Left bundle branch area pacing was found to be an effective and practical strategy for cardiac resynchronization, according to a Late-Breaking Science presentation at EHRA 2026, the annual congress of the European Heart Rhythm Association (EHRA), a branch of the European Society of Cardiology (ESC).
Cardiac resynchronization therapy (CRT) involves implanting a pacemaker device to help the chambers of the heart pump simultaneously. CRT is used in certain patients with heart failure who remain symptomatic despite guideline-recommended medical therapy and have electrical dyssynchrony. Specifically, it is a treatment option for patients with heart failure and reduced left ventricular ejection fraction (LVEF) who exhibit a dyssynchronous ECG pattern called 'left bundle branch block'.
CRT with biventricular pacing is a well-established standard approach, but up to one-third of patients do not respond. Left bundle branch area pacing (LBBAP) has emerged as a more physiological approach to restore synchrony; however, there is a lack of data from head-to-head randomized trials. The LECART trial was designed to compare LBBAP with biventricular pacing and uniquely incorporated the clinically meaningful endpoints of device-related complications requiring surgical re-interventions and failure to deliver resynchronization."
Professor Jean-Benoît le Polain de Waroux, study presenter, AZ Sint-Jan Hospital, Bruges, Belgium
The prospective, randomized LECART trial was conducted at 11 high-volume centres in Belgium. Patients were eligible for inclusion if they had heart failure of NYHA functional class II−IV, LVEF <40%, left bundle branch block and an indication for CRT according to current ESC Guidelines. Patients were randomized 1:1 to LBBAP or biventricular pacing. The primary outcome, assessed over the first year, was a four-component composite: death from any cause, heart failure hospitalisation, any device-related complication requiring a surgical re-intervention or failure to deliver the assigned resynchronisation therapy efficiently. All events were reviewed by an independent blinded adjudication committee.
The 168 randomized patients had a mean age of 69 years, with 33% being female. Most patients (67%) had NYHA class II heart failure, and 77.5% were receiving at least three out of the four ESC Guidelines-recommended pillars of heart failure medication.
Over the first year after device implantation, the incidence of the primary outcome was 25% in the biventricular pacing group and 13% in the LBBAP group (hazard ratio 2.14; 95% confidence interval [CI] 1.01 to 4.51; p=0.039). This difference was predominantly driven by a higher incidence of device-related complications with biventricular pacing vs. LBBAP (15% vs. 1%; odds ratio 6.76; 95% CI 1.48 to 31.25; p=0.006), with no significant difference observed for death, heart failure hospitalisation and implant failure.
Procedure time was significantly longer with biventricular pacing vs. LBBAP (90 minutes vs. 76 minutes; p=0.005), with similar functional improvement in both groups.
Professor le Polain de Waroux concluded: "This is the first randomized trial to demonstrate that LBBAP provides effective cardiac synchronization while decreasing the need for surgical re-intervention. The reduction in complications plus shorter procedure times with LBBAP are important both for patients and for the healthcare system as a whole."
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