Conduction System Versus Biventricular Pacing in Pacing‐Induced Cardiomyopathy: Systematic Review and Meta‐Analysis

BACKGROUND: Biventricular pacing (BVP) and conduction system pacing (CSP) can enhance pacing-induced cardiomyopathy (PICM) patients' clinical outcomes. Although BVP is a class I recommendation in guidelines, CSP may provide a superior physiological alternative to BVP. This meta-analysis compares the efficacy and safety of CSP and BVP in PICM patients. METHODS: Databases including PubMed, Cochrane Library, Web of Science, and Embase were searched from their establishment to June 2025. Data analysis was performed using Stata 17. RESULTS: Twenty observational studies involving 821 patients with PICM were included, among which 360 patients were treated with BVP and 461 patients with CSP. Results showed CSP had a greater QRS duration (QRSd) reduction than BVP (MD = -53.26 ms, 95% CI: -58.13, -48.39 vs. MD = -30.69 ms, 95% CI: -35.79, -25.59) (p < 0.001). After 15.6 months' follow-up, CSP had a higher response rate (84.7% vs. 67.6%) (RR = 1.25, 95% CI: 1.14, 1.38) (p < 0.001) and lower incidences of adverse outcomes and device-related complications (14.0% vs. 20.1%) (RR = 0.7, 95% CI: 0.5, 0.98) (p < 0.001) than BVP. Subgroup analysis showed His bundle pacing (HBP) was associated with greater QRSd shortening, while left bundle branch area pacing (LBBAP) had lower thresholds. CONCLUSIONS: The results indicate that upgrading to CSP in PICM patients significantly improves electrical synchrony, and correlates with higher response rates and lower adverse outcomes, suggesting CSP as a promising alternative pacing strategy.