Impact of left bundle branch area pacing on myocardial work: a systematic review and aggregate comparative analysis

Background Cardiac conduction disorders often necessitate permanent pacemaker implantation. While right ventricular pacing (RVP) remains a widely used approach for bradycardia, it is associated with adverse ventricular remodeling and an increased risk of heart failure. Left Bundle Branch Area Pacing (LBBAP) has emerged as a promising alternative, potentially offering better preservation of myocardial function. Non-invasive myocardial work (MW) analysis provides key insights into left ventricular (LV) systolic performance, energetics, and efficiency. This study compares MW parameters between LBBAP and RVP, as well as between LBBAP and His Bundle Pacing (HBP). Methods A systematic review and aggregate comparative analysis were conducted, evaluating four key MW parameters: Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW), and Global Work Efficiency (GWE). Data from 241 patients across five studies were analyzed across three time points: Baseline, Post-Implantation, and Last Follow-Up (median follow-up: 180 days, IQR: 7–360 days). The Cochrane risk of bias tool was applied for quality assessment, and the study was registered on PROSPERO. Results At baseline, MW parameters were comparable between LBBAP and RVP. Following implantation, LBBAP demonstrated better myocardial work preservation, with significantly higher GWI than RVP (2250.0 ± 400.0 vs. 1600.0 ± 300.0 mmHg%, p = 0.027), a difference that remained significant at the last follow-up (p = 0.035). Additionally, GWE was significantly greater in LBBAP at follow-up (p = 0.011), suggesting superior myocardial efficiency. No significant differences were observed for GCW or GWW. Similarly, when compared to HBP, LBBAP did not show any significant differences in MW parameters (all p-values > 0.05). Conclusion LBBAP exhibited better myocardial work preservation than RVP, with notable advantages in GWI and GWE, whereas no significant differences were observed between LBBAP and HBP