Key result
LBBP cuts death or heart failure hospitalization ~74% compared with biventricular pacing.
Why the study?
Robust clinical evidence from randomized clinical trials comparing left bundle-branch pacing and biventricular pacing in heart failure patients with LBBB was lacking.
Does left bundle-branch pacing (LBBP) reduce the risk of all-cause mortality or heart failure hospitalization compared with biventricular pacing in patients with heart failure, LVEF ≤35%, and complete LBBB?
RCT (n=200)
Open-label
1:1
Yes
Does left bundle-branch pacing (LBBP) reduce the risk of all-cause mortality or heart failure hospitalization compared with biventricular pacing in patients with heart failure, LVEF ≤35%, and complete LBBB?
Hazard Ratio: 0.26 (95% CI 0.12–0.57)
Absolute Event Rate: 8% vs 28%
p-value: p=<0.001
In patients with severely reduced LVEF and left bundle-branch block, left bundle-branch pacing significantly reduced the composite risk of all-cause mortality or heart failure hospitalization and improved echocardiographic super-response rates compared with standard biventricular pacing.
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Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The bottom line is that some of the patients in the Brazilian study did not have conduction-system pacing. They just had septal pacing. And pacing someone's septum who has advanced cardiomyopathy does not make them better—it probably hurts them, makes them worse.”
“We demonstrate LBB pacing [provides] a greater electrical and mechanical and echocardiographic improvement than BiV pacing in heart failure patients with LBBB, and it is potentially an alternative to BiV pacing.”
“In Brazil right now, as a community, we should not change the guidelines and tell people coming to a public hospital to get CSP. Actually, they should have CRT [with BiV pacing]. It applies for many groups without enough experience to be 100% sure that they're capturing the left bundle.”
Left bundle-branch pacing may supplant biventricular pacing in LBBB with reduced LVEF; challenges guidelines and requires replication amid conflicting RCTs.
IMPORTANCE: Left bundle-branch pacing (LBBP) has been proposed as an alternative to biventricular pacing (BiVP) for patients with heart failure with left bundle-branch block (LBBB). However, robust clinical evidence from randomized clinical trials is lacking. OBJECTIVE: To evaluate the long-term clinical outcomes of LBBP and BiVP. DESIGN, SETTING, AND PARTICIPANTS: This multicenter, prospective, randomized clinical trial enrolled 200 patients at 6 centers in China with a left ventricular ejection fraction (LVEF) of 35% or less and LBBB from October 2020 to March 2022. This study was took place from October 2020 to September 2024. These data were analyzed September 2024 to December 2024. INTERVENTIONS: Patients were randomly assigned in a 1:1 ratio to receive either LBBP or BiVP. MAIN OUTCOMES AND MEASURES: The primary end point was the time to death from any cause or heart failure hospitalization (HFH). The secondary end points included all-cause death, HFH, echocardiographic response (absolute increase in LVEF ≥5%), and super response (absolute increase in LVEF ≥15% or improvement of LVEF to ≥50%) rates. RESULTS: Of the 200 included patients, 136 were male and 64 were female. The success rate was 98% in the LBBP group and 94% in the BiVP group (P = .28). The median follow-up duration was 36 (range, 33-39) months. The primary end point of time to death or HFH was significantly lower in the LBBP group compared with BiVP (8% vs 28%; hazard ratio [HR], 0.26; 95% CI, 0.12-0.57; P < .001). There was no significant difference in all-cause mortality between the groups (2.0% vs 5.0%; HR, 0.40; 95% CI, 0.08-2.04; P = .25). However, LBBP significantly reduced the risk of HFH (7.0% vs 28.0%; HR, 0.23; 95% CI, 0.10-0.52; P < .001). The echocardiographic response rates were similar in both groups (86.0% vs 81.0%; P = .34) but the super-response rate was higher in the LBBP group (55.0% vs 36.0%; P < .007). CONCLUSIONS AND RELEVANCE: In this study, LBBP was superior to BiVP in reducing the risk of death or HFH in patients with LBBB and severely reduced LVEF. Further trials are warranted in this patient population. TRIAL REGISTRATION: Chinese Clinical Trial Registry identifier: ChiCTR2000036554.
Chen et al. (2026) conducted an RCT in Heart failure with left bundle-branch block (LBBB) (n=200). Left bundle-branch pacing (LBBP) vs. Biventricular pacing (BiVP) was evaluated on Composite of all-cause mortality and heart failure hospitalization (HR 0.26, 95% CI 0.12-0.57, p=<0.001). Left bundle-branch pacing significantly reduced the risk of death or heart failure hospitalization compared with biventricular pacing (8% vs 28%; HR 0.26) in patients with LBBB and reduced LVEF.
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