Bachmann Bundle Pacing Is a Promising Modality for Lowering Incident Atrial Fibrillation: A Network Meta-Analysis

Background Bachmann bundle pacing (BBp) provides physiologic atrial activation by delivering electrical conduction through native interatrial conduction system. However, whether BBp reduces atrial fibrillation (AF) incidence compared with interatrial septum pacing (IASp) and right atrial appendage pacing (RAAp) remains unclear. Objective To compare efficacy and safety outcomes between BBp, IASp, and RAAp. Methods A systematic search of PubMed, Scopus, and Cochrane Library was conducted from inception to December 2025. Primary endpoints were any AF incidence, de novo AF incidence, and AF burden (minutes/day). Any AF incidence included all AF diagnoses regardless of prior AF history, whereas de novo AF was restricted to patients without pre-existing AF. Secondary endpoints included paced P-wave duration (PWD), atrial pacing percentage, procedural time, and atrial lead-related complications. Results Nineteen studies comprising 2,843 patients (mean age 71.8±9.3 years) were included. BBp was associated with significantly lower any AF incidence compared with both IASp (HR0.41, 95%CI 0.29–0.57; p<0.001) and RAAp (HR0.30, 95%CI 0.21–0.41; p<0.001), yielding the highest P-score (1.000). Similarly, BBp reduced de novo AF incidence relative to IASp (OR0.27, 95%CI 0.09–0.85; p=0.025) and RAAp (OR0.21, 95%CI 0.07–0.59; p=0.003), with the highest P-score (0.993). IASp had the highest P-score for reducing AF burden (0.998). Paced PWD was shortest in BBp (P-score = 0.935). No significant differences were observed for atrial pacing percentage, procedural time, or atrial lead-related complications. Conclusion BBp significantly decreases AF incidence compared with IASp and RAAp, supporting its use as a first-line atrial pacing strategy irrespective of pre-existing AF status.