Upgrading right ventricular pacemakers to biventricular pacing or conduction system pacing: a systematic review and meta-analysis

Abstract

Guidelines recommend patients undergoing a first pacemaker implant who have even mild left ventricular (LV) impairment should receive biventricular or conduction system pacing (CSP). There is no corresponding recommendation for patients who already have a pacemaker. We conducted a meta-analysis of randomized controlled trials (RCTs) and observational studies assessing device upgrades. The primary outcome was the echocardiographic change in LV ejection fraction (LVEF). Six RCTs (randomizing 161 patients) and 47 observational studies (2644 patients) assessing the efficacy of upgrade to biventricular pacing were eligible for analysis. Eight observational studies recruiting 217 patients of CSP upgrade were also eligible. Fourteen additional studies contributed data on complications (25 412 patients). Randomized controlled trials of biventricular pacing upgrade showed LVEF improvement of +8.4% from 35.5% and observational studies: +8.4% from 25.7%. Observational studies of left bundle branch area pacing upgrade showed +11.1% improvement from 39.0% and observational studies of His bundle pacing upgrade showed +12.7% improvement from 36.0%. New York Heart Association class decreased by −0.4, −0.8, −1.0, and −1.2, respectively. Randomized controlled trials of biventricular upgrade found improvement in Minnesota Heart Failure Score (−6.9 points) and peak oxygen uptake (+1.1 mL/kg/min). This was also seen in observational studies of biventricular upgrades (−19.67 points and +2.63 mL/kg/min, respectively). In studies of the biventricular upgrade, complication rates averaged 2% for pneumothorax, 1.4% for tamponade, and 3.7% for infection over 24 months of mean follow-up. Lead-related complications occurred in 3.3% of biventricular upgrades and 1.8% of CSP upgrades. Randomized controlled trials show significant physiological and symptomatic benefits of upgrading pacemakers to biventricular pacing. Observational studies show similar effects between biventricular pacing upgrade and CSP upgrade.

EHRA clinical consensus statement on conduction system pacing implantation: endorsed by the Asia Pacific Heart Rhythm Society (APHRS), Canadian Heart Rhythm Society (CHRS), and Latin American Heart Rhythm Society (LAHRS)

“…CSP has been widely used worldwide using commercially available pacing leads and lead delivery systems, and indications are likely to broaden in the future. 88 , 113 , 114 Nevertheless, many aspects of CSP lead implantation need to be improved. The pacing leads and delivery systems were not originally designed for CSP, and the implant tools are not suitable for challenging anatomies.…”

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

“…Based on these observations, in patients with a substantial burden of RVP that cannot be minimized by programming, periodic assessment of LV function is recommended to detect PICM. Once detected, PICM may be reversible with CPP 29 . A suggested time frame for LVEF assessment is every 1–2 years in patients with high‐risk features (eg, QRS duration >115 ms at baseline and paced QRS duration >150 ms) and with reduced frequency if LV function has been stable. In the general population, the prevalence of LBBB ranges from 0.2% to 1.1% 30 .…”

“…Studies are limited in that most were not randomized, most of the randomized studies had a crossover design confounding assessments of survival, and HF outcomes assessed and entry criteria were heterogeneous. However, a meta‐analysis 29 of 6 RCTs (161 patients; 5 of 6 were crossover studies) and 47 observational studies (2644 patients) of BiV pacing upgrade demonstrated improvements in LVEF, LVESV, NYHA class, quality of life, peak exercise oxygen capacity as measured by peak VO 2 max, and QRS duration. Among complications associated with device upgrades, infection rates averaged 3.7%, pneumothorax 2.0%, cardiac perforation or tamponade in 1.4%, and lead‐related complications in 3.3%. Physiologic pacing with HBP and LBBAP has been associated with significant improvement in LVEF and HF symptoms among patients identified as having PICM 19,29,153,154 .…”

“…However, a meta‐analysis 29 of 6 RCTs (161 patients; 5 of 6 were crossover studies) and 47 observational studies (2644 patients) of BiV pacing upgrade demonstrated improvements in LVEF, LVESV, NYHA class, quality of life, peak exercise oxygen capacity as measured by peak VO 2 max, and QRS duration. Among complications associated with device upgrades, infection rates averaged 3.7%, pneumothorax 2.0%, cardiac perforation or tamponade in 1.4%, and lead‐related complications in 3.3%. Physiologic pacing with HBP and LBBAP has been associated with significant improvement in LVEF and HF symptoms among patients identified as having PICM 19,29,153,154 . A retrospective observational multicenter study 19 of 60 patients with PICM referred for upgrade to HBP revealed successful HBP in 57 (95%) of the patients, which was associated with an improvement in LVEF from 34.3% ± 9.6% to 48.2% ± 9.8% ( p < .001).…”

“…In patients with a CIED with a decline in LV function or worsening of HF symptoms attributed to substantial ventricular pacing, CRT with BiV pacing is recommended to improve LV function and improve HF symptoms. 29 2aB‐NR2. In patients with a CIED with a decline in LV function or worsening of HF symptoms attributed to substantial ventricular pacing, revision of CIED to a CSP device can be beneficial to improve LV function and symptoms of HF. 19,29,153,154 …”