Conduction system pacing vs right ventricular pacing: a clinical meta-analysis of randomized controlled trials

Background Conventional right ventricular pacing (RVP) is associated with an increased risk of pacing-induced cardiomyopathy, heart failure (HF), and atrial fibrillation. While conduction system pacing (CSP) - comprising His-bundle and left bundle branch area pacing (LBBAP) - has emerged as a promising physiological alternative, clinical data from randomized controlled trials (RCTs) is limited. Purpose This meta-analysis aimed to compare the clinical safety and efficacy of CSP versus RVP in patients requiring permanent pacing. Methods A systematic search of PubMed, Embase, and Cochrane databases was conducted from inception to February 2026 to identify RCTs comparing CSP with RVP. The primary endpoint was HF hospitalization. Secondary outcomes included all-cause or cardiovascular mortality and new-onset atrial fibrillation. Risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model with the Hartung-Knapp-Sidik-Jonkman method. Results Seven RCTs were included, enrolling 540 CSP (78% LBBAP) and 533 RVP patients. 35.2% of the patients were female, with a pooled mean age of 56.6 ± 8.4 years and a pooled baseline left ventricular ejection fraction of 54.9%. Median follow-up was 15 (12 –19.5) months. CSP was associated with 29% lower risk in HF hospitalization at a pooled median of 18 months (RR 0.29; 95% CI: 0.20 – 0.41; I² = 0%), respectively 12 months (RR 0.29; 95% CI: 0.14 – 0.58; I² = 0%) (Figure 1), and lower events in all-cause mortality (RR 0.66; 95% CI: 0.47 – 0.93; I² = 0%) (Figure 2). There was a consistent trend favoring CSP in reducing cardiovascular mortality, with low heterogeneity. New-onset atrial fibrillation showed no significant difference between the two strategies (Figure 2). Conclusions In patients with severe conduction disturbances, CSP, especially LBBAP, was clinically significantly associated with a reduction in HF hospitalization and all-cause mortality. However, there was no difference in cardiovascular mortality or new-onset atrial fibrillation. Further RCTs with longer follow-up are needed to confirm differences in long-term mortality.Figure 1.Heart failure hospitalizationFigure 2.Clinical outcomes