Mid-Term and Long-Term Clinical Events with Conduction System Pacing Versus Biventricular Pacing in HFrEF with Wide QRS: A Systematic Review and Meta-Analysis of Randomized Controlled Trials with Trial Sequential Analysis

Background/Objectives: Conduction system pacing (CSP) has emerged as a more physiological alternative to biventricular pacing (BiVP) in heart failure with reduced ejection fraction (HFrEF) and wide QRS, but recent randomized controlled trials (RCTs) have yielded discordant results. This meta-analysis aimed to compare CSP with BiVP for clinical events and functional recovery in HFrEF.

Methods

MEDLINE, Embase, and Cochrane Library were searched for RCTs through 15 April 2026. Primary outcomes were all-cause mortality (ACM) and heart failure hospitalization (HFH) at mid-term (6–12 months) and long-term (>12 months) follow-up. Random-effects meta-analyses and Trial Sequential Analysis (TSA) were performed.