Abstract 4370123: Left Bundle Branch Area Pacing versus Biventricular Pacing in Cardiac Resynchronization Therapy: An Updated Systematic Review and Meta-Analysis

Background: Left bundle branch area pacing (LBB-P) has emerged as a physiologically targeted alternative to biventricular pacing (BiV-P) for cardiac resynchronization therapy (CRT). We conducted an updated systematic review and meta-analysis to compare the impact of LBBAP versus BiV-P on clinical and procedural outcomes in patients undergoing CRT. Research Question: Does left bundle branch area pacing (LBBAP) provide superior clinical and procedural outcomes compared to biventricular pacing (BiV-P) in patients receiving cardiac resynchronization therapy? Methods: A systematic search of PubMed, Embase, and Cochrane Central was conducted in February 2025 to identify studies comparing LBB-P and BiV-P in patients undergoing CRT. Eligible studies included randomized and observational designs. Primary outcomes were all-cause mortality and heart failure–related hospitalization. Secondary outcomes included changes in QRS duration, Left ventricular ejection fraction (LVEF). Meta-analyses were performed using inverse-variance random-effects models. Heterogeneity was assessed using I2 and sensitivity was evaluated with leave-one-out analysis. Effect sizes were reported as relative risks (RR) or mean differences (MD) with corresponding 95% confidence intervals (CI). Results: Nineteen studies (18 observational and 1 randomized controlled trial) encompassing 5605 patients (LBB-P= 2428 and BiV-P= 3177) were included in this meta-analysis. Compared to BiV-P, LBB-P was associated with a significantly lower risk of all-cause mortality (RR = 0.68, 95% CI: 0.59–0.79; p < 0.00001) and HF-related hospitalization (RR = 0.51, 95% CI: 0.42–0.62; p < 0.00001). LBB-P was also associated with a greater narrowing of QRS duration (mean difference: –24.60 ms, 95% CI: –29.49 to –19.70; p < 0.00001) and greater improvement in LVEF (mean difference: 4.71%, 95% CI: 3.80 to 5.61; p < 0.0001). Conclusion: This updated meta-analysis demonstrates that LBB-P is associated with significantly lower all-cause mortality and HF-related hospitalizations compared to BiV-P in patients undergoing CRT. LBB-P also offers procedural advantages and greater improvements in electrical and functional cardiac parameters. Further large-scale randomized trials are warranted to confirm these findings.