Conduction system pacing versus biventricular pacing in heart failure with reduced ejection fraction: A systematic review and meta-analysis of randomized controlled trials

Conduction system pacing (CSP) has emerged as a promising alternative to biventricular pacing (BVP) in patients with heart failure with reduced ejection fraction (HFrEF) and ventricular dyssynchrony, but its benefits are uncertain. In this study, we aimed to evaluate clinical outcomes of CSP vs BVP for cardiac resynchronization in patients with HFrEF. PubMed, Scopus, and Cochrane databases were searched for randomized controlled trials comparing CSP to BVP for resynchronization therapy in patients with HFrEF. Heterogeneity was examined with I² statistics. A random-effects model was used for all outcomes. We included 7 randomized controlled trials with 408 patients, of whom 200 (49%) underwent CSP. Compared to BVP, CSP resulted in a significantly greater reduction in QRS duration (MD -13.34 ms; 95% confidence interval [CI] -24.32 to -2.36, P = .02; I² = 91%) and New York Heart Association functional class (standardized mean difference [SMD] -0.37; 95% CI -0.69 to -0.05; P = .02; I² = 41%), and a significant increase in left ventricular ejection fraction (mean difference [MD] 2.06%; 95% CI 0.16 to 3.97; P = .03; I² = 0%). No statistical difference was noted for left ventricular end-systolic volume (SMD -0.51 mL; 95% CI -1.26 to 0.24; P = .18; I² = 83%), lead capture threshold (MD -0.08 V; 95% CI -0.42 to 0.27; P = .66; I² = 66%), and procedure time (MD 5.99 minutes; 95% CI -15.91 to 27.89; P = .59; I² = 79%). These findings suggest that CSP may have electrocardiographic, echocardiographic, and symptomatic benefits over BVP for patients with HFrEF requiring cardiac resynchronization.