Abstract Background Biventricular pacing (BVP) is the gold standard for cardiac resynchronization therapy (CRT). Recently, studies have shown promising results for conduction system pacing (CSP) as an alternative to BVP. However, the small study samples and paucity of data concerning long term safety of these devices prevent CSP from being used as first line therapy. Purpose This study examines clinical outcomes and long term safety of CSP compared to BVP. Methods We conducted a retrospective cohort study from patients receiving CSP or BVP. All patients implanted with either CSP (N = 282) or BVP (N = 216) from 2018 to 2023 were included. Patients had to complete at least 3 months of follow-up and CSP patients had to pace at least 20% of time at first visit. The outcomes were defined as at least one heart failure hospitalization and the complication rates for both arms. Results Median [IQR] follow-up time was 1.64 years [0.73 – 2.80]. Heart failure admissions were numerically lower for CSP group but when adjusted to confounders the adjusted odds ratio was 0.75 in the CSP group compared to BVP ([95% CI, 0.43-1.31]; P = 0.32). Long term complication rates (infection, lead dysfunction, diaphragmatic stimulation requiring system revision, etc.) were lower in the CSP group (4 [1.4%] vs 10 [4.7%]; odds ratio, 0.21 [95% CI, 0.06-0.69]; P = 0.01). Short term complication rates (lead displacement, infection, pneumothorax, etc.) were however similar for both arms (16 [5.7%] vs 11 [5.1%]; odds ratio, 1.53 [95% CI, 0.64-3.65]; P = 0.33). In two patients, septal lead extraction after over a year was possible without any sequelae. The change in the QRS duration went from 150 ms to 149 ms for group (p=NS) and from 153ms to 144ms for comparable CSP group (P = 0,01). Left ventricular ejection fraction (LVEF) increased from 28% to 40% in the BVP group and from 32% to 40% in the CSP group with pre intervention LVEF less than 50% (P < 0.0001 for both groups). Procedure duration was significantly shorter for CSP (82.3 minutes [32] vs 93.1[39.1]; P = .0002). Conclusion CSP approach achieves similar clinical results as BVP, with significantly less complications, shorter implant times, shorter QRS durations and comparable LVEF improvement. All these favorable results are obtained using less leads and simpler devices.