Conduction system pacing vs biventricular pacing in heart failure patients undergoing cardiac resynchronization therapy: an updated grade-assessed systematic review and meta-analysis of randomized controlled trials

This systematic review and meta-analysis compared conduction system pacing (CSP) with biventricular pacing (BVP) for cardiac resynchronization therapy in heart failure. PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and ScienceDirect were searched from inception through 16 May 2026 for randomized trials. Random-effects Mean Difference/Odds Ratio and Peto pooling were performed with Cochrane Risk of Bias 2 and grade assessment and Twelve trials (1,152 patients) were included. CSP shortened QRS duration (mean difference [MD] -10.03 ms, 95% confidence interval [CI] -15.95 to -4.12) and increased absolute left ventricular ejection fraction at 6 months (MD 3.67% points, 95% CI 1.38–5.95). Six-month change was not significantly different (MD 2.07% points, 95% CI -0.66 to 4.80); 12-month improvement favored BVP (MD -3.28% points, 95% CI -5.00 to -1.55). Mortality (risk ratio 0.69, 95% CI 0.33–1.48), heart failure hospitalization (Peto odds ratio 1.05, 95% CI 0.47–2.33), and pneumothorax (Peto odds ratio 1.94, 95% CI 0.20–18.71) did not differ significantly. CSP showed physiological benefits without established clinical superiority. Heterogeneity, small trials, and limited follow-up restrict interpretation. International Prospective Register of Systematic Reviews (PROSPERO), CRD420261413053. Registry: https://www.crd.york.ac.uk/prospero/