In patients with heart failure (HF) and refractory atrial fibrillation (AFib) undergoing atrioventricular node ablation (AVNA), conduction system pacing (CSP) with left bundle branch area pacing (LBBAP) was noninferior to biventricular pacing (BVP) for improving LVEF, according to results from the CONDUCT-AF trial published Oct. 6 in EHJ.

The investigator-initiated trial was conducted across 10 European centers from July 2023 to May 2025. David Žižek, MD, et al., randomized 82 patients with refractory AFib, narrow QRS duration (≤120 ms), HF with an LVEF <50% and NT-proBNP >600 ng/L who were undergoing AVNA to either CSP or BVP. The mean age of the patients was 72 years, nearly half were men and 17% had no known coronary artery disease.

At six months, LVEF, the primary endpoint, improved similarly with both pacing strategies (36% to 46% with CSP and 34% to 46% with BVP; p=0.002 for noninferiority).

Changes in LV volumes, clinical parameters and the composite endpoint of worsening HF or cardiovascular death were also similar between groups. However, paced QRS duration (mean difference −14 ms; p<0.001) and procedural and fluoroscopy times were significantly shorter with CSP than with BVP.

"Given its more [favorable] procedural profile and physiological ventricular activation, CSP represents a viable alternative to BVP within a 'pace-and-ablate' strategy," write the authors, noting that "whether CSP confers incremental benefit on hard clinical endpoints remains to be determined in adequately powered randomized trials with longer follow-up."