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

Research output: Contribution to journalArticlepeer-review

Original languageEnglish
JournalHeart Rhythm O2
Accepted/In press18 Jul 2022


  • HROO-D-22-00124_R1 (1)

    HROO_D_22_00124_R1_1_.pdf, 3.85 MB, application/pdf

    Uploaded date:20 Jul 2022

    Version:Accepted author manuscript

    Licence:CC BY

King's Authors


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

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.

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”.

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].

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.

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