Multipoint pacing for cardiac resynchronisation therapy in patients with heart failure: a systematic review and meta-analysis

Introduction Multipoint pacing (MPP) has been proposed as an effective way to improve cardiac resynchronisation therapy (CRT) response. We performed a systematic review and meta-analysis evaluating the efficacy of CRT delivered via MPP compared to conventional CRT. Methods A literature search was performed from inception to January 2021 for studies in Medline, Embase and Cochrane databases, comparing MPP to conventional CRT with a minimum of 6 months follow-up. Randomised and non-randomised studies were assessed for relevant efficacy data including echocardiographic (LVESV and EF) or functional changes (NYHA class/Clinical Composite Score (CCS)). Subgroup analyses were performed by study design and programming type. Results 7 studies with a total of 1390 patients were included in the final analysis. Overall, MPP demonstrated greater echocardiographic improvement than conventional CRT in non-randomised studies [OR 5.33, 95% CI[3.05-9.33], p<0.001], however was not significant in randomised studies [OR 1.86, 95% CI[0.91-3.79], p=0.086]. There was no significant difference in LVESV reduction >15% [OR 1.96, 95% CI[0.69-5.55], p=0.20] or improvement by ≥1 NYHA class [OR 2.49, 95% CI[0.74-8.42], p=0.141] when comparing MPP to conventional CRT. In a sub-analysis, MPP programmed by widest anatomical separation (MPP-AS) signalled greater efficacy, however only 120 patients were included in this analysis. Conclusion Overall MPP was more efficacious in non-randomised studies, and not superior when assessed in randomised studies. There was considerable heterogeneity in study design making overall interpretation of results challenging. Widespread MPP programming in all CRT patients is currently not justified. Further large, randomised studies with patient-specific programming may clarify its effectiveness.