Updated Meta‐Analysis of Left Bundle Branch Area Pacing Versus Right Ventricular Pacing in Conduction System Disorders: Insights From New Evidence

INTRODUCTION: Right ventricular pacing (RVP) has long been the standard therapy for bradyarrhythmias but may induce ventricular dyssynchrony and adverse cardiac remodeling. Physiologic pacing strategies that preserve the native conduction system, particularly left bundle branch area pacing (LBBAP), have emerged as promising alternatives. This study aimed to evaluate the comparative efficacy and safety of LBBAP versus RVP through an updated meta-analysis. METHODS: Following PRISMA guidelines, we systematically searched PubMed, Cochrane CENTRAL, and ClinicalTrials.gov for relevant studies published through June 2025. Studies comparing LBBAP and RVP in patients undergoing pacemaker implantation were included. Pooled estimates were calculated using random-effects models. RESULTS: A total of 40 studies comprising 8290 patients were included. LBBAP was associated with significantly shorter QRS duration compared with RVP (30 studies, n = 5510; MD -35.56 ms, 95% CI -41.88 to -29.24; p < 0.0001). Structural remodeling also favored LBBAP, with greater improvement in left ventricular ejection fraction (16 studies, n = 1693; MD +3.77%, 95% CI 2.43-5.12; p < 0.0001) and greater reduction in left ventricular end-diastolic diameter (13 studies, n = 1666; MD -2.33 mm, 95% CI -3.59 to -1.07; p < 0.0001). Clinically, LBBAP was associated with lower heart failure hospitalization (RR 0.38, 95% CI 0.29-0.52; p < 0.0001) and reduced all-cause mortality (RR 0.55, 95% CI 0.41-0.72; p < 0.0001), along with greater reduction in NT-proBNP levels. CONCLUSION: LBBAP provides superior electrical synchrony, improved cardiac remodeling, and favorable clinical outcomes compared with RVP, while maintaining a comparable procedural safety profile.