Left Bundle Branch Area Pacing versus Right Ventricular Pacing in Cardiac Amyloidosis: the Left-Right CA study, a
Andreas Müssigbrodt1,2, Maria Herrera Bethencourt3, Karima Lounaci3
1Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, 97200, France. andreas.muessigbrodt@gmail.com.
Insights
Left bundle branch area pacing (LBBAP) in cardiac amyloidosis (CA) patients significantly reduced heart failure worsening and events compared to right ventricular pacing (RVP). LBBAP is a safe and effective alternative for pacing in CA.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Amyloidosis Research
Background:
- Cardiac amyloidosis (CA), especially transthyretin-related (ATTR-CA), commonly leads to conduction disease requiring pacing.
- Conventional right ventricular pacing (RVP) can exacerbate heart failure (HF) due to dyssynchronous activation.
- Left bundle branch area pacing (LBBAP) offers a more physiological pacing alternative, but comparative data in CA is limited.
Purpose of the Study:
- To compare the feasibility, procedural characteristics, and clinical outcomes of LBBAP versus RVP in patients with cardiac amyloidosis.
- To assess the safety and efficacy of LBBAP as an alternative pacing strategy in CA patients.
- To evaluate the impact of pacing strategy on heart failure progression in CA.
Main Methods:
- Retrospective, single-center study of 35 CA patients with cardiac implantable electronic devices (CIEDs) undergoing either LBBAP or RVP.
- Patients diagnosed with CA according to current guideline criteria.
- Comparison of procedural times, fluoroscopy, paced QRS duration, heart failure worsening, acute HF events, pacing burden, mortality, and complication rates between LBBAP and RVP groups.
Main Results:
- LBBAP resulted in a significantly shorter paced QRS duration (116 ms vs. 159 ms) compared to RVP.
- Despite a higher ventricular pacing burden, LBBAP was associated with markedly fewer HF worsening events (9.1% vs. 69.2%) and acute HF events (4.5% vs. 69.2%).
- Mortality and complication rates were comparable between the LBBAP and RVP groups.
Conclusions:
- Left bundle branch area pacing (LBBAP) is a feasible and safe pacing option for patients with cardiac amyloidosis (CA).
- LBBAP demonstrated a significant reduction in heart failure-related events compared to conventional right ventricular pacing (RVP) in CA patients.
- These findings suggest LBBAP may be a superior pacing strategy in CA, warranting further investigation in prospective studies.
Background:
Cardiac amyloidosis (CA), particularly transthyretin-related (ATTR-CA), frequently causes conduction disease requiring pacing. Conventional right ventricular pacing (RVP) may worsen heart failure (HF) through dyssynchronous activation, while left bundle branch area pacing (LBBAP) provides a more physiological alternative. Comparative data in CA are lacking.
Methods:
This single-center, retrospective study included CA patients with CIED (cardiac implantable electronic devices) with LBBAP and RVP. It aimed to compare feasibility, procedural characteristics, and outcomes between both approaches. Diagnosis of CA followed current guideline criteria. HF worsening was defined as clinical deterioration requiring escalation of diuretics or outpatient reassessment; acute HF events as hospitalizations for decompensated HF.
Results:
35 CA patients (22 LBBAP, 13 RVP) were included. Overall, 32 (91%) had transthyretin cardiac amyloidosis (ATTR-CA) and 3 (9%) light-chain amyloidosis (AL-CA). Baseline HF was more advanced in the LBBAP group (NYHA 2.6 ± 0.7 vs. 2.0 ± 0.6, p = 0.007; BNP 594 ± 617 vs. 121 ± 71 pg/mL, p = 0.006). Procedural and fluoroscopy times were longer with LBBAP, but paced QRS duration was significantly shorter (116 ± 17 vs. 159 ± 12 ms, p < 0.001). During follow-up (16 ± 10 vs. 32 ± 24 months), LBBAP was associated with markedly fewer HF worsening (9.1% vs. 69.2%, p = 0.0012) and acute HF events (4.5% vs. 69.2%, p < 0.001), despite higher ventricular pacing burden (> 40% in 90.9% vs. 53.8%, p = 0.032). Mortality (22.7% vs. 15.4%, p = 0.689) and complication rates (9.1% vs. 15.4%, p = 0.618) were comparable.
Conclusions:
LBBAP is feasible and appears safe in patients with cardiac amyloidosis and was associated with fewer heart-failure-related events compared with RVP, even in advanced disease. These findings are hypothesis-generating and warrant validation in larger prospective studies.
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