Pamporis, Konstantinos

Abstract Aims Conduction system pacing (CSP) has emerged as a physiologic alternative to cardiac resynchronization therapy (CRT) with biventricular pacing (BiVP) in heart failure with reduced ejection fraction (HFrEF), yet its comparative effects remain uncertain. This meta-analysis sought to compare outcomes of CSP vs. BiVP in patients with HFrEF undergoing CRT. Methods and results MEDLINE, Embase, Scopus, and the Cochrane Database were searched through 4 May 2026. Randomized controlled trials (RCTs) were synthesized using random-effects meta-analysis. Thirteen RCTs including 1320 participants were analysed (657 CSP, 663 BiVP). Conduction system pacing was associated with a lower risk of the composite of hospitalization for heart failure (HHF) or all-cause mortality compared with BiVP (46 vs. 83 events; odds ratio [OR] 0.51, 95% confidence interval [CI] 0.28–0.93). No significant differences were observed for HHF alone (OR 0.68, 95% CI 0.36–1.27) or all-cause mortality (OR 0.75, 95% CI 0.36–1.58). Conduction system pacing was associated with greater improvement in the 6-min walk distance (mean difference [MD] 21.53 m, 95% CI 4.33–38.73) and New York Heart Association functional class (standardized mean difference [SMD] −0.27, 95% CI −0.47 to −0.07), but not quality of life. Conduction system pacing also reduced QRS duration compared with BiVP (MD −10.94 ms, 95% CI −17.55 to −4.34), with no significant differences in left ventricular ejection fraction, left ventricular end-systolic volume, overall pacing threshold, total procedure time, fluoroscopy time, any complication, or reintervention. Conclusion In patients with HFrEF undergoing CRT, CSP is associated with lower composite risk of HHF or all-cause mortality compared with BiVP. Conduction system pacing is also associated with improved functional capacity, without significant differences in safety or procedural outcomes.

Abstract Aims Intracardiac echocardiography (ICE) is increasingly incorporated into atrial fibrillation (AF) ablation workflows, enabling real-time anatomic guidance and procedural precision. Nevertheless, ICE utilization shows substantial geographic variability, and its clinical benefit remains incompletely understood. This meta-analysis evaluated the efficacy, safety, and procedural performance of ICE-guided vs. non-ICE-guided AF ablation. Methods and results MEDLINE, the Cochrane Library, and Scopus were systematically searched through 3 August 2025. Three reviewers independently performed study selection, data extraction, and risk-of-bias assessment. Random-effects models were used to pool data from 44 AF ablation studies comprising 482 043 patients. ICE guidance was associated with lower odds of any complication (OR 0.69; 95% CI 0.53–0.89), including significant reductions in cardiac tamponade (OR 0.58; 95% CI 0.53–0.62) and mortality (OR 0.21; 95% CI 0.16–0.27). ICE-guided ablation was also associated with shorter total procedure and fluoroscopy times, reduced radiation exposure, and lower contrast agent utilization. Atrial tachyarrhythmia (AT) recurrence did not differ between groups (OR 0.92; 95% CI 0.79–1.06). However, ICE use was associated with higher odds of first-pass pulmonary vein isolation (OR 1.62; 95% CI 1.09–2.41) and successful isolation of all pulmonary veins at the end of the procedure (OR 2.12; 95% CI 1.37–3.27), and lower odds of repeat ablation (OR 0.65; 95% CI 0.59–0.72). Conclusion ICE-guided AF ablation is associated with superior procedural safety and efficiency and a similar risk of AT recurrence compared to non-ICE-guided approaches.

Abstract Background Although a rhythm control strategy is associated with an overall better prognosis in atrial fibrillation (AF), current guidelines suggest that only highly selected asymptomatic patients may be considered candidates for AF catheter ablation. Therefore, this study aimed to evaluate the association between symptom status and clinical outcomes in patients with AF. Methods A comprehensive search of Medline, the Cochrane Library, and Scopus was conducted up until September 30, 2024. Study selection, data extraction, and quality assessment were performed independently by three reviewers. Random-effects meta-analyses were used to pool the evidence. Results A total of 36 studies, comprising 217,850 participants, were included. Frequentist analysis revealed no significant difference between symptomatic and asymptomatic AF patients in terms of all-cause mortality [hazard ratio (HR) = 0.97, 95% confidence interval (CI)= (0.80, 1.17)], cardiovascular mortality (HR= 1.04, 95% CI= [0.72, 1.49]), thromboembolism (HR= 1.06, 95% CI= [0.87, 1.28]), stroke (HR= 1.06, 95% CI= [0.84, 1.34]), hospitalization (HR= 1.34, 95% CI= [0.89, 2.02]), and myocardial infarction (HR= 0.98, 95% CI= [0.70, 1.36]). However, symptomatic patients exhibited a 33% increased risk of new-onset heart failure (HR= 1.33, 95% CI= [1.19, 1.49]) and a 30% reduced risk of progression to permanent AF (HR= 0.70, 95% CI= [0.54, 0.89]). Bayesian analysis produced similar results, although the association between symptom status and new-onset heart failure was not statistically significant [HR = 1.27, 95% credible interval (CrI)= (0.76, 1.93); Bayes factor (BF10)= 1.2]. Symptomatic patients had higher odds of receiving antiarrhythmic drugs (odds ratio [OR]= 1.64, 95% CI= [1.33, 2.03]) and ablation therapy (OR= 1.47, 95% CI= [1.06, 2.05]) compared to their asymptomatic counterparts. Conclusions The risk of major clinical outcomes does not significantly differ between AF patients with and without symptoms. However, asymptomatic patients have a higher risk of progressing to permanent AF.

Abstract Background and Aims Current guidelines suggest that asymptomatic atrial fibrillation (AF) is independently associated with increased risks of stroke and mortality compared with symptomatic AF. Considering that recent investigations have provided conflicting results, the present study aimed to evaluate the association between symptom status and clinical outcomes in patients with AF. Methods Medline, Cochrane Library, and Scopus were searched until 25 March 2024. Triple-independent study selection, data extraction and quality assessment were performed. Evidence was pooled using random-effects meta-analyses. Results Thirty-six studies (217 850 participants) were included. Based on the frequentist analysis, symptomatic individuals had no significant difference in the risk of all-cause mortality [hazard ratio (HR) .97, 95% confidence interval (CI) .80–1.17], cardiovascular mortality (HR 1.04, 95% CI .72–1.49), thromboembolism (HR 1.06, 95% CI .87–1.28), stroke (HR 1.06, 95% CI .84–1.34), hospitalization (HR 1.34, 95% CI .89–2.02), and myocardial infarction (HR .98, 95% CI .70–1.36), compared to the asymptomatic group. Symptomatic patients had a 33% increased risk of new-onset heart failure (HR 1.33, 95% CI 1.19–1.49) and a 30% lower risk of progression to permanent AF (HR .70, 95% CI .54–.89). The Bayesian analysis yielded comparable results, yet the association between symptom status and new-onset heart failure was not significant (HR 1.27, 95% credible interval .76–1.93; Bayes factor = 1.2). Symptomatic patients had higher odds of receiving antiarrhythmic drugs (odds ratio [OR] 1.64, 95% CI 1.33–2.03) and ablation therapy (OR 1.47, 95% CI 1.06–2.05) compared to asymptomatic cases. Conclusions The risk of major clinical outcomes did not differ between individuals with and without AF-related symptoms. Asymptomatic patients had a greater hazard of progression to permanent AF.