July 1, 2026The American Journal of Cardiology0 citationsOpen Access
View Full PaperConduction System Pacing Versus Right Ventricular Pacing in Patients with Atrioventricular Block and Anticipated High Pacing Burden
Key Result
Conduction system pacing significantly reduced pacing-induced cardiomyopathy (HR 0.30; 95% CI 0.18-0.48; p<0.001) and preserved LVEF compared with right ventricular pacing in patients with AV block.
Study Design
Type
Meta-Analysis (n=806)
Multicenter
Yes
Structured PICO
Does conduction system pacing reduce pacing-induced cardiomyopathy and preserve LVEF compared to right ventricular pacing in patients with AV block and anticipated high pacing burden?
P
Population
806 patients with AV block or anticipated high ventricular pacing burden from 5 randomized controlled trials with a minimum 6-month follow-up.
I
Intervention
Conduction system pacing (CSP)
C
Comparator
Right ventricular pacing (RVP)
O
Outcome
Co-primary outcomes of pacing-induced cardiomyopathy (PICM) incidence and change in left ventricular ejection fraction (ΔLVEF)surrogate
Conduction system pacing substantially reduces pacing-induced cardiomyopathy, preserves LVEF, and reduces heart failure hospitalizations compared with right ventricular pacing in patients with AV block.
Main Result
Hazard Ratio: 0.3 (95% CI 0.18–0.48)
p-value: p=<0.001
Abstract
Right ventricular pacing (RVP) in patients with atrioventricular (AV) block and high anticipated pacing burden is associated with pacing-induced cardiomyopathy (PICM) in approximately 12% to 20% of patients, whereas conduction system pacing (CSP) preserves more physiologic ventricular activation and may mitigate these consequences; the totality of contemporary randomized evidence has not been systematically pooled. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing CSP with RVP in patients with AV block or anticipated high ventricular pacing burden and a minimum 6-month follow-up, with co-primary outcomes of PICM incidence and change in left ventricular ejection fraction (ΔLVEF) and secondary outcomes of heart failure hospitalization (HFH), all-cause mortality, composite clinical endpoint, and paced QRS duration (PROSPERO CRD420261400227); random-effects meta-analysis used DerSimonian-Laird estimation. Five RCTs (LBBP-FAVOUR, CSPACE, Prague CSP, PACE-HF, STAY; N=806) met inclusion criteria. CSP significantly reduced PICM (hazard ratio HR 0.30, 95% confidence interval CI 0.18-0.48; p<0.001; I²=0%; k=4), was associated with greater LVEF preservation (pooled mean difference MD +4.41%, 95% CI +1.82 to +6.99; p=0.001; I²=87%; k=5), and reduced HFH (HR 0.24, 95% CI 0.12-0.48; p<0.001; I²=0%; k=5). CSP shortened paced QRS duration (MD -27.5 ms, 95% CI -32.6 to -22.5; p<0.001; k=5). All-cause mortality was numerically lower with CSP but did not reach significance (HR 0.57, 95% CI 0.29-1.12; p=0.10; k=4). In a prespecified sensitivity analysis restricting to multicenter trials with N≥150, all findings were concordant with the primary analysis. In conclusion, CSP substantially reduces PICM, preserves LVEF, and reduces HFH compared with RVP in patients with AV block and anticipated high pacing burden, supporting its consideration as the preferred pacing strategy in appropriately selected patients.