Multipoint pacing for cardiac resynchronisation therapy in patients with heart failure: A systematic review and meta‐analysis

Abstract

Introduction Multipoint pacing (MPP) has been proposed as an effective way to improve cardiac resynchronisation therapy (CRT) response. We performed a systematic review and meta‐analysis evaluating the efficacy of CRT delivered via MPP compared to conventional CRT. Methods A literature search was performed from inception to January 2021 for studies in Medline, Embase and Cochrane databases, comparing MPP to conventional CRT with a minimum of 6 months follow‐up. Randomised and nonrandomised studies were assessed for relevant efficacy data including echocardiographic (left ventricular end systolic volume [LVESV] and ejection fraction) or functional changes (New York Heart Association [NYHA] class/Clinical Composite Score). Subgroup analyses were performed by study design and programming type. Results A total of 7 studies with a total of 1390 patients were included in the final analysis. Overall, MPP demonstrated greater echocardiographic improvement than conventional CRT in nonrandomised studies (odds ratio [OR]: 5.33, 95% confidence interval [CI]: [3.05–9.33], p < .001), however, was not significant in randomised studies (OR: 1.86, 95% CI: [0.91–3.79], p = .086). There was no significant difference in LVESV reduction >15% (OR: 1.96, 95% CI: [0.69–5.55], p = .20) or improvement by ≥1 NYHA class (OR: 2.49, 95% CI: [0.74–8.42], p = .141) when comparing MPP to conventional CRT. In a sub analysis, MPP programmed by widest anatomical separation (MPP‐AS) signalled greater efficacy, however, only 120 patients were included in this analysis. Conclusion Overall MPP was more efficacious in nonrandomised studies, and not superior when assessed in randomised studies. There was considerable heterogeneity in study design making overall interpretation of results challenging. Widespread MPP programming in all CRT patients is currently not justified. Further large, randomised studies with patient‐specific programming may clarify its effectiveness.

Synchronizing Beats: From Theory to Advances and Insight in Cardiac Resynchronization Therapy

“…Advancements in CRT have led to the exploration of alternative pacing sites, the development of newer device-based algorithms, and strategies when traditional CRT is not feasible or effective. Strategies targeting "multi-points" have shown superiority over classic CRT [2]. Additionally, conduction system pacing has arisen as a promising technique [3].…”

Pacing interventions in non-responders to cardiac resynchronization therapy

“…The authors suggested that there may be a delayed response to biventricular pacing beyond the initial 6 months owing to a myocardial substrate that needs more time to fully undergo reverse remodelling, or heart failure medication that continues to be up titrated-whether that be with MPP, MSP, or conventional CRT. A recently published meta-analysis by Mehta et al reported that in randomised studies, there is no difference between MPP and conventional CRT ( Mehta et al, 2021 ).…”

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

“…While early studies of multi-point pacing demonstrated promising improvements in short-term haemodynamic and dyssynchrony outcomes, 3–5 a recent meta-analysis of multi-point pacing found no significant benefit over conventional CRT when only randomized studies were included. 6 …”