi: 10.1161/CIRCEP.120.008874. Epub 2020 Nov 16. PMID: 33198496.\u003c/li\u003e\n \u003cli\u003eDeshmukh P, Casavant DA, Romanyshyn M, Anderson K. Permanent, direct His-bundle pacing: a novel approach to cardiac pacing in patients with normal His-Purkinje activation. Circulation. 2000 Feb 29;101(8):869-77. doi: 10.1161/01.cir.101.8.869. PMID: 10694526.\u003c/li\u003e\n \u003cli\u003eHua W, Fan X, Li X, Niu H, Gu M, Ning X, Hu Y, Gold MR, Zhang S. Comparison of Left Bundle Branch and His Bundle Pacing in Bradycardia Patients. JACC Clin Electrophysiol. 2020 Oct;6(10):1291-1299. doi: 10.1016/j.jacep.2020.05.008. Epub 2020 Aug 12. PMID: 33092757.\u003c/li\u003e\n \u003cli\u003eLewis AJM, Foley P, Whinnett Z, Keene D, Chandrasekaran B. His Bundle Pacing: A New Strategy for Physiological Ventricular Activation. J Am Heart Assoc. 2019 Mar 19;8(6):e010972. doi: 10.1161/JAHA.118.010972. Erratum in: J Am Heart Assoc. 2019 Jun 4;8(11):e002310. PMID: 30854911; PMCID: PMC6475060.\u003c/li\u003e\n \u003cli\u003eThosani AJ, Liu E, Shaw G, Belden W, Chenarides J. Rapid reversal of right ventricular pacing-induced cardiomyopathy by His bundle pacing. HeartRhythm Case Rep. 2017 Jan 24;3(3):189-191. doi: 10.1016/j.hrcr.2017.01.004. PMID: 28791212; PMCID: PMC5532750.\u003c/li\u003e\n \u003cli\u003eVijayaraman P, Naperkowski A, Subzposh FA, Abdelrahman M, Sharma PS, Oren JW, Dandamudi G, Ellenbogen KA. Permanent His-bundle pacing: Long-term lead performance and clinical outcomes. Heart Rhythm. 2018 May;15(5):696-702. doi: 10.1016/j.hrthm.2017.12.022. Epub 2017 Dec 20. PMID: 29274474.\u003c/li\u003e\n \u003cli\u003eHuang W, Su L, Wu S, Xu L, Xiao F, Zhou X, Ellenbogen KA. A Novel Pacing Strategy With Low and Stable Output: Pacing the Left Bundle Branch Immediately Beyond the Conduction Block. Can J Cardiol. 2017 Dec;33(12):1736.e1-1736.e3. doi: 10.1016/j.cjca.2017.09.013. Epub 2017 Sep 22. PMID: 29173611.\u003c/li\u003e\n \u003cli\u003eVijayaraman P, Subzposh FA, Naperkowski A, Panikkath R, John K, Mascarenhas V, Bauch TD, Huang W. Prospective evaluation of feasibility and electrophysiologic and echocardiographic characteristics of left bundle branch area pacing. Heart Rhythm. 2019 Dec;16(12):1774-1782. doi: 10.1016/j.hrthm.2019.05.011. Epub 2019 May 25. PMID: 31136869.\u003c/li\u003e\n \u003cli\u003eLi X, Li H, Ma W, Ning X, Liang E, Pang K, Yao Y, Hua W, Zhang S, Fan X. Permanent left bundle branch area pacing for atrioventricular block: Feasibility, safety, and acute effect. Heart Rhythm. 2019 Dec;16(12):1766-1773. doi: 10.1016/j.hrthm.2019.04.043. Epub 2019 Apr 29. PMID: 31048065.\u003c/li\u003e\n \u003cli\u003eTan ESJ, Soh R, Boey E, Lee JY, de Leon J, Chan SP, Gan HH, Seow SC, Kojodjojo P. Comparison of Pacing Performance and Clinical Outcomes Between Left Bundle Branch and His Bundle Pacing. JACC Clin Electrophysiol. 2023 Aug;9(8 Pt 1):1393-1403. doi: 10.1016/j.jacep.2022.12.022. Epub 2023 Feb 22. PMID: 37558292.\u003c/li\u003e\n \u003cli\u003eHindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomstr\u0026ouml;m-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. doi: 10.1093/eurheartj/ehaa612. Erratum in: Eur Heart J. 2021 Feb 1;42(5):507. Erratum in: Eur Heart J. 2021 Feb 1;42(5):546-547. Erratum in: Eur Heart J. 2021 Oct 21;42(40):4194. PMID: 32860505.\u003c/li\u003e\n \u003cli\u003eMcDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, B\u0026ouml;hm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A; ESC Scientific Document Group. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-3726. doi: 10.1093/eurheartj/ehab368. Erratum in: Eur Heart J. 2021 Oct 14;: PMID: 34447992.\u003c/li\u003e\n \u003cli\u003eKusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Aug 20;74(7):932-987. doi: 10.1016/j.jacc.2018.10.043. Epub 2018 Nov 6. Erratum in: J Am Coll Cardiol. 2019 Aug 20;74(7):1014-1016. PMID: 30412710.\u003c/li\u003e\n \u003cli\u003eEzzeddine FM, Leon IG, Cha YM. Cardiac Resynchronisation with Conduction System Pacing. Arrhythm Electrophysiol Rev. 2023 Aug 11;12:e22. doi: 10.15420/aer.2023.03. PMID: 37654672; PMCID: PMC10466271.\u003c/li\u003e\n \u003cli\u003eDevabhaktuni S, Mar PL, Shirazi J, Dandamudi G. How to Perform His Bundle Pacing: Tools and Techniques. Card Electrophysiol Clin. 2018 Sep;10(3):495-502. doi: 10.1016/j.ccep.2018.05.008. PMID: 30172286.\u003c/li\u003e\n \u003cli\u003eVijayaraman P, Subzposh FA, Naperkowski A, et al. Prospective evaluation of feasibility and electrophysiologic and echocardiographic characteristics of left bundle branch area pacing. Heart Rhythm 2019;16:1774\u0026ndash;82.\u003c/li\u003e\n \u003cli\u003eSundaram S, Vijayaraman P. Left bundle branch pacing. Herzschrittmacherther Elektrophysiol 2020;31:124\u0026ndash;34.\u003c/li\u003e\n \u003cli\u003eLang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015 Jan;28(1):1-39.e14. doi: 10.1016/j.echo.2014.10.003. PMID: 25559473.\u003c/li\u003e\n \u003cli\u003eCheng A, Helm RH, Abraham TP. Pathophysiological mechanisms underlying ventricular dyssynchrony. Europace. 2009 Nov;11 Suppl 5:v10-14. doi: 10.1093/europace/eup272. PMID: 19861385.\u003c/li\u003e\n \u003cli\u003eAbdin A, Werner C, Burri H, Merino JL, Vukadinović D, Sawan N, Gajek J, B\u0026ouml;hm M, Ukena C. Outcomes of left bundle branch area pacing compared to His bundle pacing as a primary pacing strategy: Systematic review and meta-analysis. Pacing Clin Electrophysiol. 2023 Nov;46(11):1315-1324. doi: 10.1111/pace.14836. Epub 2023 Oct 9. PMID: 37812167.\u003c/li\u003e\n \u003cli\u003eByrne MJ, Helm RH, Daya S, Osman NF, Halperin HR, Berger RD, Kass DA, Lardo AC. Diminished left ventricular dyssynchrony and impact of resynchronization in failing hearts with right versus left bundle branch block. J Am Coll Cardiol. 2007 Oct 9;50(15):1484-90. doi: 10.1016/j.jacc.2007.07.011. Epub 2007 Sep 24. PMID: 17919569.\u003c/li\u003e\n \u003cli\u003eTanaka H, Tanabe M, Simon MA, Starling RC, Markham D, Thohan V, Mather P, McNamara DM, Gorcsan J 3rd. Left ventricular mechanical dyssynchrony in acute onset cardiomyopathy: association of its resolution with improvements in ventricular function. JACC Cardiovasc Imaging. 2011 May;4(5):445-56. doi: 10.1016/j.jcmg.2011.02.012. PMID: 21565730.\u003c/li\u003e\n \u003cli\u003eKronborg MB, Mortensen PT, Poulsen SH, Gerdes JC, Jensen HK, Nielsen JC. His or para-His pacing preserves left ventricular function in atrioventricular block: a double-blind, randomized, crossover study. Europace. 2014 Aug;16(8):1189-96. doi: 10.1093/europace/euu011. Epub 2014 Feb 7. PMID: 24509688.\u003c/li\u003e\n \u003cli\u003eWeizong W, Zhongsu W, Yujiao Z, Mei G, Jiangrong W, Yong Z, Xinxing X, Yinglong H. Effects of right ventricular nonapical pacing on cardiac function: a meta-analysis of randomized controlled trials. Pacing Clin Electrophysiol. 2013 Aug;36(8):1032-51. doi: 10.1111/pace.12112. Epub 2013 Feb 25. PMID: 23438131.\u003c/li\u003e\n\u003c/ol\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":"conduction system pacing (CSP), his bundle pacing (HBP), left bundle branch area pacing (LBBAP), left ventricular (LV) function","lastPublishedDoi":"10.21203/rs.3.rs-4572835/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4572835/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRight ventricular pacing may lead to deterioration of left ventricular (LV) function. Recent guideline suggests the use of conduction system pacing (CSP) with either his bundle pacing (HBP) or left bundle branch area pacing (LBBAP). This study aimed to investigate the difference of LV function between HBP and LBBAP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is a prospective cohort study enrolling patients age\u0026thinsp;\u0026gt;\u0026thinsp;18 years requiring CSP implantation from June 2020 to January 2024 in Hasan Sadikin General Hospital, Bandung. Data regarding QRS duration and several echocardiography parameters were obtained at baseline and during follow up within 1 year after CSP implantation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFrom 66 patients, 35 were included in the HBP group. There was no difference in QRS duration at baseline between both groups with higher left ventricular ejection fraction (LVEF) in HBP group (51.17\u0026thinsp;\u0026plusmn;\u0026thinsp;13.87% vs 45.58\u0026thinsp;\u0026plusmn;\u0026thinsp;11.08%, p\u0026thinsp;=\u0026thinsp;0.078). During follow up, HBP group showed narrower QRS duration (113.40\u0026thinsp;\u0026plusmn;\u0026thinsp;17.06ms vs 120.81\u0026thinsp;\u0026plusmn;\u0026thinsp;12.12ms, p\u0026thinsp;=\u0026thinsp;0.029). LV function was preserved in HBP group while there was a trend of LV function improvement in LBBAP group (53.11\u0026thinsp;\u0026plusmn;\u0026thinsp;11.67% in LBBAP vs 53.93\u0026thinsp;\u0026plusmn;\u0026thinsp;11.45% in HBP group, p\u0026thinsp;=\u0026thinsp;0.536). Further analysis in 33 patients with LV dysfunction showed a trend of LVEF improvement in both groups (35.31\u0026thinsp;\u0026plusmn;\u0026thinsp;7.86% to 44.54\u0026thinsp;\u0026plusmn;\u0026thinsp;11.28% in HBP and 38.75\u0026thinsp;\u0026plusmn;\u0026thinsp;6.95% to 51.35\u0026thinsp;\u0026plusmn;\u0026thinsp;13.14% in LBBAP group).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eHBP resulted in narrower QRS complex. However, both HBP and LBBAP showed a trend of LV function improvement in patients with LV dysfunction.\u003c/p\u003e","manuscriptTitle":"Comparison of Left Ventricular Function after His Bundle Pacing vs Left Bundle Branch Area Pacing Implantation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:14:26","doi":"10.21203/rs.3.rs-4572835/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":"440e9258-6feb-473c-877e-b27a21064aa1","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-09T08:47:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 20:14:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4572835","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4572835","identity":"rs-4572835","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}