Is left bundle branch area pacing the optimal pacing strategy for bradyarrhythmia with preserved ejection fraction? A network meta-analysis

Abstract

Background: Cardiac physiological pacing (CPP), including biventricular pacing (BiVP), left bundle branch area pacing (LBBAP), and His-bundle pacing (HBP), has become the preferred strategy over right ventricular pacing (RVP) owing to the lower risk of pacing-induced cardiomyopathy. However, the evidence supporting CPP use in bradyarrhythmia with preserved left ventricular ejection fraction (LVEF) remains limited. Objective: Our network meta-analysis aimed to explore outcomes of CPP in bradyarrhythmia with preserved LVEF. Method: A literature review was conducted from the inception of PubMed to April 2025. Eligibility criteria were adults who underwent pacing for bradyarrhythmia. Studies must have had a mean LVEF of at least 50% or less than 10% of heart failure patients and must be head-to-head comparisons among BiVP, LBBAP, HBP, and RVP. The primary endpoint was a composite of all-cause mortality and hospitalization for heart failure. Secondary end points were dyssynchrony index, LVEF, paced QRS duration, procedural success, fluoroscopy duration, and procedure-related complications. Results: A total of 29 studies involving 8795 patients (mean age 70.7 ± 11.33 years; mean LVEF 58.9% ± 8.7%) were included. LBBAP demonstrated a lower risk of composite primary endpoint than RVP (odds ratio 0.42; 95% confidence interval 0.25–0.70; P = .001), with the highest P scores (.931). LBBAP achieved the lowest dyssynchrony index and the narrowest paced QRS duration. BiVP showed the highest LVEF at follow-up. HBP had the lowest procedural success, the longest fluoroscopy duration, and the highest procedure-related complications. Conclusion: LBBAP has the potential to be the first-line CPP strategy in bradyarrhythmia with preserved LVEF, owing to its efficacy in reducing hospitalization for heart failure and all-cause mortality.