Randomized Trial of Left Bundle Branch Pacing vs Right Ventricular Pacing in Vulnerable Cardiac Function

Qiu, N; Liu, X; Wang, Z; Wang, W; Bai, J; Wang, J; Qin, S; Zhang, L; Liang, Y; Chen, T; Zhao, X; Liao, D; Bai, Y; Su, Y; Chen, X; Ge, J

doi:10.1016/j.jacc.2026.03.161

Arrhythmias & electrophysiology

Randomized Trial of Left Bundle Branch Pacing vs Right Ventricular Pacing in Vulnerable Cardiac Function

J Am Coll CardiolPublished 23 Apr 2026Randomised controlled trial

Primary resultResultHazard ratio 0.310 95% CI 0.145–0.664

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Authors' conclusion

In patients with a high pacing burden with high risk of cardiac dysfunction, LBBP significantly reduced the risk of the composite outcome, driven primarily by a decreased risk of PICM, and is associated with better echocardiographic improvements and clinical function.

Study context

Population: Patients with a high pacing burden with high risk of cardiac dysfunctionrandomised 1:1
Participants: 160 patients

Comparison: Left bundle branch pacing (LBBP) vs right ventricular pacing (RVP)
Primary endpoint: Composite of:
All-cause mortality
HF hospitalization
Pacing-induced cardiomyopathy (PICM)
Follow-up: Median 36 months

Methodological detailsprospective, multicentre

Prospective
Multicentre

Primary result

As reported in the abstract

Hazard ratio

0.310

95% CI 0.145–0.664

P = 0.001

Events by treatment group

LBBP11.6%9 events

RVP33.9%25 events

LBBPvs RVP

HR 0.310 (95% CI 0.145–0.664); P = 0.001

Secondary outcomes

Outcome	LBBP	RVP	← Lower risk with LBBP ←→ Higher risk with LBBP →	Subdistribution HR (95% CI)	P value
PICM	6.5%	18.2%	0.10.31310	0.324 (0.119–0.883)	P = 0.028
			0.10.31310Subdistribution hazard ratio (log scale)

Outcome	← Lower with LBBP ←→ Higher with LBBP →	Mean difference (95% CI)	P value
Echocardiographic change from baseline · 36 monthsLVEF	−10−50510	5.34 (3.18–7.50)	P < 0.001
Echocardiographic change from baseline · 36 monthsLV end-diastolic diameter	−10−50510	−3.06 (−4.38 to −1.73)	P < 0.001
Echocardiographic change from baseline · 36 monthsLV end-systolic diameter	−10−50510	−3.74 (−5.07 to −2.41)	P < 0.001
	−10−50510Difference (linear scale)

Outcome	LBBP	RVP	P value
NYHA functional class · 36 months	1.66 (SD 0.60)	1.90 (SD 0.56)	P = 0.014

All-cause mortality and HF hospitalization

No significant difference in all-cause mortality: P = 0.391
No significant difference in HF hospitalization: P = 0.100

Original publication

Randomized Trial of Left Bundle Branch Pacing vs Right Ventricular Pacing in Vulnerable Cardiac Function. J Am Coll Cardiol. Published 23 April 2026. doi:10.1016/j.jacc.2026.03.161

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