Abstract 4345173: Triventricular Pacing Is Associated with Improved Functional Capacity Compared to Biventricular Pacing in Heart Failure Patients: A systematic Review and Meta-Analysis

Introduction: Cardiac resynchronization therapy (CRT) is an established intervention for heart failure (HF) patients with intraventricular conduction delays. Triventricular pacing (TriV) has emerged as a novel strategy to optimize ventricular synchrony and improve clinical outcomes. Research Questions: This systematic review and meta-analysis aimed to compare the efficacy of TriV pacing versus conventional biventricular (BiV) pacing in HF patients across key clinical, functional, and echocardiographic outcomes. Method: We searched PubMed, Scopus, and Web of Science for relevant studies that compare TriV versus BiV in patients with HF up to April 2025. The meta-analysis was performed using online RevMan. Leave-one-out meta-analysis and regression analysis were done using the OpenMetaAnalyst program. Results: A total of 6 studies were included in the meta-analysis. TriV pacing significantly improved 6-minute walk distance compared to BiV pacing (MD = 41.77 m, 95% CI: 18.08 to 65.46, p = 0.0005; I^2 = 0%), with results robust across sensitivity analyses. There was no significant difference between TriV and BiV pacing in heart failure hospitalization (RR = 0.87, 95% CI: 0.57 to 1.33, p = 0.53; I^2 = 0%) or all-cause mortality (RR = 0.82, 95% CI: 0.59 to 1.13, p = 0.23; I^2 = 0%). Similarly, no significant differences were found in LV end-diastolic volume (MD = 7.93 mL, 95% CI: -4.41 to 20.27, p = 0.21) or LV end-systolic volume (MD = 1.36 mL, 95% CI: -10.56 to 13.28, p = 0.82), both showing I^2 = 0%. LVEF changes were inconsistent across studies, with high heterogeneity (I^2= 71%), and meta-regression revealed a significant time-dependent effect (−0.94% per month, p = 0.002). Quality of life scores did not differ significantly between groups (MD = -3.58, 95% CI: -9.51 to 2.36, p = 0.24), with a slight trend favoring TriV. Conclusion: Triventricular pacing provides a significant improvement in functional capacity, as demonstrated by increased 6-minute walk distance, compared to conventional biventricular pacing in heart failure patients. However, no significant differences were observed between the two modalities in terms of hospitalization, mortality, cardiac remodeling, or quality of life. These findings suggest that while TriV pacing may offer functional benefits, its broader clinical advantages over BiV pacing remain uncertain and warrant further investigation in larger trials.