What question did this study set out to answer?

This meta-analysis aims to compare the effects of apical and non-apical pacing in cardiac resynchronization therapy on patient outcomes.

March 31, 2015Open Access

Apical vs. non-apical right ventricular pacing in cardiac resynchronization therapy: a meta-analysis

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Heart failure (n=2670). Intervention: Right ventricular apical (RVA) pacing vs. Right ventricular non-apical (RVNA) pacing. Primary outcome: Left ventricular end-systolic volume (LVESV) reduction (SMD 0.13, 95% CI -0.24 to 0.50, p=0.48).

Key Result

Right ventricular apical pacing and non-apical pacing in CRT patients resulted in similar left ventricular end-systolic volume reduction (SMD 0.13; 95% CI -0.24 to 0.50; P=0.48).

Key Points

This meta-analysis aims to compare the effects of apical and non-apical pacing in cardiac resynchronization therapy on patient outcomes.
Conducted a meta-analysis of randomized-controlled trials and observational studies.
Included 12 studies with 2670 patients evaluating RVA versus RVNA pacing.
Analyzed left ventricular end-systolic volume reduction and functional status improvement using standardized mean difference and odds ratio.
In patients with RVA and RVNA pacing, LVESV reduction was similar (SMD 0.13, 95% CI: -0.24 to 0.50, P = 0.48).
Functional status improvement was also comparable (OR 1.08, 95% CI: 0.81 to 1.45, P = 0.60).
Mortality and hospitalization outcomes could not be pooled due to heterogeneity in studies.

Study Design

Type

Meta-Analysis (n=2,670)

PICO

Population

Heart failure (n=2,670)

Intervention / Comparator

Right ventricular apical (RVA) pacing vs Right ventricular non-apical (RVNA) pacing

Primary Outcome

Left ventricular end-systolic volume (LVESV) reduction — SMD 0.13 (-0.24 to 0.50), p=0.48

Main Result

Effect estimate: SMD 0.13 (95% CI -0.24 to 0.50)

p-value: p=0.48

Limitations

Data regarding mortality and hospitalizations could not be pooled due to a small number of relevant studies with significant heterogeneity.

Abstract

AIMS: Cardiac resynchronization therapy (CRT) has been shown to improve outcomes in patients with heart failure. The optimal site of right ventricular (RV) stimulation in CRT has not been established. We aimed to conduct a meta-analysis of randomized-controlled trials and observational studies comparing the mid- and long-term effects of RV apical (RVA) and non-apical (RVNA) pacing on CRT outcomes. METHODS: We systematically searched the Cochrane library, EMBASE, and MEDLINE databases for studies evaluating RVA vs. RVNA pacing in CRT with regards to left ventricular end-systolic volume (LVESV) reduction, functional status improvement (defined as ≥1 New York Heart Association class improvement), and the clinical outcome of mortality or cardiovascular hospitalization. Effect estimates standardized mean difference (SMD) and odds ratio (OR) with 95% confidence intervals (CI) were pooled using random-effect models. RESULTS: Twelve studies comprising 2670 patients (1655 with an apical and 1015 with a non-apical RV lead position) were included. In meta-analyses, LVESV reduction and functional status improvement were similar in patients with RVA and RVNA pacing (SMD 0.13, 95% CI: -0.24 to 0.50, P = 0.48; OR 1.08, 95% CI: 0.81 to 1.45, P = 0.60, respectively). Data regarding mortality and hospitalizations could not be pooled due to a small number of relevant studies with significant heterogeneity. CONCLUSION: Our meta-analysis suggests that in CRT patients the effects of RVA or RVNA pacing on LV remodelling and functional status are similar. Mortality and morbidity outcomes with different RV lead positions should be further assessed in randomized clinical trials.