Key result
Conduction system pacing showed no significant difference compared with biventricular pacing for the composite of all-cause death or heart failure hospitalization (RR 0.70), though strict left bundle branch pacing significantly reduced the composite endpoint in subgroup analysis.
Why the study?
The relative efficacy and safety of different conduction system pacing techniques compared with biventricular pacing for cardiac resynchronization therapy remain unclear.
Does conduction system pacing reduce the composite of all-cause death or heart failure hospitalization compared to biventricular pacing in patients with heart failure and an indication for CRT?
Meta-Analysis (n=976)
Does conduction system pacing reduce the composite of all-cause death or heart failure hospitalization compared to biventricular pacing in patients with heart failure and an indication for CRT?
Relative Risk: 0.7 (95% CI 0.36–1.36)
p-value: p=0.29
While conduction system pacing overall did not significantly reduce hard clinical endpoints compared to biventricular pacing, strict left bundle branch pacing demonstrated significant benefits in reverse remodeling and clinical outcomes, highlighting the need for technique-specific approaches.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“In carefully selected patients with truly correctable LBB block, treated by highly experienced operators achieving reliable left bundle branch capture, CSP may offer superior resynchronization and clinical outcomes compared with BiVP”
“In selected patients, conduction system pacing may turn out to be the better approach in experienced hands, but that likely will be in a minority of CRT candidates, and we need more trials to be sure”
“a substantial proportion of patients had LBB block-induced cardiomyopathy, in which ventricular dysfunction is driven primarily by electrical dyssynchrony rather than irreversible myocardial injury”
Conduction system pacing is not superior to biventricular pacing for death or HF hospitalization in CRT; leaves open benefit with strict left bundle branch pacing for targeted trials.
Conduction system pacing (CSP) has emerged as a potential alternative to biventricular pacing (BiVP) for cardiac resynchronization therapy (CRT). However, the relative efficacy and safety of different CSP techniques remain unclear. We searched PubMed, Embase, Cochrane Library, and Web of Science for randomized controlled trials (RCTs) comparing CSP with BiVP. The primary outcome was the composite of all-cause death or heart failure hospitalization. Secondary outcomes included changes in left ventricular ejection fraction (LVEF) and left ventricular end-systolic volume (LVESV), echocardiographic response, QRS duration shortening, NYHA functional class improvement, and complication rate. Random-effects meta-analysis was used, with four pre-specified subgroups: CSP with optimization, strict left bundle branch pacing (LBBP), His-CRT, and left ventricular septal pacing (LVSP)-dominant. Nine RCTs (976 patients) were included. CSP showed no significant difference compared with BiVP for all-cause death or heart failure hospitalization (RR 0.70, 95% CI 0.36–1.36, P = 0.29, I 2 = 66%). Benefits varied by technique: strict LBBP provided the most consistent reverse remodeling (LVEF + 5.55%; LVESV − 23.98 mL) and hard-endpoint benefit (RR 0.29); His-CRT showed a similar but imprecise estimate derived from a single study; LVSP-dominant strategies showed no superiority. CSP also significantly improved NYHA class (MD − 0.20, P = 0.004) and shortened QRS duration (MD − 9.77 ms, P = 0.005), with no overall difference in complication rates. CSP showed no significant difference for all-cause death or heart failure hospitalization compared with BiVP, but significantly improved NYHA class and QRS duration. Subgroup analysis revealed marked heterogeneity: strict LBBP significantly reduced the composite endpoint and showed the most consistent LVEF and LVESV benefits; His-CRT showed a similar but imprecise estimate derived from a single study; LVSP-dominant strategies showed no superiority. These subgroup findings should be considered hypothesis‑generating. These findings support an individualized, technique-specific approach to CSP for CRT, but further direct comparative trials of LBBP versus other CSP techniques are needed to define its optimal role.
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yang et al. (2026) conducted a meta-analysis in Heart failure requiring cardiac resynchronization therapy (n=976). Conduction system pacing (CSP) vs. Biventricular pacing (BiVP) was evaluated on Composite of all-cause death or heart failure hospitalization (RR 0.70, 95% CI 0.36-1.36, p=0.29). Conduction system pacing showed no significant difference compared with biventricular pacing for the composite of all-cause death or heart failure hospitalization (RR 0.70), though strict left bundle branch pacing significantly reduced the composite endpoint in subgroup analysis.
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