左束支起搏与右室起搏在高危心功能患者中的随机对照试验
该前瞻性多中心随机对照试验纳入160例高起搏负荷且心功能不全高风险患者，1:1随机接受左束支起搏（LBBP）或右室起搏（RVP）。中位随访36个月，LBBP组主要复合终点（全因死亡、心衰住院或起搏诱导性心肌病）发生率显著低于RVP组（11.6% vs 33.9%；HR 0.310；95%CI 0.145-0.664；P=0.001），主要由起搏诱导性心肌病减少驱动，且超声心动图参数和NYHA心功能分级改善更优。
要点
- 高起搏负荷且心功能不全高风险患者中，LBBP较RVP显著降低主要复合终点风险。
- 获益主要来自起搏诱导性心肌病（PICM）发生率降低（6.5% vs 18.2%）。
- LBBP在左室射血分数、左室舒张末径和收缩末径及NYHA心功能分级上均优于RVP。
核心结论
- 在高起搏负荷且心功能不全高风险患者中，LBBP显著降低主要复合终点风险，主要由PICM减少驱动，并伴随更好的超声心动图改善和临床功能。
研究设计与样本
- 前瞻性、多中心、随机对照试验，160例高起搏负荷且心功能不全高风险患者按1:1随机分配至LBBP组或RVP组。
主要发现
- 中位随访36个月，主要复合终点LBBP组9例（11.6%） vs RVP组25例（33.9%）（HR 0.310；95%CI 0.145-0.664；P=0.001）。
- PICM发生率LBBP组6.5% vs RVP组18.2%（亚分布HR 0.324；95%CI 0.119-0.883；P=0.028）。
- 全因死亡（P=0.391）和心衰住院（P=0.100）组间无显著差异。
- LBBP组左室射血分数改善优于RVP组（均差5.34；95%CI 3.18-7.50；P<0.001）。
- LBBP组左室舒张末径（均差-3.06；95%CI -4.38至-1.73；P<0.001）和收缩末径（均差-3.74；95%CI -5.07至-2.41；P<0.001）改善优于RVP组。
临床怎么用
- 对于高起搏负荷且心功能不全高风险的患者，可考虑优先选择LBBP以降低PICM风险并保护心功能。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
BACKGROUND: Right ventricular pacing (RVP) is associated with an increased risk of pacing-induced cardiomyopathy (PICM) in patients with a high pacing burden. Left bundle branch pacing (LBBP), a more physiological pacing modality, may better preserve cardiac function. OBJECTIVES: This randomized trial aimed to evaluate the clinical outcomes of LBBP vs RVP in patients with a high pacing burden with high risk of cardiac dysfunction. METHODS: In this prospective, multicenter, randomized controlled trial, 160 patients with a high pacing burden with high risk of cardiac dysfunction were randomly assigned in a 1:1 ratio to either LBBP or RVP. The primary endpoint was a composite of all-cause mortality, heart failure hospitalization, or PICM. Secondary endpoints were the individual components of the primary endpoints, echocardiographic parameters, and NYHA functional class. RESULTS: During a median follow-up duration of 36 months, the primary endpoint occurred in 9 patients in the LBBP group and in 25 patients in the RVP group (11.6% vs 33.9%; HR: 0.310; 95% CI: 0.145-0.664; P = 0.001), mainly driven by PICM (6.5% vs 18.2%; subdistribution HR: 0.324; 95% CI: 0.119-0.883; P = 0.028). No significant differences were observed in all-cause mortality (P = 0.391) and heart failure hospitalization (P = 0.100) between 2 groups. LBBP showed superior improvements over RVP in left ventricular ejection fraction (mean difference: 5.34; 95% CI: 3.18-7.50; P < 0.001), left ventricular end-diastolic diameter (mean difference: -3.06; 95% CI: -4.38 to -1.73; P < 0.001), and left ventricular end-systolic diameter (mean difference: -3.74; 95% CI: -5.07 to -2.41; P < 0.001) from baseline to 36 months. Patients in the LBBP group also showed favored NYHA functional class compared with those in the RVP group at the 36-month follow-up (1.66 ± 0.60 vs 1.90 ± 0.56, P = 0.014). CONCLUSIONS: In patients with a high pacing burden with high risk of cardiac dysfunction, LBBP significantly reduced the risk of the composite outcome, driven primarily by a decreased risk of PICM, and is associated with better echocardiographic improvements and clinical function. (A multicenter, prospective, randomized, controlled trial of left bundle branch pacing and right ventricular pacing in preventing deterioration of cardiac function in patients with ventricular pacing dependence [LBBP-FAVOUR]; ChiCTR2000036553).
引用
- Qiu N, Liu X, Wang Z, et al. Randomized Trial of Left Bundle Branch Pacing vs Right Ventricular Pacing in Vulnerable Cardiac Function. J Am Coll Cardiol. 2026. PMID: 42024568. doi:10.1016/j.jacc.2026.03.161
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。