Conduction system pacing vs. biventricular pacing for cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis considering randomized controlled trials and observational studies
In brief
Conduction system pacing does not lower death or hospitalization versus biventricular pacing in randomized trials
In 11 randomized trials of 1,200 heart-failure patients, conduction system pacing achieved similar all-cause mortality and heart-failure admission rates to standard biventricular pacing, while producing a 20-millisecond reduction in paced QRS duration and a modest improvement in NYHA class. Larger, adequately powered studies are needed to determine whether these electrical and functional gains translate into real clinical benefit.
- 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
- Karanjeet Chauhan, Marwan Shawki, Thalys Sampaio Rodrigues, Han S Lim, Geoffrey R Wong, Nathaniel M Hawkins, et al.
- PMID
- 42586562
- DOI
- 10.1093/europace/euag169
Why clinicians should know about it
- Picked for Cardiology and Cardiovascular Medicine (top studies of the week, 16 August 2026): Systematic review/meta‑analysis of CRT modalities
Abstract
AIMS: Biventricular pacing (BiVP) is the gold standard for cardiac resynchronization therapy (CRT) in heart failure with reduced ejection fraction (HFrEF), yet up to 30% of patients fail to respond. Conduction system pacing (CSP) has emerged as an alternative with potential for physiological superiority. Multiple 2026 multicentre randomized controlled trials (RCTs) reported contradictory results, necessitating an updated meta-analysis. This analysis aims to compare the safety and efficacy of CSP vs. BiVP for CRT in patients with HFrEF. METHODS AND RESULTS: PubMed, Cochrane CENTRAL, and Embase were searched (January 2010-May 2026) for RCTs and observational studies. Pooled risk ratios (RRs) and mean differences (MDs) were estimated using random-effects restricted maximum likelihood models. Twenty-five studies (11 RCTs, n = 1201; 14 observational, n = 3376) involving 4577 participants were included. In the RCT-only analysis, no significant differences were found in all-cause mortality (RR 0.96; P = 0.91), heart failure (HF) hospitalization (RR 0.67; P = 0.12), or procedural complications (RR 0.83; P = 0.44). Conduction system pacing significantly shortened paced QRS duration (MD -19.52 ms, P < 0.001) and improved New York Heart Association (NYHA) class (MD -0.19, P = 0.05). Combined analysis showed larger effect sizes, including lower all-cause mortality (RR 0.74; P = 0.004) and HF hospitalization (RR 0.64; P < 0.001) in the CSP group. CONCLUSION: Randomized evidence demonstrates no significant difference between CSP and BiVP in hard clinical endpoints, despite superior electrical resynchronization and modest functional improvement with CSP. Confirmation of any clinical superiority of CSP awaits adequately powered trials reporting objective 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.