Upgrading right ventricular pacing to left bundle branch area pacing in pacemaker-induced cardiomyopathy: a systematic review and meta-analysis

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Pacemaker-induced cardiomyopathy (n=242). Intervention: Left bundle branch area pacing (LBBAP) vs. Pre-upgrade baseline. Primary outcome: Left ventricular ejection fraction (LVEF) improvement (MD 11.72, 95% CI 9.85-13.59, p=<0.001).

Sami Shoura; Shreyas Singireddy; Ragavendar Saravanabavanandan; Abdulrahim Shilbayeh; Skylar Murphy; Chetan Bhardwaj; Timir Baman; Amjad Abualsuod

doi:10.1186/s12872-026-06430-3

August 14, 2026BMC Cardiovascular DisordersOpen Access

Upgrading right ventricular pacing to left bundle branch area pacing in pacemaker-induced cardiomyopathy: a systematic review and meta-analysis

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Key result

Left bundle branch area pacing upgrade in patients with pacemaker-induced cardiomyopathy significantly improved left ventricular ejection fraction by a pooled mean of 11.72 percentage points.

Why the study?

Chronic right ventricular pacing causes pacemaker-induced cardiomyopathy, and while left bundle branch area pacing offers an alternative upgrade strategy, no formal pooled analysis comparing it with biventricular pacing exists.

Does upgrading to left bundle branch area pacing (LBBAP) improve left ventricular ejection fraction and symptoms in adults with pacemaker-induced cardiomyopathy compared to baseline or biventricular pacing?

Key Points

To assess the procedural success, clinical efficacy, and safety of upgrading right ventricular pacing to left bundle branch area pacing in patients with pacemaker-induced cardiomyopathy.
Systematic review and meta-analysis of PubMed, Embase, Cochrane, and Scopus through March 2026, registered in PROSPERO (CRD420261381943).
Included nine observational studies (N=242) for single-arm evaluation and two observational head-to-head studies (N=170) comparing left bundle branch area pacing (LBBAP) with biventricular pacing (BiVP).
Pooled effect sizes using restricted maximum likelihood (REML) models to analyze procedural success, echocardiographic changes, and functional outcomes.
LBBAP was successfully performed in 96.4% of procedures (95% CI 92.2–99.3%), with non-fatal device-related complications occurring in 1.8% of patients (3 of 242).
Upgrade to LBBAP significantly improved pooled left ventricular ejection fraction by 11.72 percentage points (95% CI +9.85 to +13.59, p<0.001), narrowed paced QRS by 51.83 ms, reduced left ventricular end-diastolic diameter by 4.10 mm, and improved NYHA class by 0.98 points (all p<0.001).
In two comparative studies (N=170), LBBAP was associated with a 4.59 percentage-point greater improvement in left ventricular ejection fraction compared to BiVP (95% CI +2.23 to +6.95).

Study Design

Type

Meta-Analysis (n=242)

Structured PICO

Does upgrading to left bundle branch area pacing (LBBAP) improve left ventricular ejection fraction and symptoms in adults with pacemaker-induced cardiomyopathy compared to baseline or biventricular pacing?

P

Population

242 adults with pacemaker-induced cardiomyopathy and chronic right ventricular pacing burden ≥20% undergoing device upgrade to left bundle branch area pacing, followed for 4.7 to 27.3 months.

I

Intervention

Left bundle branch area pacing (LBBAP) upgrade

C

Comparator

Pre-upgrade baseline (in single-arm studies) or biventricular pacing (BiVP) upgrade (in comparative studies)

O

Outcome

LBBAP procedural success rate and the change in the left ventricular ejection fraction (LVEF)surrogate

Main Result

Mean Difference: 11.72 (95% CI 9.85–13.59)

p-value: p=<0.001

Limitations

All included studies were nonrandomized observational designs, precluding causal inference
Short follow-up duration (4.7 to 27.3 months) inadequate for assessing hard clinical endpoints
Comparative analysis based on only two studies enrolling 170 patients
Potential patient overlap across the five Chinese cohorts
Variability in PICM definitions across studies
Potential patient overlap across Chinese cohorts cannot be excluded
Variability in capture confirmation and subtype reporting may contribute to clinical heterogeneity
Nonrandomized observational design of the included studies
Small-study effects cannot be definitively excluded

Implication

Upgrading to left bundle branch area pacing in patients with pacemaker-induced cardiomyopathy is associated with significant improvements in LVEF and symptoms, with limited observational data suggesting greater LVEF recovery compared to biventricular pacing.

Abstract

Background Chronic right ventricular pacing (RVP) causes pacemaker-induced cardiomyopathy (PICM) in 10–20% of patients. Left bundle branch area pacing (LBBAP) restores His-Purkinje activation and offers an alternative upgrade strategy; however, no formal pooled analysis comparing LBBAP versus biventricular pacing (BiVP) exists. Methods We searched PubMed, Embase, Cochrane, and Scopus from inception to March 2026, and pooled effect sizes using restricted maximum likelihood (REML) methods. Nine studies contributed to the single-arm meta-analysis; one further study (Huang et al.) provided comparative LBBAP-versus-BiVP data only. Full database-specific search strategies are provided in Supplemental Text S1. Results Nine observational studies ( N = 242) were eligible. LBBAP succeeded in 96.4% of the procedures (95% CI 92.2–99.3%). Pooled left ventricular ejection fraction (LVEF) improved by 11.72% points (95% CI + 9.85 to + 13.59), paced QRS narrowed by 51.83 ms, left ventricular end diastolic diameter (LVEDD) decreased by 4.10 mm (k = 5), and NYHA improved by 0.98 points (all p < 0.001). Three non-fatal device-related complications were recorded across 242 patients (pooled rate 1.8%). In two observational head-to-head studies ( N = 170) — one of which (Huang et al.) contributed comparative data only and is not among the nine single-arm studies — LBBAP was associated with a 4.59%-point greater LVEF improvement than BiVP (95% CI + 2.23 to + 6.95); with only two nonrandomized studies, this comparison is hypothesis-generating. Sensitivity analyses confirmed the robustness of the single-arm estimates. Conclusion LBBAP upgrade was associated with improvement in LVEF and symptoms in patients with PICM. Limited observational data suggest greater LVEF improvement with LBBAP than BiVP, but this finding remains hypothesis-generating. Adequately powered randomized trials with hard clinical endpoints are needed. Trial registration This review was registered in PROSPERO (CRD420261381943) after the search but before data extraction: Upgrading right ventricular pacing to left bundle branch area pacing in pacemaker-induced cardiomyopathy: a systematic review and meta-analysis.

Discussion

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Cite This Study

Shoura et al. (2026) conducted a meta-analysis in Pacemaker-induced cardiomyopathy (n=242). Left bundle branch area pacing (LBBAP) vs. Pre-upgrade baseline was evaluated on Left ventricular ejection fraction (LVEF) improvement (MD 11.72, 95% CI 9.85-13.59, p=<0.001). Left bundle branch area pacing upgrade in patients with pacemaker-induced cardiomyopathy significantly improved left ventricular ejection fraction by a pooled mean of 11.72 percentage points.

synapsesocial.com/papers/6a817a11f2fb91fc834adab0 https://doi.org/10.1186/s12872-026-06430-3

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Upgrading right ventricular pacing to left bundle branch area pacing in pacemaker-induced cardiomyopathy: a systematic review and meta-analysis

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Upgrading right ventricular pacing to left bundle branch area pacing in pacemaker-induced cardiomyopathy: a systematic review and meta-analysis

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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