Zero to Minimal Fluoroscopy Approach for Conduction System Pacing: A Meta-Analysis

Background: Conventional fluoroscopy-guided conduction system pacing (CSP) is technically challenging, prolongs procedure time, and increases radiation exposure. While ZMF offers a safer alternative, comprehensive evidence on its safety and efficacy remains limited. Therefore, we conducted a meta-analysis aiming to evaluate the feasibility and effectiveness of a zero-to-minimal fluoroscopy (ZMF) approach for CSP. Methods: We systematically searched PubMed, Embase, and Web of Science from inception to December 2024 for randomized controlled trials (RCTs) and observational studies comparing ZMF with conventional fluoroscopy for CSP. Comparative outcomes included procedural success rates, procedure time, fluoroscopy time, radiation dose, and complication rates. Mid-term lead performance data (capture threshold, sensing, impedance) were also analyzed, where available. Results: Eight eligible studies (four RCTs and four observational studies) involving 385 patients were analyzed. The ZMF approach demonstrated comparable procedural success rates (risk ratios [RR]: 1.01, 95% confidence interval [CI]: 0.97–1.06) and complication risks (RR: 0.64, 95%CI: 0.28–1.50) relative to conventional fluoroscopy. No significant difference emerged in procedure time between groups (standardized mean differences [SMD]: −0.16, 95%CI: −0.87 to −0.55). Notably, ZMF approach significantly reduced fluoroscopy time (SMD: −1.73, 95%CI: −2.61 to −0.85) and radiation exposure (SMD: −3.37, 95%CI: −5.94 to −0.79). Pooled analysis of mid-term lead performance (1–6 months) showed stable and excellent electrical parameters (capture threshold, sensing, impedance) in both groups, with no significant differences. Conclusions: ZMF for CSP significantly reduces fluoroscopy time and radiation exposure without compromising procedural efficiency or safety, or mid-term lead performance, offering significant clinical implications for radiation-sensitive populations.