Comparative Effectiveness and Safety of Conduction System Pacing versus Biventricular Pacing in Patients with Pacing-Induced Cardiomyopathy: A Systematic Review and Meta-analysis Brief title：CSP versus BVP in PICM

Comparative Effectiveness and Safety of Conduction System Pacing versus Biventricular Pacing in Patients with Pacing-Induced Cardiomyopathy: A Systematic Review and Meta-analysis Brief title：CSP versus BVP in PICM | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 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Data may be preliminary. 17 April 2025 V1 Latest version Share on Comparative Effectiveness and Safety of Conduction System Pacing versus Biventricular Pacing in Patients with Pacing-Induced Cardiomyopathy: A Systematic Review and Meta-analysis Brief title：CSP versus BVP in PICM Authors : Qing Jin 0009-0008-2226-4636 , Xingbiao Ren , and Haiyan Wang [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.174489694.41355080/v1 194 views 55 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: Biventricular pacing (BVP) and conduction system pacing (CSP) can enhance pacing-induced cardiomyopathy (PICM) patients’ clinical outcomes, yet guidelines lack a specified preferred pacing strategy. This meta-analysis compares the efficacy and safety of CSP and BVP in PICM patients. Methods: Databases including PubMed, Cochrane Library, Web of Science, and Embase were searched from their establishment to February 2025, Data analysis was performed using Stata 17. Results: Eighteen observational studies involving 679 patients with PICM were included, among which 322 patients were treated with BVP and 357 patients with CSP. Results showed CSP group had a greater QRS duration (QRSd) reduction than BVP group (MD = -54.61 ms, 95% CI: -59.67, -49.54 vs MD = -28.22 ms, 95% CI: -32.13, -24.31; P < 0.001). After 14-months follow-up, CSP group had a higher response rate (84.0% vs 66.4%) and lower incidences of adverse outcomes and device-related complications (9.6% vs 17.2%) than BVP group. Subgroup analysis showed His bundle pacing (HBP) was associated with greater QRSd shortening and stable pacing thresholds, while left bundle branch area pacing (LBBAP) had lower thresholds. Conclusions: The results indicate that CSP is superior to BVP in improving PICM patients’ clinical outcomes, suggesting that CSP may be a promising alternative pacing strategy for PICM patients. However, since most of the included studies were case series, there are certain limitations in the results. Large-scale randomized controlled trials are required to further verify the effectiveness and safety of CSP in PICM. 1. INTRODUCTION Studies have shown that long-term high-burden right ventricular pacing (RVP) can lead to delayed myocardial electrical activation and ventricular dyssynchrony, ultimately resulting in pacing-induced cardiomyopathy (PICM), characterized by progressive left ventricular systolic dysfunction with or without heart failure (HF) symptoms [1-2] . The definition of PICM varies significantly across studies, typically described as (1) exclusion of other cardiac diseases, such as myocardial infarction, primary cardiomyopathy, and valvular disease; (2) percentage of right ventricular pacing ≥20%; and (3) normal left ventricular ejection fraction (LVEF) before pacemaker implantation, with a post-implantation decline in LVEF ≥10% and a final LVEF <50% [1] . A meta-analysis involving approximately 58,000 patients showed that the prevalence of PICM in patients with chronic RVP is as high as 12% (95% CI: 11, 14) [2] . The long-term prognosis of PICM patients is worse than that of non-PICM patients. Kiehl et al found that the LVEF of PICM patients (33.7% ± 7.4%) was 24% lower than that of non-PICM patients (57.6% ± 6.1%) [3] . The risk of all-cause mortality or heart failure hospitalization (HFH) was significantly higher (54% vs 38.3%) [4] . The primary goal of managing PICM patients is to restore ventricular synchrony. Current guidelines recommend upgrading conventional RVP to biventricular pacing (BVP) [1,5] . BVP has been proven to improve cardiac function, reverse ventricular remodeling, and reduce adverse events [6-10] . However, procedural failure, non-response, and postoperative complications are not uncommon [3,8] . For patients undergoing initial pacemaker implantation, conduction system pacing (CSP) may achieve better cardiac synchrony and reduce the incidence of PICM compared to BVP [12] . CSP has been preliminarily shown to improve outcomes in PICM patients [12-24] . However, current evidence is limited to small-sample and observational studies, and there is a lack of randomized controlled trials (RCTs) comparing BVP and CSP. Whether CSP can serve as an alternative pacing strategy for PICM patients requires further validation. This study, through a case series study, evaluated the efficacy and safety of CSP and BVP in PICM patients, aiming to provide preliminary evidence for clinical decision-making. 2. METHODS This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The study was registered on PROSPERO after the initial screening of the literature (CRD42025646751). 2.1 Literature Search and Screening Strategy A comprehensive search was conducted in PubMed, Cochrane Library, Web of Science, and Embase databases for relevant literature published from their inception to February 2025. The search terms included: ”His-Purkinje system pacing”, ”HPSP”, ”His-Purkinje conduction system pacing”, ”left bundle branch pacing”, ”LBBP”, ”left bundle branch area pacing”, ”LBBAP”, ”His bundle pacing”, ”HBP”, ”cardiac resynchronization therapy”, ”CRT”, ”biventricular pacing”, ”BVP”, ”conduction system pacing”, ”CSP”, ”right ventricular pacing”, ”RVP”, ”pacemaker-induced cardiomyopathy”, ”right ventricular pacing-induced cardiomyopathy”, “PICM”. A combination of Medical Subject Headings (MeSH) terms and free-text words was used for the search strategy, as detailed in Supplementary Table 1 . Two researchers (QJ and XBR) independently screened the titles and abstracts to exclude irrelevant and duplicate studies. Subsequently, full texts were reviewed according to the inclusion and exclusion criteria, and eligible studies were identified. Reference lists of included studies were also reviewed to ensure a comprehensive search. 2.2 Inclusion and Exclusion Criteria The inclusion criteria of this meta-analysis were as follows: (1) Study type: RCTs and observational studies; (2) Study population: Patients aged ≥18 years with PICM who were upgraded to BVP or CSP; and (3) Study content: Clinical and echocardiographic data before and after device upgrade, recorded prospectively or retrospectively. Adverse outcomes and device-related complications after upgrade should also be reported. The exclusion criteria were as follows: (1) Animal studies, reviews, editorials, meta-analyses, case reports, academic theses, and conference abstracts; (2) Studies unrelated to the topic, duplicate publications, or those with unavailable relevant data; (3) Studies with a follow-up period <3 months after device upgrade; (4) Studies lacking a clear definition of PICM. 2.3 Data Extraction and Methodological Quality Assessment Two researchers (QJ and XBR) independently reviewed the literature, extracted relevant data, and assessed the methodological quality. The extracted data included (if available) : (1) General information: First author, publication year, study type, number of cases, patient age, proportion of males, upgrade strategy, follow-up duration after upgrade, upgrade success rate, response rate, RVP duration, and RVP%. (2) Clinical efficacy outcomes: LVEF, New York Heart Association (NYHA) classification, QRS duration (QRSd), left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic volume (LVESV), and pacing parameters before and after upgrade. (3) Clinical safety outcomes: Response rate, HFH, all-cause mortality, and device-related complications. Initially, this study planned to include both RCTs and observational studies; however, only observational studies were included after screening. The methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Discrepancies were resolved through discussion with a third senior researcher (HYW). The quality assessment results were not used to exclude studies. 2.4 Statistical Analysis Statistical analysis was performed using Stata 17 software. Random or fixed-effects models were used to pool data from each study. The fixed-effects model was calculated using the inverse variance method, while the random-effects model was generated using the DerSimonian-Laird (D-L) method. Clinical efficacy outcomes were expressed as mean differences (MD) and 95% confidence intervals (95% CI) to measure effect sizes. Heterogeneity among the included studies was assessed using the I² statistic. If I² > 50%, significant heterogeneity was considered present, and the random-effects model was applied; otherwise, the fixed-effects model was used. Sources of heterogeneity were explored through sensitivity analysis and meta-regression. Additionally, subgroup analysis was conducted to compare differences between the HBP and LBBAP groups. A p-value < 0.05 was considered statistically significant for differences before and after upgrading. Publication bias was evaluated using funnel plots and Egger’s test. 3. RESULTS 3.1 Study Selection A total of 3,160 articles were retrieved from the databases. After removing duplicate publications, 1,211 articles remained. By screening titles and abstracts, 1,135 irrelevant articles were excluded. The remaining articles were reviewed in full text, excluding case reports, reviews, conference abstracts, and studies with irrelevant content, unavailable full texts, or missing data. Sixteen studies met the inclusion criteria. Additionally, two more studies were identified through reference screening and included. Ultimately, 18 eligible studies were included, all of which were observational studies. The selection process is illustrated in Supplemental Figure 1. 3.2 Study Characteristics and Quality Assessment Eight studies included patients upgraded to BVP (n=322), while 13 studies included patients upgraded to CSP (n=357), with three studies encompassing both BVP and CSP groups. All studies provided clear definitions of PICM. The majority of patients were male (66.9%), with a mean age ranging from 61±9 to 77±10 years. Twelve studies reported the prevalence of atrial fibrillation, accounting for 31.5% (n=214). The mean duration of RVP was 6.2 years, and the mean follow-up duration post-upgrade was 14 months (range: 3–36 months). The BVP group had a mean response rate of 66.4%, while the CSP group showed a higher response rate of 84.0% and an implantation success rate of 91.8%. However, the criteria for defining response success varied across studies (Supplementary Table 2), potentially introducing heterogeneity. The RVP% in both groups was predominantly above 90% (except in the study by Nazeri et al). Detailed characteristics and quality assessment of the included studies are summarized in Table 1. 3.3 Impact of Upgrade on LVEF, QRSd and NYHA Classification All studies reported LVEF before upgrade and at the end of follow-up ( Figure 1A ). Significant heterogeneity was observed in the BVP group ( I² = 86%, p < 0.001), the CSP group ( I² = 37%, p = 0.08), and overall ( I² = 73%, p < 0.001), necessitating the use of a random-effects model. Both the BVP and CSP groups demonstrated significant improvements in LVEF (MD = 10.75, 95% CI: 7.24, 14.26; p < 0.001), (MD = 12.35, 95% CI: 10.95, 13.76; p < 0.001). Twelve studies reported NYHA classification before upgrade and at the end of follow-up ( Figure 1B ). A random-effects model was applied due to significant overall heterogeneity ( I² = 66%; p < 0.001). Both the BVP group (n = 146) and the CSP group (n = 263) showed reduction in NYHA classification (MD = -0.82, 95% CI: -1.13, -0.52; p < 0.001, I² = 76%), (MD = -1.03, 95% CI: -1.22, -0.84; p < 0.001, I² = 61%). Sixteen studies reported QRSd before upgrade and during follow-up ( Figure 1C ), and a random-effects model was used for meta-analysis (overall I² = 89%, p < 0.001). The CSP group and the BVP group showed a reduction in QRSd after the upgrade, with the CSP group demonstrating a MD of -54.61 (95% CI: -59.67, -49.54; p < 0.001, I² = 57%) and the BVP group showing an MD of -28.22 (95% CI: -32.13, -24.31; p < 0.001, I² = 5%). The reduction in QRSd was more pronounced in the CSP group compared to the BVP group ( p < 0.001). 3.4 Impact of Upgrade on Left Ventricular Remodeling Ten studies reported LVEDD before and after the upgrade ( Figure 2A ). In the CSP group, which included 7 studies (211 patients), LVEDD decreased by 4.06 mm (95% CI: -5.36, -2.76; p < 0.001, I² = 0%). In the BVP group, which included 4 studies (144 patients), LVEDD decreased by 5.63 mm (95% CI: -7.11, -4.15; p < 0.001, I² = 67%). Five studies reported changes in LVESV ( Figure 2B ). Compared to the pre-upgrade value of 111.71 ± 52.58 mL, LVESV significantly decreased after the upgrade (MD = -30.91, 95% CI: -40.42, -21.40; p < 0.001, I² = 17%). 3.5 Impact of Upgrade on Pacing Parameters Ten studies reported pacing thresholds before and after the upgrade ( Figure 3A ). The overall baseline threshold before the upgrade was 1.17 ± 0.69 V, which slightly increased to 1.24 ± 0.86 V after the upgrade (MD = -0.05, 95% CI: -0.15, 0.05; p = 0.17, I² = 60%), analyzed using a random-effects model. In the CSP group (n = 329), the pacing threshold increased during follow-up (MD = -0.10, 95% CI: -0.19, -0.01; p = 0.02, I² = 38%), while in the BVP group (n = 94), it decreased (MD = 0.18, 95% CI: 0.02, 0.34; p = 0.03, I² = 12%). The difference in threshold changes between the two groups was statistically significant ( p = 0.002). Seven studies reported pacing impedance ( Figure 3B ). The pacing impedance reduction in the CSP group was MD = 73.29 (95% CI: 30.05, 116.53; p < 0.001, I² = 58%), while the reduction in the BVP group was greater, with MD = 138.70 (95% CI: 50.70, 226.70; p = 0.002). However, this result should be interpreted with caution due to the inclusion of only a single study in the BVP group. Six studies in the CSP group reported changes in R-wave amplitude ( Figure 3C ). The mean R-wave amplitude at implantation was 8.41 ± 5.08 mV, and it was 9.04 ± 2.17 mV during follow-up (MD = -0.82, 95% CI: -2.05, 0.41), with high heterogeneity ( p = 0.02, I² = 62%), prompting the use of a random-effects model. The difference in R-wave amplitude remained stable within the group ( p = 0.19). 3.6 Subgroup Analysis of HBP and LBBAP The CSP group was further divided into the HBP subgroup (n = 141) and the LBBAP subgroup (n = 158) ( Figure 4 ). In terms of LVEF, subgroup analysis showed that both the HBP and LBBAP subgroups exhibited significant improvements, with increases of 13.36% (95% CI: 11.37, 15.36; p < 0.001) and 12.53% (95% CI: 10.74, 14.33; p < 0.001). The QRSd was significantly shortened by 63.05 ms (95% CI: -67.32, -58.77; p < 0.001) in the HBP subgroup and by 51.88 ms (95% CI: -58.38, -45.33; p < 0.001) in the LBBAP subgroup, both of which were superior to the BVP group (MD = -28.22, 95% CI: -32.13, -24.31; p < 0.001). The difference in QRSd between the two subgroups was statistically significant ( p < 0.05) but associated with substantial heterogeneity ( I² = 89.9%). The NYHA classification improved by 1.08 (95% CI: -1.44, -0.72; p < 0.001) in the HBP subgroup and by 1.01 (95% CI: -1.32, -0.71; p < 0.001) in the LBBAP subgroup. Additionally, the mean pacing threshold increased by 0.12 V (95% CI: -0.19, -0.06) in the LBBAP subgroup and by 0.09 V (95% CI: -0.24, 0.07) in the HBP subgroup. The pacing threshold in the LBBAP subgroup was lower than that in the HBP subgroup both at implantation (0.7 ± 0.28 V vs 1.37 ± 0.74 V; p < 0.001) and during follow-up (0.8 ± 0.36 V vs 1.54 ± 1.04 V; p < 0.001). However, the stability of the pacing threshold was inferior in the LBBAP subgroup compared to the HBP subgroup ( p = 0.0003 vs p = 0.24). If there is substantial heterogeneity between the two subgroups, a random-effects model will be used for data analysis; otherwise, a fixed-effects model will be applied. 3.7 Adverse Outcomes and Device-Related Complications Fourteen studies reported adverse outcomes or device-related complications in patients with PICM during follow-up. The mean follow-up duration was fourteen months, adverse outcomes or complications occurred in 12.6% of PICM patients. In the BVP group (n = 232), there were 28 cases of HFH or all-cause mortality (12.1%) and 12 cases of device-related complications (5.2%). In the CSP group (n = 345), there were 26 cases of HFH or all-cause mortality (7.5%) and 7 cases of device-related complications (2.0%). The most common perioperative complication was infection (2.1%), with a higher incidence in the BVP group compared to the CSP group (0.9% vs 3.9%) ( Supplementary Table 3 ). 3.8 Publication Bias and Meta-Regression Funnel plots and Egger’s test did not reveal significant publication bias for the results of QRSd, LVEF, NYHA classification, left ventricular structural parameters, and pacing parameters ( Supplementary Figure 2 ). We performed meta-regression analysis on patients with CSP to evaluate the effects of baseline LVEF, baseline NYHA classification, baseline QRSd, follow-up duration after upgrade, RVP%, right ventricular pacing duration, ΔQRSd, and age on the improvements in LVEF, QRSd, and NYHA classification. In the univariate regression model, we found that advanced age was significantly associated with greater improvement in LVEF. Additionally, improvement in QRSd was positively correlated with improvement in LVEF. Furthermore, a higher baseline NYHA class showed a stronger association with improvement in NYHA classification. Moreover, a higher RVP% was associated with greater shortening of QRSd. These findings suggest that baseline patient characteristics may be an important source of heterogeneity influencing treatment efficacy, and future studies should further validate the role of these factors ( Figure 5 ). 4. DISCUSSION This study summarizes the efficacy and safety of CSP (including HBP and LBBAP) and BVP in the treatment of PICM. Our findings suggest that CSP demonstrates potential advantages in improving electrical synchrony, increasing response rates, and reducing adverse outcomes and device-related complications. Subgroup analysis indicates that HBP excels in enhancing electrical synchrony and maintaining stable pacing thresholds, while LBBAP exhibits significantly lower pacing thresholds. In addition, CSP had better escalation outcomes in patents with older age, better cardiac synchrony recovery, poorer baseline cardiac function, and a higher RVP%. PICM is a common but often overlooked complication after right ventricular pacing. It is mainly caused by chronic high-percentage RVP, which leads to left ventricular electromechanical dyssynchrony, myocardial remodeling, and a decline in left ventricular function, potentially progressing to HF. Most current studies focus on the effects of CSP or BVP in patients with HF and reduced ejection fraction after pacing [25-27] , but PICM as a specific cause has received less attention. Treating PICM as a separate condition and intervening early may help delay or reverse disease progression, preventing or reducing HF. Studies show that left bundle branch block, QRSd ≥155 ms, and RVP% ≥ 86% are key predictors of PICM [2] . Patients with lower baseline LVEF, longer QRSd, and long-term high RVP% often have more severe left ventricular damage, and the benefits of BVP upgrade therapy on LVEF are limited in these cases [27] . Therefore, upgrade therapy should be considered early for patients with PICM risk factors. Nazeri et al. first demonstrated that BVP can reverse PICM, showing significant improvement in cardiac function in 75% of patients and reversal of left ventricular structural changes [10] . Schwerg et al further supported these findings, reporting an 85% positive response rate to BVP upgrade therapy [9] . However, in our study, the BVP response rate was only 66.4%, potentially due to differences in the definition of ”response”. Notably, Khurshid et al. found that after a median follow-up of 7 months, the BVP response rate was 86%, with 72.2% of severe PICM patients (baseline LVEF ≤ 35%) achieving LVEF improvement to > 35%, and most improvements occurring within the first three months post-upgrade [8] . This suggests that BVP upgrade may benefit patients regardless of RVP duration or baseline LVEF. Nevertheless, BVP has several limitations, including high implantation failure rates, non-response rates (20-30%), cardiac vein injury, phrenic nerve stimulation, and restricted patient selection. Additionally, BVP is non-physiological pacing and cannot restore normal ventricular activation sequences, with higher complication rates (infection 3.7%, pneumothorax 2.0%, cardiac perforation or tamponade 1.4%, and lead-related complications 3.3%) [28] . As a result, BVP upgrade is only a class IIa recommendation for PICM in current guidelines [1-2] . CSP, by engaging the His-Purkinje system, enables more physiological ventricular activation and may offer superior clinical benefits over BVP in treating PICM. Gardas et al demonstrated that in PICM patients, HBP achieved an 83% upgrade success rate, with significant advantages over BVP in QRSd reduction, LVEF improvement, NYHA classification enhancement, and mitigation of mitral regurgitation severity. Notably, the proportion of patients achieving LVEF improvement to > 35% was significantly higher in the HBP group (90.5%) compared to the BVP group (71.4%). However, HBP is limited by technical challenges, risks of His bundle injury, high lead revision rates, and elevated pacing thresholds [24] . LBBAP, as an alternative to HBP, is technically easier due to the broad distribution of the left bundle branch and is associated with lower pacing thresholds. Large-scale studies have shown that LBBAP significantly shortens QRSd, improves response rates, and reduces mortality or HFH compared to BVP, despite longer procedural times [29] . Hua et al further confirmed that LBBAP achieves similar QRSd reduction and procedural success rates as HBP but with shorter procedure and fluoroscopy times, as well as lower and more stable pacing thresholds [30] . The results of this meta-analysis align with previous studies, confirming that CSP is superior to BVP in improving clinical outcomes for PICM patients. However, earlier studies rarely directly compared CSP with BVP. By integrating data from multiple observational studies, this study provides more comprehensive evidence supporting the clinical advantages of CSP. For patients requiring upgrade therapy, direct comparisons between HBP and LBBAP are limited, and few studies report post-procedural complications and long-term outcomes, making it difficult to fully assess the long-term safety and efficacy of these pacing strategies in PICM patients. This study shows that HBP achieves greater QRSd reduction, likely due to its more physiological ventricular activation through the His-Purkinje system. Additionally, LBBAP demonstrates similar improvements in LVEF and NYHA classification compared to HBP, with lower initial pacing thresholds and comparable implantation success rates (91.3% vs 89.9%). These findings suggest that LBBAP may be a technically easier and equally effective alternative to HBP. 5. LIMITATIONS This study has limitations. First, all included studies were observational, mostly case series, lacking control groups, with high bias risk and low evidence quality. Although three studies directly compared CSP and BVP, limitations in design and sample size prevented definitive conclusions. Additionally, limited long-term data on LBBAP and HBP in PICM patients reduced comparability between subgroups. Second, despite sensitivity analysis confirming reliability, significant heterogeneity among studies, even with random-effects models, may affect result stability. Heterogeneity sources included patient baseline characteristics, small sample sizes, missing data, inconsistent PICM and response definitions, variations in pacing sites and devices, operator experience differences, and study quality. Furthermore, short follow-up in some studies may underestimate PICM incidence and the long-term impact of upgrade therapy. 6. CONCLUSION For patients with PICM, CSP may offer potential advantages over BVP in improving electrical synchrony, increasing response rates, and reducing adverse outcomes. 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Front Physiol. 2024 Jul 23;15:1355696. [23]Huang H, Li X, Long T, et al. Effectiveness of upgrade left bundle branch area pacing for right ventricular pacing-induced cardiomyopathy: Extra QRS shortening matters. Journal of arrhythmia. 2025;41 (1): e70017. [24]Gardas R, Golba KS, Soral T, et al. The Effects of His Bundle Pacing Compared to Classic Resynchronization Therapy in Patients with Pacing-Induced Cardiomyopathy. J Clin Med. 2022;11 (19):5723. [25]Ferreira Felix I, Collini M, Fonseca R, et al. Conduction system pacing versus biventricular pacing in heart failure with reduced ejection fraction: A systematic review and meta-analysis of randomized controlled trials. Heart Rhythm. 2024;21 (6):881-889. [26]Merkely B, Hatala R, Wranicz JK, et al. Upgrade of right ventricular pacing to cardiac resynchronization therapy in heart failure: a randomized trial. Eur Heart J. 2023;44 (40):4259-4269. [27]Merkely B, Hatala R, Merkel E, et al. Benefits of upgrading right ventricular to biventricular pacing in heart failure patients with atrial fibrillation. Europace. 2024;26 (7): euae179. [28]Kaza N, Htun V, Miyazawa A, et al. Upgrading right ventricular pacemakers to biventricular pacing or conduction system pacing: a systematic review and meta-analysis. Europace. 2023;25 (3):1077-1086. [29]Al Hennawi H, Khan MK, Sohail A, et al. Left Bundle Branch Pacing: A Paradigm Shift in Physiological Pacing for Patients With Atrioventricular Block and Preserved Left Ventricular Systolic Function, A Systematic Review and Meta-analysis. Curr Probl Cardiol. 2023;48 (12):101983. [30]Hua W, Fan X, Li X, et al. Comparison of Left Bundle Branch and His Bundle Pacing in Bradycardia Patients. JACC Clin Electrophysiol. 2020;6 (10):1291-1299. FIGURE LEGENDS Figure 1 Forest plot about the mean difference of LVEF, NYHA classification and QRSd of BVP and CSP. LEGEND: (A) LVEF, Left ventricular ejection fraction; (B) NYHA, New York Heart Association; (C) QRSd, QRS duration. CSP, conduction system pacing; BVP, biventricular pacing Figure 2 Forest plot about the mean difference of LVEDD and LVESV of BVP and CSP. LEGEND: (A) LVEDD, left ventricular end diastolic dimension; (B) LVESV, left ventricular end systolicvolume. CSP, conduction system pacing; BVP, biventricular pacing Figure 3 Forest plot about the mean difference of pacemaker electricalparameters of BVP and CSP. LEGEND: (A) pacing threshold; (B) sensed R-wave amplitude; (C) pacing impedance. CSP, conduction system pacing; BVP, biventicular pacing. Figure 4 Forest plot of mean difference of outcomes of LBBAP and HBP. LEGEND: (A) QRSd. (B) LVEF. (C) NYHA classification. (D) Pacing threshold. HBP, His-bundle pacing; LBBAP, left bundle branch area pacing; NYHA, New York Heart Association; LVEF, Left ventricular ejection fraction; QRSd, QRS duration. Figure 5 Meta-regression on factors associated with improvements in LVEF, NYHA, and QRSd in CSP. LEGEND: (A) Age and improvement in LVEF; (B) △QRSd and improvement in LVEF; (C) Baseline NYHA classification and changes in NYHA classification; (D) RVP%and QRSd improvement. LVEF, left ventricular ejection fraction; RVP%, percentage of right ventricular pacing; NYHA, New York Heart Association; QRSd, QRS duration; CSP, conduction system pacing Supplementary Material File (table 1.pdf) Download 104.75 KB Information & Authors Information Version history V1 Version 1 17 April 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords clinical: electrophysiology – cardioversion clinical: implantable devices – biventricular pacing/defibrillation Authors Affiliations Qing Jin 0009-0008-2226-4636 Shandong Provincial Qianfoshan Hospital View all articles by this author Xingbiao Ren Jining Medical University Clinical Medical College View all articles by this author Haiyan Wang [email protected] Shandong Provincial Qianfoshan Hospital View all articles by this author Metrics & Citations Metrics Article Usage 194 views 55 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Qing Jin, Xingbiao Ren, Haiyan Wang. Comparative Effectiveness and Safety of Conduction System Pacing versus Biventricular Pacing in Patients with Pacing-Induced Cardiomyopathy: A Systematic Review and Meta-analysis Brief title：CSP versus BVP in PICM. Authorea . 17 April 2025. 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