Conduction system pacing reduces heart failure hospitalization and cardiomyopathy risk compared to right ventricular pacingConduction system pacing may lower heart failure hospital risks

BACKGROUND: Evidence, largely observational, has been mixed on whether conduction system pacing (CSP) improves outcomes over conventional right ventricular pacing (RVP). This meta-analysis compared the efficacy and safety of CSP vs RVP in randomised controlled trials (RCTs) of patients with preserved or mildly reduced left ventricular ejection fraction (LVEF) who require permanent pacing. METHODS: We analysed RCTs comparing different CSP modalities with RVP. Databases were searched through February 24, 2026. Outcomes were pooled using random-effects models for risk ratios (RRs) and mean differences (MDs). RESULTS: Fifteen RCTs (n = 1466; mean baseline left ventricular ejection fraction (LVEF) = 59.4 ± 7.0%) showed lower pacing-induced cardiomyopathy (PICM) with CSP vs RVP (4.6% vs 16.2%; RR 0.34, 95% CI 0.19-0.60) and lower heart failure hospitalisation (HFH) (3.3% vs 9.1%; RR 0.34, 95% CI 0.17-0.70), with no difference in all-cause mortality. CSP shortened paced QRS duration (MD -30.10 ms, 95% CI -35.46 to -24.74 ms) and improved LVEF (MD +2.96%, 95% CI 1.18%-4.73%), but had lower pacing success (93.6% vs 99.5%; RR 0.95, 95% CI 0.91-0.99) and worse procedural metrics (procedure time MD +32.44 min, 95% CI 21.22-43.67 min; fluoroscopy time MD +5.27 min, 95% CI 3.89-6.65 min; radiation dose MD +24.91 mGy, 95% CI 10.27-39.55 mGy). CONCLUSIONS: In RCTs of predominantly preserved or mildly reduced LVEF requiring permanent pacing, CSP reduced PICM and HFH and preserved left ventricular function more effectively than RVP, but with longer procedural and fluoroscopy times. CSP is a reasonable preventive strategy when substantial ventricular pacing is anticipated in this population.