Conduction system pacing vs right-ventricular pacing: real-world comparative outcomes in a propensity-matched cohort

Abstract Background Conduction system pacing (CSP)—including His bundle pacing (HBP) and left bundle branch area pacing (LBBAP)—has rapidly emerged as a physiologic alternative to right-ventricular pacing (RVP). Whether these benefits translate into superior real-world outcomes remains an important clinical question. This study compares CSP and RVP in a contemporary, routine-practice single-centre cohort. Purpose To evaluate electrical performance, ventricular synchrony, procedural metrics, and safety of CSP versus RVP, using propensity score matching (PSM) to minimize baseline imbalance. Methods We retrospectively analysed consecutive CSP and RVP implants performed at Città della Salute e della Scienza di Torino between January 2022 and May 2025. CSP included HBP and predominantly LBBAP. Data were collected at implant and at 6- and 12-month follow-up. Outcomes included pacing thresholds, sensing, QRS duration, procedural and fluoroscopy times, radiation exposure, and acute/long-term complications. PSM (1:1) generated comparable CSP and RVP cohorts. Results Nearly 100 CSP implants and 172 RVP implants were performed. CSP showed electrophysiological markers consistent with effective physiologic capture. Pacing thresholds and sensing values remained stable and were comparable to RVP throughout follow-up (all p0.05). CSP produced significantly narrower QRS complexes than RVP (median 110 ms vs 130 ms, p0.01), confirming superior ventricular activation. After PSM (75 CSP vs 75 RVP), CSP procedures required longer procedure and fluoroscopy times, but radiation exposure was not higher. Both strategies demonstrated low and similar complication rates, with CSP-specific events being rare and without long-term impact on lead performance (see table 1). Conclusions In routine clinical practice, CSP—driven mainly by LBBAP—proved feasible, safe, and electrophysiologically superior to RVP, offering more physiologic ventricular activation without compromising stability or increasing radiation exposure. Despite slightly longer procedural durations, CSP represents a robust and effective pacing strategy for patients requiring ventricular pacing and may further evolve as a preferred approach in modern bradycardia management.Table 1