Mid-Term and Long-Term Clinical Events with Conduction System Pacing Versus Biventricular Pacing in HFrEF with Wide QRS: A Systematic Review and Meta-Analysis of Randomized Controlled Trials with Trial Sequential Analysis
8 affiliations
- 1Department of Internal Medicine, Macon and Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, VA 23507, USA
- 2Unidad de Revisiones Sistemáticas y Meta-Análisis (URSIGET), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima 15024, Peru
- 3Department of Cardiology, Bassett Medical Center, Cooperstown, NY 13326, USA
- 4Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, VA 22042, USA
- 5Department of Cardiology, Macon and Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, VA 23507, USA
- 6Advanced Heart Failure Center, Sentara Heart Hospital, Norfolk, VA 23507, USA
- 7Department of Medicine, Division of Cardiology, Icahn School of Medicine, Mount Sinai Fuster Heart Hospital, New York, NY 10029, USA
- 8Department of Electrophysiology, Sentara Medical Group, Sentara Health, Virginia Beach, VA 23454, USA
Abstract
Background/Objectives: Conduction system pacing (CSP) has emerged as a more physiological alternative to biventricular pacing (BiVP) in heart failure with reduced ejection fraction (HFrEF) and wide QRS, but recent randomized controlled trials (RCTs) have yielded discordant results. This meta-analysis aimed to compare CSP with BiVP for clinical events and functional recovery in HFrEF. Methods: MEDLINE, Embase, and Cochrane Library were searched for RCTs through 15 April 2026. Primary outcomes were all-cause mortality (ACM) and heart failure hospitalization (HFH) at mid-term (6–12 months) and long-term (>12 months) follow-up. Random-effects meta-analyses and Trial Sequential Analysis (TSA) were performed. Results: Eleven RCTs comprising 12 reports and 1073 patients were included. CSP showed no significant difference in mid-term ACM (RR 0.72; 95% CI 0.21 to 2.49; p = 0.605) or HFH (RR 0.97; 95% CI 0.52 to 1.81; p = 0.918). At long-term follow-up (three RCTs; n = 312), CSP showed a non-significant trend toward ACM reduction (RR 0.34; 95% CI 0.11 to 1.06; p = 0.063; low-certainty evidence) and a significant, TSA-supported reduction in HFH (RR 0.30; 95% CI 0.16 to 0.58; p < 0.001; moderate-certainty evidence). At 6 months, CSP improved LVEF (MD 2.84%; 95% CI 0.74 to 4.93; p = 0.008) and reduced QRS duration (MD −9.97 ms; 95% CI −18.57 to −1.37; p = 0.023), with NYHA improvement at 12 months (MD −0.31; 95% CI −0.50 to −0.11; p = 0.002). Conclusions: In this meta-analysis of RCTs predominantly evaluating left bundle branch area pacing, CSP was associated with a lower risk of long-term HFH compared with BiVP in HFrEF with a wide QRS, although the evidence remains limited by the small number of available trials. The observed trend toward lower long-term ACM should be considered hypothesis-generating. Larger, adequately powered RCTs with longer follow-up are needed to confirm these findings and determine whether CSP provides sustained clinical benefit over BiVP.
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BibTeX
@article{munozmoreno2026midterm,
title = {{Mid-Term and Long-Term Clinical Events with Conduction System Pacing Versus Biventricular Pacing in HFrEF with Wide QRS: A Systematic Review and Meta-Analysis of Randomized Controlled Trials with Trial Sequential Analysis}},
author = {Juan Munoz-Moreno and Carlos Diaz-Arocutipa and Carlos Espiche-Salazar and Jacob McAuliffe and Raymond L. Benza and Amin Yehya and Johanna Contreras and Erich L. Kiehl},
journal = {Journal of Clinical Medicine},
year = {2026},
month = oct,
doi = {10.3390/jcm15208087},
url = {https://www.mdpi.com/2077-0383/15/20/8087},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Mid-Term and Long-Term Clinical Events with Conduction System Pacing Versus Biventricular Pacing in HFrEF with Wide QRS: A Systematic Review and Meta-Analysis of Randomized Controlled Trials with Trial Sequential Analysis
AU - Juan Munoz-Moreno
AU - Carlos Diaz-Arocutipa
AU - Carlos Espiche-Salazar
AU - Jacob McAuliffe
AU - Raymond L. Benza
AU - Amin Yehya
AU - Johanna Contreras
AU - Erich L. Kiehl
PY - 2026
DA - 2026/10/01
JO - Journal of Clinical Medicine
DO - 10.3390/jcm15208087
UR - https://www.mdpi.com/2077-0383/15/20/8087
AB - Background/Objectives: Conduction system pacing (CSP) has emerged as a more physiological alternative to biventricular pacing (BiVP) in heart failure with reduced ejection fraction (HFrEF) and wide QRS, but recent randomized controlled trials (RCTs) have yielded discordant results. This meta-analysis aimed to compare CSP with BiVP for clinical events and functional recovery in HFrEF. Methods: MEDLINE, Embase, and Cochrane Library were searched for RCTs through 15 April 2026. Primary outcomes were all-cause mortality (ACM) and heart failure hospitalization (HFH) at mid-term (6–12 months) and long-term (>12 months) follow-up. Random-effects meta-analyses and Trial Sequential Analysis (TSA) were performed. Results: Eleven RCTs comprising 12 reports and 1073 patients were included. CSP showed no significant difference in mid-term ACM (RR 0.72; 95% CI 0.21 to 2.49; p = 0.605) or HFH (RR 0.97; 95% CI 0.52 to 1.81; p = 0.918). At long-term follow-up (three RCTs; n = 312), CSP showed a non-significant trend toward ACM reduction (RR 0.34; 95% CI 0.11 to 1.06; p = 0.063; low-certainty evidence) and a significant, TSA-supported reduction in HFH (RR 0.30; 95% CI 0.16 to 0.58; p < 0.001; moderate-certainty evidence). At 6 months, CSP improved LVEF (MD 2.84%; 95% CI 0.74 to 4.93; p = 0.008) and reduced QRS duration (MD −9.97 ms; 95% CI −18.57 to −1.37; p = 0.023), with NYHA improvement at 12 months (MD −0.31; 95% CI −0.50 to −0.11; p = 0.002). Conclusions: In this meta-analysis of RCTs predominantly evaluating left bundle branch area pacing, CSP was associated with a lower risk of long-term HFH compared with BiVP in HFrEF with a wide QRS, although the evidence remains limited by the small number of available trials. The observed trend toward lower long-term ACM should be considered hypothesis-generating. Larger, adequately powered RCTs with longer follow-up are needed to confirm these findings and determine whether CSP provides sustained clinical benefit over BiVP.
SN - 2077-0383
ER -