Upgrading right ventricular pacing to left bundle branch area pacing in pacemaker-induced cardiomyopathy: a systematic review and meta-analysis

Abstract Background Chronic right ventricular pacing (RVP) causes pacemaker-induced cardiomyopathy (PICM) in 10–20% of patients. Left bundle branch area pacing (LBBAP) restores His-Purkinje activation and offers an alternative upgrade strategy; however, no formal pooled analysis comparing LBBAP versus biventricular pacing (BiVP) exists. Methods We searched PubMed, Embase, Cochrane, and Scopus from inception to March 2026, and pooled effect sizes using restricted maximum likelihood (REML) methods. Nine studies contributed to the single-arm meta-analysis; one further study (Huang et al.) provided comparative LBBAP-versus-BiVP data only. Full database-specific search strategies are provided in Supplemental Text S1. Results Nine observational studies ( N = 242) were eligible. LBBAP succeeded in 96.4% of the procedures (95% CI 92.2–99.3%). Pooled left ventricular ejection fraction (LVEF) improved by 11.72% points (95% CI + 9.85 to + 13.59), paced QRS narrowed by 51.83 ms, left ventricular end diastolic diameter (LVEDD) decreased by 4.10 mm (k = 5), and NYHA improved by 0.98 points (all p < 0.001). Three non-fatal device-related complications were recorded across 242 patients (pooled rate 1.8%). In two observational head-to-head studies ( N = 170) — one of which (Huang et al.) contributed comparative data only and is not among the nine single-arm studies — LBBAP was associated with a 4.59%-point greater LVEF improvement than BiVP (95% CI + 2.23 to + 6.95); with only two nonrandomized studies, this comparison is hypothesis-generating. Sensitivity analyses confirmed the robustness of the single-arm estimates. Conclusion LBBAP upgrade was associated with improvement in LVEF and symptoms in patients with PICM. Limited observational data suggest greater LVEF improvement with LBBAP than BiVP, but this finding remains hypothesis-generating. Adequately powered randomized trials with hard clinical endpoints are needed. Trial registration This review was registered in PROSPERO (CRD420261381943) after the search but before data extraction: Upgrading right ventricular pacing to left bundle branch area pacing in pacemaker-induced cardiomyopathy: a systematic review and meta-analysis.