Biventricular vs. right ventricular pacing devices in patients anticipated to require frequent ventricular pacing (BioPace).

Summary

In 1,810 randomized patients (mean LVEF 55%, narrow QRS) with anticipated high ventricular pacing burden, biventricular pacing did not significantly reduce the composite of death or first heart failure hospitalization versus right ventricular pacing over 5.7 years. Mortality also did not differ, challenging the routine use of primary BiV pacing in this population.

Key Findings

• No significant difference in the composite of death or first HF hospitalization: HR 0.878 (95% CI 0.756–1.020), P=0.088.
• No significant difference in all-cause mortality: HR 0.926 (95% CI 0.789–1.088), P=0.349.
• Mean follow-up was 68.8 months, indicating durable neutral findings in a large cohort with mean LVEF 55.4% and mean QRS 118 ms.

Clinical Implications

For AV block patients with preserved LVEF and narrow QRS, standard RV pacing may be acceptable without defaulting to BiV systems; individualized selection should consider true dyssynchrony risk and future pacing burden.

Limitations

• Single-blind design and potential device-generation or programming heterogeneity over long enrollment.
• Primarily preserved LVEF/narrow QRS limits applicability to patients with LV dysfunction or wide QRS.

Future Directions

Define subgroups (e.g., emerging dyssynchrony, specific conduction disease) that may benefit from BiV or conduction system pacing; compare modern conduction system pacing vs RV/BiV in similar populations.