Decoding the evidence emerging from the studies comparing conduction system pacing with conventional cardiac resynchronization therapy

Q: What is the clinical evidence from this study?

Study design: Editorial. Population: Heart failure with reduced ejection fraction (HFrEF) and electrical dyssynchrony. Intervention: Conduction system pacing (CSP) vs. Biventricular pacing (BiVP). Primary outcome: Composite of heart failure hospitalization (HFH) or all-cause mortality (from Karakasis meta-analysis) (OR 0.51, 95% CI 0.28-0.93).

Jacopo Francesco Imberti; Davide Antonio Mei; Giuseppe Boriani

doi:10.1093/europace/euag186

July 17, 2026EP EuropaceOpen Access

Decoding the evidence emerging from the studies comparing conduction system pacing with conventional cardiac resynchronization therapy

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Key result

Conduction system pacing may reduce HFH or mortality ~49% vs BiV pacing, but evidence remains inconclusive.

OR 0.51
95% CI 0.28-0.93

Key Points

Synthesize and contextualize findings from two contemporary meta-analyses comparing conduction system pacing with conventional biventricular pacing for cardiac resynchronization therapy in heart failure.
Evaluated data from a meta-analysis pooling 13 randomized controlled trials including 1320 patients.
Evaluated data from a meta-analysis pooling 11 randomized controlled trials (1201 patients) and 14 observational studies (totaling 4577 patients).
In the trial-only meta-analysis by Karakasis et al., conduction system pacing reduced the composite endpoint of heart failure hospitalization or all-cause mortality compared with biventricular pacing (OR: 0.51; 95% CI 0.28–0.93), but not heart failure hospitalization (OR: 0.68; 95% CI 0.36–1.27) or mortality alone (OR: 0.75; 95% CI 0.36–1.58).
In Chauhan et al., trial analysis showed no significant differences for all-cause mortality (RR: 0.96; 95% CI 0.45–2.04), heart failure hospitalization (RR: 0.67; 95% CI 0.40–1.11), or procedural complications (RR: 0.83; 95% CI 0.51–1.34), whereas observational data showed reductions in mortality (RR: 0.74; 95% CI 0.61–0.91) and hospitalization (RR: 0.64; 95% CI 0.53–0.77).
Across both meta-analyses, conduction system pacing consistently achieved greater QRS narrowing and functional capacity improvements without compromising procedural safety.

PICO

P

Population

Editorial discussing two meta-analyses of trials and observational studies evaluating conduction system pacing versus biventricular pacing in patients with heart failure with reduced ejection fraction.

I

Intervention / Comparator

Conduction system pacing (CSP) vs Biventricular pacing (BiVP)

O

Primary Outcome

Composite of heart failure hospitalization (HFH) or all-cause mortality (from Karakasis meta-analysis) — OR 0.51 (0.28-0.93)

Main Result

Odds Ratio: 0.51 (95% CI 0.28–0.93)

Limitations

Most underlying studies remain relatively small with low event rates
Follow-up duration varies considerably across trials
Clinical heterogeneity due to differences in patient selection, CSP modality, operator experience, and endpoint definitions
Observational studies included in the meta-analyses are susceptible to residual confounding by indication

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Implication

Cautions against routine adoption of conduction system pacing; leaves open superiority pending larger definitive RCTs.

Abstract

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Cite This Study

Imberti et al. (2026) conducted an editorial in Heart failure with reduced ejection fraction (HFrEF) and electrical dyssynchrony. Conduction system pacing (CSP) vs. Biventricular pacing (BiVP) was evaluated on Composite of heart failure hospitalization (HFH) or all-cause mortality (from Karakasis meta-analysis) (OR 0.51, 95% CI 0.28-0.93). Conduction system pacing may reduce heart failure hospitalization or mortality compared to biventricular pacing (OR 0.51), but current evidence remains insufficient to establish clinical superiority.

synapsesocial.com/papers/6ad115e700741cc3fba7db59 https://doi.org/10.1093/europace/euag186

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Decoding the evidence emerging from the studies comparing conduction system pacing with conventional cardiac resynchronization therapy

Key Points

PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Decoding the evidence emerging from the studies comparing conduction system pacing with conventional cardiac resynchronization therapy

Key Points

PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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