Comparison of short and longterm outcomes between transthoracic echocardiography and fluoroscopy guided left bundle branch pacing

Background Left bundle branch pacing (LBBP) has emerged as a physiological pacing modality, offering advantages over traditional pacing and a higher implant success rate than His bundle pacing. Nevertheless, the procedure often requires prolonged fluoroscopy, increasing radiation exposure for patients and operators. Alternative imaging strategies are needed to reduce procedural burden and mitigate radiation risk. Purpose This study aimed to compare initial procedural performance and long-term clinical outcomes of transthoracic echocardiography (TTE)–guided versus fluoroscopy–guided LBBP in patients requiring permanent pacing. Method We conducted a single-center retrospective study of patients who underwent LBBP between April 2022 and July 2024. Procedural characteristics, including procedure and fluoroscopy times, pacing parameters, electrophysiological findings, and complications were assessed at implantation and during follow-up in both the TTE–guided and fluoroscopy–guided LBBP groups. Result A total of 140 patients (57.9% female; mean age 75.5 years) were included, with 118 undergoing TTE-guided and 22 fluoroscopy-guided LBBP. Left ventricular septal pacing was achieved in all patients, and the success rate of LBB capture was comparable between groups (84.1% vs 73.7%; p = 0.27). Lead implantation time was similar between groups (28.2 vs 36.8 minutes; p = 0.08), whereas fluoroscopy time was significantly lower with TTE guidance (61.2 vs 183.7 seconds; p < 0.01). Pacing parameters, electrophysiological characteristics, and complication rates did not differ significantly at implantation or during up to 2 years of follow-up. Conclusion TTE-guided LBBP is a feasible and safe approach. Compared with conventional fluoroscopy, TTE guidance achieved comparable procedural efficiency, stable long-term pacing parameters, and similar LBB capture success, while markedly reducing radiation exposure.