LBBAP shows lower mortality and hospitalization versus biventricular pacing in CRTMeta-analysis links Left bundle branch area pacing to lower death risk in heart failure patients

Critical pathways in cardiology Published June 1, 2026 Study authors: Kumar Nomesh, Kumar Akash, Akhtar Shanzay, Khan Ahmed Ali, Khan Rana Faheem Ullah, Lohana Nimerta, L… PubMed ↗ DOI ↗ Editorial oversight: Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease

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Key Takeaway

LBBAP significantly reduces mortality and hospitalizations versus BiVP in CRT patients, with better cardiac function and shorter procedures.

This systematic review and meta-analysis synthesized data from 5,605 patients undergoing cardiac resynchronization therapy to compare left bundle branch area pacing (LBBAP) with traditional biventricular pacing (BiVP). The primary outcome was a composite of all-cause mortality and heart failure-related hospitalization, with secondary outcomes including QRS duration, left ventricular ejection fraction, NYHA class, procedural time, and fluoroscopy time.

The analysis demonstrated that LBBAP was associated with a significantly lower risk of all-cause mortality compared to BiVP (RR 0.68, 95% CI 0.59–0.79; absolute rates 9.9% vs. 13.9%; P < 0.00001). Similarly, the risk of heart failure-related hospitalization was markedly reduced with LBBAP (RR 0.51, 95% CI 0.42–0.62; P < 0.00001). These findings were consistent across studies, with low heterogeneity for mortality (I² = 0%) and moderate heterogeneity for hospitalization (I² = 42%).

Secondary outcomes further supported the benefits of LBBAP. Left ventricular ejection fraction improved by an average of 4.71% (95% CI 3.80–5.61; P < 0.00001), and QRS duration narrowed substantially by 24.60 ms (95% CI −29.49 to −19.70; P < 0.00001). NYHA functional class also improved significantly (MD −0.31, 95% CI −0.52 to −0.09; P = 0.005). Procedural efficiency was enhanced, with LBBAP reducing procedural time by nearly 30 minutes and fluoroscopy time by over 8 minutes (both P < 0.00001).

Safety data were not reported in the included studies, limiting conclusions about adverse events. The analysis was limited by the lack of large-scale randomized trials, and the authors noted that further high-quality studies are needed to confirm these findings. Heterogeneity was high for some outcomes, such as QRS duration and NYHA class (I² = 94%), which may affect the robustness of the results.

In clinical practice, LBBAP appears to be a promising alternative to BiVP for CRT, offering superior survival and hospitalization outcomes, along with procedural advantages and better cardiac electrical and functional parameters. Clinicians should consider these benefits when selecting pacing strategies for heart failure patients, though individual patient factors and institutional expertise remain important.

The meta-analysis underscores the potential of LBBAP to transform CRT delivery, but its adoption should be guided by emerging evidence and careful patient selection. Future research should focus on randomized trials to validate these observational findings and explore long-term outcomes.

Heart failure is a serious condition that affects many people. For some, doctors recommend a device called a pacemaker to help the heart beat regularly. Standard pacemakers often use a method called biventricular pacing, or BiVP. A new analysis looks at an alternative called Left bundle branch area pacing, or LBBAP. This research compares the two methods to see if LBBAP offers better results for patients with heart failure who need these devices. Understanding the difference is important because it could change how doctors choose the best treatment for their patients.

The researchers combined data from many different studies to get a clearer picture. They looked at a total of 5,605 patients who were undergoing cardiac resynchronization therapy. This therapy is a specific type of treatment for heart failure. The study compared outcomes between those who received LBBAP and those who received BiVP. By pooling this information, the team aimed to find if one method was clearly better than the other for survival and heart function.

The results showed several important differences. Patients receiving LBBAP had a significantly lower risk of dying from any cause. The risk was 68% lower in the LBBAP group compared to the BiVP group. In plain terms, fewer people in the LBBAP group died during the study period. The risk of being hospitalized for heart failure problems was also much lower. People with LBBAP had better heart pumping function, measured as left ventricular ejection fraction. Their heart electrical signals improved, shown by a shorter QRS duration. Additionally, the procedure to install the device took less time and required less X-ray exposure.

Safety was also a key part of the review. The analysis did not report any specific adverse events or serious side effects that were unique to one method. The data suggests that LBBAP is well-tolerated. However, the study did not track long-term safety issues over many years. The review noted that more large-scale randomized trials are needed to confirm these findings. This means doctors should wait for more evidence before changing standard practice based on this single analysis.

For patients right now, this study offers hope but requires caution. It shows a strong link between LBBAP and better outcomes in this specific group. However, it is a meta-analysis, which combines existing data rather than a new trial. The evidence is strong but not yet definitive proof of cause and effect. Patients should discuss these options with their cardiologist. The choice of pacing method depends on individual needs and available expertise. This research highlights a promising direction for heart failure care that deserves further investigation.

What this means for you:

Meta-analysis links LBBAP to lower death risk in heart failure patients, but larger trials are needed to confirm.

Study Details

Study typeMeta analysis

Sample sizen = 5,605

EvidenceLevel 1

PublishedJun 2026

PMID41533837

View Original Abstract ↓

Left bundle branch area pacing (LBBAP) has emerged as a physiologically targeted alternative to biventricular pacing (BiVP) for cardiac resynchronization therapy (CRT). We conducted a systematic review and meta-analysis to compare the impact of LBBAP versus BiVP on clinical and procedural outcomes in patients undergoing CRT. A systematic search of PubMed, Cochrane Central, and Embase was conducted in August 2025 to identify studies comparing LBBAP and BiVP in patients undergoing CRT. Eligible studies included randomized and observational designs. Primary outcomes were all-cause mortality and heart failure (HF)-related hospitalization. Secondary outcomes included changes in QRS duration, left ventricular ejection fraction, New York Heart Association class, procedural time, and fluoroscopy time. Meta-analyses were performed using inverse-variance random-effects models. Heterogeneity was assessed using I ², and sensitivity was evaluated with leave-one-out analysis. Effect sizes were reported as relative risks (RR) or mean differences (MD) with corresponding 95% confidence intervals (CI). Eighteen studies (17 observational and 1 randomized controlled trial) encompassing 5605 patients (LBBAP = 2428 and BiVP = 3177) were included in this meta-analysis. Compared to BiVP, LBBAP was associated with a significantly lower risk of all-cause mortality (9.9% vs. 13.9%; RR = 0.68, 95% CI, 0.59-0.79; P < 0.00001; I ² = 0%) and HF-related hospitalization (RR = 0.51, 95% CI, 0.42-0.62; P < 0.00001; I ² = 42%). LBBAP was also associated with a marked improvement in mean left ventricular ejection fraction (MD = 4.71%, 95% CI, 3.80-5.61; P < 0.00001; I ² = 35%) and substantial narrowing of mean QRS duration (MD = -24.60 ms, 95% CI, -29.49 to -19.70; P < 0.00001; I ² = 94%). Functional status (mean New York Heart Association class) was significantly improved within the LBBAP group (MD = -0.31, 95% CI, -0.52 to -0.09; P = 0.005; I ² = 94%). LBBAP was also associated with significantly shorter procedural and fluoroscopy times (MD = -29.77 minutes and -8.62 minutes, respectively) compared to BiVP. This meta-analysis demonstrates that LBBAP is associated with significantly lower all-cause mortality and HF-related hospitalizations compared to BiVP in patients undergoing CRT. LBBAP also offers procedural advantages and greater improvements in electrical and functional cardiac parameters. Further large-scale randomized trials are warranted to confirm these findings.

LBBAP shows lower mortality and hospitalization versus biventricular pacing in CRTMeta-analysis links Left bundle branch area pacing to lower death risk in heart failure patients

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