Conduction System Versus Biventricular Pacing in Pacing-Induced Cardiomyopathy: Systematic Review and Meta-Analysis

Biventricular pacing (BVP) and conduction system pacing (CSP) can enhance pacing-induced cardiomyopathy (PICM) patients' clinical outcomes. Although BVP is a class I recommendation in guidelines, CSP may provide a superior physiological alternative to BVP. This meta-analysis compares the efficacy and safety of CSP and BVP in PICM patients.

Databases including PubMed, Cochrane Library, Web of Science, and Embase were searched from their establishment to June 2025. Data analysis was performed using Stata 17.

Twenty observational studies involving 821 patients with PICM were included, among which 360 patients were treated with BVP and 461 patients with CSP. Results showed CSP had a greater QRS duration (QRSd) reduction than BVP (MD = -53.26 ms, 95% CI: -58.13, -48.39 vs. MD = -30.69 ms, 95% CI: -35.79, -25.59) (p < 0.001). After 15.6 months' follow-up, CSP had a higher response rate (84.7% vs. 67.6%) (RR = 1.25, 95% CI: 1.14, 1.38) (p < 0.001) and lower incidences of adverse outcomes and device-related complications (14.0% vs. 20.1%) (RR = 0.7, 95% CI: 0.5, 0.98) (p < 0.001) than BVP. Subgroup analysis showed His bundle pacing (HBP) was associated with greater QRSd shortening, while left bundle branch area pacing (LBBAP) had lower thresholds.

The results indicate that upgrading to CSP in PICM patients significantly improves electrical synchrony, and correlates with higher response rates and lower adverse outcomes, suggesting CSP as a promising alternative pacing strategy.