Left Bundle Branch Area Pacing in Transthyretin Cardiac Amyloidosis: A Narrative Review
Maria Herrera Bethencourt1, Arnt V Kristen2,3, Vincent Algalarrondo4
1Department of Cardiology, CHU Martinique (University Hospital of Martinique), 97200 Fort de France, France.
Insights
Left bundle branch area pacing (LBBAP) appears safe and feasible for transthyretin amyloid cardiomyopathy (ATTR-CM) patients needing pacemakers. This pacing method may stabilize or improve heart failure symptoms, but more research is needed.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiomyopathy Research
Background:
- Transthyretin amyloid cardiomyopathy (ATTR-CM) often presents with conduction disease requiring pacemaker implantation.
- Conventional right ventricular pacing can negatively impact cardiac function.
- Left bundle branch area pacing (LBBAP) offers a potential alternative to preserve physiological cardiac activation.
Purpose of the Study:
- To review the existing evidence on the feasibility, safety, and efficacy of LBBAP in patients with ATTR-CM.
- To assess the impact of LBBAP on cardiac function and patient symptoms in this specific population.
Main Methods:
- A structured narrative review of PubMed and Google Scholar databases was conducted.
- Searched for publications on LBBAP and ATTR-CM up to November 2025.
- Included peer-reviewed articles, case reports, case series, and abstracts, excluding studies solely on light-chain cardiac amyloidosis.
Main Results:
- Ten publications involving 56 ATTR-CM patients who underwent LBBAP were included.
- High implantation success rates were observed with stable acute and mid-term electrical parameters.
- Most patients showed preserved or improved left ventricular ejection fraction, with stable narrow paced QRS complexes; symptomatic improvements were variably reported.
Conclusions:
- LBBAP seems to be a feasible and safe pacing strategy for ATTR-CM patients.
- This pacing approach may help stabilize or improve heart failure symptoms in ATTR-CM.
- Further prospective studies are required to definitively establish the clinical effectiveness of LBBAP in ATTR-CM.
Abstract:
Background/Objectives: Transthyretin cardiomyopathy (ATTR-CM) is frequently associated with conduction disease requiring pacing. Conventional right ventricular pacing may worsen cardiac function, whereas left bundle branch area pacing (LBBAP) aims to preserve physiological activation. Evidence for LBBAP in ATTR-CM remains limited. Methods: A structured narrative review of PubMed and Google Scholar was performed through November 2025 using predefined terms related to LBBAP and ATTR-CM. Peer-reviewed articles, case reports, case series, and relevant abstracts were included. Studies exclusively on light-chain cardiac amyloidosis were excluded. Results: Ten publications met inclusion criteria, comprising three case reports, five case series, one retrospective cohort without a comparator, and one cohort comparing LBBAP with cardiac resynchronization therapy (CRT). In total, 56 patients with ATTR-CM underwent LBBAP. Implantation success was high, with stable acute and mid-term electrical parameters. Follow-up (typically 3-12 months) showed stable electrical parameters with narrow paced QRS complexes and preserved or improved left ventricular ejection fraction in most reports. Symptomatic improvement and reductions in natriuretic peptides were variably described. No major lead-related complications were reported. Comparative data remain sparse and inconclusive. Conclusions: This review suggests that LBBAP is a feasible and safe pacing approach in patients with ATTR-CM and may help to stabilize or improve heart failure symptoms. Further prospective studies are needed to confirm its clinical effectiveness.
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