Conduction system pacing is superior to reduce the new-onset atrial fibrillation risk compared with right ventricular pacing: insights from pooled clinical evidence

Background Conduction system pacing (CSP) has been reported to improve clinical outcomes in comparison of right ventricular pacing (RVP). However, the performance between CSP and RVP on the risk of new-onset atrial fibrillation (AF) remains elusive. Methods Four online databases were systematically searched up to December 1st 2023. Studies comprising the rate/risk of new-onset AF between CSP and RVP group were included. Subgroup analysis was performed to screen the potential determinants for the new-onset AF risk for CSP therapy. Moreover, the pooled risk of new-onset AF based on ventricular pacing burden (Vp) between CSP and RVP group were evaluated. Results A total of five studies including 1,491 patients requiring pacing therapy were eligible. The pooled new-onset AF rates for CSP and RVP group were 0.09 and 0.26, respectively. Compared with RVP group, CSP group showed a lower pooled risk (risk ratio [RR] 0.38, P =0.000) and adjusted risk (hazard ratio [HR] 0.33, P =0.000) of new-onset AF. Meanwhile, a significant intervention-covariate interaction for the adjusted risk of new-onset AF between CSP and RVP group was identified with Vp < 20% and Vp ≥ 20%. Conclusions Our study suggests that CSP is superior to reduce the new-onset atrial fibrillation risk compared with RVP. The Vp ≥ 20% may be the key determinant on the lower risk of new-onset AF with CSP therapy. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial CRD42023492551 ### Funding Statement This work was supported by the Suzhou Science and Technology Plan Project (SKY2022151). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: None I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes 4I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings of this study are available from the corresponding author upon reasonable request.