Efficacy of multipoint versus conventional biventricular pacing in CRT: systematic review and meta-analysis of randomized trials

Abstract

BACKGROUND: MultiPoint Pacing (MPP) may enhance the clinical and echocardiographic response to Cardiac Resynchronization Therapy (CRT), but randomized evidence remains inconsistent. The objective of this study is to compare the efficacy and safety of MPP versus conventional biventricular (BiV) pacing in patients with heart failure and reduced ejection fraction. METHODS: We conducted a PROSPERO-registered (CRD420251033856) systematic review and meta-analysis of randomized controlled trials evaluating MPP versus BiV pacing. Outcomes included LVESV reduction, LVEF improvement, clinical response rate, super-response rate, and conversion to non-responder. Data were synthesized using random-effects models, and certainty was assessed with GRADE. RESULTS: Six RCTs (n = 1,766) were included. MPP significantly improved LVEF (MD 5.16%, 95% CI 3.17-7.15; P < 0.0001), clinical response rate (RR 1.35, 95% CI 1.18-1.55; P < 0.0001), and super-response rate (RR 1.54, 95% CI 1.15-2.06; P = 0.004). The pooled LVESV analysis showed a nominally significant benefit with MPP, but this was accompanied by substantial heterogeneity and a prediction interval crossing zero, limiting confidence in a universal effect; the benefit appeared more consistent in CRT-naïve patients. No significant improvement was observed in non-responder conversion (RR 0.99). Overall certainty ranged from very low to moderate. CONCLUSION: Multipoint pacing is associated with signals of improved left ventricular reverse remodeling and higher clinical response rates compared with conventional biventricular pacing. However, the high heterogeneity and a 95% prediction interval crossing zero for LVESV reduction indicate that this effect is not consistent across all populations. MPP provides clinically meaningful benefits primarily in selected patient subgroups-particularly in CRT-naïve and responder populations-rather than serving as a universal rescue strategy for established non-responders.