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

ABSTRACT

Conduction system pacing (CSP) has emerged as a promising alternative to biventricular pacing (BVP) heart failure patients with reduced ejection fraction (HFrEF) and ventricular dyssynchrony, but its benefits are still uncertain. In this study, we aim to evaluate clinical outcomes of CSP versus BVP for cardiac resynchronization in patients with HFrEF. PubMed, Scopus, and Cochrane databases were searched for randomized controlled trials (RCTs) 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 RCTs with 408 patients, of whom 200 (49%) underwent CSP. Compared to biventricular pacing, CSP resulted in a significantly greater reduction in QRS duration (MD -13.34 ms; 95% CI -24.32 to -2.36, p=0.02; I2=91%) and NYHA functional class (SMD -0.37; 95% CI -0.69 to -0.05;p=0.02; I2=41%), and a significant increase in left ventricular ejection fraction (LVEF) (MD 2.06%; 95% CI 0.16 to 3.97; p=0.03; I2=0%). No statistical difference was noted for LVESV (SMD -0.51 mL; 95% CI -1.26 to 0.24; p=0.18; I2=83%), lead capture threshold (MD -0.08 V; 95% CI -0.42 to 0.27; p=0.66; I2=66%), and procedure time (MD 5.99 min; 95% CI -15.91 to 27.89; p=0.59; I2=79%). These findings suggest that CSP may have electrocardiographic, echocardiographic, and symptomatic benefits over biventricular pacing for patients with HFrEF requiring cardiac resynchronization.