Mavilakandy Akash, Abdelrazik Ahmed M, Abouelmagd Khaled, Koev Ivelin, Chotalia Ravi, Sudhakaran Sachin, Koya Abdulmalik Idris, Antoun Ibrahim, Eldeeb Hany, Ahamed Hisham, Dhutia Harshil, Somani Riyaz, Ng G Andre, Ibrahim Mokhtar
Department of Cardiology, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester LE3 9QP, UK.
Department of Cardiovascular Sciences, University of Leicester, Leicester LE3 9QP, UK.
Europace. 2025 Jul 1;27(7). doi: 10.1093/europace/euaf106.
Atrioventricular node ablation (AVNA) with permanent pacemaker implantation is an established rate-control treatment approach for patients with AF with uncontrolled ventricular rates. Conduction system pacing (CSP) utilizing His bundle pacing (HBP) or left bundle branch area pacing (LBBAP) has advanced as a treatment alternative to standard right ventricular pacing in addition to biventricular pacing (BVP). This systematic review and meta-analysis aim to provide a comprehensive summary and evaluation of clinical outcomes in the literature for CSP in comparison to BVP in conjunction with AVNA.
This study protocol was registered in the PROSPERO registry (CRD42024510974), and the review was conducted as per the PRISMA guidelines. Databases were searched for relevant studies from inception till 11 January 2024. Results were synthesized using a random effects meta-analysis. From a total of 259 references identified, 122 full texts were assessed, and 25 studies were included in the systematic review. Of these included studies, five were used for comparative meta-analysis. A total of 1652 (HBP 1069 and LBBAP 644) and 369 patients received CSP and BVP implantation with AVNA, respectively. Conduction system pacing resulted in a narrower QRS duration (QRSd) with a change of -35.8 ms (95% CI -61.8 to -9.72; P < 0.05; I2 = 96.3%) vs. BVP. Conduction system pacing also resulted in better symptomatic improvement in from of NYHA reduction (MD -0.53, 95% CI -1.01 to -0.04, I2 = 62.1; P = 0.03). For left ventricular ejection fraction, a non-significant weighted mean increases of 3.36% (95% CI -0.75-7.47%; P = 0.11, I2 = 68.5%) was observed following CSP implantation in comparison to BVP. Conduction system pacing showed no significant differences in procedural and fluoroscopy times and had comparable periprocedural complications. His bundle pacing demonstrated a non-significant reduction in the events of acute threshold elevation in comparison to BVP (Log odds ratio -0.69, 95% CI -2.05-0.66, I2 = 0.00; P = 0.32).
Conduction system pacing with AVNA is a safe and feasible treatment option for symptomatic (AF) patients undergoing a pace and ablate strategy, offering an alternative to BVP. Overall, CSP results in a narrower QRS duration while providing comparable clinical and echocardiographic outcomes.
房室结消融（AVNA）联合永久起搏器植入是控制心室率不佳的房颤患者的一种既定的心率控制治疗方法。利用希氏束起搏（HBP）或左束支区域起搏（LBBAP）的传导系统起搏（CSP）已成为除双心室起搏（BVP）之外标准右心室起搏的一种治疗替代方案。本系统评价和荟萃分析旨在全面总结和评估文献中CSP与AVNA联合BVP相比的临床结局。
本研究方案已在PROSPERO注册库（CRD42024510974）中注册，该评价按照PRISMA指南进行。检索数据库以获取从开始到2024年1月11日的相关研究。结果采用随机效应荟萃分析进行综合。在总共识别出的259篇参考文献中，评估了122篇全文，25项研究纳入了系统评价。在这些纳入研究中，5项用于比较荟萃分析。分别有1652例（HBP 1069例和LBBAP 644例）和369例患者接受了CSP和BVP联合AVNA植入。与BVP相比，传导系统起搏导致QRS波时限（QRSd）变窄，变化为-35.8 ms（95%CI -61.8至-9.72；P<0.05；I²=96.3%）。传导系统起搏还使纽约心脏协会（NYHA）分级改善方面的症状有更好改善（MD -0.53，95%CI -1.01至-0.04，I²=62.1；P=0.03）。对于左心室射血分数，与BVP相比，CSP植入后观察到加权平均增加3.36%（95%CI -0.75 - 7.47%；P=0.11，I²=68.5%），差异无统计学意义。传导系统起搏在手术时间和透视时间方面无显著差异，围手术期并发症相当。与BVP相比，希氏束起搏在急性阈值升高事件方面有非显著降低（对数比值比-0.69，95%CI -2.05至0.66，I²=0.00；P=0.32）。
对于接受起搏和消融策略的有症状房颤患者，AVNA联合传导系统起搏是一种安全可行的治疗选择，可替代BVP。总体而言，CSP可使QRS波时限变窄，同时提供相当的临床和超声心动图结局。
