Conduction System Pacing Versus Right Ventricular Pacing in Patients With Atrioventricular Block and Anticipated High...

Area of Science:

• Cardiology
• Electrophysiology
• Medical Devices

Background:

• Right ventricular pacing (RVP) is linked to pacing-induced cardiomyopathy (PICM) in 12-20% of patients with atrioventricular (AV) block and high pacing burden.
• Conduction system pacing (CSP) offers a more physiologic ventricular activation, potentially mitigating adverse effects like PICM.
• A systematic pooling of contemporary randomized evidence comparing CSP and RVP is needed.

Purpose of the Study:

• To systematically review and meta-analyze randomized controlled trials (RCTs) comparing CSP with RVP.
• To evaluate the co-primary outcomes of PICM incidence and change in left ventricular ejection fraction (ΔLVEF).
• To assess secondary outcomes including heart failure hospitalization (HFH), all-cause mortality, and paced QRS duration.

Main Methods:

• Systematic review and meta-analysis of RCTs with a minimum 6-month follow-up.
• Included studies compared CSP versus RVP in patients with AV block or anticipated high ventricular pacing burden.
• Random-effects meta-analysis using DerSimonian-Laird estimation was performed on data from 5 RCTs (N=806).

Main Results:

• CSP significantly reduced PICM (HR 0.30) and heart failure hospitalizations (HR 0.24) compared to RVP.
• CSP was associated with greater LVEF preservation (MD +4.41%) and shortened paced QRS duration (MD -27.5 ms).
• All-cause mortality was numerically lower with CSP but did not reach statistical significance (HR 0.57).

Conclusions:

• Conduction system pacing substantially reduces PICM, preserves LVEF, and lowers HFH compared to RVP.
• CSP should be considered a preferred pacing strategy for appropriately selected patients with AV block and high pacing burden.
• Findings were consistent in sensitivity analyses restricted to multicenter trials with N≥150.