Clinical outcomes of conduction system pacing versus biventricular pacing for cardiac resynchronization therapy: A systematic review and meta‐analysis

• Published in: Journal of cardiovascular electrophysiology 2023-08, Vol.34 (8), p.1718-1729
• Main Authors: Kim, Jitae A., Kim, Seulgi E., Ellenbogen, Kenneth A., Vijayaraman, Pugazhendhi, Chelu, Mihail G.
• Format: Article
• Language: English
• Subjects: biventricular pacing; Cardiac Conduction System Disease - therapy; cardiac resynchronization therapy; Cardiac Resynchronization Therapy - adverse effects; Clinical outcomes; Clinical trials; Conduction; conduction system pacing; Congestive heart failure; Heart Failure - diagnosis; Heart Failure - therapy; His‐bundle pacing; Humans; left bundle branch pacing; Meta-analysis; Mortality; Stroke Volume; Treatment Outcome; Ventricle; Ventricular Function, Left
• ISSN: 1045-3873; 1540-8167
• DOI: 10.1111/jce.15976

Introduction Conduction system pacing (CSP) is observed to produce greater improvements in echocardiographic and hemodynamic parameters as compared to conventional biventricular pacing (BiVP). However, whether these surrogate endpoints directly translate to improvements in hard clinical outcomes such as death and heart failure hospitalization (HFH) with CSP remains uncertain as studies reporting these outcomes are scarce. The aim of this meta‐analysis was to analyze the existing data to compare the clinical outcomes of CSP versus BiVP. Methods A systematic search of the Embase and PubMed database was performed for studies comparing CSP and BiVP for patients indicated to receive a CRT device. The coprimary endpoints were all‐cause mortality and HFH. Other secondary outcomes included change in left ventricular ejection fraction (LVEF), change in NYHA class, and increase in NYHA class ≥1. A random‐effects model was chosen a priori to analyze the composite effects given the anticipated heterogeneity of included trials. Results Twenty‐one studies (4 randomized and 17 observational) were identified reporting either primary outcome and were included in the meta‐analysis. In total 1960 patients were assigned to CSP and 2367 to BiVP. Median follow‐up time was 10.1 months (ranging 2–33 months). CSP was associated with a significant reduction in all‐cause mortality (odds ratio [OR] 0.68, 95% confidence interval [CI]: 0.56–0.83) and HFH (OR 0.52, 95% CI: 0.44–0.63). Mean improvement in LVEF was also greater with CSP (mean difference 4.26, 95% CI: 3.19–5.33). Reduction in NYHA class was significantly greater with CSP (mean difference −0.36, 95% CI: −0.49 to −0.22) and the number of patients with an increase in NYHA class ≥1 was significantly greater with CSP (OR 2.02, 95% CI: 1.70–2.40). Conclusions CSP was associated with a significant reduction in all‐cause mortality and HFH when compared to conventional BiVP for CRT. Further large‐scale randomized trials are needed to verify these observations.