Trials Bolster LBBAP as an Alternative to Biventricular Pacing in CRT

Why It Matters

These mixed findings suggest LBBAP can reduce procedural complications and may be clinically comparable, yet the evidence is not yet robust enough to supplant BiV CRT as the default strategy, influencing guideline recommendations and physician decision‑making.

Key Takeaways

• LECART: LBBAP halves composite events, mainly fewer reinterventions.
• LEFT‑BUNDLE‑CRT: LBBAP not non‑inferior, similar clinical outcomes.
• His‑Alternative I: Low‑threshold His pacing matches BiV outcomes, higher revisions.
• Success depends on implantation quality and true conduction capture.
• Guidelines still favor BiV CRT as first‑line for most patients.

Pulse Analysis

Cardiac resynchronization therapy remains a cornerstone for patients with heart‑failure and wide QRS complexes, traditionally delivered via biventricular pacing. Over the past few years, conduction‑system approaches—left bundle branch area pacing (LBBAP) and His‑bundle pacing—have emerged as technically appealing alternatives that aim to engage the heart’s native electrical pathways. The European Heart Rhythm Association’s 2026 congress showcased three pivotal studies that collectively sharpen the risk‑benefit profile of these newer modalities, offering clinicians fresh data to weigh against the long‑standing BiV standard.

The LECART trial, conducted across 11 Belgian centers, enrolled 168 patients and reported a striking reduction in the composite endpoint of death, heart‑failure hospitalization, device‑related reintervention, or CRT failure—12% with LBBAP versus 25% with BiV. The advantage stemmed largely from a 2% versus 15% reintervention rate, alongside shorter procedure (76 vs 98 minutes) and fluoroscopy times. Conversely, the LEFT‑BUNDLE‑CRT study in Spain, with 175 participants, could not confirm non‑inferiority of LBBAP; response rates were high in both arms (90% vs 95%) but the confidence interval crossed the pre‑specified margin. Meanwhile, the His‑Alternative I pilot’s five‑year follow‑up showed that patients with low implant thresholds (≤2.5 V·ms) achieved mortality and remodeling outcomes comparable to BiV, though overall lead revisions and generator changes were markedly higher for His pacing.

These results underscore a nuanced shift toward individualized CRT selection. Operators with expertise in precise lead placement and low‑threshold capture may leverage LBBAP or His‑bundle pacing to lower procedural complications, yet the broader evidence still favors BiV pacing as the first‑line therapy for most candidates. Future large‑scale, long‑term trials that stratify patients by anatomy, conduction pattern, and implantation quality will be essential to define which sub‑populations truly benefit from conduction‑system pacing, potentially reshaping guideline algorithms in the coming years.