Comparative effects of biventricular and right ventricular pacing on clinical outcomes in atrioventricular block: a systematic review and meta-analysis

Background Right ventricular (RV) pacing is the standard treatment for atrioventricular (AV) block but may impair left ventricular (LV) function over time. Biventricular (BiV) pacing offers a physiologic alternative, though prior evidence has been mixed, particularly after the BioPace trial. Methods PubMed, ScienceDirect, Google Scholar, and the Cochrane Library were searched through May 2025 for randomized controlled trials (RCTs) comparing BiV and RV pacing in AV block. Thirteen RCTs ( n = 3,685) met the inclusion criteria. Outcomes included heart failure (HF) hospitalization, all-cause mortality, six-minute walk distance (6MWD), cardiovascular (CV) death, and LVEF (%) at follow-up. Results BiV pacing significantly reduced HF hospitalizations (risk ratio [RR] = 0.83, 95% CI 0.69–0.98; p = 0.03) and better preserved LVEF (mean difference = 6.17%, 95% CI 3.85–8.49; p < 0.00001). No significant differences were observed in all-cause mortality (RR = 0.87, 95% CI 0.70–1.08; p = 0.21) or CV death (RR = 0.95, 95% CI 0.75–1.21; p = 0.70). RV pacing showed a borderline improvement in 6MWD (mean difference = 10.3 m, 95% CI − 0.1 to 20.7; p = 0.05). Conclusion In patients with AV block and high pacing burden, BiV pacing reduced HF hospitalizations and better preserved systolic function compared with RV pacing. These findings support a burden-based pacing strategy, while CRT use should be individualized, considering patient profile and procedural factors. Systematic review registration This systematic review and meta-analysis was retrospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) under ID 1080380. Clinical trial number Not applicable.