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

Why clinicians should know about it

• Picked for Cardiology and Cardiovascular Medicine (paper of the day, 23 October 2026): Compares conduction-system pacing with biventricular pacing in heart failure

Abstract

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.

Abstract as published, via PubMed.