AV Node Ablation and Conduction System Pacing Versus Biventricular Pacing in Patients With AF and HF

In patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF), atrioventricular node ablation (AVNA) and permanent pacing are often pursued when rhythm control is not pursued. Biventricular pacing (BiVP) has demonstrated benefits over right ventricular pacing, while conduction system pacing (CSP) has emerged as an alternative. However, evidence directly comparing CSP with BiVP in this high-risk population remains inconsistent.

To compare CSP versus BiVP in patients with AF and HFrEF undergoing AVNA, focusing on cardiac function, clinical outcomes, and procedural metrics.

Following PRISMA guidelines, we searched PubMed, Scopus, and Web of Science through February 2026 for studies comparing CSP and BiVP in adults with AF and HFrEF undergoing AVNA. Outcomes included all-cause mortality, heart failure hospitalization (HFH), changes in left ventricular ejection fraction (LVEF), QRS duration, New York Heart Association (NYHA) class, pacing threshold, procedure duration, and fluoroscopy duration. A random-effects model was used to pool mean differences (MDs) or risk ratios (RRs) with 95% confidence intervals (CIs).

Six studies (one randomized crossover trial and five observational studies; N = 766 patients: CSP = 356, BiVP = 410) were included. All-cause mortality was significantly reduced in favor of CSP (RR 0.64 [CI: 0.44 to 0.94], p = 0.02, I² = 0%). There was also a trend towards lower HFH, but it marginally missed statistical significance (RR 0.77 [CI: 0.58 to 1.03], p = 0.08; I² = 0%). Additionally, CSP decreased NYHA class (MD -0.64 [CI: -1.18 to -0.10], p = 0.02; I² = 85%) and significantly reduced QRS duration (MD -33.56 ms [CI: -52.36 to -14.76], p = 0.0005; I² = 97%). LVEF improvement did not significantly differ between groups (MD 4.51% [95% CI: -1.50 to 10.52], p = 0.14; I² = 98%). Procedure duration and fluoroscopy times did not show statistically significant difference between the two groups (MD -11.54 min [CI: -50.05 to 26.97], p = 0.56, I² = 96%), and (MD -5.75 min [CI: -13.13 to 1.63], p = 0.13, I² = 88%), respectively. Overall pacing thresholds did not significantly differ between CSP and BiVP; however, modality-specific subgroup analysis showed comparable thresholds between HBP and BiVP, whereas LBBP was associated with significantly lower pacing thresholds than BiVP.

Among patients with AF and HFrEF undergoing AVNA, CSP may offer symptomatic and electrocardiographic advantages over BiVP, with a possible signal toward improved major clinical outcomes that requires confirmation in larger randomized studies.