Conduction system pacing vs biventricular pacing for cardiac resynchronization therapy: Frequentist and Bayesian meta-analysis of randomized controlled trials and propensity-matched studies

BACKGROUND: Cardiac resynchronization therapy (CRT) with biventricular (BiV) pacing is non-physiological, and a third of patients do not respond. OBJECTIVE: This study aimed to compare conduction system pacing (CSP) with BiV. METHODS: Systematic searching of databases was conducted to include randomized controlled trials (RCTs) and comparative propensity-matched studies. CSP includes left bundle branch pacing (LBBP), his bundle pacing, and His-/left bundle branch-optimized CRT (optimized HBP/LBBP). Frequentist and Bayesian meta-analyses were performed. RESULTS: 28 studies (13 RCTs) with 5524 patients were included. CSP was associated with better CRT response (odds ratio [OR], 1.69, 95% confidence interval [CI], 1.20-2.39; P = .0027) and better clinical response (OR, 1.83; CI, 1.12-2.99; P = .01). CSP was associated with lower odds of composite outcomes (OR, 0.51; CI, 0.30-0.88; P = .01), heart failure (HF) hospitalization (OR, 0.58; CI, 0.35-0.96; P = .0347), and all-cause mortality (OR, 0.67; CI, 0.46-0.97; P = .0340). CSP was also associated with significantly higher improvement in QRS duration, left ventricular ejection fraction, left ventricular end-systolic diameter, N-terminal pro-B-type natriuretic peptide, New York Heart Association, and 6MWD 6-minute walk distance (all P < .05). Bayesian meta-analysis consistently favored CSP across all clinical outcomes, with probability of meaningful benefit exceeding 90% for CRT response, super-response, composite outcome, and HF hospitalization. However, RCT-only analysis yielded inconsistent results across most outcomes, with only clinical response remaining statistically significant. In subgroup analyses, LBBP appears to have the most benefit across CRT response and HF hospitalization outcomes. CONCLUSION: CSP may offer potential advantages over BiV pacing in patients indicated for CRT; however, confirmation in larger randomized clinical trials is required. Copyright © 2026 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.