Real-world comparison of conduction system pacing and helix-based leadless pacemakers in single-chamber pacing: procedural outcomes from the PACEMAN study

Background Conduction system pacing (CSP) and leadless pacemakers (LPM) are emerging strategies for single-chamber ventricular pacing. Comparative data on procedural characteristics and acute electrical performance between these modalities remain limited. Objective To compare procedural metrics, acute pacing characteristics, safety outcomes, and learning curves between CSP and a novel helix-based LPM system in patients with preserved LVEF and a single-chamber pacing indication. Methods This multicenter observational study included 103 patients undergoing CSP (n = 35) or LPM (n = 68) implantation between 2022 and 2024 at two institutions. Results LPM implantation was associated with a shorter total procedure time (median 39 vs. 45 minutes, p = 0.048), but longer fluoroscopy time (7 vs. 4 minutes, p < 0.001). Electrophysiology laboratory occupancy and preparation times were comparable between groups. CSP yielded significantly narrower paced QRS durations (125 vs. 160 ms, p < 0.001) and smaller ΔQRS from baseline (5 vs. 40 ms, p = 0.009). Complication rates were low and comparable. Learning curve analysis showed progressive procedural time improvements with CSP over the first 15–20 cases, whereas LPM procedure times remained constant. Conclusions In patients with preserved LVEF and single chamber pacing indications, both CSP and LPM implantation are feasible and safe. CSP provides more physiological ventricular pacing, while LPM offers shorter and more reproducible procedures. These findings support individualized strategy selection based on clinical context and institutional expertise.