Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA.
Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.
J Cardiovasc Electrophysiol. 2023 Aug;34(8):1718-1729. doi: 10.1111/jce.15976. Epub 2023 Jun 21.
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.
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.
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).
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.
与传统的双心室起搏（BiVP）相比，心脏传导系统起搏（CSP）在改善超声心动图和血流动力学参数方面表现出更大的优势。然而，这些替代终点是否直接转化为 CSP 在死亡和心力衰竭住院（HFH）等硬临床结局方面的改善尚不确定，因为报告这些结局的研究很少。本荟萃分析旨在分析现有数据，比较 CSP 与 BiVP 的临床结局。
对 Embase 和 PubMed 数据库进行系统检索，以查找比较 CSP 和 BiVP 治疗 CRT 适应证患者的研究。主要复合终点为全因死亡率和 HFH。其他次要结局包括左心室射血分数（LVEF）的变化、纽约心脏协会（NYHA）心功能分级的变化和 NYHA 心功能分级增加≥1 级。由于预计纳入试验的异质性，选择了随机效应模型来预先分析复合效应。
共确定了 21 项研究（4 项随机研究和 17 项观察性研究），其中报告了主要结局并纳入荟萃分析。共有 1960 例患者被分配到 CSP 组，2367 例患者被分配到 BiVP 组。中位随访时间为 10.1 个月（范围为 2-33 个月）。CSP 与全因死亡率（比值比[OR]0.68，95%置信区间[CI]：0.56-0.83）和 HFH（OR 0.52，95%CI：0.44-0.63）显著降低相关。CSP 组的 LVEF 平均改善幅度也更大（平均差异 4.26，95%CI：3.19-5.33）。CSP 组 NYHA 心功能分级的改善程度也显著更大（平均差异-0.36，95%CI：-0.49 至-0.22），CSP 组 NYHA 心功能分级增加≥1 级的患者数量也显著更多（OR 2.02，95%CI：1.70-2.40）。
与传统的 BiVP 相比，CSP 可显著降低 CRT 患者的全因死亡率和 HFH。需要进一步的大规模随机试验来验证这些观察结果。
