Comparative effects of biventricular and right ventricular pacing on clinical outcomes in atrioventricular block: a systematic review and meta-analysis

Background: Right ventricular (RV) pacing is the standard treatment for atrioventricular (AV) block but may impair left ventricular (LV) function over time. Biventricular (BiV) pacing offers a physiologic alternative, though prior evidence has been mixed, particularly after the BioPace trial. Methods: PubMed, ScienceDirect, Google Scholar, and the Cochrane Library were searched through May 2025 for randomized controlled trials (RCTs) comparing BiV and RV pacing in AV block. Thirteen RCTs (n = 3,685) met the inclusion criteria. Outcomes included heart failure (HF) hospitalization, all-cause mortality, six-minute walk distance (6MWD), cardiovascular (CV) death, and LVEF (%) at follow-up. Results: BiV pacing significantly reduced HF hospitalizations (risk ratio [RR] = 0.83, 95% CI 0.69–0.98; p = 0.03) and better preserved LVEF (mean difference = 6.17%, 95% CI 3.85–8.49; p < 0.00001). No significant differences were observed in all-cause mortality (RR = 0.87, 95% CI 0.70–1.08; p = 0.21) or CV death (RR = 0.95, 95% CI 0.75–1.21; p = 0.70). RV pacing showed a borderline improvement in 6MWD (mean difference = 10.3 m, 95% CI − 0.1 to 20.7; p = 0.05). Conclusion: In patients with AV block and high pacing burden, BiV pacing reduced HF hospitalizations and better preserved systolic function compared with RV pacing. These findings support a burden-based pacing strategy, while CRT use should be individualized, considering patient profile and procedural factors. Systematic review registration: This systematic review and meta-analysis was retrospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) under ID 1080380. Clinical trial number: Not applicable. © The Author(s) 2025.