The role of guidance in delivering cardiac resynchronisation therapy: a systematic review and network meta-analysis

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Abstract

Background
Positioning the left ventricular (LV) lead at the optimal myocardial segment has been proposed to improve cardiac resynchronisation therapy (CRT) response.

Objectives
We performed a systematic review and network meta-analysis (NMA) evaluating
echocardiographic and clinical response delivered with different guidance modalities compared to conventional fluoroscopic positioning.

Methods
Randomised trials with ≥6 months follow-up comparing any combination of imaging, electrical, haemodynamic or fluoroscopic guidance were included. Imaging modalities were split whether one modality was used: cardiac magnetic resonance (CMR), speckle tracking echocardiography (STE), single-photon emission computed tomography (SPECT), cardiac computerised tomography (CT); or a combination of these, defined as “multi-modality imaging”.

Results
Twelve studies were included (n=1864). Pair-wise meta-analysis resulted in significant odds of reduction in LVESV>15% [OR 1.50, 95% CI [1.05-2.13], p=0.025], and absolute reduction in LVESV [SMD -0.25, 95% CI [-0.43 to -0.08], p=0.005] with guidance. CMR [OR 55.3, 95% CI [4.7 to 656.9], p=0.002], electrical [OR 17.0, 95% CI [2.9 to 100], p=0.002], multimodality imaging [OR 4.47, 95% CI [1.36 to 14.7], p=0.014], and haemodynamic guidance [OR 1.29-28.0], p=0.02] were significant in reducing LVESV>15%. Only STE demonstrated a significant reduction in absolute LVESV [SMD -0.38, 95% CI [-0.68 to -0.09], p=0.011]. CMR had the highest probability of improving clinical response [OR 17.9, 95% CI [5.14 to 62.5], p<0.001].

Conclusion
Overall, guidance improves CRT outcomes. STE and multimodality imaging provided the most reliable evidence of efficacy. Wide CIs observed for results of CMR guidance suggest more powered studies are required before a clear ranking is possible.
Original languageEnglish
JournalHeart Rhythm O2
Publication statusAccepted/In press - 18 Jul 2022

Keywords

  • Cardiac resynchronisation therapy; LV lead; Guidance; efficacy; systematic review; Meta-analysis

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