His-Alternative II — Direct His/LBB Pacing as an Alternative to Biventricular Pacing in Patients With Symptomatic Heart Failure Despite Optimal Medical Treatment and an ECG With a Typical Left Bundle Branch Block Pattern

doi:10.1016/j.jacep.2026.08.008

HIS Alternative II

Patient / Population Intervention / Exposition Comparaison Critère de jugement

In 148 patients with HFrEF and left bundle branch block, conduction-system pacing was non-inferior to biventricular pacing for the change in LV end-systolic volume at 6 months.

N

148patients

Schéma

Investigator-initiated, multicentre (Rigshospitalet, Copenhagen; Imperial College Healthcare NHS Trust, London), randomised 1:2 (biventricular CRT : conduction-system-pacing CRT) non-inferiority trial; patients and echocardiography/6-minute-walk assessors blinded; in the CSP arm His-bundle pacing is attempted first, then left bundle branch pacing, with a coronary-sinus LV lead as bail-out (and vice versa in the control arm); 6-month follow-up; enrolment June 2020 to February 2026.

Critère

Change in left ventricular end-systolic volume by echocardiography at 6 months (non-inferiority versus biventricular CRT); the registry also lists the success rate of His-bundle or LBB lead implantation with LBBB correction as a co-primary

Pertinence

2Important — l’un des piliers parmi d’autres.

RésultatThe relative fall in left ventricular end-systolic volume at 6 months differed by 0.9 percentage points (95% CI −6.9 to 8.7; P = 0.003 for non-inferiority, P = 0.8 for superiority); on-treatment 2.7 points (−4.6 to 10.0; P < 0.001 for non-inferiority). QRS duration, ejection fraction, NT-proBNP, NYHA class, quality of life and walking distance improved comparably, and the safety profiles were similar.

Vinther M, Philbert BT, Risum N, et al. J Am Coll Cardiol EP. 2026; published online 31 August. 10.1016/j.jacep.2026.08.008

Discussion et critique

Pacing the conduction system rather than the free wall matched biventricular CRT on reverse remodelling at six months, with the same electrical and clinical gains and no safety penalty — the first randomised comparison to say so in patients selected by Strauss criteria. It is 148 patients at two centres with a surrogate endpoint and a 10% margin, so what is shown is that the strategies are interchangeable for the ventricle, not that either changes outcomes. The investigators say the same: promising, and waiting on larger trials with longer follow-up.