Clinical and echocardiographic response of apical vs nonapical right ventricular lead position in CRT: A meta‐analysis

Abstract

BackgroundTraditionally the right ventricular (RV) pacing lead is placed in the RV apex in cardiac resynchronization therapy (CRT). It is not clear whether nonapical placement of the RV lead is associated with a better response to CRT. We aimed to perform a meta‐analysis of all randomized controlled trials (RCTs) that compared apical and nonapical RV lead placement in CRT.MethodsWe searched PubMed, EMBASE, Cochrane, Scopus, and relevant references for studies and performed meta‐analysis using random effects model. Our main outcome measures were all‐cause mortality, composite of death and heart failure hospitalization, improvement in ejection fraction (EF), left ventricle end‐diastolic volume (LVEDV), left ventricle end‐systolic volume (LVESV), and adverse events.ResultsSeven RCTs with a total population of 1641 patients (1199 apical and 492 nonapical) were included in our meta‐analysis. There was no difference in all‐cause mortality (5% vs 4.3%, odds ratio (OR) = 0.86; 95% confidence interval (CI) 0.45‐1.64; P = .65; I 2 = 11%) and a composite of death and heart failure hospitalization (14.2% vs 12.9%, OR = 0.92; 95% CI: 0.61‐1.38; P = .68; I 2 = 0) between apical and nonapical groups. No difference in improvement in EF (Weighted mean difference (WMD) = 0.37; 95% CI: −2.75‐3.48; P = .82; I 2 = 68%), change in LVEDV (WMD = 3.67; 95% CI: −4.86‐12.20; P = .40; I 2 = 89%) and LVESV (WMD = −1.20; 95% CI: −4.32‐1.91; P = .45; I 2 = 0) were noted between apical and nonapical groups. Proportion of patients achieving >15% improvement in EF was similar in both groups (OR = 0.85; 95% CI: 0.62‐1.16; P = .31; I 2 = 0).ConclusionIn patients with CRT, nonapical RV pacing is not associated with improved clinical and echocardiographic outcomes compared with RV apical pacing.

Meshless Electrophysiological Modeling of Cardiac Resynchronization Therapy—Benchmark Analysis with Finite-Element Methods in Experimental Data

“…The RV apx − LV bas lead configuration not only provided better recovery percentages, but also had a smaller LAT error with CRT EAM data (see Table A2 in the Appendix A). This is in agreement with multiple clinical studies and guidelines [11,53], although different alternatives (e.g., different RV location [20]) are still being proposed. For instance, some studies suggest that RVOT pacing may be more beneficial than standard one, specifically in cases with a decreased left ventricular ejection fraction [11,50].…”

The desire for physiological pacing: Are we there yet?

“…For example, a RV high septal/outflow tract lead position worked best with the LV lead in the lateral wall whereas with the lead at RVA the optimal LV lead location was at the epicardial LV antero‐basal wall. However, a large (n = 263) trial in CRT and a meta‐analysis of available clinical trials did not support any particular RV lead position over another in terms of clinical outcomes . The results of the theoretical modelling would suggest that RV lead position is important but maximizing CRT response has been exclusively based upon finding the optimal LV lead position.…”

Contribution to the improvement of electrical therapies and to the comprehension of electrophysiological mechanisms in heart failure and acute ischemia using computational simulation

“…During standard CRT application, the LV pacing lead is placed into a coronary sinus venous branch, usually at the lateral or posterolateral location [80]. The RV pacing lead is located inside the RV, typically in the apical wall ( Figure 2.12) [81]. In addition, a third lead is placed in the RA, which is used to monitor the sinus rhythm or as a source of stimulation and inhibition of impulses generated by the SAN.…”