Conduction system vs. biventricular pacing in heart failure with reduced ejection fraction: a meta-analysis of randomized controlled trials
In brief
Conduction system pacing halves combined heart-failure hospitalization or death risk
In a meta-analysis of 13 randomized trials with 1,320 HFrEF patients, conduction system pacing reduced the combined endpoint of heart-failure hospitalization or all-cause death by about 50% compared with traditional biventricular pacing. It also modestly improved walking distance and functional class without increasing complications, though separate effects on hospitalization or mortality alone were not significant.
- Journal
- Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology (Q1)
- Published
- 4 August 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Paschalis Karakasis, Konstantinos Vlachos, Konstantinos C Siontis, Óscar Cano, Stylianos Tzeis, Marc Strik, et al.
- PMID
- 42586561
- DOI
- 10.1093/europace/euag170
Why clinicians should know about it
- Picked for Cardiology and Cardiovascular Medicine (top studies of the week, 16 August 2026): Meta‑analysis of RCTs comparing CSP vs BiVP
Abstract
AIMS: Conduction system pacing (CSP) has emerged as a physiologic alternative to cardiac resynchronization therapy (CRT) with biventricular pacing (BiVP) in heart failure with reduced ejection fraction (HFrEF), yet its comparative effects remain uncertain. This meta-analysis sought to compare outcomes of CSP vs. BiVP in patients with HFrEF undergoing CRT. METHODS AND RESULTS: MEDLINE, Embase, Scopus, and the Cochrane Database were searched through 4 May 2026. Randomized controlled trials (RCTs) were synthesized using random-effects meta-analysis. Thirteen RCTs including 1320 participants were analysed (657 CSP, 663 BiVP). Conduction system pacing was associated with a lower risk of the composite of hospitalization for heart failure (HHF) or all-cause mortality compared with BiVP (46 vs. 83 events; odds ratio [OR] 0.51, 95% confidence interval [CI] 0.28-0.93). No significant differences were observed for HHF alone (OR 0.68, 95% CI 0.36-1.27) or all-cause mortality (OR 0.75, 95% CI 0.36-1.58). Conduction system pacing was associated with greater improvement in the 6-min walk distance (mean difference [MD] 21.53 m, 95% CI 4.33-38.73) and New York Heart Association functional class (standardized mean difference [SMD] -0.27, 95% CI -0.47 to -0.07), but not quality of life. Conduction system pacing also reduced QRS duration compared with BiVP (MD -10.94 ms, 95% CI -17.55 to -4.34), with no significant differences in left ventricular ejection fraction, left ventricular end-systolic volume, overall pacing threshold, total procedure time, fluoroscopy time, any complication, or reintervention. CONCLUSION: In patients with HFrEF undergoing CRT, CSP is associated with lower composite risk of HHF or all-cause mortality compared with BiVP. Conduction system pacing is also associated with improved functional capacity, without significant differences in safety or procedural outcomes.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.