Left bundle branch pacing vs biventricular pacing in heart failure patients undergoing cardiac resynchronization therapy: an updated systematic review and meta-analysis

INTRODUCTION To compare the efficacy and safety of left bundle branch pacing (LBBP) versus biventricular pacing (BVP) in patients with heart failure undergoing cardiac resynchronization therapy (CRT), we conducted an updated systematic review and meta-analysis.METHODS PubMed, Cochrane Library, ScienceDirect, and Embase, were searched through February 2026. Randomized controlled trials and cohort studies comparing LBBP with BVP were included. Risk of bias was assessed using RoB 2.0 for randomized trials and ROBINS-I for observational studies. Data were pooled using fixed- or random-effects models according to heterogeneity and expressed as odds ratios (OR) or mean differences (MD) with 95% confidence intervals (CI).RESULTS Twenty-four studies (9,278 patients) were included. Compared with BVP, LBBP reduced fluoroscopy time (MD − 7.00, 95% CI − 9.99 to −4.01) and procedural duration (MD − 23.62, 95% CI − 35.29 to −11.95), with similar success rates. LBBP improved CRT response (OR 1.85, 95% CI 1.06–3.23), super-response (OR 1.56, 95% CI 1.38–1.77), QRS duration (MD -17.11 95% CI -21.02 to -13.20), and LVEF (MD 3.58, 95% CI 2.95 to 4.22). LBBP also lowered all-cause mortality (OR 0.57, 95% CI 0.48 to 0.68) and heart failure hospitalization (OR 0.50, 95% CI 0.43 to 0.57]CONCLUSIONS LBBP appears superior to BVP in improving electrical, structural, and clinical outcomes while maintaining comparable safety.Protocol Registration Number CRD420261291248, and is available at: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261291248