Left Bundle Branch Area Pacing: Current Clinical Practice and Future Perspectives

Conventional right ventricular pacing (RVP) is associated with electromechanical dyssynchrony and may contribute to pacing-induced cardiomyopathy (PICM). Left bundle branch area pacing (LBBAP) has emerged as a physiological pacing strategy that engages the native conduction system. This review summarizes the current clinical evidence and future perspectives for LBBAP in both bradycardia and heart failure indications. LBBAP has been associated with improved electrical synchrony, preservation of left ventricular function, and lower rates of heart failure hospitalization and mortality compared with conventional RVP in bradyarrhythmias, although much of the evidence supporting these clinical outcomes is derived from observational studies and registries, while randomized evidence remains limited. In patients with heart failure and indications for cardiac resynchronization therapy (CRT), LBBAP has demonstrated greater QRS narrowing and favorable echocardiographic responses compared with biventricular pacing (BiVP). However, whether these physiological and echocardiographic advantages translate into superior long-term clinical outcomes remains uncertain. For patients with advanced heart failure or diffuse conduction system disease, hybrid resynchronization strategies, such as left bundle branch-optimized cardiac resynchronization therapy (LOT-CRT), combine LBBAP with coronary sinus lead pacing and may provide additional opportunities for individualized resynchronization, although their incremental clinical benefit requires further investigation. The current article outlines LBBAP capture definitions, implantation equipment, and standard electrocardiographic (ECG) capture criteria and reviews evidence from randomized clinical trials, observational studies, and registries, including specific clinical scenarios such as post-TAVR pacing and pace-and-ablate approaches, as well as early experience with integrated defibrillation leads. Current limitations and gaps in the evidence are also highlighted.