Abstract
Purpose: Adaptive servo-ventilation (ASV) is contraindicated for central sleep apnea (CSA) treatment in patients with heart failure with reduced ejection fraction (HFrEF) limiting treatment options. Though, continuous positive airway pressure (CPAP), bi-level PAP with back-up rate (BPAP-BUR) and transvenous phrenic nerve stimulation (TPNS) are alternatives, not much is known about their comparative efficacies, which formed the basis of this network meta-analysis, in which their effects on apnea hypopnea index (AHI) and subjective daytime sleepiness (based on Epworth sleepiness score (ESS)), were analyzed.Methods: PubMed was searched for potentially includable randomized controlled trials and network meta-analysis was conducted in R program using package netmeta.Results: Network meta-analysis showed no statistically significant differences between interventions in AHI reduction. In exploring heterogeneity, sensitivity analysis elicited statistically significant differences in AHI reduction between ASV and TPNS (-18.30 [-27.8; -8.79]), with BPAP-BUR (-21.90 [-30.79; -13.01]) and CPAP (-23.10 [-29.22; -16.98]), favoring ASV. Of all the interventions, only TPNS showed a statistically significant decrease in ESS (-3.70 (-5.58; -1.82)) when compared to guideline directed medical therapy (used as a common comparator across trials), while also showing significant differences when compared with ASV (-3.20 (-5.86; -0.54)), BPAP-BUR (-4.00 (-7.33; -0.68)), and CPAP (-4.45 (-7.75; -1.14)). Hasse diagram, accounting for both AHI and ESS as outcomes for relative hierarchy showed relative superiority of both ASV and TPNS over BPAP-BUR and CPAP.Conclusions: Results indicate relative superiority of TPNS and ASV to BPAP-BUR and CPAP in their effects on AHI and ESS reduction in patients with CSA and HFrEF.
Transvenous Phrenic Nerve Stimulation and Positive Airway Pressure devices for Central Sleep Apnea in Patients with Heart Failure with Reduced Ejection Fraction: A Network Meta-analysis
