Background:The effects of conduction system pacing (CSP) compared with conventional biventricular pacing (BVP) on heart function in patients with heart failure remain elusive.Methods:PubMed, Embase, Cochrane’s Library and Web of science databases were searched up to 1 October 2022 for pertinent controlled studies. Random or fixed-effect model were used to synthesize the clinical outcomes. Subgroup analysis was performed to screen the potential confounding factors.Results:Fifteen studies including 1,347 patients were enrolled. Compared with BVP, CSP was significantly associated with shortened QRS duration [WMD -22.51 ms;p= 0.000], improved left ventricular ejection fraction [WMD 5.53%;p= 0.000], improved NYHA grade [WMD -0.42;p= 0.000], higher response rate and lower heart failure rehospitalization rate. CSP resulted in better clinical outcomes in higher male proportion group than lower one compared with BVP. No significant differences of clinical outcomes were observed between left bundle branch area pacing (LBBaP) and his bundle pacing (HBP) except the pacing threshold. The pacing threshold of LBBaP was significantly lower than those in BVP and HBP.Conclusion:This study suggests that CSP might be superior to conventional BVP for HF patients. In a higher male proportion group, CSP may be associated with more benefits than BVP.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022355991; Identifier: CRD42022355991.