SYSTEMATIC REVIEW article
Front. Cardiovasc. Med.
Sec. Cardiac Rhythmology
Left Bundle Branch Area Pacing Versus Biventricular Pacing Significantly Improves Clinical Outcomes and Cardiac Remodeling in Cardiac Resynchronization Therapy: A Systematic Review and Meta-Analysis
Provisionally accepted
- 1Department of Cardiology, Ningbo NO.2 hospital, Zhejiang, China, Ningbo, China
- 2Department of Critical Care Medicine, Ningbo Medical Center Li Huili Hospital, Ningbo, Zhejiang, China
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Background: Biventricular pacing (BiVP) is the conventional approach for cardiac resynchronization therapy (CRT), yet approximately one-third of patients show no clinical response. Left bundle branch area pacing (LBBAP) enables more physiological ventricular activation through His-Purkinje conduction, but its impact on key clinical endpoints such as all-cause mortality and heart failure hospitalization (HFH) remains debated. Methods: A systematic search of PubMed, Embase, Cochrane Library, and CNKI (to May 3, 2025) identified 24 studies encompassing 6,538 patients. Study quality was assessed using Cochrane RoB 2.0 and the Newcastle–Ottawa Scale. Subgroup analyses (by follow-up duration, study design, and sex), leave-one-out sensitivity analysis, and meta-regression were performed to assess result robustness and heterogeneity sources. Trim-and-fill correction was applied to adjust for potential publication bias. Results: LBBAP was associated with a markedly lower risk compared to BiVP across several clinical outcomes. Specifically, it significantly reduced the risk of the composite endpoint (HR 0.67, 95% CI: 0.59–0.75), all-cause mortality (HR 0.83, 95% CI: 0.71–0.96), and HFH (HR 0.58, 95% CI: 0.50–0.67). Echocardiographic outcomes further supported LBBAP superiority, with higher rates of echocardiographic response (OR 1.57, 95% CI: 1.36–1.81) and super-response (OR 2.12, 95% CI: 1.62–2.76). Improvements in left ventricular ejection fraction (LVEF) were greater with LBBAP at both 3–6 months (MD 5.31%, 95% CI: 4.63–5.99) and ≥12 months (MD 4.43%, 95% CI: 2.27–6.60). Similarly, left ventricular end-diastolic diameter (LVEDD) reductions were more pronounced at 3–6 months (MD –3.48 mm, 95% CI: –5.76 to –1.21) and ≥12 months (MD –2.86 mm, 95% CI: –5.05 to –0.68). Conclusions: These findings indicate that LBBAP provides superior clinical and structural outcomes compared to BiVP in patients undergoing CRT. Large-scale, multicenter randomized controlled trials are warranted to confirm these results, assess long-term efficacy, and elucidate gender-specific variations to optimize evidence-based CRT delivery.
Keywords: left bundle branch area pacing, Biventricular Pacing, Cardiac Resynchronization Therapy, Heart Failure, Meta-analysis
Received: 09 Jun 2025; Accepted: 10 Nov 2025.
Copyright: © 2025 Zheng, Jiang, Gao, Peng, Feng and Lu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Jinmei Lu, 807549008@qq.com
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