Left Bundle-Branch Area Pacing vs Right Ventricular Pacing for Atrioventricular Block and Preserved Left Ventricular Function
Xiaofei Li, Haixiong Wang, Wenjuan Zhang, Ling You, Chunguang Qiu, Fengpeng Jia, Zhimin Liu, Xiaoming Li, Ruxing Wang, Taibo Chen, Wenhua Lin, Ming Ren, Kang’an Cheng, Hui Peng, Jing Zhou, Haitao Yang, Yongquan Wu, Haojie Zhu, Zhao Wang, Chen He, Zhijun Sun, Songyun Chu, Yang Wang, Wei Li, Yanyan Zhao, Michael R. Gold, Kenneth A. Ellenbogen, Yan Yao, Xiaohan Fan, , Hongshi Li, Yunlong Fan, Wennan Liu, Xuebin Han, Jun Li, Ying Ma, Changying Zhang, Deyan Yang, Juan Du, Qian Liu, Xiaolin Zheng, Wenjie Lu, Weiping Sun, Zefeng Wang, Botao Zhu, Beibing Di, Nixiao Zhang, Jingjing Liu, Yafei He, Rui Xiang, Yandong Su, Xiaosheng ChenImportance
For patients with atrioventricular block requiring high-burden ventricular pacing, the optimal pacing strategy to reduce heart failure (HF) and all-cause mortality remains uncertain. Robust comparative evidence on the clinical outcomes of left bundle-branch area pacing (LBBAP) vs right ventricular pacing (RVP) in this population is needed.
Objective
To compare 24-month clinical outcomes of LBBAP vs RVP in patients with atrioventricular block and preserved left ventricular ejection fraction (LVEF; ≥50%).
Design, Setting, and Participants
The LEAP-Block study was a prospective, multicenter, randomized, controlled, superiority trial conducted across 14 Chinese hospitals from January 2021 to August 2025, with last follow-up on June 3, 2025. Of 551 patients with LVEF 50% or greater requiring ventricular pacing who underwent eligibility assessment, 499 with anticipated ventricular pacing greater than 40% were randomized.
Interventions
Patients were randomized in a 1:1 ratio to LBBAP (n = 249) or RVP (n = 250).
Main Outcomes and Measures
The primary end point was a composite of all-cause death, HF events, or upgrade to biventricular pacing at 24 months. Secondary end points included pacing-induced cardiomyopathy and device-related complications.
Results
The primary analysis included 482 patients (LBBAP, n = 242; RVP, n = 240; mean age, 67 years; 46% female). Acute procedure success was comparable between the 2 groups (LBBAP, 237/242 [97.9%] vs RVP, 239/240 [99.6%]; P = .22), with left bundle-branch capture confirmed in 188 of 236 patients (79.7%). LBBAP significantly reduced the primary end point vs RVP (2.4% vs 12.5%, respectively; absolute risk difference, −10.1% [95% CI, −16.8% to −3.4%]; P = .003). Among secondary outcomes, the LBBAP group had fewer HF events (3.4% vs 11.3%; −7.9% [95% CI, −13.0% to −2.8%]). No significant differences were observed in all-cause death, biventricular pacing upgrade, device-related complications, or pacing-induced cardiomyopathy. The 24-month Kaplan-Meier estimated cumulative incidence of the primary end point was 5.0% for LBBAP vs 13.2% for RVP (hazard ratio, 0.37 [95% CI, 0.19 to 0.73]; P = .004). LBBAP superiority was consistent across all prespecified subgroups.
Conclusions and Relevance
Among patients with atrioventricular block and preserved LVEF requiring high-burden ventricular pacing, LBBAP was superior to RVP in reducing the risk of the composite end point of all-cause death, HF events, or upgrade to biventricular pacing at 24 months.
Trial Registration
ClinicalTrials.gov Identifier: