Left Bundle Branch Area Pacing vs. Biventricular Pacing in Cardiac Resynchronization Therapy: A Systematic Review and Meta-Analysis

Abstract

Background: 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.

Methods: 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-related hospitalization. Secondary outcomes included changes in QRS duration, LVEF, NYHA class, procedural time, and fluoroscopy time. Meta-analyses were performed using inverse-variance random-effects models. Heterogeneity was assessed using I² 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).

Results: 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; I² = 0%) and HF-related hospitalization (RR = 0.51, 95% CI: 0.42, 0.62; p < 0.00001; I² = 42%). LBBAP was also associated with a marked improvement in mean LVEF (MD = 4.71%, 95% CI: 3.80, 5.61; p < 0.00001; I² = 35%) and substantial narrowing of mean QRS duration (MD = -24.60 ms, 95% CI: -29.49, -19.70; p < 0.00001; I² = 94%). Functional status (mean NYHA class) was significantly improved within the LBBAP group (MD = -0.31, 95% CI: -0.52, -0.09; p = 0.005; I² = 94%). LBBAP was also associated with significantly shorter procedural and fluoroscopy times (MD = -29.77 mins and -8.62 mins, respectively) compared to BiVP.

Conclusion: 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.