Conduction System Pacing vs. Biventricular Pacing for Cardiac Resynchronization Therapy: An Updated Systematic Review and Meta‑Analysis
Abstract
Abstract Background Conduction system pacing (CSP) has emerged as a potential alternative to biventricular pacing (BiVP) for cardiac resynchronization therapy (CRT). However, the relative efficacy and safety of different CSP techniques remain unclear. Methods We searched PubMed, Embase, Cochrane Library, and Web of Science for randomized controlled trials (RCTs) comparing CSP with BiVP. Primary outcome: composite of all‑cause death or heart failure hospitalization. Secondary outcomes: change in left ventricular ejection fraction (LVEF), change in left ventricular end‑systolic volume (LVESV), echocardiographic response (structural: LVESV reduction ≥ 15%; functional: LVEF increase ≥ 5%), QRS duration shortening, NYHA functional class improvement, and complication rate. Random‑effects meta‑analysis was used, with four pre‑specified subgroups: CSP with optimization, strict left bundle branch pacing (LBBP), His‑CRT, and left ventricular septal pacing (LVSP)‑dominant. Results Ten independent RCTs (Vinther 2021/Frandsen 2026 counted as one trial) were included, CSP significantly reduced the risk of all‑cause death or heart failure hospitalization (risk ratio RR 0.47, 95% CI 0.32–0.69, P P = 0.35), Overall LVEF change did not differ (MD 2.03%, 95% CI − 0.34% to 4.39%, P = 0.09, I² = 80%), but subgroup differences were significant ( P = 0.03): strict LBBP (MD 5.55%) and His‑CRT (MD 3.12%) favored CSP. Overall LVESV change showed a non‑significant trend (MD − 6.97 mL, 95% CI − 14.30…
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