Is left bundle branch area pacing the optimal pacing strategy for bradyarrhythmia with preserved ejection fraction? A...

Cardiac physiological pacing (CPP), including biventricular pacing (BiVP), left bundle branch area pacing (LBBAP), and His-bundle pacing (HBP), has become the preferred strategy over right ventricular pacing (RVP) owing to the lower risk of pacing-induced cardiomyopathy. However, the evidence supporting CPP use in bradyarrhythmia with preserved left ventricular ejection fraction (LVEF) remains limited.

Our network meta-analysis aimed to explore outcomes of CPP in bradyarrhythmia with preserved LVEF.

A literature review was conducted from the inception of PubMed to April 2025. Eligibility criteria were adults who underwent pacing for bradyarrhythmia. Studies must have had a mean LVEF of at least 50% or less than 10% of heart failure patients and must be head-to-head comparisons among BiVP, LBBAP, HBP, and RVP. The primary endpoint was a composite of all-cause mortality and hospitalization for heart failure. Secondary end points were dyssynchrony index, LVEF, paced QRS duration, procedural success, fluoroscopy duration, and procedure-related complications.

A total of 29 studies involving 8795 patients (mean age 70.7 ± 11.33 years; mean LVEF 58.9% ± 8.7%) were included. LBBAP demonstrated a lower risk of composite primary endpoint than RVP (odds ratio 0.42; 95% confidence interval 0.25-0.70; P = .001), with the highest P scores (.931). LBBAP achieved the lowest dyssynchrony index and the narrowest paced QRS duration. BiVP showed the highest LVEF at follow-up. HBP had the lowest procedural success, the longest fluoroscopy duration, and the highest procedure-related complications.

LBBAP has the potential to be the first-line CPP strategy in bradyarrhythmia with preserved LVEF, owing to its efficacy in reducing hospitalization for heart failure and all-cause mortality.