Conduction System Pacing for Resynchronization Therapy in Heart Failure: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND

Conduction system pacing (CSP) has emerged as a promising modality for cardiac resynchronization therapy, but evidence of CSP in heart failure (HF) remains controversial.

OBJECTIVES

The authors aimed to compare the efficacy and safety of CSP, including left bundle branch area pacing (LBBAP) and His bundle pacing, to biventricular pacing (BiVP) in HF.

METHODS

The MEDLINE, EMBASE, and CENTRAL databases were searched from inception until May 2026. The primary endpoint was a composite of hospitalization for heart failure (HHF) and all-cause mortality. Secondary endpoints included clinical endpoints (HHF, all-cause mortality), cardiac resynchronization therapy responses (predefined and super-response), echocardiographic parameters (left ventricular ejection fraction and left ventricular end-systolic volume), electrophysiologic parameters (paced QRS duration and capture threshold), functional status (NYHA functional class and 6-minute walk test distance), procedural performance (procedural time, fluoroscopy time, lead implantation time), and device-related complications. (PROSPERO registration: CRD420261388077).

RESULTS

Twelve randomized controlled trials involving 1,054 patients (566 CSP and 488 BiVP) were included. CSP showed a significant reduction in primary composite endpoint (OR: 0.30; 95% CI: 0.18-0.52; I2 = 0%), improvement in left ventricular ejection fraction (mean difference: 3.06%; 95% CI: 0.82%-5.30%; I2 = 55%), and shorter paced QRS duration (mean difference:-11.49 ms; 95% CI: -20.70 to -2.28; I2 = 85%), compared with BiVP. In the LBBAP group, there were greater reductions in primary composite endpoint with higher rates of super-response (OR: 2.18; 95% CI: 1.44-3.30; I2 = 54%) compared with BiVP. No differences were observed in functional status or device-related complications.

CONCLUSIONS

CSP, and potentially LBBAP, was associated with a significantly lower composite endpoint of HHF and all-cause mortality compared with BiVP, supporting CSP as an alternative to BiVP in HF.