# CUSUM Analysis as a Predictive Tool for the Learning Curve in Left Bundle Branch Area Pacing

## TL;DR

CUSUM analysis helps track the learning curve for a new heart pacing technique, showing when operators become proficient.

## Contribution

CUSUM analysis is applied for the first time to quantify the learning curve of left bundle branch area pacing.

## Key findings

- Fluoroscopy time decreased significantly after about 65 procedures, indicating proficiency.
- CUSUM analysis reliably identified the transition to proficiency in pacing procedures.
- Electrical performance and safety remained stable throughout the learning process.

## Abstract

Background/Objectives: Left bundle branch area pacing (LBBAP) has rapidly emerged as a physiological alternative to conventional pacing. However, the learning curve for new operators remains poorly characterized. We aimed to describe the learning curve of LBBAP using cumulative sum (CUSUM) analysis in a single-center, single-operator setting. Methods: We conducted a retrospective analysis of 108 consecutive LBBAP attempts performed by a first-time operator with no prior conduction system pacing experience. Fluoroscopy time was selected as the primary performance metric. A predefined procedural target (≤6 min for non-CRT and ≤9 min for CRT implants) was used to classify each case as a success or failure. CUSUM plots were generated to identify the inflection point marking proficiency acquisition. Results: In non-CRT cases (n = 95), fluoroscopy time progressively decreased, and the CUSUM curve showed a distinct inflection after approximately 65 cases, indicating the attainment of procedural proficiency. In CRT implants (n = 9), acceptable fluoroscopy exposure was achieved soon after the non-CRT proficiency threshold was reached. Electrical performance and safety outcomes remained stable throughout the learning process. Conclusions: CUSUM provides a clear, objective, and real-time measure of operator progression during the initial learning phase of LBBAP. The technique reliably identified the proficiency transition and can be readily implemented for procedural training, credentialing, and competency monitoring in centers adopting LBBAP.