Conduction system pacing vs right ventricular pacing after TAVR: A systematic review and meta-analysis

Conduction system pacing (CSP), including His bundle pacing and left bundle branch pacing, has emerged as a physiological alternative to right ventricular pacing (RVP) for patients developing conduction disturbances after transcatheter aortic valve replacement.

We performed a systematic review and meta-analysis to compare CSP with RVP.

PubMed, Embase, and Cochrane databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A random-effects model was used for all outcomes, and heterogeneity was assessed using I² statistics. The protocol was registered in PROSPERO (CRD420251125169).

8 studies, including 784 patients, were analyzed. At 15-month follow-up, all-cause mortality did not differ significantly between CSP (left bundle branch pacing in 74%) and RVP (odds ratio 0.76; 95% confidence interval [CI] 0.51-1.14; P = .15; I² = 0%). CSP was associated with a shorter paced QRS duration after implant (mean difference -34.6 ms; 95% CI -40.2 to -29.1; P < .001) and higher left ventricular ejection fraction (mean difference +5.4%; 95% CI 3.5-7.3; P = .003) at 15-month follow-up. Heart failure hospitalization at 15 months was associated with a reduction in CSP (odds ratio 0.44; 95% CI 0.27-0.72; P = .006), whereas cardiovascular mortality, sensing, impedance, and lead dislodgement were similar between pacing strategies.

These findings suggest that CSP provides more physiological ventricular activation and may improve functional outcomes after transcatheter aortic valve replacement without affecting overall survival. Further randomized studies are warranted to confirm these observations.