Right ventricular pacing for hypertrophic obstructive cardiomyopathy: meta-analysis and meta-regression of clinical trials

Ahran D Arnold, James P Howard, Kayla Chiew, William J Kerrigan, Felicity de Vere, Hannah T Johns, Leonid Churlilov, Yousif Ahmad, Daniel Keene, Matthew J Shun-Shin, Graham D Cole, Prapa Kanagaratnam, S M Afzal Sohaib, Amanda Varnava, Darrel P Francis, Zachary I Whinnett, Ahran D Arnold, James P Howard, Kayla Chiew, William J Kerrigan, Felicity de Vere, Hannah T Johns, Leonid Churlilov, Yousif Ahmad, Daniel Keene, Matthew J Shun-Shin, Graham D Cole, Prapa Kanagaratnam, S M Afzal Sohaib, Amanda Varnava, Darrel P Francis, Zachary I Whinnett

Abstract

Aims: Right ventricular pacing for left ventricular outflow tract gradient reduction in hypertrophic obstructive cardiomyopathy remains controversial. We undertook a meta-analysis for echocardiographic and functional outcomes.

Methods and results: Thirty-four studies comprising 1135 patients met eligibility criteria. In the four blinded randomized controlled trials (RCTs), pacing reduced gradient by 35% [95% confidence interval (CI) 23.2-46.9, P < 0.0001], but there was only a trend towards improved New York Heart Association (NYHA) class [odds ratio (OR) 1.82, CI 0.96-3.44; P = 0.066]. The unblinded observational studies reported a 54.3% (CI 44.1-64.6, P < 0.0001) reduction in gradient, which was a 18.6% greater reduction than the RCTs (P = 0.0351 for difference between study designs). Observational studies reported an effect on unblinded NYHA class at an OR of 8.39 (CI 4.39-16.04, P < 0.0001), 450% larger than the OR in RCTs (P = 0.0042 for difference between study designs). Across all studies, the gradient progressively decreased at longer follow durations, by 5.2% per month (CI 2.5-7.9, P = 0.0001).

Conclusion: Right ventricular pacing reduces gradient in blinded RCTs. There is a non-significant trend to reduction in NYHA class. The bias in assessment of NYHA class in observational studies appears to be more than twice as large as any genuine treatment effect.

Keywords: Hypertrophic cardiomyopathy; Meta-analysis; Right ventricular pacing.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
Flow chart for study selection.
Figure 2
Figure 2
Effect of right ventricular pacing on left ventricular outflow tract gradient at immediate (6 months to

Figure 3

Effect of right ventricular pacing…

Figure 3

Effect of right ventricular pacing on left ventricular outflow tract gradient at short-term…

Figure 3
Effect of right ventricular pacing on left ventricular outflow tract gradient at short-term follow-up (1–3 months) in crossover randomized controlled trials.

Figure 4

Effect of right ventricular pacing…

Figure 4

Effect of right ventricular pacing on New York Heart Association class at short-term…

Figure 4
Effect of right ventricular pacing on New York Heart Association class at short-term follow-up (1–3 months) in non-randomized studies.

Figure 5

Effect of right ventricular pacing…

Figure 5

Effect of right ventricular pacing on New York Heart Association class at short-term…

Figure 5
Effect of right ventricular pacing on New York Heart Association class at short-term follow-up (1–3 months) in crossover randomized controlled trials.
Figure 3
Figure 3
Effect of right ventricular pacing on left ventricular outflow tract gradient at short-term follow-up (1–3 months) in crossover randomized controlled trials.
Figure 4
Figure 4
Effect of right ventricular pacing on New York Heart Association class at short-term follow-up (1–3 months) in non-randomized studies.
Figure 5
Figure 5
Effect of right ventricular pacing on New York Heart Association class at short-term follow-up (1–3 months) in crossover randomized controlled trials.

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Source: PubMed

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