Conduction system pacing as a primary strategy for cardiac resynchronization therapy in reduced ejection fraction: An updated systematic review and meta-analysis of randomized controlled trialswe
In brief
Conduction system pacing boosts echo response by ~70% versus biventricular pacing
A meta-analysis of 12 randomized trials (1,223 patients) found that primary-strategy conduction system pacing increased the odds of a favorable echocardiographic response by about 70% compared with standard biventricular CRT, and also modestly improved NYHA class and 6-minute walk distance (≈22 m). Trends toward lower mortality and composite events did not reach significance, so larger trials are still needed.
- Journal
- Progress in cardiovascular diseases (Q1)
- Published
- 13 August 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Shunsuke Kuroda, Yui Okamura, Iwanari Kawamura, Tadao Aikawa, Alexandros Briasoulis, Toshiki Kuno
- PMID
- 42595285
- DOI
- 10.1016/j.pcad.2026.08.004
Why clinicians should know about it
- Picked for Cardiology and Cardiovascular Medicine (paper of the day, 18 August 2026): CSP improves CRT response versus biventricular pacing in RCTs
- Picked for Epidemiology (top studies of the week, 16 August 2026).
Abstract
BACKGROUND: Biventricular pacing (BVP) is the standard for cardiac resynchronization therapy (CRT), particularly in left bundle branch block (LBBB). However, conduction system pacing (CSP) may offer superior outcomes as a physiological alternative. We evaluated the clinical efficacy of CSP compared with BVP as a primary strategy for patients with heart failure indicated for CRT. METHODS: A systematic review and meta-analysis was conducted using MEDLINE and the Cochrane Library databases. We included randomized controlled trials (RCTs) comparing CSP with BVP in patients with heart failure and a left ventricular ejection fraction below 50%. Pooled estimates were determined using a random-effects model for all outcomes. RESULTS: Twelve RCTs involving 1223 patients were included. CSP significantly improved the echocardiographic response compared with BVP in the overall cohort (odds ratio [OR]: 1.73; 95% confidence interval [CI]: 1.19-2.52) and the LBBB subgroup (OR: 1.74; 95% CI: 1.15-2.62). CSP revealed significant improvements in NYHA functional class (standardized mean difference: -0.27; 95% CI: -0.46 to -0.08) and 6-min walk distance (mean difference: 21.6 m; 95% CI: 8.07 to 35.14). While composite endpoints (OR: 0.59; 95% CI: 0.33 to 1.08) and mortality (OR: 0.90; 95% CI: 0.39 to 2.11) showed trends favoring CSP, neither reached statistical significance. There was no significant difference in procedural crossovers between the groups (OR: 1.24; 95% CI: 0.54 to 2.87). CONCLUSION: Compared with BVP, CSP improved echocardiographic and functional response in patients requiring CRT. CSP as a primary strategy may be considered in selected patients, but large RCTs with hard clinical endpoints are needed.
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.