Abstract / Summary
Abstract Background Conduction system pacing (CSP) has emerged as a physiological alternative to biventricular pacing (BiVP) for cardiac resynchronization therapy in patients with heart failure with reduced ejection fraction (HFrEF), although its comparative clinical effectiveness remains uncertain. Objectives To compare CSP with BiVP for cardiac resynchronization in patients with HFrEF. Methods We searched PubMed, Embase, Cochrane, and Clinicaltrials.gov for RCTs comparing CSP vs BiVP in patients with HFrEF. For binary outcomes, odds ratio (OR) with 95% CrI were estimated using a Bayesian binomial-normal hierarchical model. For continuous outcomes, mean differences (MD) with 95% credible intervals (CrIs) were estimated using a Bayesian random-effects model. Results Thirteen studies comprising 1,221 patients met the inclusion criteria. Compared with BiVP, CSP was associated with a lower odds of all-cause mortality (OR, 0.63; 95% CrI, 0.33–1.13), corresponding to a 94% posterior probability of benefit (OR < 1). Similarly, CSP was associated with a lower odds of heart failure hospitalization (OR, 0.75; 95% CrI, 0.41–1.36), with an 84% probability of benefit. The 95% prediction interval for mortality ranged from 0.28 to 1.45, indicating uncertainty regarding the treatment effect in future studies. CSP resulted in a high probability (> 98%) for improvement in surrogate clinical outcomes of QRS narrowing, left ventricular end-systolic volume, left ventricular end-diastolic volume, and left ventricular ejection fraction. Conclusion CSP offers advantages in surrogate outcomes over BiVP pacing in CRT selected patients; however, additional randomized trials are required before CSP can be recommended as the routine first-line CRT strategy to improve survival and reduce future hospitalizations.