Left bundle branch area pacing vs biventricular pacing for cardiac resynchronization: A systematic review and meta-analysis

BACKGROUND: Left bundle branch area pacing (LBBAP) may offer greater physiological benefits than traditional biventricular pacing (BiVP). However, there are limited data comparing the efficacy of LBBAP vs BiVP in patients with systolic heart failure (HF). OBJECTIVE: The purpose of this meta-analysis was to compare the feasibility and electromechanical and clinical outcomes of both LBBAP and BiVP. METHODS: We conducted a systematic review of studies retrieved from various databases including PubMed, Embase, Google Scholar, Scopus, and Cochrane Central Register of Control Trials (CENTRAL) published up to May 22, 2023. The risk ratio (RR) and standardized mean difference (SMD) with corresponding 95% confidence intervals (CIs) were calculated for dichotomous and continuous outcomes, respectively. RESULTS: We included 12 studies with a total of 3004 patients (LBBAP = 1242, BiVP = 1762). Pooled results showed that LBBAP resulted in a significant increase in left ventricular ejection fraction (SMD 0.40, 95% CI 0.25, 0.54, P < .00001), echocardiographic response (RR 1.19, 95% CI 1.10 to 1.29, P < .0001), improvement in New York Heart Association functional class (SMD –0.44, 95% CI –0.65 to –0.23, P < .0001), QRS duration reduction (SMD –0.90, 95% CI –1.14 to –0.66, P < .00001), left ventricular end-diastolic diameter reduction (SMD –0.31, 95% CI –0.57 to –0.05, P = .02), fewer HF hospitalizations (RR 0.72, 95% CI 0.62, 0.85, P < .0001), and improved survival (RR 0.73, 95% CI 0.58, 0.92, P = .007). In addition, LBBAP was associated with shorter fluoroscopy time (SMD –0.94, 95% CI –1.42 to –0.47, P < .0001) and lower pacing threshold at implantation (SMD –1.03, 95% CI –1.32 to –0.74, P < .00001) and at 6 months (SMD –1.44, 95% CI –2.11 to –0.77, P < .0001) as compared with BiVP. CONCLUSION: Compared with BiVP, LBBAP was associated with better electromechanical and clinical outcomes, including left ventricular ejection fraction, QRS duration, echocardiographic response, New York Heart Association functional class, HF hospitalization, and all-cause mortality in patients with systolic HF.