Left Bundle-Branch Pacing versus Right Ventricular Pacing for Atrioventricular Block

BACKGROUND: Right ventricular pacing is associated with cardiac dyssynchrony and left ventricular systolic dysfunction. Left bundle-branch pacing preserves left ventricular electrical and mechanical synchrony, but its clinical benefits relative to right ventricular pacing in patients with atrioventricular block remain unclear. METHODS: In this investigator-initiated, international, open-label, randomized, controlled trial, we assigned patients with atrioventricular block in a 1:1 ratio to receive left bundle-branch pacing or right ventricular pacing. The primary outcome was a composite of death from any cause, hospitalization for heart failure, or pacing-induced cardiomyopathy. RESULTS: A total of 702 patients underwent randomization, with 348 assigned to receive left bundle-branch pacing and 354 to receive right ventricular pacing; 17 patients (6 in the left bundle-branch pacing group and 11 in the right ventricular pacing group) were excluded before device implantation. A total of 685 patients (342 in the left bundle-branch pacing group and 343 in the right ventricular pacing group) were included in the modified intention-to-treat analysis. The mean age of the patients was 68.4 years, and 57.5% were men. At the prespecified interim analysis, the data monitoring committee recommended early termination of the trial. At a median follow-up of 35.1 months (interquartile range, 23.6 to 40.7), a primary-outcome event had occurred in 16 patients in the left bundle-branch pacing group and in 35 patients in the right ventricular pacing group (Kaplan-Meier 4-year cumulative incidence, 8.5% and 19.2%, respectively; hazard ratio, 0.41; 95% confidence interval, 0.23 to 0.75; P = 0.003 by a stratified log-rank test). Serious adverse events unrelated to implantation procedures occurred in 39 patients (11.8%) who had received left bundle-branch pacing and in 33 patients (9.3%) who had received right ventricular pacing (P = 0.32). CONCLUSIONS: Among patients with atrioventricular block, left bundle-branch pacing was superior to right ventricular pacing in reducing the risk of a composite of death from any cause, hospitalization for heart failure, or pacing-induced cardiomyopathy. (Funded by Project on New Technology of Jiangsu Province and others; OptimPacing ClinicalTrials.gov number, NCT04624763.).

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Journal
New England Journal of Medicine
Published
2026-11-08
DOI
https://doi.org/10.1056/nejmoa2612972
Primary Topic
Cardiac pacing and defibrillation studies
Type
article
Field-Weighted Citation Impact
0.00

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article

Left Bundle-Branch Pacing versus Right Ventricular Pacing for Atrioventricular Block

Binni Cai, Jiangang Zou, Michael Robert Gold, Mihail Gabriel Chelu et al.
1 links
New England Journal of Medicine
Cardiac pacing and defibrillation studies
article

Left Bundle-Branch Pacing versus Right Ventricular Pacing for Atrioventricular Block

Binni Cai, Jiangang Zou, Michael Robert Gold, Mihail Gabriel Chelu, Fayuan Fu, Fengwei Zou, Xianhong Shu, Min Shen, Kenneth A. Ellenbogen, Zachary I. Whinnett, Xiaolin Xue, Marek Jastrzębski, Zhiyong Qian, Xia Sheng, Joseph Yat‐Sun Chan, Shengwen Yang, Yangxin Chen, Lingyun Jiang, Lang He, Yongyue Wei, Jie Fan, Xingbin Liu, Yangang Su, Weijian Huang, Yao Wang, Haiyan Chen, Yuanning Xu, Xiaofeng Hou
article en

Abstract

BACKGROUND: Right ventricular pacing is associated with cardiac dyssynchrony and left ventricular systolic dysfunction. Left bundle-branch pacing preserves left ventricular electrical and mechanical synchrony, but its clinical benefits relative to right ventricular pacing in patients with atrioventricular block remain unclear. METHODS: In this investigator-initiated, international, open-label, randomized, controlled trial, we assigned patients with atrioventricular block in a 1:1 ratio to receive left bundle-branch pacing or right ventricular pacing. The primary outcome was a composite of death from any cause, hospitalization for heart failure, or pacing-induced cardiomyopathy. RESULTS: A total of 702 patients underwent randomization, with 348 assigned to receive left bundle-branch pacing and 354 to receive right ventricular pacing; 17 patients (6 in the left bundle-branch pacing group and 11 in the right ventricular pacing group) were excluded before device implantation. A total of 685 patients (342 in the left bundle-branch pacing group and 343 in the right ventricular pacing group) were included in the modified intention-to-treat analysis. The mean age of the patients was 68.4 years, and 57.5% were men. At the prespecified interim analysis, the data monitoring committee recommended early termination of the trial. At a median follow-up of 35.1 months (interquartile range, 23.6 to 40.7), a primary-outcome event had occurred in 16 patients in the left bundle-branch pacing group and in 35 patients in the right ventricular pacing group (Kaplan-Meier 4-year cumulative incidence, 8.5% and 19.2%, respectively; hazard ratio, 0.41; 95% confidence interval, 0.23 to 0.75; P = 0.003 by a stratified log-rank test). Serious adverse events unrelated to implantation procedures occurred in 39 patients (11.8%) who had received left bundle-branch pacing and in 33 patients (9.3%) who had received right ventricular pacing (P = 0.32). CONCLUSIONS: Among patients with atrioventricular block, left bundle-branch pacing was superior to right ventricular pacing in reducing the risk of a composite of death from any cause, hospitalization for heart failure, or pacing-induced cardiomyopathy. (Funded by Project on New Technology of Jiangsu Province and others; OptimPacing ClinicalTrials.gov number, NCT04624763.).

New England Journal of Medicine
Kunming University of Science and Technology (CN), Jagiellonian University (PL), Fujian Medical University (CN), Baylor St. Luke's Medical Center (US), Montefiore Medical Center (US), Medical University of South Carolina (US), Sun Yat-sen University (CN), Chinese University of Hong Kong (HK), Baylor College of Medicine (US), Capital Medical University (CN), Virginia Commonwealth University (US), Xiamen University (CN), Peking University (CN), Sichuan University (CN), Fudan University (CN), Wenzhou Medical University (CN), Beijing Chao-Yang Hospital, Capital Medical University (CN), Hammersmith Hospital (GB), First Affiliated Hospital of Wenzhou Medical University (CN), Sir Run Run Shaw Hospital (CN), West China Hospital of Sichuan University (CN), First People's Hospital of Yunnan Province (CN), Sun Yat-sen Memorial Hospital (CN), Prince of Wales Hospital (CN), First Affiliated Hospital of Xi'an Jiaotong University (CN), Zhongshan Hospital (CN), Jiangsu Province Hospital (CN), Xijing Hospital (CN), Union Hospital (CN), Imperial College London (GB), Virginia Commonwealth University Medical Center (US), Zhejiang University (CN), Nanjing Medical University (CN), Xi'an Jiaotong University (CN), Air Force Medical University (CN)
Patient-Centered Outcomes Research Institute, National Natural Science Foundation of China, National Institutes of Health
Good health and well-being
Cardiac pacing and defibrillation studies
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