LBBAP shows lower mortality and hospitalization versus biventricular pacing in CRT

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.