ORCID
0000-0002-2838-1496 (Munoz-Moreno), 0000-0001-9627-6236 (Benza), 0000-0001-5947-4778 (Yehya)
Document Type
Article
Publication Date
2026
DOI
10.3390/jcm15208087
Publication Title
Journal of Clinical Medicine
Volume
15
Issue
20
Pages
8087 (20 pp.)
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.
Rights
© 2026 by the authors.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution 4.0 International (CC BY 4.0) License.
Data Availability
Article states: "The data used for this manuscript are publicly available, as this is a systematic review. The corresponding author will respond to inquiries regarding synthesized datasets upon reasonable request."
Original Publication Citation
Munoz-Moreno, J., Diaz-Arocutipa, C., Espiche-Salazar, C., McAuliffe, J., Benza, R. L., Yehya, A., Contreras, J., & Kiehl, E. L. (2026). 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. Journal of Clinical Medicine, 15(20), Article 8087. https://doi.org/10.3390/jcm15208087
Repository Citation
Munoz-Moreno, J., Diaz-Arocutipa, C., Espiche-Salazar, C., McAuliffe, J., Benza, R. L., Yehya, A., Contreras, J., & Kiehl, E. L. (2026). 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. Journal of Clinical Medicine, 15(20), Article 8087. https://doi.org/10.3390/jcm15208087
Supplementary Materials