Abstract Body (Do not enter title and authors here): Background:

Chronic right ventricular pacing (RVP) can lead to electrical dyssynchrony, often resulting in pacemaker-induced cardiomyopathy (PICM). Although biventricular pacing (BiVP) is a standard upgrade strategy, it is associated with notable rates of non-response and procedural limitations. Conduction system pacing (CSP), including His bundle pacing (HBP) and left bundle branch pacing (LBBP), offers a more physiological approach by directly engaging the native conduction system. Emerging evidence supports the role of His-Purkinje conduction system pacing (HPCSP) in reversing adverse remodeling and improving clinical outcomes in PICM patients.

Methods:

A comprehensive literature search was performed across PubMed, Embase, Cochrane Library, and ClinicalTrials.gov through January 2025. Studies were included if they evaluated outcomes in patients with PICM who had been chronically paced in the right ventricle and subsequently upgraded to HPCSP. Key endpoints included changes in left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class.

Results:

Six studies comprising 144 patients were included. Over an average follow-up of 17.9 ± 10.5 months, significant improvement in LVEF was observed, increasing from 35 ± 8% prior to upgrade to 48 ± 12% following HPCSP (P < 0.001). Similarly, NYHA class improved from a baseline of 2.7 ± 0.8 to 1.9 ± 0.8 (P < 0.001), indicating meaningful symptomatic relief.

Conclusion:

Upgrading to His-Purkinje conduction system pacing is a safe and effective strategy in patients with PICM. It offers significant improvements in cardiac function and quality of life by restoring physiologic electrical activation. HPCSP represents a promising alternative to BiVP in this population and should be considered in clinical decision-making for pacing upgrades.