{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T18:27:26Z","timestamp":1783535246602,"version":"3.55.0"},"reference-count":39,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2025,7,9]],"date-time":"2025-07-09T00:00:00Z","timestamp":1752019200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: The role of biventricular pacing (BVP) is less well-established in patients with heart failure with reduced ejection fraction (HFrEF) without left bundle branch block (LBBB). Conduction system pacing (CSP) has gained significant traction and may provide a safe and more physiological alternative to BVP in these patients. A few small studies studying this question have reported conflicting results. This meta-analysis aims to compare procedural and clinical outcomes between CSP and BVP in this group. Materials and Methods: An online literature search was systematically conducted to retrieve studies comparing CSP and BVP in HFrEF patients with non-LBBB. Four studies with 461 patients were included. Results: Implant-derived paced QRS duration was significantly shorter (mean difference [MD] \u221219.7 ms, 95% confidence interval [CI] \u221236.2 to \u22123.3, p = 0.0355) with CSP. Echocardiographic response with significantly greater improvement in left ventricular ejection fraction (MD 5.6%, 95% CI 3.1 to 8.0, p = 0.0106) was also observed with CSP. There were no statistically significant differences in clinical outcomes such as all-cause mortality (relative risk [RR] 0.53, 95% CI 0.18 to 1.60, p = 0.133) and heart failure hospitalization (RR 0.54, 95% CI 0.19 to 1.56, p = 0.129). Conclusions: This meta-analysis suggests that CSP may have better electrical synchrony and echocardiographic response compared to BVP in HFrEF patients with non-LBBB. Further randomized studies with longer follow-up may be required to elucidate potential benefits in clinical outcomes.<\/jats:p>","DOI":"10.3390\/medicina61071240","type":"journal-article","created":{"date-parts":[[2025,7,10]],"date-time":"2025-07-10T07:38:27Z","timestamp":1752133107000},"page":"1240","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Conduction System Pacing Versus Biventricular Cardiac Resynchronization Pacing: Meta-Analysis on Outcomes in Patients with Non-Left Bundle Branch Block"],"prefix":"10.3390","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8261-131X","authenticated-orcid":false,"given":"Xuanming","family":"Pung","sequence":"first","affiliation":[{"name":"Department of Cardiology, National Heart Centre Singapore, Singapore 169609, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joe J. L.","family":"Chua","sequence":"additional","affiliation":[{"name":"Department of Cardiology, National Heart Centre Singapore, Singapore 169609, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khi Yung","family":"Fong","sequence":"additional","affiliation":[{"name":"Department of General Medicine, Changi General Hospital, Singapore 529889, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yi Yi","family":"Chua","sequence":"additional","affiliation":[{"name":"Department of Cardiology, National Heart Centre Singapore, Singapore 169609, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Germaine J. M.","family":"Loo","sequence":"additional","affiliation":[{"name":"Department of Cardiology, National Heart Centre Singapore, Singapore 169609, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-4832-0807","authenticated-orcid":false,"given":"Jonathan W. S.","family":"Ong","sequence":"additional","affiliation":[{"name":"Department of Cardiology, National Heart Centre Singapore, Singapore 169609, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian C. K.","family":"Tay","sequence":"additional","affiliation":[{"name":"Department of Cardiology, National Heart Centre Singapore, Singapore 169609, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hooi Khee","family":"Teo","sequence":"additional","affiliation":[{"name":"Department of Cardiology, National Heart Centre Singapore, Singapore 169609, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yue","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Changi General Hospital, Singapore 529889, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Colin","family":"Yeo","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Changi General Hospital, Singapore 529889, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric T. S.","family":"Lim","sequence":"additional","affiliation":[{"name":"Department of Cardiology, National Heart Centre Singapore, Singapore 169609, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kah Leng","family":"Ho","sequence":"additional","affiliation":[{"name":"Department of Cardiology, National Heart Centre Singapore, Singapore 169609, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel T. T.","family":"Chong","sequence":"additional","affiliation":[{"name":"Department of Cardiology, National Heart Centre Singapore, Singapore 169609, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3454-3866","authenticated-orcid":false,"given":"Chi Keong","family":"Ching","sequence":"additional","affiliation":[{"name":"Department of Cardiology, National Heart Centre Singapore, Singapore 169609, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0164-7925","authenticated-orcid":false,"given":"Vern Hsen","family":"Tan","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Changi General Hospital, Singapore 529889, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,7,9]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e17","DOI":"10.1016\/j.hrthm.2023.03.1538","article-title":"2023 HRS\/APHRS\/LAHRS Guideline on Cardiac Physiologic Pacing for the Avoidance and Mitigation of Heart Failure","volume":"20","author":"Chung","year":"2023","journal-title":"Heart Rhythm"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"3427","DOI":"10.1093\/eurheartj\/ehab364","article-title":"2021 ESC Guidelines on Cardiac Pacing and Cardiac Resynchronization Therapy","volume":"42","author":"Glikson","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1456","DOI":"10.1136\/heartjnl-2014-306811","article-title":"Cardiac Resynchronisation Therapy is not Associated with a Reduction in Mortality or Heart Failure Hospitalisation in Patients with Non-Left Bundle Branch Block QRS Morphology: Meta-Analysis of Randomised Controlled Trials","volume":"101","author":"Cunnington","year":"2015","journal-title":"Heart"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"881","DOI":"10.1016\/j.hrthm.2024.02.035","article-title":"Conduction System Pacing versus Biventricular Pacing in Heart Failure with Reduced Ejection Fraction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials","volume":"21","author":"Collini","year":"2024","journal-title":"Heart Rhythm"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e04","DOI":"10.15420\/aer.2024.10","article-title":"Conduction System Pacing for CRT: A Physiological Alternative","volume":"14","author":"Herweg","year":"2025","journal-title":"Arrhythmia Electrophysiol. Rev."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"2628","DOI":"10.1016\/j.jacep.2023.08.003","article-title":"His-Purkinje Conduction System Pacing Optimized Trial of Cardiac Resynchronization Therapy vs Biventricular Pacing","volume":"9","author":"Vijayaraman","year":"2023","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_8","unstructured":"Wells, G., Shea, B., O\u2019Connell, D., Peterson, J., Welch, V., Losos, M., and Tugwell, P. (2025, July 06). The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses 2021. Available online: https:\/\/www.ohri.ca\/programs\/clinical_epidemiology\/oxford.asp."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Hozo, S.P., Djulbegovic, B., and Hozo, I. (2005). Estimating the Mean and Variance from the Median, Range, and the Size of a Sample. BMC Med. Res. Methodol., 5.","DOI":"10.1186\/1471-2288-5-13"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Wan, X., Wang, W., Liu, J., and Tong, T. (2014). Estimating the Sample Mean and Standard Deviation from the Sample Size, Median, Range and\/or Interquartile Range. BMC Med. Res. Methodol., 14.","DOI":"10.1186\/1471-2288-14-135"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1136\/bmj.327.7414.557","article-title":"Measuring Inconsistency in Meta-Analyses","volume":"327","author":"Higgins","year":"2003","journal-title":"BMJ"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1016\/j.jclinepi.2017.10.005","article-title":"Advances in the GRADE Approach to Rate the Certainty in Estimates from a Network Meta-Analysis","volume":"93","author":"Bonner","year":"2018","journal-title":"J. Clin. Epidemiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1263","DOI":"10.1016\/j.hrthm.2022.04.023","article-title":"Clinical Outcomes of Conduction System Pacing Compared to Biventricular Pacing in Patients Requiring Cardiac Resynchronization Therapy","volume":"19","author":"Vijayaraman","year":"2022","journal-title":"Heart Rhythm"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1115","DOI":"10.1111\/pace.14535","article-title":"Conduction System Pacing vs. Biventricular Pacing in Patients with Ventricular Dysfunction and AV Block","volume":"45","author":"Guasch","year":"2022","journal-title":"Pacing Clin. Electrophysiol. PACE"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"976","DOI":"10.1111\/jce.15881","article-title":"Conduction System versus Biventricular Pacing in Heart Failure with Non-Left Bundle Branch Block","volume":"34","author":"Tan","year":"2023","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e011761","DOI":"10.1161\/CIRCEP.122.011761","article-title":"Electrical Resynchronization and Clinical Outcomes During Long-Term Follow-Up in Intraventricular Conduction Delay Patients Applied Left Bundle Branch Pacing-Optimized Cardiac Resynchronization Therapy","volume":"16","author":"Chen","year":"2023","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e1230","DOI":"10.1002\/cl2.1230","article-title":"PRISMA2020: An R Package and Shiny App for Producing Prisma 2020-Compliant Flow Diagrams, with Interactivity for Optimised Digital Transparency and Open Synthesis","volume":"18","author":"Haddaway","year":"2022","journal-title":"Campbell Syst. Rev."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"927","DOI":"10.1016\/j.amjcard.2010.11.010","article-title":"Defining Left Bundle Branch Block in the Era of Cardiac Resynchronization Therapy","volume":"107","author":"Strauss","year":"2011","journal-title":"Am. J. Cardiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1329","DOI":"10.1056\/NEJMoa0906431","article-title":"Cardiac-Resynchronization Therapy for the Prevention of Heart-Failure Events","volume":"361","author":"Moss","year":"2009","journal-title":"N. Engl. J. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"976","DOI":"10.1016\/j.jacc.2008.12.013","article-title":"AHA\/ACCF\/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram","volume":"53","author":"Surawicz","year":"2009","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1016\/j.jacep.2019.10.009","article-title":"Evaluating Electrocardiography-Based Identification of Cardiac Resynchronization Therapy Responders Beyond Current Left Bundle Branch Block Definitions","volume":"6","author":"Hoogland","year":"2020","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Pujol-L\u00f3pez, M., Graterol, F.R., Borr\u00e0s, R., Garcia-Ribas, C., Guichard, J.B., Regany-Closa, M., Jim\u00e9nez-Arjona, R., Niebla, M., Poza, M., and Carro, E. (2025). Clinical Response to Resynchronization Therapy: Conduction System Pacing vs Biventricular Pacing. CONSYST-CRT trial. JACC Clin. Electrophysiol., online ahead of print.","DOI":"10.1016\/j.jacep.2025.03.024"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"euad337","DOI":"10.1093\/europace\/euad337","article-title":"Conventional Biventricular Pacing Is Still Preferred to Conduction System Pacing for Atrioventricular Block in Patients with Reduced Ejection Fraction and Narrow QRS","volume":"26","author":"Glikson","year":"2023","journal-title":"Europace"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"881","DOI":"10.1016\/j.jacep.2020.11.029","article-title":"His-Optimized Cardiac Resynchronization Therapy With Ventricular Fusion Pacing for Electrical Resynchronization in Heart Failure","volume":"7","author":"Zweerink","year":"2021","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/j.hrthm.2021.07.057","article-title":"Left Bundle Branch-Optimized Cardiac Resynchronization Therapy (LOT-CRT): Results from an International LBBAP Collaborative Study Group","volume":"19","author":"Moskal","year":"2022","journal-title":"Heart Rhythm"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e006613","DOI":"10.1161\/CIRCEP.118.006613","article-title":"Permanent His Bundle Pacing for Cardiac Resynchronization Therapy in Patients With Heart Failure and Right Bundle Branch Block","volume":"11","author":"Sharma","year":"2018","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2571","DOI":"10.1016\/j.hrthm.2024.06.019","article-title":"Predictors of Failed Left Bundle Branch Pacing Implant in Heart Failure with Reduced Ejection Fraction: Importance of Left Ventricular Diameter and QRS Morphology","volume":"21","author":"Graterol","year":"2024","journal-title":"Heart Rhythm"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1016\/j.hroo.2022.05.004","article-title":"Left Bundle Branch Area Pacing in Patients with Heart Failure and Right Bundle Branch Block: Results from International LBBAP Collaborative-Study Group","volume":"3","author":"Vijayaraman","year":"2022","journal-title":"Heart Rhythm O2"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1876","DOI":"10.1161\/CIRCULATIONAHA.118.038648","article-title":"Intracardiac Delineation of Septal Conduction in Left Bundle-Branch Block Patterns: Mechanistic Evidence of Left Intrahisian Block Circumvented by His Bundle Pacing","volume":"139","author":"Upadhyay","year":"2019","journal-title":"Circulation"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1016\/j.jacep.2020.08.015","article-title":"Left Bundle Branch Area Pacing for Cardiac Resynchronization Therapy","volume":"7","author":"Vijayaraman","year":"2021","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"3547","DOI":"10.1093\/eurheartj\/eht290","article-title":"An Individual Patient Meta-Analysis of Five Randomized Trials Assessing the Effects of Cardiac Resynchronization Therapy on Morbidity and Mortality in Patients with Symptomatic Heart Failure","volume":"34","author":"Cleland","year":"2013","journal-title":"Eur. Heart J."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1247","DOI":"10.1016\/j.hrthm.2012.03.016","article-title":"Acute Hemodynamic Response to Biventricular Pacing in Heart Failure Patients with Narrow, Moderately, and Severely Prolonged QRS Duration","volume":"9","author":"Ploux","year":"2012","journal-title":"Heart Rhythm"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1002\/ejhf.2736","article-title":"Effects of Haemodynamically Atrio-ventricular Optimized His Bundle Pacing on Heart Failure Symptoms and Exercise Capacity: The His Optimized Pacing Evaluated for Heart Failure (HOPE-HF) Randomized, Double-Blind, Cross-over Trial","volume":"25","author":"Whinnett","year":"2023","journal-title":"Eur. J. Heart Fail."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"euaf050","DOI":"10.1093\/europace\/euaf050","article-title":"European Society of Cardiology (ESC) Clinical Consensus Statement on Indications for Conduction System Pacing, with Special Contribution of the European Heart Rhythm Association of the ESC and Endorsed by the Asia Pacific Heart Rhythm Society, the Canadian Heart Rhythm Society, the Heart Rhythm Society, and the Latin American Heart Rhythm Society","volume":"27","author":"Glikson","year":"2025","journal-title":"Europace"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"760","DOI":"10.1111\/jce.15853","article-title":"Predictors of Procedural Failure of Left Bundle Branch Pacing in Scarred Left Ventricle","volume":"34","author":"Ponnusamy","year":"2023","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1016\/j.hrthm.2022.10.019","article-title":"Biventricular Endocardial Pacing and Left Bundle Branch Area Pacing for Cardiac Resynchronization: Mechanistic Insights from Electrocardiographic Imaging, Acute Hemodynamic Response, and Magnetic Resonance Imaging","volume":"20","author":"Elliott","year":"2023","journal-title":"Heart Rhythm"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1016\/j.hrthm.2022.10.027","article-title":"Distance between the Lead-Implanted Site and Tricuspid Valve Annulus in Patients with Left Bundle Branch Pacing: Effects on Postoperative Tricuspid Regurgitation Deterioration","volume":"20","author":"Hu","year":"2023","journal-title":"Heart Rhythm"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1202","DOI":"10.1016\/j.hrthm.2022.03.005","article-title":"Tricuspid Regurgitation Outcomes in Left Bundle Branch Area Pacing and Comparison with Right Ventricular Septal Pacing","volume":"19","author":"Li","year":"2022","journal-title":"Heart Rhythm"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Reddy, V.Y., Nair, D.G., Doshi, S.K., Doshi, R.N., Chovanec, M., Ganz, L., Sabet, L., Jiang, C., and Neuzil, P. (2025). First-in-Human Study of a Leadless Pacemaker System for Left Bundle Branch Area Pacing. Heart Rhythm., online ahead of print.","DOI":"10.1016\/j.hrthm.2025.04.030"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/7\/1240\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:07:15Z","timestamp":1760033235000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/7\/1240"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,9]]},"references-count":39,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2025,7]]}},"alternative-id":["medicina61071240"],"URL":"https:\/\/doi.org\/10.3390\/medicina61071240","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7,9]]}}}