The edition · Cardiology
Left bundle branch area pacing matched biventricular pacing after AV node ablation
CONDUCT-AF tests conduction system pacing where heart failure meets refractory atrial fibrillation. Also: mitral regurgitation thresholds for transthyretin amyloid that sit well below guideline cut-offs, plaque lipid content and preventive PCI, and what SELECT can and cannot say about how semaglutide protects.
The edition in brief
CONDUCT-AF randomised 82 patients with refractory atrial fibrillation, LVEF below 50%, narrow QRS and raised NT-proBNP who were undergoing atrioventricular node ablation to left bundle branch area pacing or biventricular pacing. LVEF rose by about 10–12 points in both arms; the difference was 0.4% (95% CI −3.1 to 3.8), meeting non-inferiority, with shorter paced QRS and shorter procedures for conduction system pacing. In 1101 patients with transthyretin amyloid cardiomyopathy, disease-specific mitral regurgitation thresholds far below guideline cut-offs classed 21% as severe rather than about 12–13% and predicted death and heart failure admission better. A post hoc PREVENT analysis linked the benefit of preventive PCI on non-flow-limiting plaques to lipid-rich lesions on near-infrared spectroscopy (adjusted HR 0.23), with none in lipid-poor lesions. A SELECT mediation analysis could not attribute semaglutide's 20% MACE reduction to weight, CRP, HbA1c or other measured risk factors with any certainty.
In transthyretin amyloid, mitral regurgitation becomes dangerous well below guideline thresholds
Grade mitral regurgitation in transthyretin amyloid quantitatively and treat lower volumes as prognostically important, without changing intervention criteria yet.
Preventive PCI of non-flow-limiting plaque was linked to benefit only when the plaque was lipid-rich
Do not change practice on preventive PCI from this subgroup, but expect plaque composition to shape the next trials.
SELECT mediation analysis could not pin semaglutide's cardiovascular benefit on any measured risk factor
Prescribe semaglutide for cardiovascular protection on the SELECT trial criteria, not on expected weight loss.
After AV node ablation, the pacing programme matters in the first weeks
Start with a higher paced rate after AV node ablation and reduce it over the following weeks.
Conduction system pacing was non-inferior to biventricular pacing after AV node ablation
Consider left bundle branch area pacing as the pacing strategy for AV node ablation in heart failure, where local expertise supports it.
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