Left bundle branch area pacing in children: a systematic review and meta-analysis of feasibility, safety, and outcomes

Background Chronic right ventricular pacing in children has been associated with pacing-induced cardiomyopathy. While left bundle branch area pacing (LBBAP) offers a physiological alternative to preserve synchronous activation, its application in the paediatric population involves distinct technical and anatomical challenges Objectives To systematically evaluate the procedural feasibility, safety, and electromechanical outcomes of LBBAP in paediatric patients. Methods PubMed/MEDLINE, Embase, Scopus, and Cochrane databases were searched using medical subject heading terms “left bundle branch area pacing,” “LBBAP,” “conduction system pacing,” “paediatric,” “children,” “congenital heart disease,” and similar keywords. Random-effects meta-analyses of proportions and means, subgroup analyses, and meta-regressions were conducted. Results A total of 127 paediatric patients (≤ 18 years) in 8 cohorts were included. The pooled procedural success rate was 80.0%, with a low aggregate complication rate of 9.7% and satisfactory early-to-intermediate term capture thresholds. Statistical analyses revealed no significant clinical predictors of procedural feasibility. While current data did not identify patient size as a significant limitation, a numerically lower success rate was observed in complex congenital heart disease (CHD) compared to simple CHD (64.0% vs. 83.6%). The mean postprocedural QRS duration and left ventricular ejection fraction showed no significant changes. Notably, among the 50 patients with available echocardiographic data, LBBAP yielded a statistically significant reduction in left ventricular end-diastolic dimension Z-scores (pooled mean difference −1.12; p = 0.026). Conclusions Preliminary evidence suggests that LBBAP is a feasible physiological pacing strategy in paediatric patients that demonstrates an acceptable safety profile and is associated with reduced left ventricular dimensions. Although the impacts of patient size and complex congenital heart disease on procedural success did not reach statistical significance in this cohort, both factors likely remain notable technical challenges. Systematic Review Registration ( https://www.crd.york.ac.uk/PROSPERO/view/CRD420261287485 ) PROSPERO CRD420261287485.