Conduction system pacing is superior to reduce the new-onset atrial fibrillation risk compared with right ventricular pacing: insights from pooled clinical evidence

Background Conduction system pacing (CSP) has been reported to improve clinical outcomes in comparison of right ventricular pacing (RVP). However, the performance between CSP and RVP on the risk of new-onset atrial fibrillation (AF) remains elusive. Methods Four online databases were systematically searched up to December 1 st 2023. Studies comprising the rate/risk of new-onset AF between CSP and RVP group were included. Subgroup analysis was performed to screen the potential determinants for the new-onset AF risk for CSP therapy. Moreover, the pooled risk of new-onset AF based on ventricular pacing burden (Vp) between CSP and RVP group were evaluated. Results A total of five studies including 1,491 patients requiring pacing therapy were eligible. The pooled new-onset AF rates for CSP and RVP group were 0.09 and 0.26, respectively. Compared with RVP group, CSP group showed a lower pooled risk (risk ratio [RR] 0.38, P =0.000) and adjusted risk (hazard ratio [HR] 0.33, P =0.000) of new-onset AF. Meanwhile, a significant intervention-covariate interaction for the adjusted risk of new-onset AF between CSP and RVP group was identified with Vp < 20% and Vp ≥ 20%. Conclusions Our study suggests that CSP is superior to reduce the new-onset atrial fibrillation risk compared with RVP. The Vp ≥ 20% may be the key determinant on the lower risk of new-onset AF with CSP therapy.