Safety profile of left bundle branch area pacing compared with other pacing modalities: acute and long-term outcomes

Background/Introduction

Left bundle branch area pacing (LBBAP) is increasingly adopted as a physiological pacing strategy, yet comparative real-world data evaluating its acute safety, pacing stability and long-term clinical outcomes versus other pacing modalities remain limited.

Purpose

To compare acute and long-term safety outcomes of LBBAP, septal, apical, conventional CRT and CRT-upgrade pacing.

Methods

We analysed a prospective cohort of 426 patients with follow-up echocardiography: LBBAP (n = 145), septal (n = 137), apical (n = 90), CRT (n = 46) and CRT-upgrade (n = 8). Acute safety outcomes included procedural duration and peri-implant complications. Long-term endpoints were all-cause mortality, heart-failure (HF) hospitalisation, and a composite endpoint (death + HF hospitalisation ± urgent device intervention). Pacing performance included capture stability, paced QRS morphology and pacing percentage. Continuous variables were compared using ANOVA (or Kruskal–Wallis when non-normal); categorical variables with χ² (or Fisher’s exact). Kaplan–Meier analysis with log-rank testing compared survival, and Cox proportional hazards (adjusted for age, sex and baseline LVEF) identified independent predictors of adverse outcomes.

Results

The sample has a median age was 78 years (IQR 71–83) and 66.7 % were male and the median of follow-up was 425 days. Procedural duration differed significantly among pacing types (ANOVA p < 0.001), being shortest with LBBAP and longest in CRT/upgrade. No acute lead dislodgement or septal perforation occurred. LBBAP achieved the highest capture stability and pacing percentage, with loss of capture < 2 % (χ² p < 0.05).

HF hospitalisation and composite events were significantly lower with LBBAP than with CRT (χ² p = 0.03; log-rank p = 0.04), while mortality did not differ significantly (p = 0.09). Kaplan–Meier analysis confirmed superior event-free survival for LBBAP (Figure 1). In Cox regression, age independently predicted composite events (HR 1.07 per year, p = 0.04), whereas pacing modality was not significant after adjustment.

Conclusions

LBBAP demonstrated an excellent acute and long-term safety profile, with minimal complications, stable capture and significantly fewer HF hospitalisations and composite events compared with other pacing strategies. Mortality differences were not statistically significant. Higher event rates in CRT reflected baseline risk rather than device safety.

LBBAP emerges as a safe, reliable and physiologically advantageous pacing option in contemporary clinical practice.KM_AllTypes_Composite