Conduction System Pacing Versus Right Ventricular Pacing in Atrioventricular Block: A Systematic Review and Meta‐Analysis of Randomized Controlled Trials

INTRODUCTION: Right ventricular pacing (RVP) is the standard therapy for atrioventricular (AV) block but may cause ventricular dyssynchrony with long-term use. This meta-analysis evaluates the efficacy and safety of conduction system pacing (CSP), including His bundle pacing (HBP) and left bundle branch area pacing (LBBAP), as a physiologic alternative to RVP. METHODS: A systematic search was conducted across PubMed, Google Scholar, Cochrane CENTRAL, and ClinicalTrials.gov from inception to August 2025, for randomized controlled trials (RCTs). Outcomes were analyzed as risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs) and pooled using the Mantel-Haenszel random-effects model in R (version 4.4.2). RESULTS: Five RCTs enrolling 659 patients were included. CSP was associated with a significant improvement in LVEF compared with RVP (MD: 1.31%; 95% CI: 0.49 to 2.14; p < 0.01). While CSP resulted in a significantly narrower paced QRS duration (MD: -28.44 ms; 95% CI: -38.96 to -17.92; p < 0.01), the procedure time was longer with CSP (MD: 25.86 min; 95% CI: 23.09 to 28.63; p < 0.01). The risk of device and lead-related complications was comparable between cohorts (RR: 1.35; 95% CI, 0.28 to 6.63; p = 0.71). CONCLUSION: Conduction system pacing (CSP) slightly improves LVEF and achieves a significantly narrower paced QRS compared with right ventricular pacing (RVP). Although associated with longer procedure times, CSP does not increase device- or lead-related complications. These findings suggest that CSP offers more physiological ventricular activation while maintaining comparable safety to conventional RVP. TRIAL REGISTRATION: PROSPERO number: CRD420251152303.