A systematic review and meta-analysis of randomized controlled trials (RCTs) published in the Open Heart reported an improvement in the clinical and cardiac outcomes with right ventricular pacing (RVP) compared to conduction system pacing (CSP).

The analysis compared the clinical effectiveness of CSP versus RVP in patients with atrioventricular block (AVB). MEDLINE, Embase, and Cochrane databases were searched from inception to October 2025. 

Only RCTs enrolling patients with AVB and directly comparing CSP with RVP were included. Outcomes were pooled using hazard ratios (HRs), risk ratios (RRs), and mean differences with 95% confidence intervals (CIs). Heterogeneity was assessed using I² statistics, and sensitivity analyses were conducted to evaluate robustness. Primary outcomes included heart failure hospitalization (HFH), all-cause mortality (ACM), and a composite endpoint, along with cardiac functional parameters.

A total of five RCTs comprising 985 patients were included in the analysis. CSP was associated with a significant reduction in the composite endpoint compared with RVP (HR 0.54; 95% CI 0.31–0.95; p=0.03). The risk of HFH was also markedly lower in the CSP group (RR 0.30; 95% CI 0.17–0.54; p<0.0001). 

However, no statistically significant difference was observed for ACM between the two pacing strategies (RR 0.69; 95% CI 0.36–1.30; p=0.25). Secondary outcomes favored CSP, with significant improvement in left ventricular ejection fraction (LVEF) (p=0.008) and shorter QRS duration (p=0.002) compared with RVP.

CSP was associated with improved clinical and cardiac outcomes compared with RVP in AVB. The effect on overall mortality remains uncertain based on available randomized evidence.