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Updated: Jul 6, 2026
Benefits of Cardiac Resynchronization Therapy in an Asynchronous Heart Failure Model Induced by Left Bundle Branch Ablation and Rapid Pacing
Published on: December 11, 2017
Conduction system pacing vs biventricular pacing for cardiac resynchronization therapy: Frequentist and Bayesian
Raymond Pranata1, Wilbert Huang1, Christopher Daniel Tristan2
1Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia; Department of Cardiovascular Medicine, Siloam Hospitals Lippo Village, Tangerang, Indonesia.
Insights
Conduction system pacing (CSP) shows improved cardiac resynchronization therapy (CRT) response and reduced mortality compared to biventricular (BiV) pacing. Further large randomized trials are needed to confirm these benefits for CRT patients.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Biventricular (BiV) pacing for cardiac resynchronization therapy (CRT) is often non-physiological, leading to a significant non-response rate in about one-third of patients.
- Alternative pacing strategies are needed to improve CRT outcomes.
Purpose of the Study:
- To compare the efficacy and safety of conduction system pacing (CSP) with traditional BiV pacing in patients requiring CRT.
Main Methods:
- A systematic literature search identified randomized controlled trials (RCTs) and propensity-matched studies.
- Meta-analyses (Frequentist and Bayesian) were performed on data from 5524 patients across 28 studies.
- CSP techniques included left bundle branch pacing (LBBP) and His bundle pacing (HBP).
Main Results:
- CSP demonstrated superior CRT response (OR 1.69) and clinical response (OR 1.83) compared to BiV pacing.
- CSP was associated with significantly lower rates of composite outcomes (OR 0.51), heart failure hospitalization (OR 0.58), and all-cause mortality (OR 0.67).
- Significant improvements were observed in QRS duration, LVEF, LVESD, NT-pro BNP, NYHA class, and 6MWD with CSP.
Conclusions:
- Conduction system pacing (CSP) presents a promising alternative to BiV pacing for CRT, offering potential advantages in patient response and clinical outcomes.
- Left bundle branch pacing (LBBP) showed particular benefit in subgroup analyses.
- Larger, high-quality randomized clinical trials are necessary to validate these findings and establish CSP as a standard CRT approach.
Background:
Cardiac resynchronization therapy (CRT) with biventricular (BiV) pacing is non-physiological, and a third of patients do not respond.
Objective:
This study aimed to compare conduction system pacing (CSP) with BiV.
Methods:
Systematic searching of databases was conducted to include randomized controlled trials (RCTs) and comparative propensity-matched studies. CSP includes left bundle branch pacing (LBBP), his bundle pacing, and His-/left bundle branch-optimized CRT (optimized HBP/LBBP). Frequentist and Bayesian meta-analyses were performed.
Results:
28 studies (13 RCTs) with 5524 patients were included. CSP was associated with better CRT response (odds ratio [OR], 1.69, 95% confidence interval [CI], 1.20-2.39; P = .0027) and better clinical response (OR, 1.83; CI, 1.12-2.99; P = .01). CSP was associated with lower odds of composite outcomes (OR, 0.51; CI, 0.30-0.88; P = .01), heart failure (HF) hospitalization (OR, 0.58; CI, 0.35-0.96; P = .0347), and all-cause mortality (OR, 0.67; CI, 0.46-0.97; P = .0340). CSP was also associated with significantly higher improvement in QRS duration, left ventricular ejection fraction, left ventricular end-systolic diameter, N-terminal pro-B-type natriuretic peptide, New York Heart Association, and 6MWD 6-minute walk distance (all P < .05). Bayesian meta-analysis consistently favored CSP across all clinical outcomes, with probability of meaningful benefit exceeding 90% for CRT response, super-response, composite outcome, and HF hospitalization. However, RCT-only analysis yielded inconsistent results across most outcomes, with only clinical response remaining statistically significant. In subgroup analyses, LBBP appears to have the most benefit across CRT response and HF hospitalization outcomes.
Conclusion:
CSP may offer potential advantages over BiV pacing in patients indicated for CRT; however, confirmation in larger randomized clinical trials is required.
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