Pacing‐Induced Cardiomyopathy in Leadless and Transvenous Pacemakers: A Meta‐Analysis and Meta‐Regression

ABSTRACT Background Leadless pacemakers have been developed to reduce complications associated with transvenous systems; however, their impact on pacing‐induced cardiomyopathy (PICM) remains uncertain. This study aimed to evaluate the prevalence of PICM following leadless pacing, compared PICM risk with transvenous pacing, and assessed cardiac resynchronization therapy (CRT) upgrade. Methods This systematic review and meta‐analysis followed PRISMA guidelines. PubMed, Scopus, and ScienceDirect were searched up to January 2026. Studies reporting PICM following leadless pacing or comparing leadless and transvenous systems were included. Random‐effects models estimated pooled prevalence and risk ratios (RRs), and meta‐regression explored potential modifiers. Results Eight studies comprising 3224 patients with leadless pacing were included. The pooled prevalence of PICM following leadless pacing was 13% (95%CI: 4%–23%; I 2 = 92%). In comparative analysis (5 studies; n = 6025), the risk of PICM was similar between leadless and transvenous pacing (RR 1.00; 95%CI: 0.77–1.29; I 2 = 52%). Leadless pacing was associated with a lower observed rate of CRT upgrade (RR 0.56; 95%CI: 0.48–0.66; I 2 = 42%), although this finding should be interpreted cautiously because it may reflect patient selection, procedural factors, and differing thresholds for CRT upgrade. Meta‐regression identified baseline heart failure (HF) as a significant predictor of PICM ( p < 0.0001). Conclusion Leadless pacemakers demonstrate a non‐inferior risk of PICM and similar safety profiles to transvenous systems, while a lower observed rate of CRT upgrade. Future studies should standardize PICM definitions and improve reporting of pacing burden, ventricular function, and patient‐level outcomes.