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Randomized Controlled Trial
. 2025 Aug 4;27(8):euaf181.
doi: 10.1093/europace/euaf181.

Two-year outcomes of left bundle branch area pacing versus traditional right ventricular pacing in middle-aged adults: a registry-based trial

Matteo Bertini  1 , Luca Canovi  1 , Francesco Vitali  1 , Lina Marcantoni  2 , Gianni Pastore  2 , Mario Volpicelli  3 , Orlando Munciguerra  3 , Mauro Biffi  4 , Matteo Ziacchi  4 , Luca Rossi  5 , Valeria Carinci  6 , Paolo Sirugo  6 , Paolo Pastori  7 , Jacopo Francesco Imberti  8 , Pier Luigi Pellegrino  9 , Erminia Guerriero  10 , Biagio Sassone  11 , Enrico Bertagnin  11 , Giuseppe Coppola  12 , Michele Malagù  1 , Cristina Balla  1 , Giorgia Azzolini  1 , Gloria Zuccari  1 , Francesco Zanon  2 , Giuseppe Boriani  8 , Marco Zuin  1
Affiliations
Randomized Controlled Trial

Two-year outcomes of left bundle branch area pacing versus traditional right ventricular pacing in middle-aged adults: a registry-based trial

Matteo Bertini et al. Europace. .

Abstract

Aims: Prolonged right ventricular pacing (RVP) increases the risk of cardiomyopathy, atrial fibrillation, heart failure (HF), and mortality. This registry-based trial compared left bundle branch area pacing (LBBAP) with RVP in patients younger than 65 years.

Methods and results: Using the ConTempoRary Cardiac Stimulation in Clinical practicE: lEft, BivEntriculAr, Right, and conDuction System Pacing (TREEBEARD) registry (NCT06324682), patients were randomized 1:1 to LBBAP or RVP. The primary endpoint was a composite of cardiovascular (CV) death and HF hospitalization (HFH); secondary endpoints included individual components and all-cause mortality. A total of 344 patients (mean age 58.5 years, 215 males, 172 per arm) were included. At 2 years, the primary composite endpoint occurred in 6.3% of LBBAP vs. 12.7% of RVP patients (HR, 0.78; 95% CI, 0.59-0.87), representing a 22% risk reduction. Subgroup analyses aligned with primary findings. Left bundle branch area pacing significantly reduced HFH risk (HR, 0.79; 95% CI, 0.63-0.86) but showed no difference in CV mortality (HR, 1.02; 95% CI, 0.79-1.32) or all-cause mortality (HR, 1.00; 95% CI, 0.72-1.38).

Conclusion: Left bundle branch area pacing significantly lowered the 2-year composite of CV death and HFH compared to RVP in patients aged <65 years old. However, it did not reduce CV or all-cause mortality individually compared to RVP.

Clinical trial registration: TREEBEARD (NCT06324682).

Keywords: Cardiovascular death; Heart failure; Left bundle branch area pacing; Right ventricular pacing.

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Conflict of interest statement

Conflict of interest: M.B. received speaker’s fees from Biotronik, Abbott, and Boston Scientific and small consultant fees from Biotronik, Boston Scientific, and Microport. L.M. received speaker’s fees from Biotronik. F.Z. received speaker fees from Abbott, Biotronik, Boston Scientific, Medtronic, and Microport. M.Z received speaker’s fees from Abbott, Biotronik, Boston Scientific, and Edwards Lifesciences. G.B. is the principal investigator of the Applying ARtificial Intelligence to define clinical trajectorieS for personalized predicTiOn and early deTEction of comorbidity and muLtimorbidity pattErnS (ARISTOTELES) project that received funding from the European Union within the Horizon 2020 research and innovation programme (grant no. 101080189). G.B. reported small speaker fees from Bayer, Boehringer Ingelheim, Boston, Daiichi Sankyo, Janssen, and Sanofi outside of the submitted work. The other authors have no conflicts of interest to disclose.

Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Study flowchart. LBBAP, left bundle branch area pacing; RVP, right ventricular pacing.
Figure 2
Figure 2
Study outcomes. The primary outcome was a composite of death from cardiovascular causes and hospitalization for heart failure (A). The cumulative incidences for the primary outcome and the constituents of the primary outcome, hospitalization for heart failure (B), and death from cardiovascular causes (C) were estimated using the Kaplan–Meier. Included in these analyses are all patients enrolled. Hazard ratios and 95% confidence interval were estimated with the use of Cox regression models, stratified according to the pacing modality. The graphs are truncated at 48 months. The inset of each panel shows the same data on an enlarged y axis. CV, cardiovascular; HF, heart failure; LBBAP, left bundle branch area pacing; RVP, right ventricular pacing.
Figure 3
Figure 3
Primary composite outcome, according to prespecified subgroups. The primary outcome of the trial, a composite of death from cardiovascular causes and hospitalization for heart failure, is shown, according to subgroups. AF, atrial fibrillation; A–P, ablate and pace; AVB, atrioventricular block; HF, heart failure; HTN, arterial hypertension; LBBAP, left bundle branch area pacing; LVEF, left ventricular ejection fraction; MI, myocardial infarction; RVP, right ventricular pacing; SSS, sinus sick syndrome.
See this image and copyright information in PMC

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