Clinical Report: Conduction System Pacing Versus Biventricular Pacing in CRT

Overview

This systematic review and meta-analysis compares conduction system pacing (CSP) and biventricular pacing (BVP) in heart failure patients, highlighting specific metrics such as left ventricular ejection fraction (LVEF), NYHA class, and heart failure hospitalization risk.

Background

Cardiac resynchronization therapy (CRT) is essential for managing heart failure with reduced ejection fraction. BVP is the standard approach, but it has limitations, including procedural challenges and variable patient responses. CSP offers a promising alternative that may enhance patient outcomes.

Data Highlights

Key Findings

• CSP resulted in a greater improvement in LVEF compared to BVP (MD: 4.22%, 95% CI: 2.74%–5.70%).
• Patients receiving CSP showed a significant reduction in heart failure hospitalization risk (RR: 0.65, 95% CI: 0.49–0.87).
• CSP was associated with a greater reduction in QRS duration (MD: -19.60 ms, 95% CI: -24.18 to -15.02 ms).
• ACM rates were comparable between CSP and BVP groups (RR: 0.87, 95% CI: 0.62–1.22).
• CSP demonstrated shorter fluoroscopy times (MD: -5.04 min, 95% CI: -8.62 to -1.45 min) with similar complication rates.

Clinical Implications

CSP may provide superior clinical outcomes in heart failure patients compared to traditional BVP, particularly in those with classical CRT indications. Clinicians should consider CSP as a viable alternative, especially in patients who may not respond well to BVP, and should evaluate patient selection criteria carefully.

Conclusion

While CSP shows promising benefits over BVP, the evidence remains of low to very low certainty as assessed by the GRADE framework. Further large-scale randomized controlled trials are necessary to confirm these findings and guide clinical practice.

Related Resources & Content

1. Clinical Research in Cardiology, 2021 -- Comparative Analysis of Conduction System Pacing versus Right Ventricular Pacing for Bradyarrhythmia Management: A Systematic Review and Meta-Analysis
2. npj Digital Medicine, 2026 -- Accelerated Assessment of Left Ventricular Cardiac Activation Using Geometric Deep Learning: Advancing Planning for Cardiac Resynchronization Therapy
3. Frontiers in Cardiovascular Medicine, 2026 -- Global evidence on the cost-effectiveness of cardiac resynchronization therapy for heart failure: a systematic review
4. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure - PMC
5. JACC, 2022 -- Randomized Trial of Left Bundle Branch vs Biventricular Pacing for Cardiac Resynchronization Therapy
6. Pediatric Cardiology — Pediatric Conduction System Pacing and Congenital Heart Disease: Insights from a Series of 24 Cases at a Single Institution
7. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure - PMC
8. Randomized Trial of Left Bundle Branch vs Biventricular Pacing for Cardiac Resynchronization Therapy | JACC