Multi-lead pacing for cardiac resynchronization therapy in heart failure: a meta-analysis of randomized controlled trials

Abstract

Aims Multi-lead pacing is a potential therapy to improve response to cardiac resynchronization therapy (CRT) by providing rapid activation of the myocardium from multiple sites. Here we perform a meta-analysis of randomized controlled trials to assess the efficacy of multi-lead pacing. Methods and Results A literature search was performed which identified 251 unique records. After screening, 6 studies were found to meet inclusion criteria, with 415 patients included in the meta-analysis. Four studies performed multi-lead pacing with two left ventricular (LV) leads and one right ventricular (RV) lead. One study used two RV leads and one LV lead, and one study used both configurations. There was no difference between multi-lead pacing or conventional CRT in LV end-systolic volume (mean difference [MD] -0.54 ml, p = 0.93) or LV ejection fraction (MD 1.42%, p = 0.40). There was a borderline significant improvement in Minnesota Living With Heart Failure Questionnaire score for multi-lead pacing versus conventional CRT (MD -4.46, p = 0.05), but the difference was not significant when only patients receiving LV-only multi-lead pacing were included (MD -3.59, p = 0.25). There was also no difference between groups for six-minute walk test (MD 15.06m, p = 0.38) or New York Heart Association class at follow-up (odds ratio [OR] 1.49, p = 0.24). There was no difference in mortality between groups (OR 1.11, p = 0.77). Conclusion This meta-analysis does not support the use of multi-lead pacing for CRT delivery. However, significant variation between studies was noted, and therefore a benefit for multi-lead pacing in select patients cannot be excluded, and further investigation may be warranted.

Pacing interventions in non-responders to cardiac resynchronization therapy

“…The influence of bias is less likely to be prominent in larger multicentre studies. As such, therapies which initially sound promising, such as AV/VV optimisation ( Brabham and Gold, 2013 ) and multipoint/multi-lead pacing ( Elliott et al, 2022a ) have lost momentum due to negative results in clinical trials of unselected patients. In actuality, their primary benefit could have been demonstrated by specifically targeting a non-responder population, where the potentially larger impact on measurable parameters may be adequate to power randomised trials at a reasonable sample size.…”

“…The V3 trial ( Bordachar et al, 2018 ) and STRIVE-CRT ( Gould et al, 2022 ) are important negative trials which showed no significant difference in clinical or echocardiographic outcomes between standard of care and multi-lead pacing in unselected CRT populations. A meta-analysis of 415 patients by Elliott et al ( Elliott et al, 2022a ) again reported no difference between TriV pacing and conventional BiV pacing.…”