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

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.

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.

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.

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.