Home›Cardiology› Conduction-system pacing shows no significant improvement over biventricular pacing in heart failure patients
Conduction-system pacing shows no significant improvement over biventricular pacing in heart failure patientsNew pacing methods show no major gains over standard treatment
Pacing and clinical electrophysiology : PACEPublished October 7, 2026Study authors: Abomohsen Mustafa, Rifai Mohamed, Mojahedi Azad, Bakr Hager Mohamed, Alkuwaiti Mohanad A, Elgendy Mo…PubMed ↗DOI ↗Editorial oversight: Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease
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Key Takeaway
Note that conduction-system pacing does not significantly improve LVEF or mortality compared to biventricular pacing.
This meta-analysis evaluated the efficacy and safety of conduction-system pacing (CSP) compared to biventricular pacing (BiVP) in 976 adults with heart failure with reduced ejection fraction (HFrEF) undergoing cardiac resynchronization therapy. The analysis focused on primary outcomes including changes in left ventricular ejection fraction (LVEF), heart-failure hospitalization, and all-cause mortality.
The meta-analysis found no statistically significant differences between CSP and BiVP for LVEF (MD, 1.90 percentage points; 95% CI, -1.05 to 4.86; p = 0.176), heart-failure hospitalization (RR, 0.83; 95% CI, 0.31 to 2.22; p = 0.660), or all-cause mortality (RR, 1.05; 95% CI, 0.40 to 2.70; p = 0.900). A modest improvement in NYHA functional class was observed with CSP (MD, -0.17; 95% CI, -0.34 to -0.00; p = 0.049). Other metrics, including QRS duration and ventricular volumes, showed no significant differences.
Authors noted limitations including the need for larger randomized trials with standardized CSP capture criteria, longer follow-up periods, and adequately powered clinical endpoints. While CSP may be a feasible physiological alternative in selected patients and experienced centers, BiVP remains the established default strategy for these patients.
How this fits prior evidence
This meta-analysis addresses the clinical utility of conduction-system pacing in HFrEF patients. It provides evidence regarding the efficacy of CSP compared to biventricular pacing, which is a standard treatment for these patients. While the study does not directly relate to the prior coverage of septal scar as a marker of mechanical difficulty or the impact of heart failure on mortality in stroke patients, it contributes to the broader understanding of pacing modalities in heart failure management.
Living with heart failure is a daily challenge, and doctors are always looking for ways to improve how the heart pumps. One method being explored is conduction-system pacing (CSP). This technique aims to mimic the heart's natural electrical pathways more closely than the current standard, known as biventricular pacing (BiVP).
Researchers looked at data from 976 adults with heart failure. They compared the new CSP method against the established BiVP method. The results showed that while CSP is a feasible option for some patients, it did not lead to significant improvements in heart pumping strength, hospitalization rates, or overall survival compared to the standard treatment.
There was a modest improvement in how patients felt during daily activities, but other metrics like heart size and procedure safety were similar between both methods. Because the study was a review of existing data, the authors note that larger trials with longer follow-up times are still needed to see the full picture.
What this means for you:
Newer heart pacing methods are feasible but do not currently outperform standard treatment for heart failure.
Common questions
Is the new pacing method safer than the current one?
The study found no significant differences in safety, complications, or lead issues between the new conduction-system pacing and the standard biventricular pacing. Both methods appear to have similar safety profiles for patients with heart failure.
Does the new pacing method help people live longer?
The data from 976 patients showed no statistically significant difference in all-cause mortality between the new conduction-system pacing and the standard biventricular pacing. Both methods performed similarly regarding survival rates.
Does the new method improve heart function?
The study found no significant improvement in the heart's pumping strength (left ventricular ejection fraction) when using the new conduction-system pacing compared to the standard biventricular pacing.
BACKGROUND: Conduction-system pacing (CSP) has emerged as a physiological alternative to conventional biventricular pacing (BiVP) for cardiac resynchronization therapy (CRT) in patients with heart failure with reduced ejection fraction (HFrEF). However, whether CSP provides superior clinical, echocardiographic, procedural, or safety outcomes compared with BiVP remains uncertain.
METHODS: We conducted a systematic review, pairwise meta-analysis, and frequentist network meta-analysis of randomized controlled trials comparing CSP with BiVP in adults with HFrEF undergoing CRT. PubMed/MEDLINE, Embase, Scopus, Web of Science, and CENTRAL were searched from inception to May 5, 2026. The primary outcomes were change in left ventricular ejection fraction (LVEF), heart-failure hospitalization, and all-cause mortality. Secondary outcomes included NYHA functional class, QRS duration, ventricular volumes, procedural metrics, echocardiographic response, feasibility, device-related outcomes, and safety. Risk ratios or mean differences with 95% confidence intervals were pooled using random-effects models. Network meta-analysis compared individual pacing strategies, including His-bundle pacing (HBP), left bundle branch area/left bundle branch pacing, mixed CSP, and BiVP.
RESULTS: Nine randomized controlled trials including 976 participants were analyzed. Compared with BiVP, CSP was not associated with a statistically significant improvement in LVEF (MD, 1.90 percentage points; 95% CI, -1.05 to 4.86; p = 0.176), heart-failure hospitalization (RR, 0.83; 95% CI, 0.31 to 2.22; p = 0.660), or all-cause mortality (RR, 1.05; 95% CI, 0.40 to 2.70; p = 0.900). Network meta-analysis showed no statistically significant superiority of any individual CSP modality over BiVP for the primary outcomes. CSP was associated with a modest improvement in NYHA functional class (MD, -0.17; 95% CI, -0.34 to -0.00; p = 0.049), but no significant differences were observed in QRS duration, LVESV, LVEDV, pacing threshold, procedural time, fluoroscopy time, echocardiographic response, procedural success, complications, lead revision, infection or explantation, crossover, or ventricular arrhythmias requiring ICD therapy.
CONCLUSIONS: In randomized evidence, CSP was not consistently superior to BiVP for LVEF improvement, heart-failure hospitalization, mortality, ventricular remodeling, procedural outcomes, or safety in patients with HFrEF undergoing CRT. CSP may represent a feasible physiological alternative in selected patients and experienced centers, but BiVP remains the established default strategy. Larger randomized trials with standardized CSP capture criteria, longer follow-up, and adequately powered clinical endpoints are needed.
