Clinical Outcomes of Conduction System versus Right Ventricular Pacing after TAVR: A Systematic Review and Meta-Analysis.

BACKGROUND

Permanent pacemaker implantation is required in up to 25% of patients after transcatheter aortic valve replacement (TAVR). Conventional right ventricular pacing (RVP) may promote dyssynchrony, whereas conduction system pacing (CSP) preserves physiological activation.

RESEARCH QUESTION: Does CSP improve clinical, echocardiographic, electrical, and procedural outcomes compared with RVP in patients requiring pacing after TAVR?

METHODS

We conducted a PROSPERO-registered systematic review and meta-analysis following PRISMA 2020. PubMed, Embase, Scopus, and ClinicalTrials.gov were searched through June 2026 for randomized and comparative observational studies of CSP versus RVP after TAVR. Random-effects models generated risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs). Prediction intervals, cumulative meta-analysis, leave-one-out analyses, and GRADE assessment were performed.

RESULTS

Six studies, one randomized trial and five observational studies, enrolled 675 patients (CSP, n = 344; RVP, n = 331). CSP was associated with fewer heart-failure hospitalizations (RR 0.49, 95% CI 0.29-0.83; p = 0.017; I2 = 5%) and shorter paced QRS duration (MD -31.05 ms, 95% CI -34.07 to -28.02; p < 0.001; I2 = 0%). All-cause mortality, cardiovascular death, and change in left ventricular ejection fraction did not differ significantly. Implantation success was modestly lower with CSP (RR 0.91; p = 0.014).

CONCLUSION

CSP was associated with fewer heart-failure hospitalizations and shorter paced QRS duration than RVP after TAVR. Evidence was predominantly observational, and no significant differences were demonstrated in mortality or change in left ventricular ejection fraction. The potential clinical relevance of CSP when a high ventricular pacing burden is anticipated remains plausible but was not directly demonstrated by the available data; adequately powered randomized trials are required before routine adoption.