Conduction system pacing improves LVEF and reduces HF hospitalization vs biventricular pacing in heart failureConduction system pacing shows promise for heart failure patients

Frontiers in Medicine Published June 5, 2026 DOI ↗ Editorial oversight: Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease

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Key Takeaway

Consider CSP as a promising alternative to BVP in HF, but interpret results cautiously due to low certainty evidence.

This systematic review and meta-analysis compared conduction system pacing (CSP) with biventricular pacing (BVP) in adult heart failure patients with LVEF ≤ 50%, including 7,019 patients from multiple studies. The primary outcomes were changes in LVEF, NYHA class, QRS duration, HF hospitalization, and all-cause mortality.

CSP was associated with a greater improvement in LVEF (mean difference 4.22%, 95%CI 2.74% to 5.70%), NYHA class (MD -0.34, 95%CI -0.47 to -0.21), and QRS narrowing (MD -19.60 ms, 95%CI -24.18 to -15.02 ms). HF hospitalization risk was reduced with CSP (RR 0.65, 95%CI 0.49 to 0.87), while all-cause mortality was comparable (RR 0.87, 95%CI 0.62 to 1.22). Echocardiographic non-response was lower (RR 0.58, 95%CI 0.41 to 0.82) and super-response higher (RR 1.86, 95%CI 1.43 to 2.43) with CSP. Fluoroscopy time was shorter with CSP (MD -5.04 min, 95%CI -8.62 to -1.45 min). Complication rates were similar between groups.

Limitations include low to very low certainty of evidence and publication bias detected for LVEF; a trim-and-fill analysis confirmed directional benefit (adjusted MD 2.14%). The authors note that findings are hypothesis-generating and highlight the urgent need for large-scale, adequately powered RCTs before widespread adoption of CSP in routine practice.

This systematic review and meta-analysis looked at data from 7,019 adult patients with heart failure and a reduced pumping function. The researchers compared conduction system pacing with biventricular pacing to see which approach worked better.

The analysis found that conduction system pacing led to greater improvements in heart pumping strength and symptoms. Patients also experienced shorter electrical signals in the heart and a lower risk of needing hospitalization for heart failure. The procedure also took less time during the initial setup.

However, the risk of death from any cause was similar for both groups. The researchers noted that the overall certainty of this evidence is low to very low. They also detected some publication bias in the data regarding heart pumping strength. Because of these limitations, the findings should be viewed as hypothesis-generating. Large-scale clinical trials are urgently needed to confirm these benefits before conduction system pacing becomes a standard treatment option.

What this means for you:

Evidence is low certainty; large trials needed before widespread adoption.

Study Details

Study typeMeta analysis

EvidenceLevel 1

PublishedJun 2026

View Original Abstract ↓

BackgroundConduction system pacing (CSP) has emerged as a physiological alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT) in patients with heart failure (HF) with reduced ejection fraction (HFrEF). This systematic review and meta-analysis aimed to comprehensively compare the clinical efficacy and safety of these two strategies using the most up-to-date evidence.MethodsPubMed, Embase, Web of Science, and Cochrane Library were systematically searched up to March 2026 for randomized controlled trials (RCTs) and observational studies comparing CSP with BVP in adult HF patients (LVEF ≤ 50%). Primary outcomes included changes in LVEF, NYHA class, QRS duration, HF hospitalization (HFH), and all-cause mortality (ACM). Secondary outcomes included echocardiographic response, procedural parameters, and complications. Random-effects models were used. Heterogeneity was assessed using the I2 statistic. Publication bias was assessed using funnel plots, Egger's test, and trim-and-fill analysis. Certainty of evidence was appraised using the GRADE framework.Results35 studies (10 RCTs, 25 observational; N = 7,019) were included. Compared with BVP, CSP was associated with greater improvement in LVEF (MD: 4.22%, 95%CI: 2.74%–5.70%; I2 = 72%), NYHA class (MD: −0.34, 95%CI: −0.47 to −0.21; I2 = 30%), and QRS narrowing (MD: −19.60 ms, 95%CI: −24.18 to −15.02 ms; I2 = 83%). CSP significantly reduced HFH risk (RR: 0.65, 95%CI: 0.49–0.87; I2 = 50%) and echocardiographic non-response (RR: 0.58, 95%CI: 0.41–0.82; I2 = 70%), while increasing super-response (RR: 1.86, 95%CI: 1.43–2.43; I2 = 34%). ACM was comparable between groups (RR: 0.87, 95%CI: 0.62–1.22). CSP was associated with shorter fluoroscopy time (MD: −5.04 min, 95%CI: −8.62 to −1.45 min), with similar complication rates. Benefits were most pronounced in patients with classical CRT indications (LVEF ≤ 35% with LBBB) and confirmed conduction system capture. Publication bias was detected for LVEF; trim-and-fill analysis confirmed directional benefit (adjusted MD: 2.14%). GRADE assessment demonstrated low to very low certainty of evidence.ConclusionCSP may be associated with superior echocardiographic and electrocardiographic outcomes compared with BVP, but the overall certainty of the evidence remains low to very low. These findings should be considered hypothesis-generating and highlight the urgent need for large-scale, adequately powered RCTs to validate the potential benefits of CSP before its widespread adoption in routine clinical practice.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420251074973, identifier CRD420251074973.

Conduction system pacing improves LVEF and reduces HF hospitalization vs biventricular pacing in heart failureConduction system pacing shows promise for heart failure patients

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