Association between electrical and mechanical remodeling after cardiac resynchronization therapy: systematic review and meta-analysis of observational studies

Abstract

Cardiac resynchronization therapy (CRT) may improve not only impaired left ventricular contractility but can also induce reverse remodeling of native conduction system. Measurement of intrinsic QRS complex width during follow-up is the simplest method to assess reverse electrical remodeling (RER). We aimed to provide a literature review and meta-analysis on incidence and impact of RER and its association with mechanical remodeling. A systematic review and random-effect meta-analysis of studies reporting data on RER was performed. A total of 16 studies were included in this meta-analysis with 930 patients undergoing CRT (mean age 64.0 years, 64.1% males). The weighted mean incidence of RER was 42%. Reverse mechanical remodeling assessed by echocardiography was more frequently observed in patients with RER compared to patients without RER (75.7% vs. 46.6%; odds ratio [OR] 3.7, 95% confidence interval [CI] 2.24-6.09, p < 0.01). Mechanical responders had a mean iQRS shortening of 7.7 ms, while mechanical non-responders experienced a mean widening of iQRS by 5.2 ms (p < 0.01). Clinical improvement was more frequent in patients with RER vs. patients without RER (82.9% vs. 49.0%; OR 5.26; 95% CI 2.92-9.48; p < 0.01). No significant difference in all-cause mortality between patients with and without RER was found. Mean difference between baseline intrinsic QRS and post-implantation paced QRS was significant in patients with later RER (21.2 ms, 95% CI 9.4-32.9, p < 0.01), but not in patients without RER (6.6 ms, 95% CI -2.2-15.4, p = 0.14). Gender, initial left bundle block morphology and heart failure etiology were found not to be predictive for RER. Our meta-analysis demonstrates that shortening of iQRS duration is a common finding during follow-up of patients undergoing CRT and is associated with mechanical reverse remodeling and clinical improvement. Clinical Trial Registration: Prospero Database-CRD42021253336.

Keywords: Cardiac resynchronization therapy; Electrical remodeling; Mechanical remodeling; QRS duration, QRS shortening.