Conduction system pacing versus right ventricular pacing in preserved or mildly reduced ejection fraction: A meta-analysis of randomized trials

Authors

• Abdalhakim Shubietah, Advocate Health - MidwestFollow
• Mohamed Saad Rakab, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
• Elsayed Balbaa, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
• Qasem Salah, Department of Medicine, An-Najah National University, Nablus, Palestine.
• Mohamed S. Elgendy, Faculty of Medicine, Tanta University, Tanta, Egypt.
• Ahmed Elbataa, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
• Ameer Awashra, Department of Medicine, An-Najah National University, Nablus, Palestine.
• Ahmed Emara, Faculty of Medicine, Al-Azhar University, Cairo, Egypt. Electronic address: emara9055@gmail.com.
• Rocio Carla Barriga Guzman, Department of Cardiology, University of Nebraska Medical Center, Lincoln, NE, USA.
• Ahmed Mansour, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
• Anan Abu Rmilah, Department of Medicine, University of Iowa, Iowa City, IA, USA.
• Moath Hattab, Department of Medicine, An-Najah National University, Nablus, Palestine.
• Yousef Hawas, Faculty of Medicine, Tanta University, Tanta, Egypt.
• Mohamed R. Murad, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
• Belal Mohamed Hamed, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
• Mohanad Qwaider, Department of Medicine, College of Medicine and Life Sciences, The University of Toledo, Toledo, OH, USA.
• Mahmoud Ismayl, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
• Mohammed Mhanna, Division of Cardiovascular Medicine, University of Iowa, Iowa City, IA, USA.
• Marwan M. Refaat, Department of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Beirut, Lebanon.
• Mohammed Ruzieh, Bluhm Cardiovascular Institute, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
• Peter A. Brady, Advocate Health - Midwest
• Ahmed Altibi, Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA.

Recommended Citation

Shubietah A, Rakab MS, Balbaa E, et al. Conduction System Pacing Versus Right Ventricular Pacing in Preserved or Mildly Reduced Ejection Fraction: A Meta-Analysis of Randomized Trials. Can J Cardiol. Published online April 21, 2026. doi:10.1016/j.cjca.2026.04.009

Affiliations

Advocate Illinois Masonic Medical Center

Abstract

Background: Prior evidence, largely observational, has been mixed on whether conduction system pacing (CSP) improves outcomes over conventional right ventricular pacing (RVP). This study compares the efficacy and safety of CSP versus RVP in randomized controlled trials (RCTs) of patients with preserved or mildly reduced left ventricular ejection fraction (LVEF) who require permanent pacing.

Methods: We meta-analyzed RCTs comparing different CSP modalities with RVP. Databases were searched through February 24, 2026. Outcomes were pooled using random-effects models for risk ratios (RRs) and mean differences (MDs).

Results: Fifteen RCTs (n=1,466; mean baseline LVEF 59.4±7.0%) showed lower pacing-induced cardiomyopathy (PICM) with CSP versus RVP (4.6% vs 16.2%; RR 0.34; 95% CI 0.19-0.60) and lower HF hospitalization (HFH) (3.3% vs 9.1%; RR 0.34; 95% CI 0.17-0.70), with no difference in all-cause mortality. CSP shortened paced QRS duration (MD -30.10 ms; 95% CI -35.46 to -24.74) and improved LVEF (MD +2.96%; 95% CI 1.18-4.73), but had lower pacing success (93.6% vs 99.5%; RR 0.95; 95% CI 0.91-0.99) and worse procedural metrics (procedure time MD +32.44 min; 95% CI 21.22-43.67; fluoroscopy time MD +5.27 min; 95% CI 3.89-6.65; radiation dose MD +24.91 milligray [mGy]; 95% CI 10.27-39.55).

Conclusions: In RCTs of predominantly preserved or mildly reduced LVEF requiring permanent pacing, CSP reduced PICM and HF hospitalization and preserved LV function more effectively versus RVP, but with longer procedural and fluoroscopy times. CSP is a reasonable preventive strategy when substantial ventricular pacing is anticipated in this population.

Type

Article

PubMed ID

42025689