His-Purkinje system pacing versus biventricular pacing in clinical efficacy: a systematic review and meta-analysis

Study selection

Initially, a total of 126 potentially eligible articles were retrieved from the databases (Fig. 1), and 89 records were left after exclusion of duplications. Of these, by screening via the titles and abstracts, 67 were subsequently excluded, and 13 [14, 27,28,29,30,31,32,33,34,35,36,37,38] were included in this meta-analysis after further excluding single-arm studies, study protocols, and studies with irrelevant outcomes.

Fig. 1figure 1

Flowchart of database search and study identification

Study characteristics and quality evaluation

Ten of the included articles [27,28,29,30,31, 34,35,36,37,38] were observational studies, and three [14, 33] were randomized studies. The meta-analysis included 1,121 patients recruited from 29 centers in all. Patients who received HPSP (LBBaP or HBP) and BVP were generally frequency-matched on age and sex (Table 1), period of the follow up were six months in seven studies [14, 27,28,29, 32, 33, 36], 12 months in two studies [30, 35], 14 months [34], 18 months [31], 24 months [37] and 27 months [38] in one study each. All patients had HF and CRT indication in 13 studies [14, 27,28,29,30,31,32,33,34,35,36,37,38]. In 9 studies [27,28,29,30, 32, 34,35,36,37,38], all of the patients (68%, n = 763) had LBBB, while in 8 studies [28,29,30,31,32, 34, 35, 38], the majority of the subjects had non-ischemic cardiomyopathy (63%, n = 584). Meanwhile, 92% (n = 972) of the population used β-blockers in 11 studies [27,28,29,30, 32,33,34,35,36,37,38], and 76.4% (n = 847) used Angiotensin-Converting Enzyme Inhibitors (ACEI)/ Angiotensin Receptor Blockers (ARB)/ Angiotensin Receptor-Neprilysin Inhibitor (ARNI) in 12 studies [27,28,29,30,31,32,33,34,35,36,37,38]. All included [14, 27,28,29,30,31,32,33,34,35,36,37,38] studies were graded with a score of greater than 6 points, and none of the included studies was of poor quality. Quality assessment of the included studies is presented in Table 2 and Fig. 2.

Table 1 Characteristics of the included studiesTable 2 Details of study quality evaluation via the NOSFig. 2figure 2

Quality judgements about each risk of bias item presented as percentages across three RCT studies

Change of QRSd

Articles with wide QRSd were analyzed using a random-effect model in different groups. The result of 11 studies [14, 27,28,29,30, 32,33,34,35, 37, 38] showed that the HPSP group had a significantly greater reduction in a mean of QRSd compared with BVP (MD: -26.25 ms, 95% confidence interval (CI): -34.54 to -17.92, P < 0.001, I2 = 91%). Similarly, in patients with LBBB, BVP presented a less reduction in a mean of QRSd than HPSP (MD: -25.63 ms, 95% CI: -33.61 to -17.64, P < 0.001, I2 = 86%) in 8 studies [27,28,29,30, 32, 34, 35, 37]. No difference in a mean of QRSd was observed between HPSP and BVP in three RCT studies [14, 32, 33] (MD: -27.61 ms, 95% CI: -59.24 to 4.01, P < 0.001, I2 = 94%) (Fig. 3).

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