Authors' objectives: The objective of this report is to systematically review the evidence for the use of BVP, as either a de novo implant or as an upgrade, in the management of AV block with normal left ventricular systolic function at the MUHC.

Authors' recommendations: The available evidence regarding the use of BVP in AV block patients is weak in terms of the number of studies identified, the relatively small sample sizes, and the lack of meaningful clinical outcome data and short duration of follow-up within each study. Based on the GRADE guidelines the quality of the evidence was rated as Low to Very Low on all outcomes. In patients with normal LVEF, the use of BVP as an initial mode of pacing in AV block patients remains unsupported as the evidence shows no significant difference in clinical endpoints compared to RVP. In patients with low LVEF undergoing de novo pacing and in those with HF undergoing an upgrade from RVP, there is fairly consistent evidence of modest improvement of ventricular function (increased LVEF, reduced end systolic volume), and modest symptomatic improvement (NYHA score, walk test and QoL). It should be noted that these studies included a substantial number of patients with characteristics that are indications for BVP in heart failure at baseline, and therefore do not provide evidence regarding the independent risk of AV block in contributing to heart failure. The 2013 guidelines for use of BVP published by the Canadian Cardiovascular Society (CCS) also reached a similar conclusion to our report in terms of the quality of evidence. Based on the BLOCK-HF trial alone, the CCS noted that the quality of evidence was "moderate". None the less, they issued a "Conditional Recommendation" that BVP "might be considered for patients with new-onset high-degree AV block requiring chronic RV pacing, signs and/or symptoms of HF, and LVEF≤ 45%". The CCS guideline points out that the BLOCK-HF trial enrolled only those with de novo implants and its results may not apply to those who are already chronically paced. Further it notes that most patients in the BLOCK-HF trial had symptomatic HF. This is similar to our own observation above regarding RCTs of de novo BVP implantation in AV Block patients with low LVEF. It should be noted that unlike clinical guideline documents our report does not provide guidance on how individual patients should be treated. Rather our focus has been to distinguish between those situations where there is good evidence to support the use of BVP and where there is not.

Project Status: Completed

Year Published: 2016

URL for published report: http://www.mcgill.ca/tau/files/tau/muhc_tau_2016_78_biv_heart_block.pdf

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Canada

Organisation Name: Technology Assessment Unit of the McGill University Health Centre (MUHC)

Contact Address: Technology Assessment Unit of the MUHC, 536-5100 Boul. Maisonneuve O, Montreal, H4A 3T2

Contact Name: eva.suarthana@mcgill.ca

Contact Email: nisha.almeida@muhc.mcgill.ca

Copyright: Technology Assessment Unit of the McGill University Health Centre (MUHC)