His-Purkinje System Pacing versus Biventricular Pacing in clinical efficacy: A Systematic Review and Meta-Analysis

Background His-Purkinje system pacing (HPSP), including His-bundle pacing (HBP) and Left bundle branch pacing area (LBBaP), imitates the natural conduction of the heart as an alternative to biventricular pacing (BVP) in cardiac resynchronization therapy (CRT). However, current evidence on the feasibility and efficacy of HPSP were from studies with limited sample size, and the aim of this study was to provide a comprehensive assessment through a systematically review and meta-analysis. Methods PubMed, EMBASE, Cochrane Library and Web of Science database were searched from inception to October 27, 2022 to compare the clinical outcomes associated with HPSP and BVP in patients for CRT. Clinical outcomes of interest including QRS duration (QRSd), left ventricular (LV) function and New York Heart Association (NYHA) functional classification, pacing threshold, echocardiographic and clinical response and hospitalization rate of HF were also extracted and summarized for meta-analysis. Results A total of 12 studies (nine observational studies and three randomized studies) involving 644 patients were included. The patients were matched on age and sex and were followed for 6–24 months. Compared with BVP, CRT patients treated by HPSP had shorter QRSd [mean difference (MD): -28.03 ms, 95% confidence interval (CI): -35.54 to -20.53, P ༜0.001, I 2 = 85%], greater LV functional improvement with increased left ventricular ejection fraction (LVEF) (MD: 5.81, 95% CI: 4.24 to 7.38, P ༜0.001, I 2 = 0%) and decreased left ventricular end-diastolic dimension (LVEDD) (MD: -4.05, 95% CI: -5.89 to -2.20, P ༜0.001, I 2 = 0%), more improved NYHA functional classification (MD: -0.45, 95% CI: -0.67 to -0.23, P ༜0.001, I 2 = 70%). In addition, HPSP were more likely to have higher echocardiographic [odds ratio (OR): 2.76, 95% CI: 1.74 to 4.39, P < 0.001, I 2 = 0%], clinical (OR: 2.10, 95% CI: 1.16 to 3.80, P = 0.01, I 2 = 0%) and super clinical (OR: 3.17, 95% CI: 2.09 to 4.79, P < 0.001, I 2 = 0%) responses than BVP, while there was no difference in the hospitalization rate of HF (OR: 0.34, 95% CI: 0.10 to 1.17, P = 0.09, I 2 = 0%) between them. When considering threshold change, HBP was less stable than LBBaP (MD: -0.16 V, 95% CI: -0.25 to -0.06, P = 0.0009, I 2 = 35%), but had no difference with BVP (MD: 0.11 V, 95% CI: -0.09 to 0.31, P = 0.28, I 2 = 0%). Conclusion Our findings suggested that HPSP was associated with more remarkable improvement of cardiac function in patients with indication for CRT and a potential alternative to BVP to achieve a physiological pacing through native his-purkinje system.